Trends in the prevalence of ketoacidosis at diabetes diagnosis: the SEARCH for diabetes in youth study

Characteristics of Turkish children with Type 2 diabetes at onset: a multicentre, cross-sectional study

AIMS

To describe the baseline clinical and laboratory findings and treatment modalities of 367 children and adolescents diagnosed with Type 2 diabetes in various paediatric endocrinology centres in Turkey.

METHODS

A standard questionnaire regarding clinical and laboratory characteristics at onset was uploaded to an online national database system. Data for 367 children (aged 6-18 years) newly diagnosed with Type 2 diabetes at 37 different paediatric endocrinology centres were analysed.

RESULTS

After exclusion of the children with a BMI Z-score < 1 SD, those with genetic syndromes associated with Type 2 diabetes, and those whose C-peptide and/or insulin levels were not available, 227 cases were included in the study. Mean age was 13.8 ± 2.2 (range 6.5-17.8) years, with female preponderance (68%). Family history of Type 2 diabetes was positive in 86% of the children. The mean BMI was 31.3 ± 6.5 kg/m² (range 18.7-61) and BMI Z-score was 2.4 ± 0.8 (range 1-5). More than half (57%) of the children were identified by an opportunistic diabetes screening due to existing risk markers without typical symptoms of diabetes. Only 13% (n = 29) were treated solely by lifestyle modification, while 40.5% (n = 92) were treated with metformin, 13% (n = 30) were treated with insulin, and 33.5% (n = 76) were treated with a combination of insulin and metformin initially. Mean HbA_1C levels of the insulin and combination of insulin and metformin groups were 98 (11.1%) and 102 mmol/mol (11.5%), respectively, and also were significantly higher than the lifestyle modification only and metformin groups mean HbA_1C levels (70(8.6%) and 67 mmol/mol (8.3%), respectively).

CONCLUSIONS

An opportunistic screening of children who are at high risk of Type 2 diabetes is essential, as our data showed that > 50% of the children were asymptomatic at diagnosis. The other important result of our study was the high rate of exclusion from the initial registration (38%), suggesting that accurate diagnosis of Type 2 diabetes in youth is still problematic, even for paediatric endocrinologists.

Risk of hyperglycemic crisis episode in diabetic patients with bipolar disorder: A nationwide population-based cohort study

BACKGROUND

Suboptimal management of diabetes can lead to a hyperglycemic crisis episode (HCE), which could be further enhanced in the presence of bipolar disorder (BD) and the prescription of antipsychotics. This study aims to investigate the risk of HCE in diabetic patients with BD. Additionally, the duration of antipsychotic prescription on HCE risk is examined.

METHODS

Using the Taiwan National Health Insurance Research Database, 6099 diabetic patients with BD and 24,378 diabetic patients without BD matched by gender, age, index year, and Charlson Comorbidity Index score were enrolled between 1999 and 2010 and followed to the end of 2013. Participants who developed HCE during the follow-up period were identified. Cox regression analysis was used to calculate the hazard ratio (HR) with 95% confidence interval (CI) of the HCE incidence rate between two groups studied.

RESULTS

Diabetic patients with BD were associated with an increased risk of HCE compared with unaffected controls after adjusted for baseline demographics and duration of antipsychotic prescription (3.84 versus 2.71 per 1,000 person-years, HR: 1.41, 95% CI: 1.15-1.71). Also, this study revealed that male gender, more comorbidities, and a longer duration of antipsychotic prescription were potential risk factors for developing HCE.

LIMITATIONS

This study only deals with data on the duration of antipsychotic prescription, without showing the effects of different antipsychotics on HCE risk.

CONCLUSION

This study highlights the need to pay attention to the risk of HCE in diabetic patients with BD and the importance of careful prescription of antipsychotics to reduce the HCE incident.

Pediatric stroke as the presenting symptom of new-onset type 1 diabetes mellitus without DKA: case report and literature review

Background Stroke and other neurologic complications are rare in pediatric type 1 diabetes mellitus (T1DM) without severe diabetic ketoacidosis (DKA) or poor glycemic control. Case presentation A previously healthy, 10-year-old female presented with acute thalamic stroke, non-acidotic new T1DM diagnosis and negative hypercoagulopathy workup. She received routine insulin therapy and aspirin, and returned to neurologic baseline within a year without stroke recurrence. Conclusions The contribution of non-acidotic hyperglycemia to stroke risk is better described in adults. Even though unable to prove causality, this case should at least raise awareness of the possible association of pediatric new-onset diabetes and stroke for optimal outcomes.

