DKA question

[IcanHealYou]

Hey everyone,

This has been bugging me for quite a while. Why does DKA only happen in hyperglycemic states? DKA happens when there is severe insulin deficiency and no sugar is being taken in by cells. So the body will start breaking down fat to get sugar but in turn also release ketones. Eventually there is an abundance of ketones which causes acidosis.

However logically this can seem to happen whether a person is in hyperglyemic or hypoglyemic states. In either one the body does not have enough sugar absorption. The only rationale i can come up with as to why it won't happen in hypoglycemic states is that a person may have taken too much insulin which means all the sugar has been absorbed. The cells will have enough sugar but not in the bloodstream. However people can become hypoglycemic w/o insulin medication through exericise or not eating.

Can someone shed some light as to why DKA only happens in hyperglycemic states?

[RNMeg]

I'm by no means a diabetes expert, but I suspect it might have something to do with the quick lethality of hypoglycemia versus hyperglycemia. DKA takes more than a few hours to develop, whereas if someone is severely hypoglycemic, they'll die before they have time to develop DKA. People can live for days with hyperglycemia, but only a few hours (if that) with hypo. Maybe someone with more knowledge can give a better answer

[classicdame, MSN, EdD]

MegRN2B: I like your answer

[blondy2061h, MSN, RN]

Even if you're hypoglycemic, your liver still produces some glucose output (unless you've been severely malnourished for a long time), though obviously not enough to meet demand created by the insulin, and if you're hypoglycemic, you obviously have plenty of insulin to move that glucose into cells, so while it's possible to get ketones with hypoglycemia, it's unlikely. And like Meg said, the fast onset means the hypoglycemia will be fatal (or more likely successfully treated) before a severe ketotic state. In young kids, they can get a syndrome called "Ketotic Hypoglycemia."

Ketones are a normal occurrence in the healthy body. Low carb dieters will also often have ketones. But it's on a MUCH different scale. I'm sure there's other conditions where ketones can cause acidosis, but without the hyperglycemia it wouldn't be DKA, as the D stands for "diabetic."

[GilaRRT]

Great question and point. DKA is specific to diabetes, yet many other conditions can cause ketone production. Ketones in acute hypoglycemia is not typical, because glycolysis shuts down without glucose causing the TCA & ETS to shut down in essence. As cells run out of ATP, they quit working, then tissue quits working, then organs, then the body. This process occurs quickly and the mechanisms for gluconeogenesis and alternative fuels may not have enough time to work before vital organs shut down. Or, these systems could be depleated of resources, such as the inability of a malnourished person to release glycogen. (depleation of hepatic stores)

Hope that helped. I can provide a more on depth answer later on. Forgive any typos, I am typing this on my Iphone while sitting in the terminal at Denver International.

[IcanHealYou]

Great question and point. DKA is specific to diabetes, yet many other conditions can cause ketone production. Ketones in acute hypoglycemia is not typical, because glycolysis shuts down without glucose causing the TCA & ETS to shut down in essence. As cells run out of ATP, they quit working, then tissue quits working, then organs, then the body. This process occurs quickly and the mechanisms for gluconeogenesis and alternative fuels may not have enough time to work before vital organs shut down. Or, these systems could be depleated of resources, such as the inability of a malnourished person to release glycogen. (depleation of hepatic stores)

Hope that helped. I can provide a more on depth answer later on. Forgive any typos, I am typing this on my Iphone while sitting in the terminal at Denver International.

In theory wouldn't glycolysis, TCA and ETS stop with hyperglycemic states as well? In either hyper or hypoglycemic states the cells are not getting sugar for energy. Since it only happens to in type 1 they pt. won't have insulin anyway for sugar absorption, so in both situation they are deprived of sugar. Whether there is sugar in the bloodstream or not, it comes down to sugar being able to get to the cells.

Unless I'm getting the definition wrong and glycemic states don't refer to glucose levels in the bloodstream.

[blondy2061h, MSN, RN]

Great question and point. DKA is specific to diabetes, yet many other conditions can cause ketone production. Ketones in acute hypoglycemia is not typical, because glycolysis shuts down without glucose causing the TCA & ETS to shut down in essence. As cells run out of ATP, they quit working, then tissue quits working, then organs, then the body. This process occurs quickly and the mechanisms for gluconeogenesis and alternative fuels may not have enough time to work before vital organs shut down. Or, these systems could be depleated of resources, such as the inability of a malnourished person to release glycogen. (depleation of hepatic stores)

Hope that helped. I can provide a more on depth answer later on. Forgive any typos, I am typing this on my Iphone while sitting in the terminal at Denver International.

Typing about gluconeogenesis. On an iPhone. In the airport. Major props from me there!

[GilaRRT]

In theory wouldn't glycolysis, TCA and ETS stop with hyperglycemic states as well? In either hyper or hypoglycemic states the cells are not getting sugar for energy. Since it only happens to in type 1 they pt. won't have insulin anyway for sugar absorption, so in both situation they are deprived of sugar. Whether there is sugar in the bloodstream or not, it comes down to sugar being able to get to the cells.

Unless I'm getting the definition wrong and glycemic states don't refer to glucose levels in the bloodstream.

I may cause more confusion without typing on a computer proper; however, remember back to your A&P & micro. Specifically, the molecular biology portions. Parts of gluconeogenesis can actually bypass the glucose, insulin, glycolysis pathway. Fatty acids for example, are turned into Acetyl-co-A then fed into the TCA cycle, in essence bypassing glycolysis. However, this process leaves behind allot of mess that is not at all healthy for the human body.

[GilaRRT]

Perhaps that was a little confusing. So, we have all this sugar outside that cannot enter due to lack of insulin. However, the fatty acids bypass this process and are turned into Acetyl-co-A. That Acetyl-Co-A can go right into the TCA/Krebs cycle, thus you can make energy by bypassing the traditional and less messy method.

[IcanHealYou]

Right, when the body needs energy and have depleted glucose and glycogen stores the body will look for sugar in the blood stream. If found insulin will help facilitate it into the cell.

If there is not sugar, the body will start to break down fat with lipolysis to make glycerol and fatty acids. The fatty acids break down to ketone and the body will use that for energy now.

So why will the body not break down fat with you are in a hypoglycemic state causing DKA?

Now you say when there is not sugar, glycolysis TCA and ETS will shutdown, but since the ketones can be converted into a form to enter TCA energy can still be formed. However ketones are acidic and in high levels will cause DKA. But I'm still not understanding why the body won't go into DKA if it is hypoglycemic.

In hypoglycemic states there is no sugar absorption, no sugar in cells, so the body will go to fat still for energy.

[GilaRRT]

With an acute hypoglycemic event, there is not much time to mobilize alternative pathways. With DKA and conditions such as malnutrition, the body typically has a heads up. Remember, DKA is typically a slower onset process. It takes the liver a bit of time to mobilize alternative energy pathways.

[IcanHealYou]

Ahh great thanks a lot. So meg was right =D. Thanks for using the physiology to back up the answer Gila. There seems to be less of that sorta stuff in nursing school. I miss pure science courses.