The Long-Term Incidence of Hospitalization for Ketoacidosis in Adults with Established T1D—A Prospective Cohort Study

• Published in: The journal of clinical endocrinology and metabolism Vol. 105; no. 1; pp. 231 - 241
• Main Authors: Thomas, Merlin, Harjutsalo, Valma, Feodoroff, Maija, Forsblom, Carol, Gordin, Daniel, Groop, Per-Henrik
• Format: Journal Article
• Language: English
• Published: US Oxford University Press 01-01-2020; Copyright Oxford University Press
• Subjects: Care and treatment; Cholesterol; Cohort analysis; Complications and side effects; Diabetes; Diabetes mellitus (insulin dependent); Diabetic acidosis; Diabetic ketoacidosis; Diabetic nephropathy; End-stage renal disease; Glomerular filtration rate; Hospital care; Ketoacidosis; Kidney diseases; Nephropathy; Risk factors; Statistics; Type 1 diabetes; Finland
• ISSN: 0021-972X; 1945-7197
• DOI: 10.1210/clinem/dgz003

Abstract
Context
The long-term natural history of diabetic ketoacidosis (DKA) and its risk factors are poorly understood.
Objective
To determine the long-term incidence and predictors of DKA in adults with longstanding type 1 diabetes (T1D).
Design
All hospitalizations and deaths due to DKA between 1996 and 2016 were identified in 4758 adults with T1D from the Finnish Diabetic Nephropathy Study (FinnDiane), and a cohort of 16 224 adults with T1D from the Finnish general population.
Results
Between 1996 and 2015, there were 1228 DKA events in the FinnDiane participants (1.4/100 person-years) and 4914 DKA events (1.8/100 person-years) in adults with T1D from the general population. The majority were hospitalized only once. There was a modest increase in the frequency of DKA in the FinnDiane over the follow-up (~2.4%/year [95% CI, 0.3–4.5%]; P = 0.03). Predictors of DKA were glucose control, CSII, smoking and alcohol consumption, and raised high-density lipoprotein cholesterol and triacylglycerides. Diabetic nephropathy and renal impairment were associated with DKA; patients with end-stage renal disease, macroalbuminuria, and microalbuminuria had 2.09-fol (95% CI, 1.40–3.12), 1.65-fold (95% CI, 1.23–2.19), and 0.87-fold (95% CI, 0.61–1.24) risk of DKA compared with patients with normal albumin excretion rate, respectively. Patients with an estimated glomerular filtration rate <60 mL/min/1.73 m2 were also more likely to be hospitalized for DKA (HR 1.71 [95% CI, 1.26–2.67]).
Conclusions
DKA remains a common cause of hospitalization in individuals with longstanding T1D. These data suggest that the goal to use SGLT2 inhibitors for their vasculo- and renoprotective actions may be problematic, as those most likely to benefit may also have the highest risk for DKA.