Incidence of diabetic ketoacidosis in newly diagnosed type 1 diabetes children in western Saudi Arabia: 11-year experience

Background A wide range of reports on the incidence of diabetic ketoacidosis (DKA) at the onset of type 1 diabetes mellitus (T1DM) in children have been published worldwide. Reports from Saudi Arabia are limited. The aim of this study was to assess the incidence, clinical pattern and severity of DKA in children with newly diagnosed T1DM and the association of autoimmune conditions with initial DKA occurrence at King Abdulaziz Medical City - Jeddah. Methods This retrospective chart review was conducted during the period 2005-2015. All newly diagnosed T1DM children during the study period were investigated (n = 390). Data were collected on the demographic characteristics, body mass index (BMI), DKA severity, length of hospital stay and follow-up data on the type of diabetes therapy. Results The incidence of DKA among newly diagnosed T1DM pediatric patients was 37.7% (n = 147). Moderate and severe DKA cases were significantly higher among female children (p = 0.04). Patients diagnosed with DKA had lower BMI (20.87 ± 5.21) than their counterparts (p = 0.03). The median length of hospital stay was higher among severe DKA compared to moderate and mild cases (5.0, 4.5 and 4.0 days, respectively). Conclusions The incidence of DKA among newly diagnosed T1DM is still high compared to developed countries; however, it is relatively lower than previous reports in Saudi Arabia. Immediate interventions, such as awareness campaigns, are vital to reduce the burden of this preventable health sequela among children with DM.

Risk of ketoacidosis in children at the time of diabetes mellitus diagnosis by primary caregiver status: a population-based retrospective cohort study

BACKGROUND

Diabetic ketoacidosis is the leading cause of death among children with type 1 diabetes mellitus, and is an avoidable complication at first-time diagnosis of diabetes. Because having a usual provider of primary care is important in improving health outcomes for children, we tested the association between having a usual provider of care and risk of diabetic ketoacidosis at onset of diabetes.

METHODS

Using linked health administrative data for the province of Quebec, we conducted a population-based retrospective cohort study of children aged 1-17 years in whom diabetes was diagnosed from 2006 to 2015. We estimated adjusted risk ratios (RRs) for an episode of diabetic ketoacidosis at the time of diabetes diagnosis in relation to usual provider of care (family physician, pediatrician or none) using Poisson regression models with robust error variance.

RESULTS

We identified 3704 new cases of diabetes in Quebec children from 2006 to 2015. Of these, 996 (26.9%) presented with diabetic ketoacidosis. A decreased risk of this complication was associated with having a usual provider of care; the association was stronger with increasing age, reaching statistical significance among those aged 12-17 years. Within this age group, those who had a family physician or a pediatrician were 31% less likely (adjusted RR 0.69, 95% confidence interval [CI] 0.56-0.85) or 38% less likely (adjusted RR 0.62, 95% CI 0.45-0.86), respectively, to present with diabetic ketoacidosis, relative to those without a usual provider of care.

INTERPRETATION

For children with newly diagnosed diabetes, having a usual provider of care appears to be important in decreasing the risk of diabetic ketoacidosis at the time of diabetes diagnosis. Our results provide further evidence concerning the need for initiatives that promote access to primary care for children.

Care of Children and Adolescents with Diabetes Mellitus and Hyperglycemia in the Inpatient Setting

PURPOSE OF REVIEW

Children and adolescents with acute hyperglycemia and diabetes mellitus frequently have acute, potentially life-threatening presentations which require high-acuity care in an inpatient and often intensive care setting. This review discusses the evaluation and care of hyperglycemia and diabetes mellitus in hospitalized children in both critical and non-critical care settings, highlighting important differences in their care relative to adults.

RECENT FINDINGS

Diabetic ketoacidosis remains highly prevalent at diagnosis among children with type 1 diabetes, and hyperglycemic hyperosmolar state is increasingly prevalent among children with type 2 diabetes. Recent clinical trials have investigated the potential benefits of various types of intravenous fluids and their rates of administration as well as the risks and benefits of intensive glucose control in critically ill children. The Endocrine Society has developed guidelines focused on managing hyperglycemic hyperosmolar state, outlining important aspects of care shown to decrease morbidity and mortality. In the non-critical illness setting, intensive therapy on newly diagnosed diabetes is increasingly recommended at the outset. With the increasing incidence of diabetes mellitus in children and adolescents, recent studies addressing acute diabetes emergencies help inform best practices for care of hospitalized children with hyperglycemia and diabetes.

