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Increasing prevalence of diabetic ketoacidosis at diabetes diagnosis among children in Quebec: a population-based retrospective cohort study.

ABSTRACT: BACKGROUND:Diabetic ketoacidosis at type 1 diabetes diagnosis is a preventable life-threatening complication. Canadian data on the temporal trends of the prevalence of diabetic ketoacidosis at the onset of type 1 diabetes in children are unknown. We aimed to determine the temporal changes in diabetic ketoacidosis prevalence at diabetes diagnosis in Quebec. METHODS:We conducted a population-based cohort study of children (aged 1-17 yr) living in Quebec who were diagnosed with diabetes between 2001 and 2014, using multiple health administrative linked databases available at the Institut national de santé publique du Québec through the Quebec Integrated Chronic Surveillance System. We used multivariate Poisson regression analysis with robust error variance to determine trends in the prevalence of diabetic ketoacidosis. RESULTS:We found that 25.6% (1471/5741) of children presented with diabetic ketoacidosis at diabetes diagnosis. The incidence of diabetes was stable at 30 cases per 100 000 children per year during the study period. The age- and sex-standardized rates of diabetic ketoacidosis increased from 22% (95% confidence interval [CI] 17%-26%) in 2001 to 30% (95% CI 24%-36%) in 2014. The relative increase of diabetic ketoacidosis prevalence at diabetes diagnosis over the study period was 2.0% per year (rate ratio 1.02; 95% CI 1.01-1.03). INTERPRETATION:Despite a stable incidence of type 1 diabetes, we found that the prevalence of diabetic ketoacidosis at diabetes onset increased between 2001 and 2014. Our findings are concerning and demonstrate a need to continue to campaign to recognize type 1 diabetes before diabetic ketoacidosis supervenes.

SUBMITTER: Robinson ME

PROVIDER: S-EPMC6517121 | biostudies-literature | 2019 Apr-Jun

REPOSITORIES: biostudies-literature

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Increasing prevalence of diabetic ketoacidosis at diabetes diagnosis among children in Quebec: a population-based retrospective cohort study.

Robinson Marie-Eve ME Li Patricia P Rahme Elham E Simard Marc M Larocque Isabelle I Nakhla Meranda M MM

CMAJ open 20190401 2

<h4>Background</h4>Diabetic ketoacidosis at type 1 diabetes diagnosis is a preventable life-threatening complication. Canadian data on the temporal trends of the prevalence of diabetic ketoacidosis at the onset of type 1 diabetes in children are unknown. We aimed to determine the temporal changes in diabetic ketoacidosis prevalence at diabetes diagnosis in Quebec.<h4>Methods</h4>We conducted a population-based cohort study of children (aged 1-17 yr) living in Quebec who were diagnosed with diabe ...[more]

PMID: 31088804

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Project description:Background/objectiveThe prevalence of diabetic ketoacidosis (DKA) in gestational diabetes mellitus (GDM) is very low. We describe a patient with GDM in whom severe DKA with intrauterine fetal demise developed in the setting of nonadherence to therapy.Case reportA 33-year-old woman, G2P0010, with no preexisting diabetes mellitus (DM) presented at 30 weeks of gestation with acute-onset altered sensorium, nausea, and emesis. GDM was diagnosed at 15 weeks of gestation with a serum glucose level of 266 mg/dL (70-134 mg/dL) after 1-hour 50-gram glucose challenge test. Glycated hemoglobin (HbA1C) was 5.9% (41 mmol/mol) at the time of GMD diagnosis. Insulin was initiated at week 20 of gestation. On presentation, serum glucose level of 920 mg/dL (70-110 mg/dL), pH of 7.02 (7.32-7.43), anion gap level of 38 mmol (5-17 mmol), bicarbonate level of 5.0 mEq/L (22-29 mEq/L), and large serum ketones were found. Ultrasound showed intrauterine fetal demise. She received intravenous fluids and continuous insulin. Following the spontaneous delivery of a nonviable fetus, DKA was resolved. Negative antiglutamic acid decarboxylase, islet cell, and zinc transporter 8 antibodies, C-peptide level of 2.4 ng/dL (1.1-4.4 ng/dL), and HbA1C level of 9% (75 mmol/mol) were found. Inpatient management included basal-bolus and sliding scale insulin therapies. Metformin was added upon discharge 7 days after admission. The HbA1C levels were 5.3% (34 mmol/mol) and 5% (31 mmol/mol) at the 3- and 6-month follow-ups, respectively. Insulin was discontinued. Currently, the patient is on metformin and glucagon-like peptide 1 receptor agonist.DiscussionThe development of insulin resistance during pregnancy is driven by multiple factors. Approximately 1% to 2% of pregnant women with impaired glucose tolerance develop DKA; most cases occur in women with type 1 DM. The approximate incidence of DKA in GDM is 0.02%.ConclusionDKA complicating GDM is extremely infrequent, but it cannot be dismissed. Early recognition along with prompt and appropriate medical and obstetrical management is critical.

Project description:ObjectiveTo identify the factors associated with diabetic ketoacidosis at diagnosis of type 1 diabetes in children and young adults.DesignSystematic review.Data sourcesPubMed, EMBASE, Web of Science, Scopus, and Cinahl and article reference lists.Study selectionCohort studies including unselected groups of children and young adults presenting with new onset type 1 diabetes that distinguished between those who presented in diabetic ketoacidosis and those who did not and included a measurement of either pH or bicarbonate in the definition of diabetic ketoacidosis. There were no restrictions on language of publication.Results46 studies involving more than 24,000 children in 31 countries were included. Together they compared 23 different factors. Factors associated with increased risk were younger age (for <2 years old v older, odds ratio 3.41 (95% confidence interval 2.54 to 4.59), for <5 years v older, odds ratio 1.59 (1.38 to 1.84)), diagnostic error (odds ratio 3.35 (2.35 to 4.79)), ethnic minority, lack of health insurance in the US (odds ratio 3.20 (2.03 to 5.04)), lower body mass index, preceding infection (odds ratio 3.14 (0.94 to 10.47)), and delayed treatment (odds ratio 1.74 (1.10 to 2.77)). Protective factors were having a first degree relative with type 1 diabetes at the time of diagnosis (odds ratio 0.33 (0.08 to 1.26)), higher parental education (odds ratios 0.4 (0.20 to 0.79) and 0.64 (0.43 to 0.94) in two studies), and higher background incidence of type 1 diabetes (correlation coefficient -0.715). The mean duration of symptoms was similar between children presenting with or without diabetic ketoacidosis (16.5 days (standard error 6.2) and 17.1 days (6.0) respectively), and up to 38.8% (285/735) of children who presented with diabetic ketoacidosis had been seen at least once by a doctor before diagnosis.ConclusionsMultiple factors affect the risk of developing diabetic ketoacidosis at the onset of type 1 diabetes in children and young adults, and there is potential time, scope, and opportunity to intervene between symptom onset and development of diabetic ketoacidosis for both parents and clinicians.

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Increasing prevalence of diabetic ketoacidosis at diabetes diagnosis among children in Quebec: a population-based retrospective cohort study.

Publications

Increasing prevalence of diabetic ketoacidosis at diabetes diagnosis among children in Quebec: a population-based retrospective cohort study.

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