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BMI, polypharmacy, lab testingmay help diagnose DKA and identify
high risk of its recurrence
Demographic variables, especially body mass index and polypharmacy, could potentially aid in identifying subjects at
high risk of recurrent diabetic ketoacidosis. In addition, beta-hydroxybutyrate measurement adds rigor to the diagnosis
of diabetic ketoacidosis, conclude two presentations on diagnosing diabetic ketoacidosis and risk factors for its
recurrence.
V
ishal Sehgal, MD, of the University of
Tennessee Health Science Center,
Memphis, explained, “Diabetic
ketoacidosis and its recurrence continue
despite near-universal availability of insulin.
So we set out to describe factors associ-
ated with recurrent diabetic ketoacidosis
in a community hospital.”
He added, “The cost of healthcare seems
to rise every year with no corresponding
improvement in healthcare statistics. In this
context, any scientific study should focus
on reducing healthcare costs, in addition
to reducing the morbidity and mortality.”
All patients admitted with the diagnosis of
diabetic ketoacidosis from 2013 to 2015
were identified. Patients with multiple
admissions were identified and compared
with patients who were admitted for dia-
betic ketoacidosis only once.
The unadjusted association between each
of the variables and diabetic ketoacidosis
was determined using chi-square tests for
categorical variables and t-tests for con-
tinuous variables. Logistic regression was
used to calculate odds ratios and 95%
confidence intervals for all categorical
variables. Multivariable logistic regression
was used to determine predictors of recur-
rent diabetic ketoacidosis.
A total of 116 patients accounted for 349
admissions during the 33-month study
period. Of the 116 patients with diabetic
ketoacidosis, 58 experienced only one
episode and the remainder were admit-
ted multiple times.
Unadjusted results suggested that patients
with lower body mass index, mean body
weight and higher anion gap values were
more likely to suffer recurrent diabetic
ketoacidosis. In multivariable analysis, how-
ever, body mass index and polypharmacy
were the strongest predictors of recurrent
diabetic ketoacidosis.
Low body mass index and polypharmacy
are easily quantifiable in day-to-day clin-
ical practice. The results provide simple
and easily available markers of patients at
high risk of recurrent diabetic ketoacidosis.
If confirmed in other data sets and pop-
ulations, these markers might help direct
interventions toward high-risk patients to
reduce their morbidity and mortality.
Dr Sehgal concluded that demographic
variables, especially body mass index
and polypharmacy, could potentially aid in
identifying subjects at high risk of recurrent
diabetic ketoacidosis.
He said, “Our study helped define two
easily quantifiable markers of readmis-
sion to hospital in patients with diabetic
ketoacidosis. Such identification could be
extrapolated to hospital readmissions for
other disease pathologies as well.”
He continued, “If validated in other studies,
interventions may be designed to reduce
hospital readmissions in this population.
Such interventions could help save the
healthcare system billions of dollars.”
In a related study on diabetic ketoacidosis
presented at the American College of Clin-
ical Endocrinology’s Scientific and Clinical
Congress, John M. Miles, MD, FACE, of the
University of Kansas Medical Center, Kan-
sas City, assessed diagnostic criteria for
the disorder.
Dr Miles explained that American Diabetes
Association diagnostic criteria for diabetic
ketoacidosis include the triad of ketonuria,
hyperglycemia (glucose ≥250 mg/dL), and
serum bicarbonate ≤18 mEq/L.
Serum bicarbonate is not specific for dia-
betic ketoacidosis, however, and American
Diabetes Association recommendations on
laboratory testing for diabetes state that
urine ketone testing should not be used for
diagnosing diabetic ketoacidosis in view of
its qualitative nature and inability to detect
the dominant ketone body anion in diabetic
ketoacidosis, beta-hydroxybutyrate.
In a prior study, these limitations led Dr
Miles and coinvestigators to suggest that
admission beta-hydroxybutyrate ≥3.8
mmoL/L could be used in place of these
criteria to diagnose diabetic ketoacidosis.
In the present study, Dr Miles’s team
reviewed records from adult admissions
for diabetic ketoacidosis from 2012–2016
to assess the sensitivity and specificity of
the American Diabetes Association criteria,
using beta-hydroxybutyrate ≥3.8 mmoL/L to
define diabetic ketoacidosis.
Trace or negative ketonuria was consid-
ered to be inconsistent with a diagnosis of
diabetic ketoacidosis, whereas small, moder-
ate, or large ketones were considered to be
© Photo by Jean Whiteside/AACE 2017
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