Diabetic Ketoacidosis at Onset of Type 1 Diabetes: Rates and Risk Factors Today to 15 Years Ago

Diabetic ketoacidosis (DKA) is a serious, potentially lethal complication of type 1 diabetes mellitus that may be present at diagnosis. The aim of this study was to determine factors associated with presentation in DKA in new-onset youth and compare the rate of DKA and risk factors to a similar study 15 years prior. This study was a retrospective chart review of newly diagnosed patients with type 1 diabetes mellitus from 2010 to 2013. Of the 276 patients, 29% presented in DKA, compared with 38% 15 years prior (P < .002). Those with Medicaid, those misdiagnosed at initial encounter, and those not evaluated by a pediatrician initially were more likely to present in DKA (P = .002, P = .002, P < .001, respectively). The diagnosis of diabetes was not elicited in one third of patients who ultimately presented in DKA. Pediatricians should be reeducated to ask about polyuria and polydipsia in routine encounters. Furthermore, public awareness initiatives are needed to reduce late presentation in DKA.

Diabetic ketoacidosis in children newly diagnosed with type 1 diabetes mellitus: Role of demographic, clinical, and biochemical features along with genetic and immunological markers as risk factors. A 20-year experience in a tertiary Belgian center

BACKGROUND

Diabetic ketoacidosis (DKA) is the leading cause of morbidity and mortality in children with type 1 diabetes (T1D). Little is known about the association between genetic and immunological markers and the risk for DKA at onset of T1D. The aim of this study was to create a model foreseeing the onset of DKA in newly diagnosed patients.

METHODS

This retrospective study included 532 T1D children (aged <18 years at diagnosis) recruited in our hospital, from 1995 to 2014. DKA and its severity were defined according to the criteria of ISPAD. Genetic risk categories for developing T1D were defined according to the Belgian Diabetes Registry. Multivariate statistical analyses were applied to investigate risk factors related to DKA at diagnosis.

RESULTS

Overall 42% of patients presented DKA at diagnosis. This study outlined the major risk of DKA at diagnosis for younger children (<3 years) and for those belonging to ethnic minorities. Children carrying neutral genotypes had a 1.5-fold increased risk of DKA at diagnosis than those with susceptible or protective genotypes, a paradoxical observation not previously reported. Only solitary positive IA-2A increased the risk of DKA at diagnosis. The proposed model could help to predict the probability of DKA in 70% of newly diagnosed cases.

CONCLUSIONS

This was the first reported implication of IA-2A positivity and neutral genotypes predisposing to DKA at diagnosis regardless of its severity. Earlier diagnosis through genetic and immunological screening of high-risk children could decrease DKA incidence at diabetes onset.

Clinical Use of Degludec in Children and Adolescents with T1D: A Narrative Review with Fictionalized Case Reports

The use of insulin in children and adolescents with type 1 diabetes (T1D) is a challenge because of the heterogeneity of these patients and their lifestyles, with consequent unpredictability in blood glucose levels. A new ultra-long-acting basal insulin, insulin degludec (degludec), has the potential to mitigate some of these challenges, notably variability in the glucose-lowering action of the basal insulin component of an insulin regimen, and consequent risks of hypo- and hyperglycemia. However, the protracted half-life and steady state pharmacokinetics of degludec potentially bring some new challenges. In particular, the adjustment of therapy in response to commonly encountered clinical situations might require a different approach when degludec is used in place of other currently used basal insulins in this challenging patient population. The purpose of this article is to guide clinicians through a series of case histories in the use of this insulin. These include, but are not limited to, how to initiate, titrate, switch from other basal insulin or pump therapy; how to alleviate difficulties arising as a result of unpredictable lifestyle/habits; and how to maintain treatment following diabetic ketoacidosis. The guidance presented in this review illustrates that degludec is a good option for a diverse range of children and adolescents with T1D, providing much needed flexibility in the treatment of this challenging patient population.Funding Novo Nordisk.

The Incidence of Diabetic Ketoacidosis During "Emerging Adulthood" in the USA and Canada: a Population-Based Study

BACKGROUND

As children with diabetes transition to adulthood, they may be especially vulnerable to diabetic ketoacidosis (DKA). Cross-national comparisons may inform efforts to avoid this complication.

OBJECTIVE

To compare DKA hospitalization rates in the USA and Manitoba, Canada, during the vulnerable years known as "emerging adulthood."

DESIGN

Cross-sectional study using inpatient administrative databases in the USA (years 1998-2014) and Manitoba, Canada (years 2003-2013).

PARTICIPANTS

Individuals aged 12-30 years hospitalized with DKA, identified using ICD-9 (USA) or ICD-10 codes (Manitoba).

MAIN MEASURES

DKA hospitalization rates per 10,000 population by age (with a focus on those aged 15-17 vs. 19-21). Admissions were characterized by gender, socioeconomic status, year of hospitalization, and mortality during hospitalization.

