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November 9, 1999

Hyperglycemia and DKA

Question from Minnesota, USA:

Why is it that some people can have a 500 blood glucose, but not have ketones, while I can be at 240 or thereabouts and be spilling large ketones in my urine?


I’ve never read a specific biochemical analysis of this phenomenon; but is certainly true. At one extreme there is the condition of hyperosmolar coma where blood sugars can rise over 1000�mg/dl and where ketosis is minimal and there is the antithesis, where there is severe ketosis without extreme hyperglycemia. Fortunately these extremes are not often seen nowadays.

The explanation most often given for hyperosmolality (i.e. very high blood sugars without much ketosis) is there has been a primary distortion of the thirst mechanism so that water lost in the urine as part of the osmotic diuresis of glucose is not adequately replaced. Where the disturbance is primarily ketotic, this is regarded as an exaggerated response to the need for energy from fatty acids in the liver when glucose cannot reach the cell interior. It is necessary to suppose that these different responses are also governed by different genetic patterning.

Additional Comments from Dr. John Schulga
The other thing to remember is that if a person with type 1 diabetes is not taking enough carbohydrate and also insufficient insulin, there can be a situation where the body will utilise other energy sources, predominantly fat, and so ketosis and ketonuria will develop without significant hyperglycaemia.