Diabetic ketoacidosis: risk factors, mechanisms and management strategies in sub-Saharan Africa: a review

Abstract

Diabetic ketoacidosis is the most common hyperglycaemic emergency in patients with diabetes mellitus, especially type 1 diabetes. It carries very high mortality in sub-Saharan Africa, both in the treated patients and those who are presenting to hospital with diabetes for the first time. Objective: To review the risk factors, mechanisms and management approaches in diabetes ketoacidosis in published literature and to discuss them in the context of why a significant proportion of patients who develop diabetic ketoacidosis in sub-Saharan Africa still have high mortality. Data source: Literature review of relevant published literature from both Africa and the rest of the world. Data synthesis: The main causes or precipitants of DKA in patients in SSA are newly diagnosed diabetes, missed insulin doses and infections. The major underlying mechanism is insulin deficiency. Treated patients miss insulin doses for various reasons, for example, inaccessibility occasioned by; unavailability and unaffordability of insulin, missed clinics, perceived ill-health and alternative therapies like herbs, prayers and rituals. Infections also occur quite often, but are not overt, like urinary tract, tuberculosis and pneumonia. Due to widespread poverty of individuals and nations alike, the healthcare systems are scarce and the few available centres are unable to adequately maintain a reliable system of insulin supply and exhaustively investigate their hospitalised patients. Consequently, there is little guarantee of successful outcomes. Poor people may also have sub-optimal nutrition, caused or worsened by diabetes, more so, at first presentation to hospital. Intensive insulin therapy in such individuals mimics 're-feeding syndrome', an acute anabolic state whose outcome may be unfavourable during the period of treatment of diabetic ketoacidosis. Conclusions: Although mortality and morbidity from diabetic ketoacidosis remains high in sub-Saharan Africa, improved healthcare systems and reliable insulin supply can reverse the trend, at least, to a large extent. Individuals and populations need empowerment through education, nutrition and poverty eradication to improve self-care in health and living with diabetes

Diabetic Ketoacidosis: Demographic Data, Clinical Profile and Outcome in a Tertiary Care Hospital

“…So, healthcare professionals' alertness may need to be increased, particularly during certain months of the year. Polyuria, polydipsia, abdominal pain, vomiting, and altered level of consciousness were the commonest presenting complaints of DKA consistent with findings in previous studies (16,24).…”

Diabetic Ketoacidosis Misdiagnosed as Ectopic Gestation in an 18-Year-Old Ghanaian: A Case Report

“…DKA, in a resource limited setting such as Ghana, is diagnosed based on clinical features such as polyuria, polydipsia, polyphagia, weight loss, nausea, vomiting and abdominal pains, decreased loss of consciousness and weakness as well as biochemical evidence of hyperglycemia, usually >13.9 mmol/L, venous blood pH<7.3, bicarbonate <15 mmol/L, glycosuria, ketonemia and ketonuria [2][3][4]9]. Important investigations such as blood gases and blood ketones [2,9] are almost nonexistent at the district and regional hospitals of Ghana but may be restricted to some teaching hospitals where they are seldom being done due to lack of appropriate reagents.…”

“…Important investigations such as blood gases and blood ketones [2,9] are almost nonexistent at the district and regional hospitals of Ghana but may be restricted to some teaching hospitals where they are seldom being done due to lack of appropriate reagents. a combination of sensitive urinary pregnancy tests (UPT), transvaginal ultrasound (TVUSG) and serum hCG estimations and clinical features of vaginal bleeding, abdominal pains and vomiting [7,10,11].…”

Management of diabetes in resource-poor settings

“…Recent anthropological research from Cameroon also showed that obesity can be a deep-rooted status symbol. 12 Acute metabolic complications commonly develop in those with diabetes and these are associated with high mortality: 10-30% in diabetic ketoacidosis 13 and up to 41% in hyperglycaemic hyperosmolar non-ketotic coma (HONK). 14 These mortality rates are often caused by lack of insulin and delayed presentation.…”