Recurrent Diabetic Ketoacidosis Research Articles

Trends in Incidence of Hospitalization for Hypoglycemia and Diabetic Ketoacidosis in Individuals With Type 1 or Type 2 Diabetes With and Without Severe Mental Illness in Denmark From 1996 to 2020: A Nationwide Study.

To examine trends in incidence of acute diabetes complications in individuals with type 1 or type 2 diabetes with and without severe mental illness (SMI) in Denmark by age and calendar year. We conducted a cohort study using nationwide registers from 1996 to 2020 to identify individuals with diabetes, ascertain SMI status (namely, schizophrenia, bipolar disorder, or major depression) and identify the outcomes: hospitalization for hypoglycemia and diabetic ketoacidosis (DKA). We used Poisson regression to estimate incidence rates (IRs) and incidence rate ratios (IRRs) of recurrent hypoglycemia and DKA events by SMI, age, and calendar year, accounting for sex, diabetes duration, education, and country of origin. Among 433,609 individuals with diabetes, 8% had SMI. Risk of (first and subsequent) hypoglycemia events was higher for individuals with SMI than for those without SMI (for first hypoglycemia event, IRR: type 1 diabetes, 1.77 [95% CI 1.56-2.00]; type 2 diabetes, 1.64 [95% CI 1.55-1.74]). Individuals with schizophrenia were particularly at risk for recurrent hypoglycemia events. The risk of first DKA event was higher in individuals with SMI (for first DKA event, IRR: type 1 diabetes, 1.78 [95% CI 1.50-2.11]; type 2 diabetes, 1.85 [95% CI 1.64-2.09]). Except for DKA in the type 2 diabetes group, IR differences between individuals with and without SMI were highest in younger individuals (<50 years old) but stable across the calendar year. SMI is an important risk factor for acute diabetes complication and effective prevention is needed in this population, especially among the younger population and those with schizophrenia.

Social and Metabolic Characteristics Associated With Multiple DKA Admissions at a Large County Hospital.

Diabetic ketoacidosis (DKA) is a preventable, deadly, and costly complication of type 1 diabetes mellitus (T1DM). Some individuals with T1DM have recurrent DKA admissions. We sought to characterize social factors that differ between patients with single vs multiple DKA admissions at an urban, safety-net hospital. We queried the electronic health records for T1DM patients admitted for DKA from 2019 to 2021. Admission laboratory values, demographic information, and detailed social histories were collected and analyzed statistically, including logistical regression. A total of 243 patients were admitted for DKA, 64 of whom had multiple DKA admissions. There was no significant difference between the groups in their admission laboratory values, hospital length of stay, health-care payer status, history of homelessness, current employment, living alone, independence of activities of daily living, and barriers to discharge. T1DM patients with multiple DKA admissions had greater rates of substance use disorder (33.0% vs 60.9%; P < .001), especially with cannabis (6.7% vs 25.0%; P < .001), tobacco (26.3% vs 46.3%; P = .002), and psychoactive substance use (1.1% vs 6.3%; P = .043). Regression models of substance use showed increased risk with any substance use (odds ratio [CI] 3.17 [1.78-5.73]; P < .001) and cannabis (3.70 [1.55-8.83]; P = .003). We identified substance use as a possible predictor of T1DM patients at risk for multiple DKA admissions. Our findings identify a group of T1DM patients for whom interventions may help to decrease recurrence of DKA episodes within similar community hospital populations.

THU384 Too Sweet To Digest; A Case Of Persistent Lactic Acidosis Secondary To Glycogenic Hepatopathy

