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254 Diabetic Ketoacidosis

Diabetic Ketoacidosis Client Education
Sheet
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BASIC INFORMATION
• Cats are more likely to be subjectively
underweight, and dogs are more likely to • Chemistry profile: hyperglycemia is always
present. Other typical findings:
Definition be overweight. ○ Hypokalemia
A serious, often life-threatening form of • Physical exam findings related to DM (e.g., ○ Hypophosphatemia; 50% of dogs and
diabetes mellitus (DM), diabetic ketoacidosis cataracts in dogs) or to the concurrent disease 65% of cats
(DKA) is characterized by hyperglycemia, may be noted. ○ Hypomagnesemia
glucosuria, ketonemia/ketonuria, and metabolic ○ Hyponatremia: may be pseudohypona-
acidosis. Etiology and Pathophysiology tremia secondary to hyperglycemia; for
• In dogs and cats with DM, there is a lack every 100 mg/dL increase in glucose
Synonym of insulin or resistance to insulin. concentration, sodium concentration
DKA • Without insulin, hyperglycemia develops, decreases 1.6 mEq/L.
leading to osmotic diuresis and the classic ○ Elevated liver enzyme activities
Epidemiology clinical signs of DM: polyuria, polydipsia, ○ Azotemia, prerenal and renal; more
SPECIES, AGE, SEX polyphagia, and weight loss. common in cats
Most commonly, dogs and cats are middle-aged • Without glucose as an energy source for • Urine analysis
or older, with a median age of 8 years for dogs cells, fat cells are broken down, releasing ○ Glucosuria (p. 1227)
and 9 years for cats (p. 251). free fatty acids. The liver converts free fatty ○ Ketonuria; standard test does not detect
acids to triglycerides and ketone bodies (i.e., beta-hydroxybutyrate (p. 1355)
GENETICS, BREED PREDISPOSITION acetoacetic acid, beta-hydroxybutyric acid, ○ Possible pyuria
Siamese and Abyssinian cats may have an acetone). • Urine culture; should always be performed
increased risk for DKA. • Typically, a concurrent illness leads to an in patients with DKA regardless of urine
increase in secretion and blood concentrations sediment exam findings
RISK FACTORS of stress hormones glucagon, epinephrine, cor- • Thoracic and abdominal radiographs
Uncontrolled or undiagnosed DM tisol, and growth hormone, which counteract ○ Hepatomegaly
the actions of insulin further. ○ +/− Free abdominal fluid; if present, most
ASSOCIATED DISORDERS • The stress hormones stimulate lipolysis, likely secondary to neoplasia or pancreatitis
Concurrent disorders occur in approximately gluconeogenesis, and glycogenolysis, leading • Abdominal ultrasound is useful to diagnose
70% of dogs and 55%-90% of cats. Most to a worsening hyperglycemia and continued concurrent disease processes (e.g., pancreatitis).
common ones: formation of ketone bodies.
• Dogs: urinary tract infection (p. 232), acute • A state of ketosis and acidosis develops as Advanced or Confirmatory Testing
pancreatitis (p. 742), hyperadrenocorticism ketone bodies continue to accumulate and • Serum ketones
(p. 490) saturate the body’s buffering systems. ○ Requires a handheld ketone meter
• Cats: hepatic lipidosis (p. 444), acute pan- ○ Chance of DKA is low if serum ketones ≤
creatitis (p. 740), chronic renal failure (p. DIAGNOSIS 2.8 mmol/L in dogs and ≤ 2.55 mmol/L
169), cholangiohepatitis (p. 160), neoplasia in cats.
Diagnostic Overview • Endocrine testing
Clinical Presentation Diagnosis is based on documentation of hyper- ○ Hyperadrenocorticism and hypothyroid-
HISTORY, CHIEF COMPLAINT glycemia, glucosuria, ketonuria/ketonemia, ism can occur in dogs with DKA.
• Patients may present with clinical signs and metabolic acidosis. Routine blood tests ○ To test for hyperadrenocorticism, an
related to uncontrolled DM, DKA, and/or will identify hyperglycemia. Ketones can be ACTH stimulation test should be per-
a concurrent disease. detected by a urine dipstick using urine or formed (p. 485) if clinically indicated.
• History is variable due to the progressive serum as the sample. A quantitative value can be ○ To test for hypothyroidism (p. 525), a
nature of DKA. Signs include those typical obtained using a handheld ketone meter. Ideally, thyroid panel may be performed if clini-
of uncomplicated DM as well as the DKA acidosis should be confirmed by identification cally indicated.
(e.g., anorexia, vomiting). of metabolic acidosis by blood gas measure- • Abdominal fluid analysis (p. 1343); may be
• Most common clinical signs: ment (p. 1315). If this is not possible, a low supportive of pancreatitis or help diagnose
○ Polyuria/polydipsia bicarbonate concentration or an elevated anion neoplasia.
○ Lethargy or depression gap measurement on a blood chemistry profile • Fine-needle aspirate +/− biopsy of liver
○ Anorexia helps support the diagnosis. ○ Aspirates may confirm hepatic lipidosis
○ Vomiting (cats) or neoplasia (dogs and cats).
○ Weight loss Differential Diagnosis ○ A biopsy may be required to diagnosis
• Clinical signs related to the DKA typically • Hyperglycemic hyperosmolar syndrome cholangiohepatitis (p. 160).
progress quickly. • Diabetic ketosis without acidosis ○ If infectious cholangiohepatitis is sus-
pected, aerobic and anaerobic cultures
PHYSICAL EXAM FINDINGS Initial Database of bile are recommended (p. 1112).
• Physical exam findings can vary in severity. • A CBC, serum biochemical profile, and
Potential findings related to DKA: urinalysis with bacterial culture and sensitiv- TREATMENT
○ Dehydration ity tests should be performed. Ideally, blood
○ Abdominal pain gases should also be measured. Treatment Overview
○ Decreased mentation • CBC: nonspecific changes are seen. Patients with diabetic ketosis but not acidosis
○ Lateral recumbency ○ Nonregenerative anemia (50% of are typically stable and do not present with
○ Hepatomegaly dogs) signs such as vomiting, anorexia, or lethargy.
○ Tachypnea ○ Leukocytosis +/− left shift They may have a small amount of ketones
○ An acetone odor of the breath ○ +/− Thrombocytosis in their urine and/or serum. These patients
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