Date Published: March 22, 2018
Author(s): Nontobeko F.M. Ndebele, Mergan Naidoo.
Diabetic ketoacidosis (DKA) is a biochemical triad of hyperglycaemia, ketoacidosis and ketonaemia and one of the potentially life-threatening acute metabolic complications of diabetes mellitus. This study aimed at describing the clinical profile of patients presenting with DKA to a busy rural regional hospital in KwaZulu-Natal.
A retrospective review of clinical notes of patients presenting with DKA to the Emergency Department was performed over a 10-month period. Data included patients’ demographic profile, clinical presentation, precipitating factors, comorbidities, biochemical profile, length of hospital stay and outcome.
One hundred and five black South African patients above the age of 12 years were included in the study. Sixty-four (60.95%) patients had type 1 diabetes mellitus (T1DM) and 41 (39.05%) patients had type 2 diabetes mellitus (T2DM). Patients with T2DM were significantly older than those with T1DM (52.1 ± 12.4 years vs. 24.4 ± 9.5 years, p < 0.0001). The acute precipitant was identified in 68 (64.76%) cases with the commonest precipitant in T1DM patients being poor adherence to treatment, whereas in T2DM, the most common precipitant was infection. Nausea and vomiting were the most common presenting symptoms with the majority of patients presenting with non-specific symptoms. Fifty-seven (54.29%) cases had pre-existing comorbidities, with higher prevalence in T2DM than T1DM patients. Glycated haemoglobin was severely elevated in the majority of patients. Patients remained hospitalised for an average of 8.9 ± 7.5 days. The mortality rate was 17.14%, and 12 of the 18 deaths occurred in patients with T2DM. The prevalence of DKA was higher in patients with T1DM and those with pre-existing comorbidities. The mortality rate remains alarmingly high in older patients with T2DM.
Diabetic ketoacidosis (DKA) is a potentially life-threatening emergency condition caused by acute hyperglycaemia that may be associated with both type 1 and type 2 diabetes mellitus.1 The cardinal biochemical manifestations include hyperglycaemia, ketonaemia or ketonuria and metabolic acidosis.2 Normoglycaemic DKA has also been described.3 Classically, patients present with clinical features that may include a history of polyuria, polydipsia, polyphagia, nausea and vomiting.4 But, over the last decade, there has been a change in the way patients with DKA present5 as more patients tend to now present with a variety of non-specific symptoms that may result in the diagnosis being missed by the primary care physician.6,7
A retrospective review of clinical files from patients presenting to the ED at Ngwelezana Hospital was performed. Clinical files from patients above the age of 12 years in which the diagnosis of DKA had been made were included in the study. Only patients who presented between March 2015 and December 2015 were considered for inclusion. Patients were classified as type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM) based on the history obtained at presentation. In addition, clues from their treatment regimens suggested their type, that is, those with the requisite phenotypical characteristics on injectable insulin only were assumed to have T1DM and those with certain phenotypical characteristics on oral hypoglycaemic agents or both oral medication and injectables were assumed to have T2DM. Clinicians working in the ED asked patients about medication compliance routinely and this was documented in the clinical files.
Files of 105 participants with the diagnosis of DKA were reviewed. The age of the participants ranged from 14 to 75 years, with mean and standard deviation (SD) being 38.45 ± 16.6 years, respectively. Median age was 37 years and the male to female ratio was 1.05: 1. Table 1 cross-tabulates gender and age with mortality.
Diabetic ketoacidosis occurred in patients with both T1DM and T2DM, but was more common in the former group. High prevalence of DKA in T1DM is a well-documented finding.9,21 Although it could manifest at any age, it is more common in the younger population. In this study, just over two-thirds of the participants were less than 50 years of age, which is in line with most of studies from HICs where the majority of patients with DKA were between the ages of 18 and 44 years.18
This study had several limitations. Firstly, it was a retrospective review of records performed at one hospital that cares mainly for adults and excluded the paediatric population. There was no consistency in completion of clinical notes that may have contributed to an information bias. The study was conducted over a period of 10 months, which may have limited the ability to detect slight changes in the population.
Diabetic ketoacidosis is a common and often life-threatening complication of diabetes mellitus, especially in patients with T2DM with comorbid conditions. The overall mortality rate in this unit is worrying and is the indicator that there is room for improvement which needs to be addressed by the clinical managers in the hospital. High-risk patients presenting with DKA need to be rapidly assessed, and appropriate resuscitation involving a multidisciplinary team needs to be implemented. Early and appropriate critical care intervention may help reduce the mortality rate among the identified high-risk population. Community awareness of this serious complication is also needed, including routine screening for diabetes at primary health level coupled with at least a bi-annual monitoring of HbA1c levels.