Abstract Disclosure: T. Ayub: None. L.A. Robles: None. F. Sami: None. S. Saleem: None. S. Guntupalli: None. Glycogenic hepatopathy (GH) is an under-recognized cause of persistent lactic acidosis and hepatomegaly in patients with uncontrolled DM and diabetic ketoacidosis (DKA). A 19-year-old female with history of type 1 DM with recurrent DKA presented with complaints of nausea, vomiting and abdominal pain for 1 week. Physical exam showed normal vitals and lower abdominal tenderness. Her initial labs showed glucose 250 mg/dl, high anion gap metabolic acidosis with beta hydroxy butyrate of 11.3 mmol/l, lactic acid 3.2mm/l, and mild transaminitis. She was diagnosed with DKA and started on insulin drip. Anion gap responded to IV insulin and fluid therapy and was transitioned to SQ insulin. However, she had increase in her lactic acid (8.2mm/l), without hemodynamic compromise, despite fluid resuscitation. Secondary work up including blood, urine, sputum cultures were non diagnostic for an infectious etiology. Abdominal imaging showed a liver span of 26 cm. There were no signs of end organ hypoperfusion, medication or toxin mediated insult as evident by normal transthoracic echo, iron studies, urine drug screen, alcohol level and negative hepatitis panel. Review of prior hospitalizations showed recurrent episodes of DKA with similar uptrend in lactic acid levels with negative secondary work up. Prior imaging revealed hepatomegaly during DKA episodes with resolution after strict glycemic control. Given uncontrolled DM type 1 with reversible and recurrent hepatomegaly, transaminitis, hyperlipidemia and elevated lactic acid, a clinical diagnosis of glycogenic hepatopathy was made. Patient declined liver biopsy due to concerns for complications. She was discharged on home insulin regimen with outpatient follow up. GH or hepatic glycogenosis is a reversible cause of lactic acidosis and hepatomegaly seen in uncontrolled DM type 1. Pathogenesis involves presence of fluctuating levels of hyperglycemia and insulin, concomitantly, that leads to glycogen storage. Insulin inhibits gluconeogenesis resulting in decreased conversion of pyruvate to glucose and high lactic acid levels, in the absence of any infectious, metabolic and hypoxic etiology. Lactic acidosis can be worsened when treated with high dose Insulin. Definite diagnosis of GH requires liver biopsy or gradient dual-echo MRI but can be made clinically in the setting of uncontrolled DM1, hepatomegaly, transaminitis and elevated lactic acid levels. Prompt recognition of GH can prevent unnecessary diagnostic testing and can decrease the duration of hospital stay. Treatment is strict glycemic control with resolution of condition and no long-term complications. Presentation: Thursday, June 15, 2023

The effect of poor glycemic control on cognitive function in children and adolescents with type 1 diabetes mellitus: A single-center cross-sectional study (2019-2020).

To investigate the effect of chronic hyperglycemia, hypoglycemia, and diabetic ketoacidosis (DKA) on the cognitive function of children and adolescents with type 1 diabetes mellitus (T1DM), and explore whether early disease onset correlated with cognitive impairment. Children and adolescents with T1DM who attended the Pediatric Diabetes Clinic between January 2019 and 2020, aged between 5-14 years, with a mean of 3 glycated hemoglobin (HbA1c) readings ≥7% (53 mmol/mol) during the study period reflecting a hyperglycemic status and who agreed to participate were interviewed about their history of hypoglycemia and DKA. Participants were personally interviewed by a clinical psychologist to assess their cognitive function using a validated Arabic version of the Stanford-Binet test. Higher mean HbA1c levels were associated with cognitive dysfunction in three verbal domains: fluid reasoning, quantitative reasoning, and working memory. Frequent hypoglycemia negatively affected verbal knowledge. In contrast, significant hypoglycemia affected both verbal and nonverbal domains of cognition, specifically verbal and nonverbal fluid reasoning, knowledge, and working memory. Children with recurrent DKA performed below average in nonverbal fluid reasoning tasks. Additionally, moderate or severe DKA, regardless of its frequency, affected children's overall intelligence quotient. Regardless of disease onset, exposure to glycemic variability subjects children and adolescents to subtle and measurable cognitive dysfunction resulting in significant morbidity.

Emergency Department Presentations of Diabetic Ketoacidosis in a Large Cohort of Children

Background. Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of childhood diabetes. However, the influence of demographic factors on presentation are not well-defined. Methods. We included children from 12 centers who were &lt;18 years with DKA (glucose &gt; 300 mg/dL, serum pH &lt; 7.25, or serum bicarbonate &lt;15 mEq/L) enrolled in the Pediatric Emergency Care Applied Research Network (PECARN) Fluid Therapies Under Investigation in DKA (FLUID) Trial. Data were also collected for children who presented to the centers during the enrollment period but were not enrolled due to disease or treatment-related reasons. We compared demographic, clinical, and biochemical findings among children with newly and previously diagnosed diabetes and children in different age groups. Results. Of the 1,679 DKA episodes in 1,553 children, 799 (47.5%) episodes occurred in children with newly diagnosed diabetes and 396 (23.6%) were severe (pH &lt; 7.1). Newly diagnosed children &lt;6 years of age were not more likely to have severe DKA in terms of pH, but had more severe hypocarbia and higher blood urea nitrogen levels, factors previously associated with the risk of cerebral injury. Lower socioeconomic status (SES) (based on family income and maternal education level) were associated with more severe DKA in new onset children, and recurrent DKA in the previously diagnosed children. Conclusions. Greater efforts are needed to identify the children with diabetes early and to prevent recurrent DKA, particularly among children in low-SES groups. Young children with DKA may need more intensive monitoring due to higher risk of cerebral injury.

