Narrative reviewindependent cross-checkfull text checked I-INS-08 in-depth review
Review on diabetic ketoacidosis
Diabetic ketoacidosis.
Overview
Dhatariya KK et al.. Nat Rev Dis Primers 2020 · PMID 32409703 · DOI 10.1038/s41572-020-0165-1
DKA is an emergency that can kill; it is treated with fluids, insulin and salts, and insulin must not be stopped in type 1 diabetes even when not eating.
Does the study support the specific claim? No · Methodological quality: moderate
Plain-language summary
Study explained simply
- What did the researchers want to find out?
Epidemiology, pathogenesis, diagnosis and management of DKA
- How was the study done?
Narrative expert review (Nature Reviews Disease Primers)
- How many people, animals or samples were studied?
not applicable; Adults and children with diabetes
- What was actually found?
DKA is diagnosed by high glucose, ketones and acid; it kills <1% when treated in rich countries but up to 26-41% where treatment is lacking; treatment is fluids, insulin and potassium, and insulin must never be stopped in type 1 diabetes even when not eating.
- How large was the observed effect?
not applicable
- What do the results mean in everyday life?
DKA is an emergency.
- What are the study's limitations?
Narrative expert review without systematic methods; one author has research support from insulin makers.
- What does it say about Elawady's specific claim?
- Do the results apply to Germany and Europe?
International.
- What can explicitly not be concluded from this study?
Quantitative estimates.
Scientific in-depth review
1. Full reference
- Authors
- Dhatariya KK et al.
- Journal
- Nat Rev Dis Primers
- Year
- 2020
- Identifier
- PMID 32409703 DOI 10.1038/s41572-020-0165-1
- Verification
- verified – PubMed efetch 2026-10-25 (this agent)
- Retracted
- no
- Corrections
- none
- Extent checked
- full text
- Conflicts of interest and funding
K.K.D.: NHS employee. N.S.G.: grants from ADA and NIDDK. E.C.: FONDECYT (Chile). G.E.U.: NIH/NCATS grants and research grant support to Emory University for investigator-initiated studies from Dexcom, Novo Nordisk and Sanofi (insulin manufacturers).
2. Research question
Epidemiology, pathogenesis, diagnosis and management of DKA
3. Study design and population
- Study design
- Narrative review – Narrative expert review (Nature Reviews Disease Primers; accepted manuscript), no systematic search or methods section
- Population
Adults and children with diabetes
- Country
International
- Period
To 2020
- Sample size
not applicable
- Inclusion and exclusion criteria
Not applicable: non-systematic narrative review; no search strategy or selection criteria reported.
4. Methods and endpoints
- Exposure / intervention
not applicable
- Comparator
not applicable
- Endpoints
not applicable
- Statistical methods
not applicable
5. Actual results
- Results
Diagnosis requires D (raised glucose or diabetes history), K (raised blood/urine ketoacids) and A (high anion gap metabolic acidosis). In developed countries the risk of death from DKA is <1% in children and adults, but DKA is the leading cause of mortality among children and adults <58 years with T1DM (>50% of all deaths in children with diabetes); mortality reaches 8-10% in those >65-75 years and is reported as 3-13% in children in developing countries, 30% in India and 26-41.3% in sub-Saharan Africa, where lack of access to insulin/treatment contributes. Treatment: intravenous fluids, intravenous insulin (adults typically 0.1 unit/kg bolus then fixed-rate 0.1 unit/kg/h; children 0.1 unit/kg/h after fluid bolus per ISPAD), potassium repletion and treatment of the precipitant. 'Sick day rules': in T1DM insulin must never be stopped, even if the person does not consume solids or fluids. Starvation ketosis (intake <500 kcal/day) differs from DKA: beta-hydroxybutyrate reaches 5-6 mmol/l only after several days of near-absolute starvation, renal compensation usually keeps bicarbonate >=18 mmol/l, whereas in DKA similar ketone levels develop within hours of insulin deprivation. Corticosteroids are listed among drugs that precipitate DKA/HHS.
- Absolute risks
Descriptive rates cited from other studies: DKA incidence 8-51.3 per 1,000 patient-years in T1DM worldwide (263 per 1,000 patient-years in a Chinese study); case fatality <1% in high-income settings, 8-10% in older adults, up to 26-41.3% in some low-resource settings.
- Authors' conclusion
Early diagnosis and management are paramount.