KEY RESULTS

The DKA rate was slightly higher in the USA among those aged 15-17: 4.8 hospitalizations/10,000 population vs. 3.7/10,000 in Manitoba. Among those aged 19-21, the DKA hospitalization rate rose 90% in the USA to 9.2/10,000, vs. 23% in Manitoba, to 4.5/10,000. In both the USA and Manitoba, rates were higher among those from poorer areas, and among adolescent girls compared with adolescent boys. DKA admissions rose gradually during the period under study in the USA, but not in Manitoba.

CONCLUSIONS

In years of "emerging adulthood," the Canadian healthcare system appears to perform better than that of the USA in preventing hospitalizations for DKA. Although many factors likely contribute to this difference, universal and seamless coverage over the lifespan in Canada may contribute.

Misdiagnosis and Diabetic Ketoacidosis at Diagnosis of Type 1 Diabetes: Patient and Caregiver Perspectives

IN BRIEF Diabetic ketoacidosis (DKA) is a life-threatening complication that frequently occurs at diagnosis of type 1 diabetes, occurs more commonly when a patient is misdiagnosed, is the leading cause of death in children with type 1 diabetes, and is associated with worse long-term outcomes. Our retrospective online survey found that 25% of all participants were misdiagnosed and that misdiagnosis was associated with an 18% increased risk for DKA compared to those correctly diagnosed. Adult providers should consider type 1 diabetes when diagnosing type 2 diabetes, and pediatric providers should rule out type 1 diabetes when a patient reports nonspecific viral symptoms.

A structured 1-year education program for children with newly diagnosed type 1 diabetes improves early glycemic control

BACKGROUND

The diagnosis of type 1 diabetes (T1D) brings significant medical, psychosocial, and educational challenges for the child, family, and medical team. We developed a structured certified diabetes educator (CDE) led program spanning the year after diagnosis with the goal of supporting families as their understanding of this chronic disease and its management evolves.

OBJECTIVE

The aim of this study was to determine the effect of this program upon hemoglobin A1c (HbA1c), and how this effect is mitigated by socioeconomic status (SES).

METHODS

Patients enrolled in the type 1 year 1 (T1Y1) program were assigned a CDE who provided intensive coaching, tailored to family lifestyle, and readiness to assume independence. We identified all patients diagnosed with T1D in the 2 years before (controls) and after (T1Y1 group) the start of the T1Y1 program on January 7, 2014.

RESULTS

There were 675 patients diagnosed with T1D between July 2012 and June 2016 (284 controls, 391 T1Y1). HbA1c was significantly lower in the T1Y1 group at 6 (6.7% vs. 7.1%, P < 0.001), 12 (7.3% vs. 7.8%, P < 0.001) and 18 (7.6% vs. 7.9%, P = 0.01) months, but not 24 (7.8% vs. 8%, P = 0.14) months after diagnosis. This effect was not observed in patients with lower SES.

CONCLUSION

Additional structured education and support in the year after diagnosis can improve short-term outcomes in children with T1D, but this effect may not persist after discontinuing intensive coaching. Families of lower SES did not benefit from this approach.

Is Age a Risk Factor for Cerebral Edema in Children With Diabetic Ketoacidosis? A Literature Review

Cerebral edema (CE) is a rare but potentially fatal complication of diabetic ketoacidosis (DKA) in children with type 1 diabetes. CE is frequently mentioned as being more common in young children. The primary objective of this study was to review the evidence suggesting that younger age is a risk factor for the development of CE during DKA. The secondary objective was to assess if younger children are at a higher risk of DKA and severe DKA. A literature review was performed, and studies which reported the frequency of CE, DKA and severe DKA in children <3 and 3 to 5 years of age were included. Among the 6 studies reporting the frequency of CE that were identified, 5 good-quality studies found no significant association between younger age and higher risk of CE. Twenty-seven studies (DKA frequency: 11.3% to 54%) reported DKA frequency as a function of age. Most published studies found a higher frequency of DKA in children <5 years of age (20/25 studies), and in particular in those in the first 2 to 3 years of life (8/8 studies). There was inconclusive evidence to determine whether the severity of DKA was influenced by age. In conclusion, the commonly held view that CE is more common in younger children is not supported by the existing literature. Published data suggest that DKA (and possibly severe DKA) is more common in very young children. Regardless of age, all children with DKA should be monitored carefully for the development of CE.

The number of adults with incident type 1 diabetes phenotype in Iceland is half the number in children - A population based study

AIMS

Type1 diabetes is generally regarded as an abruptly presenting disease in children without family history. The incidence and prevalence of insulin requiring diabetes in adults is unclear. The aim of this study was to clarify this issue by examining the epidemiology of type 1 diabetes diagnosed in adulthood in a countrýs whole population.