Epidemiology of Diabetic Ketoacidosis in the Waikato Region of New Zealand: 2000-2019.

Diabetic ketoacidosis (DKA) is not well characterised in New Zealand. This study is aimed at characterising the change in epidemiology and severity of DKA from 2000 to 2019 at a tertiary hospital in the Waikato region of New Zealand. A retrospective clinical data review of all patients admitted to Waikato District Health Board hospitals with DKA was undertaken. Characteristics and severity of DKA were assessed by type of DKA admission (diagnosed at admission, nonrecurrent, and recurrent), ethnicity, social deprivation, intensive care unit (ICU) admission, and length of hospital stay, with linear regression reporting on changes over time. There were 1254 admissions for DKA (564 individual patients), two-thirds being recurrent events. Nonrecurrent DKA patients were younger, whilst recurrent admissions for DKA were associated with T1D, female gender, greater socioeconomic deprivation, and rural living (all P values < 0.01). DKA admission increased 8-fold between 2000 and 2019, mostly due to an increased number of recurrent events, particularly in Māori and female patients (P < 0.001). ICU admissions increased over time (P < 0.001) whilst length of hospital stay trended down (P = 0.031). The rise in recurrent DKA is concerning, particularly in youth and indigenous Māori. Healthcare inequities need to be addressed, including adequate access to mental health support to ensure optimal outcomes for all patients with diabetes.

Unexpected cause of recurrent diabetic ketoacidosis in type 1 diabetes: a case report

BackgroundGastrointestinal (GI) symptoms are commonly observed in patients with diabetic ketoacidosis (DKA), which usually resolves completely with therapy. However, GI symptoms can persist after DKA resolves, which can pose diagnostic and management challenges for physicians, especially when dealing with an exceptional diagnosis such as cannabinoid hyperemesis syndrome (CHS).Case presentationIn this case report, we present a patient with type 1 diabetes who had been treated for DKA 6 times in the past year and was eventually diagnosed with CHS.ConclusionIn conclusion, this case demonstrates that a presumptive and incorrect diagnosis can mislead physicians, especially when dealing with challenging diagnoses. Therefore, patients with type 1 diabetes with unusual presentations, such as unexpectedly high pH and bicarbonate levels, with hyperglycemic ketosis should be screened for illicit drug use, especially cannabis.

Diagnostic Challenge of Adult-onset Type 1 Diabetes Mellitus in a Remote Hospital

Type 1 Diabetes Mellitus (T1DM) is a chronic endocrinological disease due to an autoimmune process. The prevalence of T1DM is 9.5% worldwide, with the incidence of 15 out of 100,000 people, ranging from childhood to 40 years of age. Autoimmunity-related late-onset Diabetes Mellitus (DM) patients could be diagnosed as classic T1DM or latent autoimmune diabetes in adults (LADA). A 30-year-old male patient with unremarkable previous medical history was admitted to the emergency room with dyspnea for the last three days that was worsened six-hour before admission. Physical examinations showed a body Mass Index (BMI) of 18.75 kg/m2, irregular pulse, and Kussmaul breathing. The patient was diagnosed with diabetic ketoacidosis (DKA) on May 23, 2019. He was discharged with subcutaneous insulin pen injections. Two years later, he was readmitted with DKA due to discontinuing his treatment. He stated that the reason for stopping the insulin was because he was tired of injecting it. The patient was hospitalized and was discharged with oral antidiabetic agents to cope with his injection tiredness issue. One week later, the patient complained of dyspnea and was diagnosed with recurrent DKA. He was hospitalized and prescribed subcutaneous insulin. In this kind of situation, a diagnosis of LADA for patients presenting with DKA without prior history of DM in early adulthood needs to be considered. In contrast to the classic T1DM, the need for insulin occurs late in LADA. Affordable and widely available ancillary examinations are needed, including in remote hospitals. Finally, motivational support for patients is as important as the pharmacological treatment since lifelong insulin injections are needed.

