Diabetic ketoacidosis continues to be a life-threatening hyperglycemic emergency in people with diabetes. (1)

In 2015, the IDF estimated the prevalence of Type 2 diabetes in adults to be 14.6% in the UAE (2), however, there is limited knowledge about the incidence of Type 1 diabetes and the characteristics of patients presenting with DKA.

DKA typically occurs in patients with Type 1 DM, although diabetes prone ketosis in patients with Type 2 diabetes is also now a well-recognized entity. (3)

Several factors may be involved in precipitating an episode of DKA. Early diagnosis of diabetes and recognition of the precipitating factors can help to prevent these emergencies.

 

AimMethod
We performed a retrospective cross-sectional analysis of patients admitted to the medical wards and intensive care units of a tertiary care hospital in Dubai, UAE in the period of June 2014 to December 2016. Variables recorded included age, gender, ethnicity, type of diabetes, HbA1c at presentation, antibody status, precipitating factors and time to resolution of DKA from the diagnosis.

The patients included in the analysis fulfilled the criteria of DKA as per the Joint British Diabetes Societies guidelines. (4)

Significant ketonuria (more than 2+ on standard urine dipstick), Blood glucose greater than 250 mg/dl or known Diabetes Mellitus, pH less than 7.3 and/or serum HCO3 less than 15mmol/L.

Results
A total of 182 patients (n=182) were admitted over this period who satisfied the above criteria of DKA. Out of these 55% were males and 45% females. A relatively equal gender distribution, unlike studies reported elsewhere in the region, which found a higher female preponderance for DKA. (5)

Though the majority (60%) of those presenting with DKA had type 1 diabetes, a significant number (27%) had a diagnosis of type 2 diabetes. (Table 1) Due to financial constraints, a small number of patients remained unclassified; this was because we were unable to send requests for their anti-body status. Diabetes is indeed a heterogeneous disorder and the emerging entity of ketosis prone type 2 diabetes is a possibility in some of our patients.

Table 2 shows the antibody status identified in our cohort of patients.

The most common precipitating factor for the episode of DKA was interruption of treatment as either complete discontinuation, reduced frequency or quantity of doses taken. (Table 3) The next most frequent cause was infections and pancreatitis. We also noted that the majority of patients had poor glycemic control as reflected by an HbA1c above 10%, which may explain why they rapidly progressed into DKA with minor interruptions in their treatment. (Table 4) The next interesting observation was the number of patients presenting with DKA without a prior history of diabetes (10% of the total admissions). (Table 3)

Table 1    Diabetes Classification

Type of Diabetes	Patients
Type 1	109
Type 2	49
Others	5
Not Known	19
Total
182
Table 2       Antibody Status

Antibody Status	Patients
Positive	43
Negative	27
Not done	63
Not Applicable	49
Table 3            Precipitating Factors

Precipitating Factor	Patients
Missed Dose	53
Infections	44
Newly diagnosed DM	18
Pancreatitis	12
Others	56
Table 4            HbA1c (%) levels at presentation

HbA1c	Patients with DKA
≤7.5	6
7.6-9.9	43
≥10	132




Discussion
The observation that 10% of DKA admissions were in individuals with previously undiagnosed diabetes draws our attention to the fact that we need to educate the public on the warning sign of diabetes, so people can seek medical attention early and avoid presenting in extremis with a hyperglycemic emergency.

References:

Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic Crises in Adult patients with Diabetes. Diabetes Care 2009; 32(7): 1335-1343.
IDF Diabetes Atlas Seventh edition 2015
Umpierrez GE, Smiley D, Kitabchi AE. Ketosis-prone type 2 diabetes mellitus. Ann Int Med 2006; 144:350–7.
Savage MW, Dhatariya KK, Kilvert A et al; Joint British Diabetes Societies.Joint British Diabetes Societies guideline for the management of diabetic ketoacidosis. Diab Med 2011;28:508-15.
Mussa H. Almalki, Badurudeen Mahmood Buhary, Shawana Abdulhamid Khan, Abdulrahman Almaghamsi1 and Fahad Alshahrani.  Clinical and Biochemical Characteristics of Diabetes Ketoacidosis in a Tertiary Hospital in Riyadh. Clinical Medicine Insights: Endocrinology and Diabetes 2016:9

Clinical profiles and precipitating factors for DKA at a tertiary center in Dubai, UAE