Diabetes-Related Sudden Deaths: Postmortem Biochemical Approach Diagnostic Algorithm of Diabetes

Öz

This review aims to summarize, in light of current evidence, forensic medicine-specific approaches in the postmortem diagnosis of deaths due to acute complications of diabetes—diabetic ketoacidosis (DKA), hyperosmolar hyperglycemic state (HHD), and severe hypoglycemia—in sudden, unexpected, and suspicious deaths, and to propose a practical, step-by-step evaluation algorithm.

Studies published between 2000 and 2025 in forensic medicine, forensic pathology, and clinical endocrinology literature, including vitreous and blood biochemistry, hemoglobin A1C (HbA1c), ketone bodies, insulin/C-peptide, and auxiliary markers, were synthesized by comparing them in terms of sampling site and time, autolysis and postmortem interval (PMI) effects, differential diagnostic criteria, and threshold values. Turkish and international mortality data were evaluated contextually.

It has been found that: the combined assessment of vitreous glucose and blood or pericardial β-hydroxybutyrate (BHB) increases the diagnostic power in differentiating DKA and HHD; HbA1c is a reliable indicator of antemortem glycemic status even under conditions of advanced hemolysis and decay; histochemical examination of the injection site and insulin/analog analysis in the vitreous contribute to diagnosis in cases of suspected insulin overdose; integration of digital clinical records with biochemical data is important for the accurate classification of these cases.

Postmortem biochemistry is indispensable in the diagnosis of sudden deaths due to diabetes. Based on the literature and our own findings, we recommend routinely adding vitreous glucose, blood or pericardial BHB, and HbA1c to forensic autopsy protocols; and supporting this with targeted sampling and toxicological analyses in cases of hypoglycemia and insulin toxicity.

Anahtar Kelimeler

• Diabetes mellitus
• Diabetic ketoacidosis
• Hypoglycemia
• Postmortem biochemistry
• Forensic autopsy
• Hemoglobin A1C

Etik Beyan

No ethics committee decision was taken for the study.

Teşekkür

We thank all authors who contributed to the article.

Diyabete Bağlı Ani Ölüm: Diyabetin Postmortem Biyokimyasal Değerlendirmesi ve Tanısal Algoritması

Öz

Bu derlemede; ani, beklenmedik ve şüpheli ölümlerde diyabetin akut komplikasyonlarına-diyabetik ketoasidoz (DKA), hiperozmolar hiperglisemik durum (HHD) ve şiddetli hipoglisemiye - bağlı ölümlerin postmortem tanısında adli tıbba özgü yaklaşımları güncel kanıtlar ışığında özetlemek ve pratikte uygulanabilir, adım adım bir değerlendirme algoritması önermek amaçlanmıştır. 

2000–2025 yılları arasında yayımlanmış adli tıp, adli patoloji ve klinik endokrinoloji literatüründeki vitreus ve kan biyokimyası, hemoglobin A1C (HbA1c), keton cisimcikleri, insülin/C-peptid ve yardımcı belirteçleri içeren çalışmalar; örnekleme yeri ve zamanı, otoliz ve postmortem interval (PMI) etkileri, ayırıcı tanı kriterleri ve eşik değerler yönünden karşılaştırılarak sentezlenmiştir. Türkiye ve uluslararası mortalite verileri bağlamsal olarak değerlendirilmiştir. 

Vitreus glikozu ile kan veya perikardiyal β-hidroksibutiratın (BHB) birlikte değerlendirilmesinin DKA ve HHD ayırımında tanısal gücü arttırdığı, HbA1c’nin ileri hemoliz ve çürüme koşullarında dahi antemortem glisemik durumun güvenilir bir göstergesi olduğu, insülinin aşırı doz alımı şüphesinde enjeksiyon bölgesinin histokimyasal incelemesi ve vitreusta insülin/analog analizlerinin tanıya katkı sağladığı, bu vakaların doğru sınıflanması için dijital klinik kayıtların biyokimya verileriyle entegrasyonunun önemli olduğu bilgisine ulaşılmıştır. 

Postmortem biyokimya, diyabete bağlı ani ölümlerin tanısında vazgeçilmezdir. Literatür ve tarafımızca; adli otopsi protokollerine vitreus glikozu, kan veya perikardiyal BHB ve HbA1c’nin rutin olarak eklenmesi; hipoglisemi ve insülin toksisitesinde hedefli örnekleme ve toksikolojik analizlerle desteklenmesi önerilmektedir.

Anahtar Kelimeler

• Diyabet
• Diyabetik ketoasidoz
• Hipoglisemi
• Postmortem biyokimya
• Adli otopsi
• Hemoglobin A1C

Etik Beyan

Çalışma için etik kurul kararı alınmamıştır.

Teşekkür

Makaleye katkıda bulunan tüm yazarlara teşekkür ederiz.

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