1365-P: Recurrent Diabetic Ketoacidosis—Patient Characteristics and Clinical Outcomes in Qatar

Background: Recurrent diabetic ketoacidosis (DKA) is associated with poor clinical outcomes. Objective: We aimed to examine patients’ characteristics and clinical outcomes for patients hospitalized with recurrent DKA in Qatar. Methods: The hospital database was interrogated for patients admitted with DKA to government hospitals in Qatar between 2015 to 2020. Precipitating cause, clinical characteristics, laboratory data, severity of DKA, complications, need for admission to the intensive care unit, length of hospital stay, time to resolution of DKA, and mortality rates were evaluated in patients with recurrent (&amp;gt;1 admission) compared to a single admission. Results: A total of 1612 episodes of DKA, of which 434 patients (26.9%) had recurrent DKA, were evaluated. Compared to patients who had a single admission for DKA, those with recurrent DKA were younger [35.0 (24.0-53.0) vs 39.0 (28.0-54.0) years, p&amp;lt;0.001], more likely to be females (50.6% vs 37.1%, p&amp;lt;0.001), more likely to have type 1 diabetes (47.9% vs. 33.4%, p&amp;lt;0.001), a longer duration of diabetes [12.0 (5.0-19.0 vs 5.0 (0.0-13.0) years, p&amp;lt;0.001], more likely to have severe DKA (48.6% vs 38%, p&amp;lt;0.001), with a shorter time to resolution of DKA [12.5 (9.0-24.0) vs 23.0 (10.0-33.0) hours, p&amp;lt;0.001]. There was no difference in the precipitating cause of DKA, need for admission to the intensive care unit, hospital stay or inpatient mortality. On multivariable logistic regression analysis, significant predictors of occurrence of recurrent DKA were younger age (OR, 0.96; 95% CI, 0.95-0.98; p= 0.0001), female gender (OR, 0.63; 95% CI, 0.46-0.85; p= 0.003) and longer duration of diabetes (OR, 1.07; 95% CI, 1.04-1.09, p= 0.0001). Conclusion: In this cohort study, recurrent DKA was associated with younger age, female predominance and longer duration of diabetes. However, hospital course and inpatient mortality rates did not differ from those with a single admission for DKA. Disclosure M.Eledrisi: None. I.Alabdulrazzak: None. H.M.Alkabbani: None. M.K.Aboawon: None. A.A.Ali: None. M.F.Elhaj: None. A.O.E.Ahmed: None. H.Alqahwachi: None. R.A.Malik: None.

Clinical and biochemical determinants of length of stay, readmission and recurrence in patients admitted with diabetic ketoacidosis

Background The increasing prevalence of diabetic ketoacidosis (DKA) related admissions poses a significant burden on the healthcare systems globally. However, data regarding the predictors of healthcare resource utilization in DKA is limited and inconsistent. This study aimed to identify key predictors of hospital length of stay (LOS), readmission and recurrent DKA episodes. Methods We undertook a retrospective cross-sectional analysis of all DKA admissions from 2015 to 2021 across four hospitals in Qatar. The primary outcomes were the length of stay (LOS), 90-day readmission and 6-month and 1-year DKA recurrence. Results We included 922 patients with a median age of 35 years (25–45). 62% were males with type-1 diabetes-mellitus (T1DM) and type-2 DM (T2DM), present in 52% and 48% of patients. The median LOS was 2.6 days (IQR 1.1–4.8), and the median DKA resolution time was 18 h (10.5–29). Male-gender, new-onset DM, higher Charlson Comorbidity Index (CCI), lower haemoglobin, sodium and potassium, higher urea, longer DKA duration and MICU admission predicted a longer LOS in a multivariate regression analysis. None of the factors were significantly associated with 90-day readmission. Patients with pre-existing T1DM were more likely to have a six-month DKA recurrence than pre-existing T2DM. Patients with a 6-month DKA recurrence, female gender and T1DM had higher odds of 12-month recurrence, whereas a consult with a diabetes educator at the index admission was associated with decreased odds of recurrence. Conclusions/interpretation This is the most extensive study from the Middle-East region reporting on LOS, readmissions and the recurrence of DKA. Results from this study with a diverse population may be valuable for physicians and healthcare systems to decrease the diabetes-related healthcare burden in DKA patients.

