Diabetic Ketoacidosis (DKA)

As part of my Medical Nutrition Therapy (MNT) rotation, my preceptor has asked me to create a summary sheet of certain illnesses and complications associated with various disease states. One of which, is diabetic ketoacidosis (DKA).

What is DKA?

DKA is a serious complication of diabetes that occurs when your body produces high levels of blood acids called ketones.
It develops when your body is unable to produce enough insulin. Insulin normally plays a key role in helping sugar (glucose) — a major source of energy for your muscles and other tissues — enter your cells. Without enough insulin, your body begins to break down fat as an alternate fuel. This process produces a buildup of toxic acids in the bloodstream called ketones, eventually leading to diabetic ketoacidosis if untreated.

What causes DKA?

1. Not enough insulin

2. Not enough food

3. Low blood glucose

When cells don’t get the glucose they need for energy, your body begins to burn fat for energy, which produces ketones. Ketones are acids that build up in the blood and appear in the urine when your body doesn’t have enough insulin. They are a warning sign that your diabetes is out of control or that you are getting sick. High levels of ketones can poison the body. When levels get too high, you can develop DKA. DKA may happen to anyone with diabetes, though it is rare in people with type 2. Treatment for DKA usually takes place in the hospital. But you can help prevent it by learning the warning signs and checking your urine and blood regularly. DKA usually develops slowly. But when vomiting occurs, this is life-threatening and can develop in a few hours.

Sugar is a main source of energy for the cells that make up your muscles and other tissues. Normally, sugar enters your cells with the help of insulin. If you don’t have enough insulin in your body, your body won’t be able to use sugar properly for energy. This prompts the release of hormones that break down fat as an alternate fuel. In turn, this process produces toxic acids known as ketones. Excess ketones accumulate in the blood and eventually “spill over” into the urine.

Early symptoms include:

– Polydypsia (increase of thirst)

– Polyuria (frequent urination)

– Hyperglycemia (high blood glucose levels)

– High level of ketones in the urine

– Fatigue, dry skin, nausea, difficulty breathing, fruity odor on the breath (caused from the presence of ketones)

When diagnosing DKA, a healthcare provider should pay close attention to the following lab values:

Blood Glucose: If there isn’t enough insulin in your body to allow sugar to enter your cells, your blood sugar level will rise (hyperglycemia). As your body breaks down fat and protein for energy, your blood sugar level will continue to rise.

Ketone level: When your body breaks down fat and protein for energy, toxic acids known as ketones enter your bloodstream.

Blood acidity: If you have excess ketones in your blood, your blood will become acidic (acidosis). This can alter the normal function of various organs throughout your body.

– Blood electrolyte tests, Urinalysis, Chest X-ray, and an Electrocardiogram (ECG)

The treatment for DKA involves a three-pronged approach:

1. Fluid Replacement: receive fluids, orally or intravenously, until rehydrated. These fluids will replace those that have been lost through excessive urination and dilute the excess sugar in the blood.

2. Electrolyte Replacement: Electrolytes are minerals in your blood that carry an electric charge, such as sodium, potassium and chloride. The absence of insulin can lower the level of several electrolytes in your blood. You’ll receive electrolytes through your veins to help keep your heart, muscles and nerve cells functioning normally.

3. Insulin Therapy: Insulin reverses the processes that cause diabetic ketoacidosis. Along with fluids and electrolytes, you’ll receive insulin therapy — usually through a vein. When your blood sugar level falls below 240 mg/dL (13.3 mmol/L) and your blood is no longer acidic, you may be able to stop intravenous insulin therapy and resume your normal subcutaneous insulin therapy.

Diabetic ketoacidosis is usually triggered by an illness or insulin therapy.

An infection or other illness can cause your body to produce higher levels of certain hormones, such as adrenaline or cortisol. Unfortunately, these hormones work against insulin — sometimes triggering an episode of diabetic ketoacidosis. Pneumonia and urinary tract infections are common culprits.

Missed insulin treatments or inadequate insulin therapy can leave you with too little insulin in your system, triggering an episode of diabetic ketoacidosis.

Other possible triggers of DKA could include:

– Stress

– Physical or emotional stress

– High fever

– Surgery

– Heart attack

– Alcohol or drug abuse, specifically cocaine

While DKA is being treated, there are complications that patients and healthcare providers need to be aware of as well. Complications could include:

Hypoglycemia: Insulin allows sugar to enter your cells. This causes your blood sugar level to drop. If your blood sugar level drops too quickly, you may develop low blood sugar.

Hypokalemia: Fluids and insulin used to treat diabetic ketoacidosis may cause your potassium level to drop too low. A low potassium level can impair the activities of your heart, muscles and nerves.

Cerebral Edema: Adjusting your blood sugar level too quickly can produce swelling in your brain. This complication appears to be more common in children, especially those with newly diagnosed diabetes.

American Diabetes Association- DKA

Mayo Clinic- DKA

DKA3

DKA2

DKA

Advertisements

Cystic Fibrosis-Related Diabetes (CFRD)

The most common types of diabetes are type 1 and type 2 diabetes. CFRD has some features that are common in both. Type 1 diabetes used to be called insulin-dependent or juvenile-onset diabetes. It occurs most often in childhood. People with type diabetes can’t make any insulin, so they must take insulin to stay alive. This is why type diabetes is often called “insulin-dependent diabetes.” People with type diabetes who miss insulin doses get very sick and can get ketoacidosis (a life-threatening change in blood acidity). Type 2 diabetes used to be called non–insulin dependent or adult-onset diabetes. It is caused by the lack of a normal response to insulin in addition to not making enough insulin. This type of diabetes occurs most often in overweight people over the age of 0. People with type 2 diabetes don’t often get ketoacidosis, but they can get very sick when their blood sugars are too high. People with type 2 diabetes do not always need insulin to manage their diabetes. Some use insulin. Some take pills. Most are told to lose weight. Some manage type 2 diabetes through diet and exercise alone.

