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Recurrent DKA increases mortality risk in at-risk patients with diabetes
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More than one in five patients with recurrent diabetic ketoacidosis will die within 3 years, with young, socially disadvantaged patients prescribed antidepressants most at risk for death, according to recent study findings.
“The most striking finding from this investigation is the substantial short-term risk of death associated with recurrent [diabetic ketoacidosis] admissions in patients with type 1 diabetes,” Fraser W. Gibb, MBChB, PhD, FRCP (Edin), consultant physician and honorary clinical senior lecturer at the Edinburgh Centre for Endocrinology and Diabetes, United Kingdom, and colleagues wrote. “In keeping with other modern cohorts, we found a low rate of inpatient mortality in patients presenting with [diabetic ketoacidosis]. ... However, the frequency of subsequent sudden death at home, particularly in young people, is unacceptably high.”
Fraser W. Gibb
In a retrospective cohort study, Gibb and colleagues analyzed data from all patients with type 1 diabetes admitted with diabetic ketoacidosis (DKA) to the Royal Infirmary of Edinburgh, a large university teaching hospital, during a 6-year period (2007-2012; n = 298; 628 admissions). DKA deaths were checked against mortality data from the national Scottish Care Information–Diabetes Collaboration database. Researchers analyzed electronic health record data for date of diabetes diagnosis, most recent HbA1c, length of inpatient hospital stay, lab data, diabetes complications and social deprivation status (using the Scottish index of multiple deprivation). Median follow-up was 3.4 years. Lifetime national DKA admission data were available for all patients diagnosed with diabetes from 1981 onward (n = 271). Researchers stratified these patients into three groups: one lifetime DKA episode (n = 96), two to five lifetime DKA episodes (n = 111) and more than five DKA episodes (n = 64).
There were no deaths identified during inpatient admissions for the management of DKA, according to researchers, but 44 patients (14.8%) with prior DKA presentation died during follow-up. Of these deaths, 52.3% occurred at home at a median age of 38 years; 10 deaths (eight at home) occurred within 2 months of the final DKA admission, and all deaths were unanticipated, according to researchers.
Among patients with at least five lifetime admissions for DKA, 15 (23.4%) died during a median of 2.4 years’ follow-up (HR = 6.18; 95% CI, 2.1-18.3). Among patients with two to five DKA admissions, 15 (13.5%) died during a median of 3.7 years (HR = 3.02; 95% CI, 1.1-8.4); a single lifetime DKA admission was associated with a 5.2% risk for death during a median follow-up of 4.1 years. The median age of death was lower in those with at least five DKA admissions (median age, 32 years) vs. those with two to five admissions (median age, 53 years) or one lifetime DKA admission (median age, 53 years).
In multivariable analysis, researchers found that a greater number of DKA admissions, longer diabetes duration, previous psychiatric admissions and older age at diagnosis were independent predictors of death.
“The clinical and research implications are that we need to confirm these findings in large national data sets (as opposed to a single hospital) and also consider new strategies to help support these vulnerable patients following discharge from hospital,” Gibb told Endocrine Today. – by Regina Schaffer
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Fraser W. Gibb, MBChB, PhD, FRCP (Edin), can be reached at the Edinburgh Centre for Endocrinology and Diabetes, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh EH16 4SA, United Kingdom; email: fraser.gibb@ed.ac.uk.
Disclosure: The researchers report no relevant financial disclosures.
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