Clinical characteristics and prognoses of patients with diabetic ketoacidosis in Finland

AimsTo assess the prognosis and risk factors for diabetic ketoacidosis (DKA) in Tampere University Hospital (Tays) in a retrospective case-control study. MethodsAll 282 patients (age ≥15 years) treated for DKA in Tays during the period 2014–2020 were included. A total of 846 controls adjusted for age, gender, diabetes type and municipality, and without any DKA during follow-up were collected from the Finnish National Diabetes Registry. HbA1c, mental and behavioural disorders, and mortality obtained from the Finnish National Diabetes Registry were compared between patients with and without DKA. ResultsPatients’ median age was 36 years. Ten percent of the patients with DKA died during the median follow-up time of three years. Mortality rate was sixfold higher in patients with DKA than among the controls (OR 6.28; 95% CI 3.17–12.42). Patients with DKA had higher rates of substance abuse (OR 4.68; 95% CI 3.23–6.78) and depression (OR 2.24; 95% CI 1.58–3.18), and higher median HbA1c levels (84 vs. 61 mmol/mol, p < 0.001). Nineteen percent of the DKA patients (n = 53) had recurrent DKA. ConclusionsDKA is a strong indicator for premature death. Poor glycaemic control, depression and substance abuse are risk factors for DKA.

Is HbA1c an Indicator of Diabetic Ketoacidosis Severity in the Pediatric Population?

Glycosylated hemoglobin (HbA1c) reflects how well blood glucose is controlled and is one of the strongest predictors of chronic complications of diabetes mellitus. The degree of acidosis helps determine the severity of diabetic ketoacidosis (DKA) (mild: pH 7.2-7.3; moderate: pH 7.1-7.2; severe: pH <7.1) and guides the level of care and predicts outcome. Many studies have implicated that higher HbA1c levels lead to recurrent DKA. However, there is no description of the association of higher HbA1c with the severity of DKA. One hundred thirty-eight electronic medical records of patients aged 1 to 21 years admitted to the pediatric intensive care unit with DKA between 2011 and 2015 were analyzed. We excluded 50 patients because the HbA1c level was not available. Spearman correlation analyzed the data for 88 patients included in the study. The mean HbA1c was 13.3, with female patients having more admissions compared with male patients (58% vs 42%). The age group from 13 to 21 years accounted for 77.3% of the patients. The duration of type 1 diabetes mellitus did not affect the HbA1c level. Likewise, the blood glucose and serum creatinine level did not show a statistical correlation with blood pH levels. Mean HbA1c for mild, moderate, and severe DKA groups were 11.4%, 12.2%, and 14.8%, respectively. Blood pH and HbA1c returned a negative correlation (correlation coefficient, -0.557; P = 0.005). The HbA1c level correlated positively with the 3 groups of DKA (correlation coefficient, 0.595; P = 0.01). A higher A 1c was associated with more severe DKA.

ODP153 Recurrent hypertriglyceridemia-induced pancreatitis due to multifactorial chylomicronemia syndrome in a patient with ketosis-prone diabetes mellitus

Abstract Background Hypertriglyceridemia-induced pancreatitis is associated with significant morbidity and mortality. The triad of diabetic ketoacidosis (DKA), severe hypertriglyceridemia, and acute pancreatitis have been occasionally described in severely obese patients with type 2 diabetes mellitus (T2DM). However, the occurrence of this triad in newly diagnosed ketosis-prone diabetes mellitus (KPDM) is rarely reported. Herein, we report a long-term follow-up of a Thai man with KPDM complicated with recurrent pancreatitis due to multifactorial chylomicronemia syndrome. Case Description A 33-year-old Thai male patient with a history of insulin-independent diabetes mellitus, recurrent hypertriglyceridemic pancreatitis, and recurrent DKA (three times within the past 5 years) came to our hospital in 2020 for the management of plasma triglyceride levels. At the age of 29 years (BMI 31.2 kg/m2), he experienced the first hypertriglyceridemia-induced pancreatitis (plasma triglyceride 8,189 mg/dL) in association with DKA. After resolution of DKA, insulin therapy was successfully discontinued for 3 years. Then, recurrent hypertriglyceridemic pancreatitis in association with multiple organ failures was developed during travelling to India. After treatment with plasmapheresis and continuous intravenous insulin infusion, he was able to extubate but pulmonary embolism at right pulmonary artery was discovered. Subcutaneous low molecular weight heparin was given for 6 months and then discontinued. The last hypertriglyceridemia-induced pancreatitis attack in association with DKA was aggravated by a high fat buffet meal 1 month prior to our hospital visit. He denied any tobacco, alcohol, or substance use. The patient had no known family medical history of lipid disorders. Further investigations revealed preserved beta-cell function by mixed meal stimulation test and negative pancreatic autoantibodies. Genetic testing showed no mutation in lipoprotein lipase (LPL) and its co-factors. Therefore, multifactorial chylomicronemia syndrome with KPDM was diagnosed. The patient was referred to multidisciplinary team for lifelong weight loss, limiting intake of fat and simple carbohydrates, and adherence to lipid-lowering medications. Subsequent follow-up 2 years later showed no recurrent pancreatitis. Conclusion The triad of acute pancreatitis, severe hypertriglyceridemia and DKA constitutes a unique subgroup of patients which insulin deficiency state is the core defect in association with underlying genetic predisposition. Molecular diagnosis of underlying genetic defect should be pursued to exclude familial chylomicronemia syndrome. In patients with multifactorial chylomicronemia syndrome, long-term management with dietary modifications together with pharmacotherapy remains the cornerstone of successful treatment. Presentation: No date and time listed

