Ketosis-onset diabetes and ketosis-prone diabetes: same or not?

One third of cases of new-onset diabetic ketosis in adults are associated with ketosis-prone type 2 diabetes-A systematic review and meta-analysis

AIMS

Ketosis-prone type 2 diabetes was defined by the World Health Organization in 2019. According to the literature, the diagnosis is based on the presence of ketosis, islet autoantibody negativity and preserved insulin secretion. Our meta-analysis assessed the prevalence and clinical characteristics of ketosis-prone type 2 diabetes among patients hospitalised with diabetic ketoacidosis (DKA) or ketosis.

METHODS

The systematic search was performed in five main databases as of 15 October 2021 without restrictions. We calculated the pooled prevalence of ketosis-prone type 2 diabetes (exposed group) within the diabetic population under examination, patients with ketoacidosis or ketosis, to identify the clinical characteristics, and we compared it to type 1 diabetes (the comparator group). The random effects model provided pooled estimates as prevalence, odds ratio and mean difference (MD) with 95% confidence intervals.

RESULTS

Eleven articles were eligible for meta-analysis, thus incorporating 2010 patients of various ethnic backgrounds. Among patients presenting with DKA or ketosis at the onset of diabetes, 35% (95% CI: 24%-49%) had ketosis-prone type 2 diabetes. These patients were older (MD = 11.55 years; 95% CI: 5.5-17.6) and had a significantly higher body mass index (BMI) (MD = 5.48 kg/m2 ; 95% CI: 3.25-7.72) than those with type 1 diabetes.

CONCLUSIONS

Ketosis-prone type 2 diabetes accounts for one third of DKA or ketosis at the onset of diabetes in adults. These patients are characterised by islet autoantibody negativity and preserved insulin secretion. They are older and have a higher BMI compared with type 1 diabetes. C-peptide and diabetes-related autoantibody measurement is essential to identify this subgroup among patients with ketosis at the onset of diabetes.

Prevalence and Gender Differences of Metabolic Syndrome in Young Ketosis-Prone Type 2 Diabetic Individuals: A Retrospective Study

PURPOSE

This study aimed to identify the prevalence and gender differences of metabolic syndrome in young new-onset ketosis-prone type 2 diabetic (KPT2D) individuals.

PATIENTS AND METHODS

A retrospective study was conducted in Shanghai Xin Hua Hospital from 2007 to 2019. A total of 304 patients from 12 to 40 years of age with newly diagnosed diabetes presenting with ketosis were analyzed. The clinical features and laboratory results of KPT2D and type 1 diabetic (T1D) individuals were compared. Prevalence and gender differences of metabolic syndrome in the KPT2D subjects were analyzed.

RESULTS

The prevalence of metabolic syndrome (P < 0.0001) was significantly higher in young KPT2D than T1D subjects. The prevalence of high blood pressure (P < 0.0001), central obesity (P < 0.0001), low plasma HDL-C concentration (P = 0.045), and hypertriglyceridemia (P < 0.0001) was elevated in the KPT2D subjects compared with T1D. Male predominance (89%) was presented in the KPT2D subjects. The prevalence of metabolic syndrome (P = 0.0002) was significantly higher in young male than female KPT2D subjects. The presence of central obesity (P < 0.0001) and high blood pressure (P =0.03) was higher in male KPT2D subjects than female. The presence of serum triglyceride concentrations ≥ 2.3mmol/L was significantly higher (P = 0.011) in male KPT2D subjects than female.

CONCLUSION

Significantly higher prevalence of metabolic syndrome in young KPT2D patients compared with T1D patients could be an important reference for diabetic differential diagnosis. KPT2D presented a higher predominance in young males, who had higher prevalence of metabolic syndrome than young females.

