Pathogenesis and Pathophysiology

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In DKA the major culprit is insulin deficiency. Insulin deficiency may be relative, for example, in the setting of severe infection, where normal amounts of insulin are insufficient or absolute when insulin therapy is neglected. At some stage insulin deficiency becomes coupled with an excess of counter-regulatory hormones and cytokines [9,10]. The traditional catabolic (stress) hormones include glucagon, epinephrine,

Table 1. Classification of clinical pictures and diagnostic criteria (adapted from Standards of Medical Care in Diabetes - 2004/2006 POSITION STATEMENT Diabetes Care 27:S94-S101, 2004, 2006 by the American Diabetes Association, Inc.).

Diabetic ketoacidosis

Table 1. Classification of clinical pictures and diagnostic criteria (adapted from Standards of Medical Care in Diabetes - 2004/2006 POSITION STATEMENT Diabetes Care 27:S94-S101, 2004, 2006 by the American Diabetes Association, Inc.).

Diabetic ketoacidosis

Stress

Compensated

Hyperosmolar

ketosis

DKA

Mild

Moderate

Severe

hyperglycaemia

Plasma

Variable

Generally

Generally

Generally

Generally

>35-40

glucose

increased

increased

increased

increased

mmol/L

Arterial

Normal

Normal

Decreased

7.0-7.25

<7.0

Generally

pH

>7.25

normal

Serum

Normal

Marginally

15-18

10-15

<10

>15

bicarbonate

decreased

mmol/L

mmol/L

mmol/L

mmol/L

Urine

Increased

Increased

Increased

Increased

Increased

Normal/

ketones

marginally increased

Blood

Increased

Increased

Increased

Increased

Increased

Normal/

ketones

marginally increased

Anion gapa

Normal/ marginally increased

Marginally increased

>10

>12

>12

Variable

Mental

Normal

Normal

Normal

Normal/

Drowsy-

Drowsy-

status

drowsy

coma

coma

growth hormone and Cortisol, all of which have well-described metabolic actions. The metabolic actions of cytokines are in general not so well understood and it is possible that many of these actions are mediated by hypothalamo-pituitary activation and subsequent elevation of catabolic hormones.

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