1162-P: Clinical Characteristics and Outcomes in Patients Hospitalized with Diabetic Ketoacidosis

Background: Diabetic ketoacidosis (DKA) is an acute complication of uncontrolled diabetes that is associated with increased morbidity and mortality. Objective: We aimed to examine clinical characteristics and care outcomes for patients hospitalized for DKA. Methods: We reviewed the hospital database for patients who were admitted with DKA from 2015 to 2020 in government hospitals in Qatar. Clinical characteristics, laboratory data, the severity of DKA, complications, need for admission to the intensive care unit, length of hospital stay, time to resolution of DKA, and mortality rates were evaluated in patients with type 1 diabetes (T1DM) compared to those with type 2 diabetes (T2DM) . Results: A total of 1613 episodes of DKA in 1330 patients (39.3% with T1DM and 60.7% with T2DM) were evaluated. Non-adherence to therapy was the commonest cause (40.5%) of DKA in patients with T1DM, while infection was the commonest cause (32.9%) in those with T2DM. There was no difference in the severity of DKA, mean serum glucose, mean serum sodium, and arterial pH on presentation in both groups of patients. Both groups had poorly controlled glucose (mean HbA1c of 10.1% and 10.5% in T1DM and T2DM groups respectively) . There was no difference in the time to resolution of DKA (18 hours in the T1DM group and 20 hours in the T2DM group) . Patients with T2DM had higher rates of admission to the intensive care unit (39.1% vs. 26.9% for T1DM, p&amp;lt;0.001) , longer hospital stay (mean 5 days vs. 2 days in the T1DM group, p&amp;lt;0.001) , while patients with T1DM had higher rates of recurrent DKA (35.6% vs. 21.2% in the T2DM group, p&amp;lt;0.001) . Mortality rates were significantly higher in patients with T2DM compared to those with T1DM patients (7.6% vs. 0.95%, respectively, p&amp;lt;0.001) . Conclusion: In this cohort study, poorly controlled glucose was prevalent among patients admitted with DKA. Despite higher rates of recurrent DKA in patients with T1DM, those with T2DM had more complicated hospital course and higher mortality. Disclosure M.Eledrisi: None. S.A.Beshyah: None. M.K.Aboawon: None. H.M.Alkabbani: None. A.A.Ali: None. I.Alabdulrazzak: None. M.Elhaj: None. A.O.E.Ahmed: None. H.Alqahwachi: None. J.Daghfal: None.

Diabetic ketoacidosis: a canary in the mine for mental health disorders?

Recurrent diabetic ketoacidosis (DKA) has been linked to mental health disorders, but less is known about single DKA episodes. Most studies are retrospective, lacking control groups. To prospectively examine psychosocial factors in patients presenting with recurrent or single episode DKA and compare with people who have not had DKA. Case-controlled study (consecutive adult DKA admissions April 2015 to December 2016) at Western Health, Melbourne. Data were prospectively collected regarding diagnosed mental health disorders, likely depression (Patient Health Questionnaire (PHQ-9)), diabetes distress (Problem Areas in Diabetes (PAID) questionnaire) and presence of adverse social factors. A control group without a history of DKA was also recruited. Of 123 patients admitted with DKA (164 consecutive episodes), 70 consented to participate and 73 age-matched Type 1 diabetes controls were recruited. Eleven (61%) of 18 with recurrent DKA had a diagnosed mental health disorder versus 8 (19%) of 42 in the single episode group (P = 0.016). The prevalence of likely depression using PHQ-9 was: recurrent 50%; single 40%; and controls 22% (recurrent vs controls, P = 0.036; single vs controls, P = 0.053). Severe diabetes distress (PAID) was present in 47% of recurrent and 34% of single episode DKA (P = 0.387). As a group, DKA patients had significantly more unemployment, illicit drug use and tobacco smoking, a lower level of formal education and less regular medical contact compared with controls. Mental health disorders and adverse socioeconomic factors appear to be common in patients with DKA. The diagnosis of DKA presents an excellent opportunity to screen for depression and offer appropriate intervention.