METHODS

Complete clinical and prescription data were used to identify cases of insulin requiring diabetes in the Icelandic population 18 years and older during the decade preceding February 2013. Health care databases and the insulin reimbursement system allowed for near 100% ascertainment of cases.

RESULTS

Mean age at diagnosis was 32.1 years. The WHO age-adjusted incidence rate was 4.29/100.000 individuals and the point prevalence 0.10%. One fourth of cases were diagnosed after the age of forty. The male-to-female incidence rate ratio was 1.59. Almost 30% of cases presented with diabetic ketoacidosis and 40% had a positive family history.

CONCLUSION

Type 1 like diabetes commonly presents in adults and family history is not rare. One can expect one case of type 1 diabetes in adults for every two children diagnosed. These results emphasize the need to acknowledge the possibility of absolute insulin deficiency in any newly presenting adult with diabetes.

[Diagnosis and insulin therapy of type 1 diabetes mellitus (Update 2019)]

This guideline summarizes diagnosis of type 1 diabetes, including accompanying autoimmune disorders, insulin therapy regimens and glycemic target values.

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

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.

Diabetic ketoacidosis among adult patients with diabetes mellitus admitted to emergency unit of Hawassa university comprehensive specialized hospital

Objective

This study was aimed to assess the prevalence and associated factors of diabetic ketoacidosis among adult patients admitted in emergency department of Hawassa university comprehensive specialized hospital. An institution based retrospective cross-sectional study design was conducted among 195 adult patients aged 16 years and above with known or previously unknown diabetes cases presented in the emergency unit.

Result

In our study from the total 195 patients medical record reviewed 78 (40%) developed DKA. Out of the total reviewed medical record 55 (28.2%) and 23 (11.8%) were with type-1 and type 2 diabetes mellitus respectively. From acute complication of diabetes, diabetic ketoacidosis was a leading cause 78 (77%) followed by hypoglycemia 14 (14%) and hyperosmolar hyperglycemic state (9%). During multiple logistic regression analysis age and hypertension were found to have significant association with diabetic ketoacidosis.

Electronic supplementary material

The online version of this article (10.1186/s13104-019-4186-3) contains supplementary material, which is available to authorized users.

Complications of diabetes in China: health system and economic implications

BACKGROUND

The prevalence of diabetes and diabetic complications increased alarmingly which also brought heavy burden to patients and health system.

METHODS

We used mix approaches to summarize evidence from published articles and policy documents on the extent and trends of diabetic complications, potential causes, and awareness and services utilization of diabetes in China.

RESULTS

The annual direct medical expense per patient varied among different types of complications and increased dramatically with the number of diabetic complication and patients were exposed to great financial risk. The number of health policies and strategies on diabetes and its complications at the national level is limited. Primary and secondary preventions such as health education and early diagnosis are necessary.

CONCLUSIONS

With an increasingly burden of non-communicable diseases such as diabetes and its complications, efforts should be invested in education, early screening mechanism and patient management programs to improve the primary and secondary prevention of diabetes and its complications. An integrated services delivery system centered on primary level is recommended to promote education, early case-detection and screening, patient management, referral and care-coordination between primary, secondary and tertiary health care providers.

DKA cases over the last three years: has anything changed?

BACKGROUND

Diabetic ketoacidosis (DKA) has been related mainly to type 1 diabetes mellitus (T1DM). However, it is not solely related to T1DM. The purpose of this study was to assess the prevalence of DKA among type 1 and type 2 patients with diabetes mellitus, who were hospitalized in our Clinic due to DKA, as well as to determine the etiology beyond DKA.

PATIENTS AND METHODS

A cohort of 109 patients with DKA, 17-86 years of age, who were hospitalized in the Department of Endocrinology, Diabetes and Metabolism of our hospital between 2015 and 2017, were included in the study.

RESULTS

Among the 109 patients, 50 (45.9%) had mild DKA, 48 (44.1%) had moderate DKA, whereas 11 patients (10%) had severe DKA. Sixty-five patients (60%) developed DKA as the first manifestation of T1DM, 30 patients (27%) developed DKA in the context of type 2 diabetes (T2DM), mainly due to the co-existence of serious infections, 11 patients (10%) had T1DM, but had omitted their insulin dosages, and 3 patients (3%) developed DKA due to unknown reasons.

CONCLUSIONS

Most patients with DKA presented with mild and moderate DKA and only a minority presented with the severe form of the disease. The etiology of DKA was mainly T1DM and less frequent uncontrolled T2DM, usually due to the co-existence of severe infections, while only in a tiny minority, the causes remained unidentifiable.

