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Risk of Early Death Tied to Episodes of Diabetic Ketoacidosis

Type 1 diabetes patients had a 30% higher risk of dying within six years after more than four hospitalizations for diabetic ketoacidosis…

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Those who were hospitalized only once for DKA had a 10% greater risk of dying within five years. The findings, presented at the American Diabetes Association’s Scientific Sessions, also revealed that patients who had a longer hospital stay during DKA admission were at a greater risk of dying during follow-up.

New research showed that in a cohort of adult patients with type 1 diabetes who were hospitalized with diabetic ketoacidosis (DKA), almost all patients survived the hospitalization, but they had an increased risk of early death. After one hospitalization for DKA, patients had a 10% greater risk of dying within five years, but, more importantly, they had a 30% increased risk of dying within six years after more than four hospitalizations for DKA.

Dr. Fraser W. Gibb (Edinburgh Centre for Endocrinology & Diabetes, Scotland) presenting this study at the American Diabetes Association (ADA) 2015 Scientific Sessions, stated that, it was also "really quite striking" that the patients had a median age of 31 when they died after multiple DKA hospitalizations, and many died at home, often from "uncertain causes." Therefore, there is an urgent need for greater efforts to manage psychological and medical morbidity in this young, high-risk population and for prospective, larger studies to better identify mortality risk, he said.

The researchers investigated the clinical features of DKA and differences between patients who had one vs multiple hospitalizations for DKA and examined predictors and rates of DKA mortality.

Dr. Gibb and colleagues retrospectively identified 298 adult patients with type 1 diabetes who were admitted to their hospital for DKA from 2007 to 2014 (a total of 631 admissions). They also obtained death records for these patients until 2014. The patients had a mean age of 32, and most were 20 to 40 years old when they presented to the hospital emergency department with DKA.

Most patients (189 patients; 63.4%) had only one hospitalization for DKA, but 27 patients (9.1%) had more than four hospitalizations for DKA. There were no inpatient deaths during DKA admission. However, 43 patients (14.4%) died during about 5 years of follow-up. The median time to death was 390 days, "but within that, about a quarter of patients were dying within 2 months of the last admission," Dr. Gibb noted. In this subgroup of 10 patients with death within two months, eight of the deaths occurred at home. The patients had a median age of 41. The cause of death was "unclear" in five patients and was due to cardiovascular events, poisoning, sepsis, or pulmonary thromboembolism in the other patients. "These are largely unanticipated and arguably preventable deaths with unclear cause of death in most patients," Dr. Gibb said.

About one in 10 patients (10.6%) with a single hospitalization due to DKA died within 4.6 years; 18.3% of patients with two to four hospitalizations died within 5 years, and 29.7% of patients with more than four hospitalizations died within 6.4 years (P = .016). Although the follow-up was slightly longer in patients with more than four hospitalizations, with adjustment, this was still a two- to threefold higher risk, Dr. Gibb stressed.

The patients who were most likely to die during follow-up had a longer hospital stay during DKA admission (P < .001), higher plasma urea levels (P < .001), and a longer duration of diabetes (P = .004) and were older when they had their last DKA admission (P = .001). HbA1c and social class were not associated with mortality. Factors associated with a significantly increased risk of dying during follow-up after hospitalization for DKA included psychological issues (odds ratio [OR], 2.26), peripheral neuropathy (OR, 2.56), ischemic heart disease (OR, 4.06), alcohol excess (OR, 2.57) and prior admission to intensive care (OR, 2.46).

On the one hand, inpatient DKA deaths were extremely rare in their center, Dr. Gibb summarized. However, the subsequent risk of death was high in patients with type 1 diabetes with multiple episodes of DKA requiring hospitalization, and many of the deaths occurred suddenly in young people. "It does raise the question of whether greater efforts are required to deal with psychological issues and manage medical risk" in these young, at-risk patients, he concluded.

Practice Pearls:

  • About one in 10 type 1 patients (10.6%) with a single hospitalization due to DKA died within 4.6 years
  • Factors associated with a significantly increased risk of dying during follow-up after hospitalization for DKA included psychological issues, peripheral neuropathy, ischemic heart disease and alcohol excess.
  • Greater efforts are required to deal with psychological issues and manage medical risk in these young, at-risk patients.

American Diabetes Association 2015 Scientific Sessions; June 7, 2015; Boston, Massachusetts. Abstract 273-OR