Risk factors, outcomes, and predictors of resolution of acute kidney injury in children with diabetic ketoacidosis.

Acute kidney injury (AKI) is a common complication in patients with diabetic ketoacidosis (DKA) (incidence 35-77%). AKI evolution during DKA treatment/recovery is poorly understood. Our aim was to assess children with DKA for prevalence, short-term kidney outcomes, severity, and predictors of AKI development and resolution. This retrospective cohort study included children aged 2-14years admitted with DKA between January 2016 and May 2020 in a Saudi tertiary care hospital. We defined AKI as an increase in serum creatinine of > 1.5 times baseline or > 3mg/dL (26mmol/L) within 48h. Of 213 patients admitted with DKA, 172 (80.75%) developed AKI: stage 1 in 83 (38.96%), stage 2 in 86 (40.37%), and stage 3 in 3 (1.4%). No patient required dialysis. Multivariate analysis showed an increased risk of developing AKI with male gender (OR = 2.85) and lower serum bicarbonate (OR = 0.83) when adjusted for initial heart rate, hematocrit, new onset diabetes, and recurrent AKI. The mean time to AKI resolution was 13.21 ± 6.78h. Factors leading to prolonged recovery from AKI in linear regression analysis were older age (B coefficient = 0.44, p = 0.01), recurrent DKA episodes (B coefficient = 3.70, p value 0.003), increased acidosis severity (B coefficient = - 0.44, p = 0.04), increased time to anion gap normalization (B coefficient = 0.44, p = 0.019), and increased initial glucose (B coefficient = 0.01, p = 0.011). In our cohort, AKI is a common, but mostly transient complication in children presenting with DKA, and its severity is associated with longer intensive care stays and time for acidosis resolution. AKI was associated with male gender, and lower serum bicarbonate. Proper consideration of such risk factors is needed for AKI assessment and management in future DKA clinical practice guidelines. A higher resolution version of the Graphical abstract is available as Supplementary information.

AACE2021-A-1011: Recurrent Diabetic Ketoacidosis: Can We Prevent It?

Diabetic ketoacidosis begets another attack. It's often a challenge in treating diabetic children. Factors associated with recurrent diabetic ketoacidosis include psychological disturbance, depression, antidepressant use, abnormal eating pattern, social deprivation, female sex especially in teen age, and uncontrolled diabetes. Recurrent diabetic ketoacidosis is an independent predictor of short term mortality at 2-6 years. This retrospective study included review of medical records of 32 type 1 diabetic patients, 19 females and 13 males who were admitted with diabetic ketoacidosis to King Fahad hospital, Madina, Saudi Arabia. They aged 14 to 32 years. Data included for each patient included age, sex, number of attacks of diabetic ketoacidosis in last 2 years (from August 2018 to August 2020), HbA1c, and use of insulin pump or antidepressants. All cases presented with metabolic ketoacidosis and ketonuria. The largest number of attacks was 4 admissions per year in a female who was on antidepressant and has HbA1c 10.4% in her last admission. The mean HbA1c in females was 9.45% and in males 9.59%. 4 female patients are on insulin pump and 2 female patients have end stage renal disease. Adverse effects of recurrent diabetic ketoacidosis admissions include social burden, economic cost and patient morbidity/mortality. Suggested strategy for prevention of recurrent diabetic ketoacidosis include education of patient and care givers, multidisciplinary team composed of endocrinologist/diabetologist, dietician, psychiatrist, psychologist, social worker and diabetic educator. Continuous glucose monitors can also prevent or reduce recurrence of diabetic ketoacidosis.