Diabetic ketoacidosis at diagnosis of type 1 diabetes and glycemic control over time: The SEARCH for diabetes in youth study

BACKGROUND

The diagnosis of type 1 diabetes (T1D) in youth is often associated with diabetic ketoacidosis (DKA). We aimed to evaluate if the presence of DKA at diagnosis of T1D is associated with less favorable hemoglobin A1c (HbA1c) trajectories over time.

METHODS

The SEARCH for Diabetes in Youth study of 1396 youth aged <20 years with newly diagnosed T1D were followed for up to 13 (median 8 [interquartile range or IQR 6-9]) years after diagnosis. Of these, 397 (28%) had DKA (bicarbonate level < 15 mmol/L and/or pH < 7.25 (venous) or < 7.30 (arterial or capillary) or mention of DKA in medical records) at diabetes onset. Longitudinal HbA1c levels were measured at each follow-up visit (average number of HbA1c measures 3.4). A linear piecewise mixed effects model was used to analyze the effect of DKA status at diagnosis of T1D on long-term glycemic control, adjusting for age at diagnosis, diabetes duration at baseline, sex, race/ethnicity, household income, health insurance status, time-varying insulin regimen and glucose self-monitoring, study site, and baseline fasting C-peptide level.

RESULTS

At baseline, HbA1c levels were significantly higher in youth with T1D diagnosed in DKA vs those who were not (9.9% ± 1.5% vs 8.5% ± 1.4%, respectively). After the first year with diabetes, there was a significant difference in the rate of change in HbA1c levels by DKA status: HbA1c was 0.16% higher each year in youth with DKA compared to those without (interaction P-value<0.0001), after adjusting for aforementioned covariates.

CONCLUSIONS

DKA at T1D diagnosis is associated with worsening glycemic control over time, independent of demographic, socioeconomic, and treatment-related factors and baseline fasting C-peptide.

Childhood onset type 1 diabetes at a tertiary hospital in south-western Iran during 2000-2015: Rapid increase in admissions and high prevalence of DKA at diagnosis

AIMS

Incidence of type 1 diabetes mellitus (T1DM) is increasing worldwide. We aimed to study trends in presentation and incidence of childhood diabetes in the last 15years in south-western Iran.

METHODS

During a detailed review of compiled records of the main tertiary children's hospital of southwest of Iran, from January 2000 to December 2009, the following clinical information relevant to diabetes were analysed: admissions, demographic data, clinical and laboratory findings, hospital course, and mortality. Study continued 5years more to find out the real rate of increase. Significant findings with respect to the incidence of DKA, gender and age of subjects were summarized from among these cases. A total of 297 (known and new) cases were enrolled in the 1st (10year) stage of study and 691 new subjects in the 2nd (5year) period to check the trend in the whole 15year study period.

RESULTS

In the 1st period; excluding 129 repeated admissions, 297 cases were enrolled for analysis: 223 new and 74 known cases. Among the new cases, 67.3% presented with DKA, without any gender bias. Mortality rate in DKA subjects was 4% with higher risk in the <2year group and in girls (boy: girl=1:7; p=0.039). Adding the 2nd study period (total 15years) disclosed a rapid rise of incidence (new cases/5year) as 89, 134 and 691 new diabetes cases for the 1st, 2nd and 3rd 5year period of study respectively. The final annual incidence for <15year age group in 2015 was 13.35/100000.

CONCLUSIONS

The most new cases of T1DM presented with DKA, which is similar to the other developing countries. Such an increasing incidence of DM proposes more attention for periodic retraining of families and health staff to earlier diagnosis and management of new subjects, and to reduce morbidity and mortality rates.

Mitochondrial NAD+/NADH Redox State and Diabetic Cardiomyopathy

Significance: Diabetic cardiomyopathy (DCM) is a frequent complication occurring even in well-controlled asymptomatic diabetic patients, and it may advance to heart failure (HF). Recent Advances: The diabetic heart is characterized by a state of "metabolic rigidity" involving enhanced rates of fatty acid uptake and mitochondrial oxidation as the predominant energy source, and it exhibits mitochondrial electron transport chain defects. These alterations promote redox state changes evidenced by a decreased NAD⁺/NADH ratio associated with an increase in acetyl-CoA/CoA ratio. NAD⁺ is a co-substrate for deacetylases, sirtuins, and a critical molecule in metabolism and redox signaling; whereas acetyl-CoA promotes protein lysine acetylation, affecting mitochondrial integrity and causing epigenetic changes. Critical Issues: DCM lacks specific therapies with treatment only in later disease stages using standard, palliative HF interventions. Traditional therapy targeting neurohormonal signaling and hemodynamics failed to improve mortality rates. Though mitochondrial redox state changes occur in the heart with obesity and diabetes, how the mitochondrial NAD⁺/NADH redox couple connects the remodeled energy metabolism with mitochondrial and cytosolic antioxidant defense and nuclear epigenetic changes remains to be determined. Mitochondrial therapies targeting the mitochondrial NAD⁺/NADH redox ratio may alleviate cardiac dysfunction. Future Directions: Specific therapies must be supported by an optimal understanding of changes in mitochondrial redox state and how it influences other cellular compartments; this field has begun to surface as a therapeutic target for the diabetic heart. We propose an approach based on an alternate mitochondrial electron transport that normalizes the mitochondrial redox state and improves cardiac function in diabetes.

