Diabetes Basics
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þ DM Syndromes
 - DKA
  + ketosis without significant hyperosmolarity due to total or relative
    insulin absence
  + "Type 1," younger, thin, rare in type 2 unless severe stress
 - HHS
  + hyperosmolarity without significant ketosis due to insulin resistance
  + "Type 2"
  + obese, elderly, develops over many days

þ Ketosis Prone Diabetes
 - Increasing #s of patient with "type 2" DM with episodes of DKA, esp Latino
   and black
 - Variable terminology: "atypical type 1", "type 1 B", "Flatbush type 1", "type
   1.5", "latent auto-immune diabetes in adults (LADA), etc.
 - Type 1, classically: childhood onset, lower BMI, complete failure of insulin
   production, "insulin dependent" for life, DKA prone, auto-antibodies to islet
   cells
 - Type 2, classically: adult onset, higher BMI, higher insulin levels, "insulin
   resistant", no auto-antibody, not ketosis prone, not insulin dependent

þ DKA-Type 1 vs Type 2 DM and the Effect of Ethnicity
 - 141 patients with DKA, recontacted 2.5 years later to find out current
   treatment
 - 39% type 2, 53% type 1, 8% no "type" initial presentation
 - Type 1 mostly lean, younger onset
 - Type 2: 33% BMI<25, 51% BMI>30, age of onset more broadly distributed
 - 50% of the type 2 pts had no identifiable stress factor associated with DKA
 - 25% hyperosmolar >320mOsm/L in type 1 and 2
 - Latin A 47% type 2, 34% type 1, whites type 1 80%, type 2 17%, AA/black 53%
   type 1, 44% type 2 when recontacted
   [Balasubramanyam, et al, New Profiles in DKA. Arch Intern Med, Oct 25, 1999]

þ DKA in Type 1 and Type 2 DM
 - 176 admissions, 138 pts, glu>250, HCO3<15, art pH<7.3 or ven pH<7.25, mod-
   large urinary ketones
 - 30 pts with type 2 DM (no auto-aby, obese, FH, prior treatment), 29% with no
   precipitant other than stopping meds, 70% BMI >27
 - Infections 21% type 1, 48% type 2
 - 85% of admits due to stopping meds
 - Type 1 slightly more acidotic by ~ 0.06, 21% with BMI >27
   [Newton, Raskin, DKA in type 1 and 2 DM. Arch Intern Med, Sept 27,2004]

þ Ketosis Prone Diabetes
 - 294 pts with DKA, followed for 1-5 yrs, looked at B-cell autoimmunity and
   function,  insulin dependence, clinical and biochemical features
 - Proposed new classification scheme for KPD
 - KPD type 1A: A+B- permanent and complete B cell failure, require life-long
   insulin (classic "type 1")
 - KPD type 1B: A-B- permanent and complete B cell failure, no auto-aby,
   require lifelong insulin
 - KPD type 2A: A+B+ preserved B cell function at time of dx, +auto-aby, some
   reversible B-cell dysfx, some progressive to require life long insulin
 - KPD type 2B: A-B+, preserved B-cell fx, majority can discontinue insulin
   (classic 2)
   [Newton, Raskin, DKA in type 1 and 2 DM. Arch Intern Med, Sept 27,2004]