Otieno C F, Kayima J K, Omonge E O, Oyoo G O
Department of Medicine, College of Health Sciences, University of Nairobi, P. O. Box 19676-00202, Nairobi, Kenya.
East Afr Med J. 2005 Dec;82(12 Suppl):S197-203. doi: 10.4314/eamj.v82i12.9382.
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.
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.
Literature review of relevant published literature from both Africa and the rest of the world.
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.
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.
糖尿病酮症酸中毒是糖尿病患者中最常见的高血糖急症，尤其是1型糖尿病患者。在撒哈拉以南非洲地区，无论是接受治疗的患者还是首次因糖尿病入院的患者，其死亡率都非常高。
回顾已发表文献中糖尿病酮症酸中毒的危险因素、发病机制和管理方法，并结合撒哈拉以南非洲地区很大一部分发生糖尿病酮症酸中毒的患者死亡率仍然很高的原因进行讨论。
对来自非洲和世界其他地区的相关已发表文献进行文献综述。
撒哈拉以南非洲地区患者发生糖尿病酮症酸中毒的主要原因或诱因是新诊断的糖尿病、胰岛素剂量漏用和感染。主要的潜在机制是胰岛素缺乏。接受治疗的患者因各种原因漏用胰岛素，例如，胰岛素无法获取，这是由胰岛素供应不足和无力承担费用、错过门诊、自认为健康状况不佳以及使用草药、祈祷和仪式等替代疗法导致的。感染也很常见，但并不明显，如尿路感染、肺结核和肺炎。由于个人和国家普遍贫困，医疗保健系统匮乏，少数可用的中心无法充分维持可靠的胰岛素供应系统，也无法对住院患者进行全面检查。因此，成功治疗的保证很小。贫困人口的营养状况可能也不理想，糖尿病会导致或加重这种情况，尤其是在首次入院时。对这类患者进行强化胰岛素治疗会引发“再喂养综合征”，这是一种急性合成代谢状态，在糖尿病酮症酸中毒治疗期间其结果可能不利。
尽管撒哈拉以南非洲地区糖尿病酮症酸中毒的死亡率和发病率仍然很高，但改善医疗保健系统和可靠的胰岛素供应至少可以在很大程度上扭转这一趋势。需要通过教育、营养和消除贫困来增强个人和人群的能力，以改善糖尿病患者的健康自我护理和生活状况。
