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Diabetic ketoacidosis

  • Overview
  • Theory
  • Diagnosis
  • Management
  • Follow up
  • Resources
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Last reviewed:16 Jun 2025
Last updated:10 Jun 2025

Summary

Diabetic ketoacidosis (DKA) is characterized by a biochemical triad of hyperglycemia, ketonemia, and acidemia, with rapid symptom onset.

Common symptoms and signs include polyuria, polydipsia, polyphagia, weakness, weight loss, tachycardia, dry mucous membranes, poor skin turgor, hypotension, and, in severe cases, shock.

Successful treatment includes correction of volume depletion, ketogenesis, hyperglycemia, electrolyte imbalances, and comorbid precipitating events, with frequent monitoring.

Complications of treatment include hypoglycemia, hypokalemia, hypoxemia, and rarely pulmonary edema.

Cerebral edema is a rare but potentially rapidly fatal complication. It may be prevented by avoiding overly rapid fluid and electrolyte replacement.

Definition

DKA is an acute metabolic complication of diabetes that is potentially fatal and requires prompt medical attention for successful treatment. It is characterized by absolute (total absence of) or relative (levels insufficient to suppress gluconeogenesis and ketone production) insulin deficiency and elevation of counterregulatory hormones (glucagon, epinephrine, norepinephrine, cortisol, and growth hormone).[1]​ It is the most common acute hyperglycemic complication of type 1 diabetes mellitus.[1]​ While most cases occur in patients with type 1 diabetes, DKA can also affect patients with type 2 diabetes.

This topic covers DKA in adults.

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History and exam

Other diagnostic factors

  • polyuria
  • polyphagia
  • polydipsia
  • weight loss
  • weakness
  • nausea or vomiting
  • abdominal pain
  • dry mucous membranes
  • poor skin turgor
  • sunken eyes
  • tachycardia
  • hypotension
  • Kussmaul respiration
  • acetone breath
  • altered mental status
  • hypothermia

Risk factors

  • type 1 diabetes
  • inadequate or inappropriate insulin therapy
  • infection
  • myocardial infarction
  • previous episode of hyperglycemic or hypoglycemic crisis
  • high hemoglobin A1c (HbA1c)
  • adverse social determinants of health
  • age <45 years
  • presence of other diabetes-related complications
  • presence of other chronic health conditions
  • pancreatitis
  • stroke
  • acromegaly
  • hyperthyroidism
  • use of certain drugs
  • Cushing syndrome
  • Hispanic, Asian or black ancestry
  • bariatric surgery
  • prolonged fasting or carbohydrate restriction
  • pregnancy
  • dementia
  • mental health disorders
  • alcohol and/or substance use

Diagnostic tests

1st tests to order

  • plasma glucose
  • ABG
  • capillary or serum ketones
  • urinalysis
  • serum BUN
  • serum creatinine
  • serum sodium
  • serum potassium
  • serum chloride
  • serum magnesium
  • serum phosphate
  • anion gap calculation
  • serum lactate
  • LFT
  • serum amylase
  • serum lipase
  • serum osmolality
  • CBC
  • ECG

Tests to consider

  • serum creatine kinase (CK)
  • CXR
  • high sensitivity cardiac troponin
  • blood, urine, or sputum cultures

Treatment algorithm

Contributors

Authors

Aidar R. Gosmanov, MD, PhD, FACE

Associate Professor of Medicine

Division of Endocrinology

Albany Medical College

Chief, Endocrinology Section

Albany VAMC

Albany

NY

Disclosures

ARG declares that he has no competing interests.

Laleh Razavi Nematollahi, MD

Assistant Professor of Medicine

Cleveland Clinic Lerner College of Medicine

Case Western Reserve University

Cleveland

OH

Disclosures

LRN declares that she has no competing interests.

Acknowledgements

Dr Aidar Gosmanov and Dr Laleh Razavi Nematollahi would like to gratefully acknowledge Professor Abbas E. Kitabchi, the previous contributor to this topic.

Disclosures

AEK is an author of a number of references in this topic.

Peer reviewers

David Jenkins, DM, FRCP

Consultant Physician

Worcestershire Royal Hospital

Worcester

UK

Disclosures

DJ declares that he has no competing interests.

Udaya M. Kabadi, MD, FRCP(C), FACP, FACE

Professor of Medicine

University of Iowa

Iowa City

IA

Disclosures

UMK declares that she has no competing interests.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Umpierrez GE, Davis GM, ElSayed NA, et al. Hyperglycaemic crises in adults with diabetes: a consensus report. Diabetologia. 2024 Aug;67(8):1455-79.Full text Abstract

American Diabetes Association. Standards of care in diabetes - 2025. Diabetes Care. 2025 Jan ;48(suppl 1):S1-352.Full text

Dhatariya KK, Glaser NS, Codner E, et al. Diabetic ketoacidosis. Nat Rev Dis Primers. 2020 May 14;6(1):40. Abstract

Umpierrez G, Korytkowski M. Diabetic emergencies - ketoacidosis, hyperglycaemic hyperosmolar state and hypoglycaemia. Nat Rev Endocrinol. 2016 Apr;12(4):222-32. Abstract

Reference articles

A full list of sources referenced in this topic is availablehere.

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