Metformin-decavanadate treatment ameliorates hyperglycemia and redox balance of the liver and muscle in a rat model of alloxan-induced diabetes

MetfDeca treatment ameliorate glucose and insulin levels, and reduce the levels of oxidized glutathione, reactive oxygen species, malondialdehyde, and 4-hydroxyalkenal; the superoxide and catalase activities, and glutathione levels were regulated.

2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2019

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

[Diabetic ketoacidosis in children: epidemiological and prognostic aspects]

INTRODUCTION

In Congo, data on diabetic ketoacidosis (DKA) in children are old and rare. This study aims to describe the sociodemographic features of DKA and to identify risk factors for mortality.

PATIENTS AND METHODS

We conducted an analytical study on DKA in childred at the University Hospital in Brazzaville over the period from January 2013 to June 2016. We examined the socio-demographic, clinical, paraclinical and evolutionary variables. Chi-Square Test, Fisher's exact test and odds ratio were used in the univariate analysis process and logistic regression model in the multivariate analysis.

RESULTS

Out of 172 children hospitalized with diabetes 55 (31%) were hospitalized with ketoacidosis. They were girls (33; 60%) with an average age of 11.1± 4.9 years (ranging from 1 months to 17 years), 61.8% of parents came from low socioeconomic status. Ketoacidosis was the revealing symptom in 67.2 % of cases. The diagnosis made before hospitalization was wrong (50%). The triggering factor was often an infection (52.7%). Mortality rate was 12.7%. The risk factors for mortality in the univariate analysis were: age < 5 years (p=0,000006), average consultation time higher than 7 days (p= 0.001), severe dehydration (p = 0.0006), hemodynamic disorders (p= 0.0006), severe undernutrition (p= 0.02), Glasgow Coma Scale < 9 (p= 0.007) and diarrhea (p= 0.001).

CONCLUSION

The importance and the seriousness of ketoacidosis impose preventive measures based on awareness, information and education campaigns as well as on the management of risk factors for mortality.

A mixed method approach to understanding the factors surrounding delayed diagnosis of type one diabetes

AIMS

This study examined delayed type one diabetes (T1D) diagnosis, along with the associated severity markers, in the United States. Qualitative reflection was explored to add depth of understanding.

METHODS

975 parents of a minor child with T1D were recruited through snowball, social media requests to complete a 55-question online survey on the experience of diagnosis.

RESULTS

34% of children with T1D had a delayed diagnosis. When compared to those without a delayed diagnosis, these children were more likely to have an Emergency Room diagnosis (39.8% vs. 24.6%), be transported by ambulance or life flight (30.7% vs. 15.3%), be hospitalized (93.7% vs. 83.9%), spend time in an Intensive Care Unit (42.2% vs. 21.3%), and be in diabetic ketoacidosis (DKA) (42.2% vs. 21.3%). Younger children were at increased risk, with higher rates of DKA and fewer days of symptoms. Many parents experienced frustration receiving a prompt diagnosis for their child, including an inability to schedule a physician appointment, proper glucose testing, and concerns being dismissed by professionals.

CONCLUSION

More physician and parent education is needed. Doctors should conduct glucose screenings when diabetes symptoms are present. Parents need education to recognize excessive thirst and frequent urination as reasons to seek medical treatment.

Trends in Hospital Admission for Diabetic Ketoacidosis in Adults With Type 1 and Type 2 Diabetes in England, 1998-2013: A Retrospective Cohort Study

OBJECTIVE

This study determined trends in hospital admission for diabetic ketoacidosis (DKA) in adults with type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) from 1998 to 2013 in England.

RESEARCH DESIGN AND METHODS

The study population included 23,246 adults with T1DM and 241,441 adults with T2DM from the Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES). All hospital admissions for DKA as the primary diagnosis from 1998 to 2013 were identified. Trends in hospital admission for DKA in incidence, length of hospital stay, 30-day all-cause readmission rate, and 30-day and 1-year all-cause mortality rates were determined using joinpoint regression, negative binomial regression, and logistic regression models.

