Electrolyte Imbalance in Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is a serious complication of diabetes. It occurs when a lack of insulin leads to potentially life-threatening acidosis and imbalances of electrolytes in the blood.

Although DKA is more common in people with type 1 diabetes, it can also occur in those with type 2. If there’s no insulin or not enough insulin, your body starts to break down fat and muscle to generate ketones for energy instead.

High concentrations of ketones acidify the blood, which causes symptoms like nausea, vomiting, fruity breath, brain fog, rapid heart rate, and difficulty breathing.

High blood sugar causes excessive urination and the leakage of sugar into the urine. This in turn leads to loss of body water and dehydration as well as loss of essential electrolytes, including sodium and potassium, explains StatPearls.

Insulin is also essential for directing potassium into the body’s cells, so without it, potassium levels can also rise very high. The level of another electrolyte, bicarbonate, also falls as the body tries to compensate for excessively acidic blood, says the National Kidney Foundation (NKF).

According to the American Diabetes Association, DKA can be deadly and is almost always treated in a hospital, as complex electrolyte imbalances cannot be managed at home. If you or anyone else is experiencing DKA symptoms, immediately speak to a doctor, go to the emergency room, or call 911.

Bicarbonate is an electrolyte that normally counteracts blood acidity. In DKA, the bicarbonate level falls as ketone production increases and acidosis progresses, says the NKF.

A bicarbonate level of less than 15 milliequivalents per liter (mEq/L) is one of the accepted criteria for diagnosing DKA, according to StatPearls, though it can be higher in milder cases of DKA.

According to a report published in 2024, doctors often do not recommend supplementing bicarbonate unless acidosis is severe, as it can cause a drop in potassium levels.

Treatment of DKA includes prompt hydration and intravenous (IV) insulin supplementation to lower blood sugar, which leads to gradual normalization of blood glucose levels and resolution of the acidosis.

Potassium may be low in people with DKA, says Cedars Sinai. Excessive urination or vomiting means you lose too much potassium.

Plus, a combination of high blood sugar and limited insulin production or poor insulin function means the cells may not use potassium as effectively as they usually would. This can lead to high levels of potassium in the blood, potentially leading to dangerous, abnormal heart rhythms.

When doctors prescribe insulin to treat DKA, serum potassium levels may drop further. Insulin can rapidly return potassium to the cells that a highly acidic and low-insulin state had previously shifted into the bloodstream.

According to Cleveland Clinic, symptoms of low potassium may include:

• Fatigue
• Muscle weakness
• Muscle cramps
• Irregular heart rhythms and palpitations
• Excessive urination and thirst
• Fatigue
• Constipation

Similar to high potassium levels, low potassium can also lead to life-threatening heart rhythm abnormalities, according to research. Frequent monitoring and timely correction of low potassium can be lifesaving.

Usually, oral potassium supplementation can help restore levels, but in people with DKA, IV infusion with fluids and potassium alongside oral potassium may be the best way to replenish potassium rapidly.

Some doctors propose treating the low potassium with infusion and the DKA with insulin at the same time. But current guidelines suggest that if potassium drops below 3.3 millimoles per liter (mmol/L), insulin treatment should stop until levels return to normal.

Sodium is essential for maintaining stable blood pressure and regulating fluid balance in the body.

High blood glucose causes excessive urination with loss of body water and sodium. This can lead to dehydration and low blood pressure. When the body needs to restore water to the bloodstream, it does so by pulling it from other tissues. This influx of water into the bloodstream may further dilute blood sodium.

According to Mayo Clinic, low sodium can cause a range of symptoms, including:

• Nausea
• Confusion
• Fatigue
• Restlessness
• Muscle weakness
• Spasms
• Cramps
• Seizures or coma, in severe cases

Healthcare providers use insulin and IV fluids containing sodium chloride, also known as a saline drip, to treat the sodium and water deficit caused by DKA.

DKA is a serious but preventable diabetes complication, notes Cleveland Clinic. Frequent monitoring of blood sugar, taking prescribed medications, and checking your insulin pump for cannula kinks or disconnected tubing can help you make sure you’re getting enough insulin and managing diabetes well.

Checking for ketones in the blood or urine using a home testing kit can also help detect DKA early.

Regularly establishing blood sugar goals with your doctor is crucial. During times of stress or illness, more frequent monitoring may be necessary, as blood sugar tends to fluctuate. Seeking prompt medical attention for early signs of DKA can prevent serious complications.