Version July 2025
| DKA | HHS | |||
| Mild | Moderate | Severe | ||
| Plasma glucose (mg/dL) | ≥200 or prior history of diabetes | ≥200 or prior history of diabetes | ≥200 or prior history of diabetes | ≥600 |
| Plasma glucose (mmol/L) | ≥11.1 | ≥11.1 | ≥11.1 | ≥33.3 |
| Arterial pH | >7.25 and <7.30 | 7.0 to 7.25 | <7.0 | ≥7.30 |
| Serum bicarbonate (mEq/L) | 15 to <18 | 10 to <15 | <10 | ≥18 |
| Urine ketones¶ | Positive | Positive | Positive | ≤ Small |
| Serum ketones – Nitroprusside reaction¶ | Positive | Positive | Positive | ≤ Small |
| Serum ketones – Enzymatic assay of beta-hydroxybutyrate (normal range <0.6 mmol/L) | 3 to 6 mmol/L | 3 to 6 mmol/L | >6 mmol/L | <3 mmol/L |
| Effective serum osmolality (mOsm/kg)Δ | Variable | Variable | Variable | >300 |
| Anion gap◊ | >10 | >12 | >12 | Variable |
| Alteration in sensoria or mental obtundation | Alert | Alert/drowsy | Stupor/coma | Stupor/coma |
DKA: diabetic ketoacidosis; HHS: hyperosmolar hyperglycemic state; SGLT2: sodium-glucose cotransporter 2.
* There may be considerable diagnostic overlap between DKA and HHS. The thresholds for plasma glucose in DKA do not apply to individuals treated with SGLT2 inhibitors. In such individuals, severe acidemia may be present despite normal or near-normal plasma glucose levels.
¶ These assays use the nitroprusside reaction method and can underestimate ketonemia in early stages of DKA and overestimate ketonemia during DKA resolution. Therefore, enzymatic measurement of serum or blood beta-hydroxybutyrate is preferred when available.
Δ Calculation: 2[measured Na+ (mEq/L)] + glucose (mg/dL)/18 or 2[measured Na+ (mEq/L)] + glucose (mmol/L).
◊ Calculation: (Na+) – (Cl– + HCO3–) (mEq/L). This calculation should be made using the Na+ concentration reported by the laboratory and not the "glucose-corrected" Na+ value.Adapted from: Kitabchi AE, Umpierrez GE, Murphy MB, Kreisberg RA. Hyperglycemic crises in adult patients with diabetes: A consensus statement from the American Diabetes Association. Diabetes Care 2006; 29:2739.
Updated with additional data from: