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Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Epidemiology and pathogenesis

Irl B Hirsch, MD
Michael Emmett, MD
Section Editors
David M Nathan, MD
Joseph I Wolfsdorf, MB, BCh
Deputy Editor
Jean E Mulder, MD


Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS, also called hyperosmotic hyperglycemic nonketotic state) are two of the most serious acute complications of diabetes. They each represent an extreme in the hyperglycemic spectrum.

The epidemiology and the factors responsible for the metabolic abnormalities of DKA and HHS in adults will be discussed here. The clinical features, evaluation, diagnosis, and treatment of these disorders are discussed separately. (See "Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Clinical features, evaluation, and diagnosis" and "Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment".)


Diabetic ketoacidosis (DKA) is characteristically associated with type 1 diabetes. It also occurs in type 2 diabetes under conditions of extreme stress such as serious infection, trauma, cardiovascular or other emergencies, and, less often, as a presenting manifestation of type 2 diabetes, a disorder called ketosis-prone diabetes mellitus. (See "Syndromes of ketosis-prone diabetes mellitus".)

DKA is more common in young (<65 years) patients, whereas hyperosmolar hyperglycemic state (HHS) most commonly develops in individuals older than 65 years [1,2]. The National Diabetes Surveillance Program of the Centers for Disease Control (CDC) estimated that there were 140,000 hospital discharges for DKA in 2009 in the United States, compared to 80,000 in 1988 (figure 1) [2]. Population-based data are not available for HHS. The rate of hospital admissions for HHS is lower than the rate for DKA, and accounts for less than 1 percent of all primary diabetic admissions [1,3-5].

The mortality rate for hyperglycemic crisis declined between 1980 and 2009 (figure 2) [6]. Mortality in hyperglycemic crisis is primarily due to the underlying precipitating illness and only rarely to the metabolic complications of hyperglycemia or ketoacidosis [1,7]. The prognosis of hyperglycemic crisis is substantially worse at the extremes of age and in the presence of coma and hypotension [7-10].

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Literature review current through: Nov 2017. | This topic last updated: Jul 05, 2016.
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