Uncommon Presentations of Diabetes: Zebras in the Herd

The majority of patients with diabetes are diagnosed as having either type 1 or type 2 diabetes. However, when encountered in clinical practice, some patients may not match the classic diagnostic criteria or expected clinical presentation for either type of the disease. Latent autoimmune, ketosis-prone, and monogenic diabetes are nonclassical forms of diabetes that are often misdiagnosed as either type 1 or type 2 diabetes. Recognizing the distinguishing clinical characteristics and understanding the diagnostic criteria for each will lead to appropriate treatment, facilitate personalized medicine, and improve patient outcomes.

Atypical forms of diabetes mellitus in Africans and other non-European ethnic populations in low- and middle-income countries: a systematic literature review

BACKGROUND

Atypical presentations of diabetes mellitus (DM) have been reported in non-European ethnic populations under various names. It is unclear whether those names are used for the same or different clinical phenotypes. Unclear terminology may lead to inappropriate treatment and an underestimation of the burden caused by atypical diabetes phenotypes overlapping with classic types of diabetes. This review aimed to describe the terms used for atypical forms of diabetes and to investigate whether the terms are used for similar or different phenotypes.

METHODS

PubMed and Scopus were searched for relevant publications in French or English available before 15 September 2015 using the terms: "Atypical diabetes", "Malnutrition Related Diabetes Mellitus (MRDM)", "Fibro-calculus pancreatic diabetes (FCPD)", Protein deficient Pancreatic Diabetes (PDPD)", "African diabetes", "Ketosis prone-type 2 diabetes", "tropical diabetes", "Flatbush diabetes", "J-type diabetes". Titles, abstracts screening and quality assessment were performed by two independent authors. Observational studies addressing atypical diabetes in humans aged 14 years and above were included. One author extracted data from selected articles.

RESULTS

22 articles among 350 identified articles were retained for data extraction. Two atypical diabetes phenotypes were identified, each of them with a variety of names but similar definitions. One phenotype occurred in very thin people less than 30 years of age, typically from poor socio-economic backgrounds and requires insulin for life. It differs from type 1 diabetes in the tolerance of high blood glucose without ketosis in the absence of exogenous insulin. The second phenotype resembles type1 diabetes as it presents with ketosis at onset but responds well, as type2 diabetes, to oral hypoglycemic drugs after initial stabilization with insulin. It occurs in individuals who are usually over 30 years of age, with normal or overweight and absence of auto antibodies mainly found in type 1 diabetes.

CONCLUSION

The scarce existing literature used various terms for similar diabetes phenotypes. Agreement on nomenclature for the various forms of diabetes using the above reported characteristics are needed in populations where atypical forms of diabetes exist as well as better characterization of phenotypes and genotypes to inform evidence based treatment.

Evaluation and management of ketosis-prone diabetes

INTRODUCTION

Patients presenting with diabetic ketoacidosis (DKA) who lack the classic phenotype of autoimmune type 1 diabetes have become increasingly identified in recent decades. This has led to the recognition of heterogeneous syndromes of 'ketosis-prone diabetes' (KPD). Evaluation and optimal management of KPD differs from that of 'typical' type 1 or type 2 diabetes. Awareness of these differences and a systematic approach to diagnosis and treatment can improve glycemic control and prevent both acute and chronic complications of diabetes.

AREAS COVERED

This article reviews the Aß classification scheme ('A' for autoantibody status and 'ß' for beta cell functional reserve) which accurately delineates subgroups of KPD, and addresses the relevance of defining these subgroups for clinical outcomes and long-term insulin dependence. Subsequently, the detailed evaluation and management of KPD patients after their index DKA episode is described.

EXPERT COMMENTARY

Among patients presenting with DKA, it is important to diagnose specific subgroups of KPD and not assume that they represent exclusively patients with autoimmune type 1 diabetes. The Aß classification is an accurate aid to diagnosis, and permits optimal management of the subgroups (e.g., insulin treatment for the ß- subgroups; follow-up testing and a range of treatment options for the ß+ subgroups).

