Utility of plasma beta-hydroxybutyrate to define resolution of diabetic ketoacidosis

Background Diabetic ketoacidosis (DKA) is a common, life-threatening complication of type 1 diabetes (T1D) characterized by unregulated ketogenesis caused by relative or absolute insulin deficiency. DKA management requires frequent biochemical monitoring. Plasma ss-hydroxybutyrate (BOHB) has not been included in traditional definitions of DKA resolution. Objective The aim of this study was to determine a cut-point level of BOHB to define DKA resolution in patients with T1D treated with intravenous (IV) insulin. Subjects We identified patients with T1D receiving IV insulin for DKA treatment at a quaternary children's hospital from January 1, 2017 through December 31, 2020 who had plasma measurements of BOHB after DKA onset and whose DKA resolved by traditional laboratory criteria (venous pH (vpH) >= 7.3, serum bicarbonate (HCO3) >= 15 mmol/L, and/or anion gap (AG) <= 14 mmol/L). Methods Associations between plasma BOHB and vpH, HCO3, and AG were evaluated via scatterplots. Receiver operating characteristic (ROC) curves and area under the curve (AUC) were used to evaluate BOHB cut-points to predict DKA resolution. Results We analyzed 403 patients with 471 unique encounters. Plasma BOHB showed the most robust relationship with AG. The ROC curve comparing plasma BOHB to the accepted definition of DKA resolution, AG <= 14 mmol/L, had an AUC of 0.92. A BOHB value of <1.5 mmol/L had a sensitivity of 83% and specificity of 87%; this cut-point correctly classified 86% of the observations. Conclusions A plasma BOHB value of <1.5 mmol/L can be used to define resolution of DKA.