Diabetes

T1DM: The body cannot make insulin

T2DM: The body lacks normal responses to insulin and does not make enough insulin

CFRD: The body cannot make or use insulin

Causes of CFRD

CFRD is unique, though it shares features with both type and type 2 diabetes. As in type diabetes, the pancreas does not make enough insulin. Thus, people with CF have insulin deficiency. This is likely due to scars in the pancreas because of thick mucus. Most people with CF make less insulin than normal, though not all with CF get diabetes. Some people with CF get diabetes because they may have insulin resistance. This means that the cells in the body do not use insulin the right way so more insulin is needed to change food into fuel and keep blood sugars in the normal range. Because many with CF have both insulin deficiency and insulin resistance, more people with CF get diabetes than do people without CF. Even when people with CF are not acutely ill, their chronic underlying infections can cause insulin resistance. A third cause of insulin resistance is higher than normal cortisol levels. The hormone cortisol is a steroid. It is made in the adrenal glands. Our bodies make higher than normal cortisol levels in response to stress. High cortisol levels get in the way of insulin’s action. Steroid-containing drugs (called corticosteroids) can also increase cortisol levels. These drugs are sometimes needed to treat lung disease. When taken, they can, for a little while, worsen blood sugar control. In people with CF who do not have diabetes, using corticosteroids can give them diabetes for a little while during and after corticosteroid treatment. People can have CFRD only sometimes (intermittent CFRD) or always (chronic CFRD). If you have intermittent CFRD, you may only need to take insulin when sick or during steroid treatment. If you have chronic CFRD, you need insulin treatment at all times to prevent high blood sugar levels. Although CFRD is unique from type or type 2 diabetes, the problems caused by diabetes are the same for all. These include eye, kidney, and nerve problems. These problems are caused by many years of blood sugar levels that are too high. Every person’s goal for diabetes treatment, no matter what kind they have, is to keep blood sugar levels as normal as they can. This helps to prevent diabetes-caused problems.

Complications with Hyperglycemia:

          Vision Problems

          Kidney Problems

          Neurological Problems (Nerve Damage)

Goal: To Keep Blood Sugar Levels Normal

              A1C: 7%

              A1C may also be reported as eAG: 154 mg/dl

              Before a meal (preprandial plasma glucose): 70–130 mg/dl

              1-2 hours after beginning of the meal (Postprandial plasma glucose)*: Less than 180 mg/dl

ADA Normal Blood Sugar Levels

Managing Cystic Fibrosis-Related Diabetes

cfrd

cfrd1

cfrd2

Sixty Five Roses

Cystic fibrosis is the most common fatal genetic disorder in North America. The disorder produces thick, sticky mucus secretions that may seriously impair the function of multiple organs in the body. Most notably, these organs are the pancreas and lungs. Just a few decades ago, an infant born with CF seldom survived to adulthood. Today, the outlook is much brighter, with adults reaching their 30’s, 40’s, and some even into their 50’s.

Cystic fibrosis has three major consequences: chronic lung disease, pancreatic insufficiency, and abnormally high electrolyte concentrations in the sweat. Chronic lung disease develops because the airways in the lungs become congested with mucus, causing breathings to be strenuous. As the thick mucus stagnates in the bronchial tubes, bacteria multiply there. Lung infections are the usual cause of death in people with cystic fibrosis.

Cystic fibrosis causes some degree of pancreatic insufficiency in all cases, with about 90% of cases serious enough to require enzyme replacement therapy. With aging, damage to the pancreas deteriorates. The thick mucus obstructs the pancreatic ducts and interferes with the secretion of digestive enzymes, pancreatic juices, and pancreatic hormones. Eventually, the pancreatic cells are surrounded by mucus and are gradually replaced by fibrous tissues. Malabsorption of many nutrients including fat, protein, vitamins, and minerals often leads to malnutrition. Additionally, the secretion of insulin may be affected resulting in glucose intolerance and diabetes.

The therapy of cystic fibrosis aims to promote appropriate growth and development and prevent respiratory failure and complications. Treatment includes respiratory, diet, and drug therapy.

Nutrient losses through malabsorption, frequent infections, rapid turnover rate of protein and essential fatty acids, high protein catabolism, and high basal energy expenditures raise energy needs for people with cystic fibrosis to between 120%-150% of the RDA for gender and age. Extra energy is needed simply to breathe. RDs estimate individual energy requirements based on basal metabolic rate, activity level, pulmonary function, and degree of malabsorption.

Obtaining enough energy can be complicated, but because people with CF frequently experience a loss of appetite that is aggravated by repeated infections, emotional stress, and drug therapy. Coughing to clear the lungs may trigger vomiting or reflux of foods from the stomach. Thus the person with cystic fibrosis finds it difficult to take in enough food energy, protein, and other nutrients to meet needs.

NIH- Cystic Fibrosis

Cystic Fibrosis Foundation

cysticfibrosis01cystic-fibrosis-cfcystic-fibrosis