Diabetic Ketoacidosis: A Common Debut of Diabetes Among African Americans With Type 2 Diabetes

Priyathama Vellanki, MD; Guillermo E. Umpierrez, MD


Endocr Pract. 2017;23(8):971-978. 

In This Article

Abstract and Introduction


Objective: More than half of African Americans (AA) with a new diagnosis of diabetic ketoacidosis have clinical and metabolic features of type 2 diabetes during follow-up. This particular presentation of diabetes has been termed as ketosis-prone type 2 diabetes (KPDM) or atypical diabetes.

Methods: We review the epidemiology, diagnosis, pathophysiology, and acute and long-term management of AA with KPDM and compare these similarities to patients with type 2 diabetes.

Results: In contrast to the long-term insulin requirement of auto-immune type 1 diabetes, patients with KPDM are able to discontinue insulin after a few months of therapy and maintain acceptable glycemic control for many years on either diet or oral agents. Patients with KPDM have significant impairment of both insulin secretion and insulin action at presentation; however, at the time of near-normoglycemia remission, insulin secretion and action improve to levels similar to hyperglycemic patients with ketosis-resistant type 2 diabetes. In the long term, however, patients with KPDM have a decline in β-cell function similar to patients with type 2 diabetes. Recent studies indicate that treatment with metformin and dipeptidyl peptidase-4 inhibitors can prolong the period of near-normoglycemia remission for several years compared to placebo therapy.

Conclusion: KPDM is a unique but common presentation of newly diagnosed African Americans with type 2 diabetes.


According to the Centers for Disease Control, the incidence of diabetic ketoacidosis (DKA) is increasing in the United States. Since 1980, the number of hospital discharges for DKA increased from 80,000 in 1988 to ~140,000 in 2009.[1] The majority (66%) of primary DKA episodes occur in patients diagnosed with type 1 diabetes, and the rest (34%) are in patients with type 2 diabetes. DKA, which was previously thought of as a key clinical feature of type 1 diabetes, has been shown to occur in children and adult patients with newly diagnosed type 2 diabetes.[2–4] Patients with type 2 diabetes and poor metabolic control can also develop DKA under stressful conditions such as trauma, surgery, or infection.[2,4] In addition, DKA can be the clinical presentation of many newly diagnosed children, adolescents, and adult patients with type 2 diabetes without a precipitating cause.[5–10] Their clinical presentation is acute with severe hyperglycemia and ketosis similar to classic type 1 diabetes, but after a few months of insulin therapy, patients are able to stop insulin therapy and remain in near-normoglycemia remission with diet and/or oral antidiabetic agents.[8–12]

During the past 2 decades, many investigators considered such patients as having a unique subtype of diabetes referred to in the literature as idiopathic type 1 diabetes, atypical diabetes, Flatbush diabetes, diabetes type 1.5 (somewhere between types 1 and 2), and more recently as ketosis-prone type 2 diabetes mellitus (KPDM). Despite their acute presentation, several cross-sectional and longitudinal studies by our group and others have indicated that DKA is a unique common clinical presentation in newly diagnosed patients with type 2 diabetes rather than a unique subtype of "atypical" diabetes.

While there is considerable heterogeneity in patients who present with DKA, in this review, we will discuss the clinical, immunogenic, and metabolic features and management of patients with newly diagnosed diabetes presenting with KPDM and highlight similarities to patients with ketosis-resistant type 2 diabetes.