Diagnostic Usefulness of Serum Albumin as a Predictor of Diabetic Ketoacidosis

Context:

Diabetes mellitus is one of the most prevalent diseases worldwide. One of the acute complications of diabetes mellitus is diabetic ketoacidosis. It becomes essential for the healthcare physicians to identify the individuals who are likely to be prone to the development of ketosis. Serum albumin levels may be a cost-effective and simple parameter to prognosticate the risk of ketosis.

Aims:

This study was done to find a relationship between serum albumin levels and ketonuria.

Settings and Design:

After ethical approval, this prospective case–control study was carried out in patients diagnosed as type-2 diabetes mellitus.

Subjects and Methods:

Serum albumin levels were measured by bromo cresol green method. Measurement of urine ketones was done manually using dipsticks, a semi-quantitative manual method.

Statistical Analysis Used:

Student's t-test was used to compare continuous variables and Chi-square test for categorical variables. Pearson's correlation was done to establish correlation.

Results:

In the normoalbuminemic group, 72% were ketones negative and only 28% had positive ketones in urine, while in the hypoalbuminemic group, 50.7% had negative urine ketones and 49.3% had positive ketonuria. The mean value for ketones in urine was 9.7 mg/dL in the hypoalbuminemic group, but it was only 4.3 mg/dL in the normoalbuminemic group. Pearson's correlation between serum albumin and urine ketone levels was performed and the r-value was found to be −0.305.

Conclusions:

Serum albumin levels may predict the occurrence of ketosis in diabetic patients.

Prediabetes Directly Deteriorates into Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic Syndrome Triggered by Acute Pancreatitis: A Case Report Illustrating a "Chicken and Egg" Paradigm in Ketosis-Prone Diabetes

INTRODUCTION

Diabetic crises occur most often in patients with type 1 diabetes and occasionally in type 2 diabetes, especially under stressful conditions. However, a diabetic crisis occurring directly from prediabetes is an unusual phenomenon.

CASE REPORT

A 45-year-old woman presented with postprandial left upper quadrant abdominal pain, nausea, and vomiting. She had a past medical history of prediabetes with impaired fasting glucose and HbA1c 6.4%. On admission, routine laboratory tests showed high anion gap metabolic acidosis (pH 6.92), anion gap 41 mmol/L, blood glucose 931 mg/dL, beta-hydroxybutyrate 28 mmol/L, and calculated effective osmolarity 322 mOsm/kg; she was diagnosed with diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS), and DKA-related abdominal pain. Later, the patient was found to have elevated lipase and amylase, and diagnosed with acute pancreatitis. Since DKA can induce abdominal pain and nonspecific lipase elevation, both of which are characteristics of acute pancreatitis, while acute pancreatitis can conversely trigger DKA, there exists a "chicken and egg" paradigm. Therefore, the differential diagnosis is discussed.

CONCLUSION

It is important to differentiate DKA from concomitant causes of abdominal pain to avoid missing the underlying etiology, which can be the trigger for DKA. During diabetic crises, treating the underlying trigger is just as important as managing metabolic derangements in order to achieve favorable outcomes; meanwhile, managing acute pancreatitis-associated hyperglycemia can promote recovery. Additionally, diabetic crisis that directly evolves from prediabetes illustrates an atypical form of diabetes called ketosis-prone diabetes; we briefly discuss its clinical characteristics, classification, and follow-up.

Clinical characteristics, beta-cell dysfunction and treatment outcomes in patients with A-β+ Ketosis-Prone Diabetes (KPD): The first identified cohort amongst Asian Indians

OBJECTIVE

Ketosis-prone diabetes (KPD), an atypical form of diabetes, has emerged as a heterogeneous syndrome in multiple ethnic groups. The objectives of this study were to look into the clinical characteristics of adult Asian Indian patients with recently diagnosed, antibody negative diabetes presenting with unprovoked ketoacidosis (A-β+ KPD) and to determine the natural course of recovery of beta-cell functions on serial follow-up over one year.

