Differentiating Diabetic ketoacidosis from other diseases

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [2]


Diabetic ketoacidosis (DKA) must be differentiated from other conditions presenting with hyperglycemia, ketosis and metabolic acidosis. The differentials include diabetes mellitus, non-ketotic hyperosmolar state, impaired glucose tolerance, ketotic hypoglycemia, alcoholic ketosis, starvation ketosis, lactic acidosis, salicylic acid ingestion, uremic acidosis and drug-induced acidosis. All these conditions may be differentiated on the basis of history findings, clinical features and laboratory abnormalities.

Differentiating Diabetic Ketoacidosis From Other Diseases

Diabetic ketoacidosis must be differentiated from other diseases causing the following conditions:[1][2][3][4][5][6][7][8]

Schematic showing DKA as a confluence of hyperglycemia, ketosis and acidosis
Characteristic Common to DKA Condition History Findings Clinical Features Lab abnormalities
Hyperglycemia Diabetes mellitus
Non-ketotic hyperosmolar state
Impaired glucose tolerance
Ketosis Alcoholic ketosis
Starvation ketosis
Metabolic acidosis Lactic acidosis
Salicylic acid ingestion
Uremic acidosis
Drug-induced acidosis

Differentiating Diabetic Ketoacidosis from Hyperosmolar Hyperglycemia state

Parameters Diabetic ketoacidosis (DKA) Hyperosmolar hyperglycemic state (HHS)
Plasma glucose
  • > 250 mg/dl
  • > 600 mg/dl
Serum osmolality
  • Variable
  • > 320 mOsm/kg
Plasma and urine ketones
  • Positive
  • None or trace
Serum bicarbonate
  • < 18 mEq/L
  • > 15 mEq/ L
Arterial ph
  • < 7.30
  • > 7.30
Anion gap
  • > 12
  • < 12

Differential diagnosis of increased anion gap metabolic acidosis

anion gap metabolic acidosis
Lactic acidosis
Check for hyperglycemia and ketonuria
Not Present
Diabetic ketoacidosis
BUN, ↑ creatinine and history of hemodyalysis
Uremic acidosis
Physical findings include odor of alcohol
Ethanol level in serum or expired air
Auditory symptoms present
Ethanol overdose
Salicylic acid overdose


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