6. Strengths
- Authored by recognised international DKA experts across adult and paediatric care
- Comprehensive coverage of epidemiology, pathophysiology, diagnosis, management and outcomes, with extensive primary citations
- Explicitly distinguishes DKA from starvation, alcoholic and SGLT2-inhibitor (euglycaemic) ketoacidosis
7. Weaknesses
- Narrative review without systematic search, selection or appraisal methods
- Epidemiological figures are cited from heterogeneous primary studies, not pooled
- One author reports research funding from insulin manufacturers (Novo Nordisk, Sanofi)
- Most management evidence from North America, Europe and Australia, as the authors note
8. Risk of bias
- Orienting tool
- none (narrative review; no standard RoB tool applies)
- Type of assessment
- structured assessment based on the full text by a single reviewer (no formal double review)
- Full formal assessment
- no
- Overall risk of bias
- some concerns
- Rationale
Overall changed from low to some_concerns to reflect the non-systematic design and disclosed industry support; for the factual points used here (DKA is potentially fatal, insulin and fluids are the treatment) the evidence base is robust. Single-reviewer structured judgement; a formal assessment would need two independent reviewers.
| Domain | Judgement | Rationale |
|---|---|---|
| Evidence selection | some concerns | No systematic search or selection criteria; selection by expert judgement. |
| Consistency with guidelines/primary evidence | low | Statements on diagnosis and management match ADA, JBDS and ISPAD guidance and are referenced to primary studies. |
| Conflicts of interest | some concerns | One author has industry research support including insulin manufacturers; core conclusions are nevertheless standard of care. |
| Quantitative claims | some concerns | Mortality and incidence figures are cited from heterogeneous studies without appraisal. |
Full-text review (25 October 2026): Added mortality figures (<1% high-income; 8-10% elderly; 26-41.3% sub-Saharan Africa), sick-day rule that insulin must never be stopped, starvation-ketosis vs DKA distinction, dosing, and COI (incl. insulin-manufacturer grants); bias changed low -> some_concerns.
9. Assessment of the statistical interpretation
No original analysis; figures are descriptive citations. The low case-fatality in high-income settings is a consequence of treatment with fluids and insulin; the much higher mortality where insulin/treatment access is limited is consistent with DKA being lethal when not properly treated.
10. Relevance to the specific claim
Contradicts C-INS-08, C-INS-02, C-FAST-01, C-FAST-03.
11. Independent contrary findings
12. Transferability to Germany and Europe
Directly transferable; treatment principles match UK/European (JBDS) and ISPAD guidance; authors note European DKA hospitalisation trends.
13. Overall methodological judgement
Authoritative, guideline-consistent narrative reference. Directly contradicts the claims that DKA does not kill, that it should be treated by fasting without insulin or fluids, that insulin should be stopped when not eating, and that high glucose plus ketones during fasting is harmless.
| Multidimensional assessment | |
|---|---|
| Authenticity of the source | verified |
| Methodological quality | moderate |
| Risk of bias | some concerns |
| Precision of results | not applicable |
| Directness | direct |
| Reproducibility | replicated |
| Consistency with the overall evidence | consistent |
| Regional transferability | high |
| Adequacy of the interpretation (by the archive) | not applicable |
14. Open questions
Mechanism of cerebral oedema in paediatric DKA; optimal insulin dose in young children; DKA burden in low-resource settings.
15. Linked fact checks
- Injected insulin halts the Krebs cycle, blocks protein and DNA synthesis, starves the brain of glucose and causes seizures and blood clots. – Studies contradicting or limiting the claim
- There is no such thing as type 1 diabetes; 'type 1' is a state of high sugar seen mainly in athletes with high needs; type 1 patients do not develop complications; insulin before puberty is a catastrophe (short stature, thyroid problems, cysts). – Studies contradicting or limiting the claim
- Diabetic ketoacidosis (DKA) does not kill anyone; it should be treated with corticosteroids and complete fasting from food and drink for days, without insulin and without intravenous fluids; giving insulin in this situation is 'the black disaster'. – Studies contradicting or limiting the claim
- People with diabetes can stop insulin and diabetes medication by following the Tayebat system ('zero medicine'), as shown by followers who stopped insulin and are 'perfectly fine'. – Studies contradicting or limiting the claim
- Insulin and diabetes drugs pull glucose out of the blood and out of the cells, producing an internal 'famine'. – Studies contradicting or limiting the claim
- Fasting brings gut hormones, above all insulin, to zero ('your fasting insulin equals zero'). – Studies contradicting or limiting the claim
- Rising blood glucose and acetone (ketones) during fasting are evidence that the liver is working properly, not a danger; high glucose plus acetone is not insulin deficiency. – Studies contradicting or limiting the claim
- Laboratory values such as blood glucose and acetone are only signs of the body's changing strategy and not causes; there is no need to measure glucose or blood pressure. – Studies contradicting or limiting the claim