Intensive sick day rules to prevent recurrent diabetic ketoacidosis- An intervention that exemplifies health disparities

ObjectiveDiabetic ketoacidosis (DKA) is the leading cause of morbidity and mortality in children with type 1 diabetes (T1D). In established T1D patients, DKA is frequently a result of insulin omission or inadequate insulin administration during illness or stress. Ethnic minorities and patients with lower socioeconomic status are affected disproportionately. We hypothesized that implementation of intensive sick day rules with frequent reinforcement would reduce hospitalizations secondary to DKA in T1D youth irrespective of their demographics. MethodsIntensive sick day rules were implemented beginning January 2016. All T1D patients seen in the pediatric endocrinology clinic or hospital between January 1st 2015 through December 31st 2017 were included for chart review. Categorical variables were analyzed with Chi-square test. For the continuous variables, t test was used. Episodes of DKA per 100 patients were compared using the trends test over the three-year period. Patients who had DKA in 2015 were analyzed as a subgroup. ResultsThe frequency of DKA episodes per 100 patient years for 2015 was 19.1, for 2016 was 15.2 and was 12.4 for 2017. This decrease was statistically significant (p=0.006). The decline was also statistically significant for the subgroup of patients who developed DKA in 2015 and followed longitudinally. The decline was not uniform across all patient groups and DKA episodes remained associated with African- American race, Medicaid insurance status and higher HbA1c throughout the years. ConclusionImplementation of intensive sick day rules led to a decrease in total number of DKA admissions in our population with T1D youth. However, this intervention did not reduce the health disparity in this population and African-Americans on Medicaid insurance continued to form the disproportionate majority of admissions with DKA. This study highlights the need for further research into interventions that can improve outcomes across racial and socio-economic barriers.

Predictors and outcomes of recurrent diabetic ketoacidosis in Israeli adults

AimsTo identify risk factors for recurrent episodes of DKA that may allow the development of an effective prevention strategies. MethodsRetrospective analysis of admissions for DKA in adult patients between 2004, and 2017 in a tertiary hospital. The clinical characteristics and outcomes of DKA of patients were stratified into an isolated episode of DKA (group 1) and recurrent episodes (group 2). Results: 385 patients were included in the study, 281 had a single admission of DKA, and 104 had recurrent admissions. There were no statistically significant differences between the two groups in demographic or clinical variables. Patients in the recurrent DKA group had a younger age at diabetes diagnosis, 32.1 ± 17.08 vs. 36.13 ± 19.52 (p = 0.05). Patients with A1C greater than 9.0% were associated with recurrent DKA in cox regression analysis (HR 2.023; 95% Cl 1.112–3.679; p = 0.021). Recurrent DKA was a significant predictor of one-year mortality in cox regression analysis (HR 0.172; 95% CI 0.04–0.742; p = 0.018). ConclusionHigh A1C levels, which account for poorly controlled diabetes, was identified as the strongest predictor of recurrent DKA. This patient population warrants particular attention and the development of intervention strategies in further studies.

Clinical, psychological and demographic factors in a contemporary adult cohort with diabetic ketoacidosis and type 1 diabetes.

Diabetic ketoacidosis (DKA) is a potentially life-threatening but often preventable acute complication of type 1 diabetes (T1D). Understanding clinical and psychosocial characteristics of people with DKA, particularly those with multiple presentations, may aid the development of prevention strategies. To describe clinical, psychological and demographic factors in adults with DKA and particularly those factors associated with recurrent admissions. A retrospective analysis was performed of all admissions with DKA in people with T1D over a 4-year period from 1 November 2013 to 31 October 2017 at a metropolitan tertiary hospital in Australia. Potential cases were identified by International Classification of Diseases-10th Revision coding data. Data were then manually extracted by clinicians from the electronic medical record. There were 154 clinician-adjudicated admissions for DKA among 128 people with T1D. Of these, 16 (13%) had multiple DKA admissions. Forty-one (32%) had a history of depression. The most common factors contributing to presentation included insulin omission (54%), infection (31%), alcohol excess (26%) and new diabetes diagnosis (16%). Compared to people with single admissions, those with recurrent DKA were more likely to smoke (69% vs 27%, P = 0.003), be unemployed (31% vs 11%, P = 0.04) and use illicit substances (44% vs 17%, P = 0.02). There is a high prevalence of psychiatric illness, illicit substance use and social disadvantage among people admitted with DKA, particularly those with recurrent presentations. Insulin omission, often due to inappropriate sick day management, was the most common reason for DKA occurrence. Innovative multidisciplinary models of care are required to address these challenges.