RESEARCH DESIGN AND METHODS

Newly diagnosed adult diabetes patients (n=11) with suspected KPD (A-β+) were prospectively studied over a period of 1-year with serial evaluations of clinical, biochemical and beta-cell secretion characteristics. These were compared with a control group (n=23) of KPD (A+β-) (classical Type 1A diabetes) with similar presentation. Beta-cell secretion was assessed by fasting and stimulated C-peptide values after a standard mixed meal challenge. Glycaemic control and treatment outcomes were also documented.

RESULTS

In comparison to the A+β- KPD controls, the A-β+ KPD patients had a significantly older age, higher BMI, stronger family history of type 2 diabetes, more severe ketoacidosis and higher fasting and stimulated C-peptide level at presentation. On serial follow-up, the patients with KPD achieved complete recovery of their beta-cell function with remission from insulin-dependence within 3-4months without further recurrences of DKA.

CONCLUSIONS

This is the first reported series of A-β+ KPD from India. The phenotype of Indian A-β+ KPD patients differs from their Western counterparts in that they are relatively younger and leaner, though the male preponderance and natural history of recovery of beta-cell dysfunction bears similarity.

Characteristics of Type 2 Diabetes with Ketosis in Baoshan, Yunnan of China

OBJECTIVES

The study provided data to demonstrate the characteristics of type 2 diabetes (T2D) with ketosis in rural parts of south-west border of China in order to help health professionals with optimizing diabetic care.

METHODS

All hospitalized adult diabetic patients consecutively between January 2011 and July 2015 in Baoshan People's Hospital, Yunnan province of China, were evaluated. T2D with ketosis, ordinary T2D (without ketosis), and type 1 diabetes (T1D) patients were analyzed according to the clinical and biochemical parameters and chronic complications in these subjects.

RESULTS

The prevalence of T2D with ketosis was 12% in the whole study subjects. Overweight and obese patients were predominant (49.1%) in T2D patients with ketosis. The mean HbA1c (13.3 ± 3.1%, P = 0.01), fasting plasma glucose (16.9 ± 6 mmol/L, P < 0.0001), and plasma triglyceride (4.0 ± 4.0 mmol/L, P < 0.0001) in T2D patients with ketosis were significantly higher than ordinary T2D patients without ketosis. Infections were the most common inducements in T2D patients with ketosis. Chronic complications including peripheral neuropathy (34.9%), retinopathy (12.7%), diabetic foot (18.1%), and persistent microalbuminuria (11.7%) were common in T2D patients with ketosis.

CONCLUSIONS

. This study indicated the poor glycemic control in diabetic patients in rural areas of south-west part of China. More efforts were urgently required to popularize public health education and improve medical quality in diabetic treatment in these regions.

Ketosis onset type 2 diabetes had better islet β-cell function and more serious insulin resistance

Diabetic ketosis had been identified as a characteristic of type 1 diabetes mellitus (T1DM), but now emerging evidence has identified that they were diagnosed as T2DM after long time follow up. This case control study was aimed at comparing the clinical characteristic, β-cell function, and insulin resistance of ketosis and nonketotic onset T2DM and providing evidence for treatment selection. 140 cases of newly diagnosed T2DM patients were divided into ketosis (62 cases) and nonketotic onset group (78 cases). After correction of hyperglycemia and ketosis with insulin therapy, plasma C-peptide concentrations were measured at 0, 0.5, 1, 2, and 3 hours after 75 g glucose oral administration. Area under the curve (AUC) of C-peptide was calculated. Homoeostasis model assessment was used to estimate basal β-cell function (HOMA-β) and insulin resistance (HOMA-IR). Our results showed that ketosis onset group had higher prevalence of nonalcoholic fatty liver disease (NAFLD) than nonketotic group (P = 0.04). Ketosis onset group had increased plasma C-peptide levels at 0 h, 0.5 h, and 3 h and higher AUC(0-0.5), AUC₀₋₁, AUC₀₋₃ (P < 0.05). Moreover, this group also had higher HOMA-β and HOMA-IR than nonketotic group (P < 0.05). From these data, we concluded that ketosis onset T2DM had better islet β-cell function and more serious insulin resistance than nonketotic onset T2DM.