Diabetic ketoacidosis natural history, complications and prognosis

If left untreated, patients with diabetic ketoacidosis (DKA) may progress to develop multi-organ failure and death. Common complications of diabetic ketoacidosis (DKA) include hypokalemia, cerebral edema, hyperglycemia, ketoacidemia, renal tubular necrosis and pulmonary edema.

• If left untreated, diabetic ketoacidosis may progress to multi-organ failure and death
• Early in the course of the ketoacidotic process, hyperventilation results in a decrease in pCO2. The metabolic acidosis is compensated, and pH may be normal or only slightly reduced (e.g., in mild or moderate DKA)
• As DKA progresses into the severe stage, more significant acidosis occurs and pH falls
• If compensatory hyperventilation does not occur for the acidosis, such as, in pulmonary disease (pneumonia, asthma, or adult respiratory distress syndrome) or CNS depression (e.g., cerebral edema), the acidosis becomes more severe and results in a poor prognosis
• Although acidosis impairs myocardial contractility, heart failure and cardiogenic shock are rare in children with DKA
• Hypotension or shock during DKA is nearly always the result of hypovolemia or cerebral edema in children
• Heart failure, myocardial infarction, and arrhythmias during DKA are seen commonly in untreated diabetic ketoacidosis

People with diabetic ketoacidosis need close and frequent monitoring for complications. Surprisingly, the most common complications of DKA are related to the treatment:^{[1][2][3][4][5]}

• Hypokalemia and often, potassium depletion
• Cerebral edema
• Hyperglycemia
• Ketoacidemia
• Fluid and electrolyte depletion
• Aspiration
• Unrecognized renal tubular necrosis
• Pulmonary edema

• The following are the signs of poor prognosis in diabetic ketoacidosis at the time of diagnosis:^[6][7][8]
  • Hypothermia
  • Coma
  • Oliguria
  • Extremes of age (young and elderly)
  • Intercurrent comorbidity, for example, myocardial infaction, sepsis
  • Positive tropinins without evident acute coronary syndrome
  • High platelet to lymphocyte ratio

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