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Possibility to reduce mortality in diabetic ketoacidosis.

In the review ‘‘Morbidity and Mortality of Diabetic Ketoacidosis With and Without Insulin Pump Care,’’ the authors write on p. 1149, ‘‘The purpose of this review is to discuss DKA [diabetic ketoacidosis] morbidity and mortality in youth with T1D [type 1 diabetes] ...’’ and on p. 1150 ‘‘It is important to differentiate between all causes of death and diabetes-related causes of death.’’ Their Table 1 on p. 1150 shows that still 90 years after introduction of insulin in the treatment of diabetes mellitus, the number of diabetes-related deaths is considerable. On p. 1152, they write ‘‘Advances in diabetes care and technology offer the possibility that mortality from DKA in youth with known T1D can be greatly reduced.’’ Therefore, for the readers of Diabetes Technology and Therapeutics, perhaps information of progress in the understanding of pathophysiology of coma, the most important of all diabetes-related causes of death, would be interesting, which is surprisingly not discussed by Realsen et al. According to Edge et al., Nyenwe et al., and Marcin et al., the immediate cause of the life-threatening coma in DKA is very low blood pH (i.e., a high concentration of hydrogen ions). The glycolytic enzyme phosphofructokinase is pHdependent, as its activity decreases with decreasing pH, and thus glucose utilization in brain cells is impaired. The increase and normalization of the low blood pH with infusions of alkalizing solutions make possible recovery of the comatose patient to full alertness. With other words, the lethality of coma in DKA is zero (e.g., Wagner et al.). Realsen et al. write in their Conclusions on p. 1152 that ‘‘Advances in diabetes care and technology offer the possibility that mortality from DKA in youth with known T1D can be greatly reduced’’—the result of Wagner et al. is an example that this is already reality.