Diabetes and diabetic

ketoacidosis
• Diabetes mellitus is a metabolic disease characterized by
hyperglycemia due to absolute or relative deficiency of insulin.
• It is a major cause for morbidity and mortality.
• In spite of this high blood glucose, the entry of glucose into the cell is
inefficient. Hence, all cells are starved of glucose.
• The disease may be classified as follows-
• 1. Type 1 Diabetes Mellitus
also known as Insulin-dependent diabetes
• mellitus; About 5% of total diabetic patients are of type 1. Here circulating
insulin level is deficient.

• 2. Type 2 Diabetes Mellitus

• also known as non-insulin dependent diabetes mellitus. Most of the
patients belong to this type. Here circulating insulin level is normal or mildly
elevated or slightly decreased, depending on the stage of the disease.
• Clinical Symptoms in Diabetes Mellitus
• 1. When the blood glucose level exceeds the renal threshold glucose is excreted in
urine (glucosuria).
• 2. Due to osmotic effect, more water accompanies the glucose (polyuria).
• 3. To compensate for this loss of water, thirst center is activated, and more water is
taken (polydypsia).
• 4. To compensate the loss of glucose and protein, patient will take more food
(polyphagia).
• 5. The loss and ineffective utilization of glucose leads to breakdown of fat and protein.
This would lead to loss of weight.
• 6. Often the presenting complaint of the patient may be chronic recurrent infections
such as boils, abscesses, etc.
• Chronic Complications of Diabetes Mellitus
• 1. Vascular Diseases: Atherosclerosis in medium sized vessels. micro angiopathy,
which lead to diabetic retinopathy and nephropathy.
• Complications in Eyes: Early development of cataract of lens is due to the
increased rate of sorbitol formation, caused by the hyperglycemia. Retinal
microvascular abnormalities lead to retinopathy and blindness.
• Peripheral neuropathy:Neuropathy may lead to risk of foot ulcers and gangrene.
Hence, care of the feet in diabetic patients is important.
 Laboratory Investigations in Diabetes
Random blood sugar estimation and oral glucose tolerance tests are used for the
diagnosis
1. Plasma glucose level - For monitoring a diabetic patient, periodic check of fasting
and postprandial plasma glucose are to be done at least once in 3 months.
2. Complete lipid profile -Total cholesterol, triglycerides, HDL and LDL cholesterol
levels may be done once in six months.
3. Kidney function tests- Blood urea and serum creatinine may be done at least
twice an year.
5. Glycated Hemoglobin- The best index of long-term control of blood
glucose level is measurement of glycated hemoglobin.
• Management of Diabetes Mellitus
1. Diet and Exercise: This is the first line of treatment. A diabetic
patient is advised to take a balanced diet with high protein content, low
calories, devoid of refined sugars and low saturated fat.
2. Oral hypoglycemic agents: They are mainly of two types; sulphonyl
urea and biguanides.
• They are mainly used in Type 2 diabetes
3. Insulin injections: Insulin is the drug of choice in Type 1 disease.
4. Prevention of complications.
• Acute Metabolic Complications
• Diabetic Keto Acidosis
• Ketosis is more common in type 1 diabetes mellitus.
• Normally the blood level of ketone bodies is less than 1 mg/dl and
only traces are excreted in urine (not detectable by usual tests). But
when the rate of synthesis exceeds the ability of extrahepatic tissues
to utilize them, there will be accumulation of ketone bodies in blood.
This leads to ketonemia, excretion in urine (ketonuria).
• Both together constitute the condition known as ketosis.
• Diagnosis of Ketosis
• The presence of ketosis can be established by the detection of ketone
bodies in urine by Rothera’s test.
• The urine of a patient with diabetic keto acidosis will give positive
Benedict's test as well as Rothera’s test.
• But in starvation ketosis, Benedict's test is negative, but Rothera's
test will be positive
• Cause for Ketosis
• The combination of hyperglycemia, glucosuria, ketonuria and
ketonemia is called diabetic ketoacidosis .
• Untreated diabetes mellitus is the most common cause for ketosis.
Even though glucose is in plenty, the deficiency of insulin causes
accelerated lipolysis and more fatty acids are released into circulation.
• Oxidation of these fatty acids increases the acetyl CoA pool. Enhanced
gluconeogenesis restricts the oxidation of acetyl CoA by TCA cycle,
since availability of oxaloacetate is less.
• Consequences of Ketosis
• i. Metabolic acidosis: Acetoacetate and beta-hydroxy butyrate are
acids. When they accumulate, metabolic acidosis results.
• ii. Coma: Hypokalemia, dehydration and acidosis contribute to the
lethal effect of ketosis.