Hyperglycemic Crises in Adult Patients With Diabetes

Response to Kitabchi et al.

In their consensus statement on hyperglycemic crises in adult patients with diabetes, Kitabchi et al. (1) indicated the diagnostic and severity criteria for diabetic ketoacidosis (DKA) due to arterial pH (7.25 to 0.30, 7.00 to <7.24, and <7.00) and serum bicarbonate (15 to 18, 10 to <15, and <10 mEq/l) levels. DKA is one of the most common acid-base disorders in clinical practice. Thus, diagnosis of DKA should be based on the concept of acid-base physiology and its understanding (2).

Cardinal features of DKA are hyperketonemia, metabolic acidosis, and hyperglycemia. Furthermore, coincidences of infection, dehydration, vomiting, etc., as precipitating factors and/or clinical manifestations are common in DKA, most of which give significant influences on acid-base equilibrium. In fact, double or triple acid-base disturbances with metabolic alkalosis, respiratory alkalosis, and hyperchloremic acidosis are common and are observed in 43–50% of DKA cases (3–5). In such a situation, arterial pH and/or serum bicarbonate levels could be in various ranges necessarily, and sometimes acidemia and serum bicarbonate level are offset. For a diagnosis of mixed acid-base disorder, even in simple acid-base disorder, systematic step-by-step approach and analysis are required (2) to identify clinically important acid-base disorders. While the diagnostic and severity classification criteria using arterial pH and serum bicarbonate by Kitabchi et al. (1) is useful, it should not be used solely in such a fashion. We would like to suggest the exclusion of parameters of arterial pH and serum bicarbonate values, including anion gap, from the text and the table on diagnosis and severity criteria or at least the addition of a sentence in the footnote of Table 1 indicating that these parameters should be reserved for diagnosis of DKA as a simple metabolic acidosis.

• © 2009 by the American Diabetes Association.