RESULTS

For T1DM, the incidence of hospital admission for DKA increased between 1998 and 2007 and remained static until 2013. The incidence in 2013 was higher than that in 1998 (incidence rate ratio 1.53 [95% CI 1.09-2.16]). For T2DM, the incidence increased 4.24% (2.82-5.69) annually between 1998 and 2013. The length of hospital stay decreased over time for both diabetes types (P ≤ 0.0004). Adults with T1DM were more likely to be discharged within 2 days compared with adults with T2DM (odds ratio [OR] 1.28 [1.07-1.53]). The 30-day readmission rate was higher in T1DM than in T2DM (OR 1.61 [1.04-2.50]) but remained unchanged for both diabetes types over time. Trends in 30-day and 1-year all-cause mortality rates were also stable, with no difference by diabetes type.

CONCLUSIONS

In the previous two decades in England, hospitalization for DKA increased in adults with T1DM and in those with T2DM, and associated health care performance did not improve except decreased length of hospital stay.

Peripheral Neuropathy as a Complication of Diabetic Ketoacidosis in a Child with Newly Diagnosed Diabetes Type 1: A Case Report

Neurological complications of diabetic ketoacidosis are considered to be a serious clinical problem. The most common complication is cerebral edema. However, these neurological complications also include less common entities such as ischemic or hemorrhagic stroke, cerebral venous and sinus thrombosis or peripheral neuropathy. We present a case of a 9-year old girl admitted to our intensive care unit with new onset type 1 diabetes, diabetic ketoacidosis, cerebral edema, multifocal vasogenic brain lesions and bilateral lower limb peripheral paresis. The patient developed polydipsia and polyuria one week before admission. The initial blood glucose level was 1136 mg/dL and severe acidosis was present (pH 7.1; BE-25.9). Computed tomography scan showed brain edema and a hypodense lesion in the left temporal region. Brain magnetic resonance imaging revealed more advanced multifocal brain lesions. Nerve conduction studies demonstrated damage of the motor neurons in both lower limbs with dysfunction in both peroneal nerves and the right tibial nerve. With treatment and physiotherapy, the patient’s health gradually improved. Acute neuropathy after ketoacidosis is a rare complication and its pathogenesis is not clear. Patients with diabetic ketoacidosis require careful monitoring of neurological function, even after normalization of their glycemic parameters.

Methods for Measuring Risk for Type 2 Diabetes in Youth: the Oral Glucose Tolerance Test (OGTT)

PURPOSE OF REVIEW

The oral glucose tolerance test (OGTT) is used both in clinical practice and research to assess glucose tolerance. In addition, the OGTT is utilized for surrogate measures of insulin sensitivity and the insulin response to enteral glucose and has been widely applied in the evaluation of β-cell dysfunction in obesity, prediabetes, and type 2 diabetes. Here we review the use of the OGTT and the OGTT-derived indices for measurement of risk markers for type 2 diabetes in youth.

RECENT FINDINGS

Advantages of using the OGTT for measures of diabetes risk include its accessibility and the incorporation of physiological contributions of the gut-pancreas axis in the measures of insulin response to glucose. Mathematical modeling expands the potential gains from the OGTT in physiology and clinical research. Disadvantages include individual differences in the rate of glucose absorption that modify insulin responses, imperfect control of the glycemic stimulus, and poor intraindividual reproducibility. Available research suggests the OGTT provides valuable information about the development of impaired glycemic control and β-cell function in obese youth along the spectrum of glucose tolerance.

Type 1 diabetes

Type 1 diabetes is a chronic autoimmune disease characterised by insulin deficiency and resultant hyperglycaemia. Knowledge of type 1 diabetes has rapidly increased over the past 25 years, resulting in a broad understanding about many aspects of the disease, including its genetics, epidemiology, immune and β-cell phenotypes, and disease burden. Interventions to preserve β cells have been tested, and several methods to improve clinical disease management have been assessed. However, wide gaps still exist in our understanding of type 1 diabetes and our ability to standardise clinical care and decrease disease-associated complications and burden. This Seminar gives an overview of the current understanding of the disease and potential future directions for research and care.

Infant-juvenile type 2 diabetes

In recent years, we have witnessed an increase in the number of cases of type 2 diabetes mellitus (DM2) in children and adolescents, which has paralleled the increase in the worldwide prevalence of obesity. Although screening the general population does not appear to be cost-effective, special attention should be paid to children with excess weight, obesity or other factors that predispose them to a state of insulin resistance. When faced with the diagnosis of childhood DM2, the presence of comorbidities (such as hypertension, dyslipidemia and microalbuminuria) should be assessed, and appropriate treatment and follow-up should be administered to prevent the onset of complications, given that the DM2 in this population group will last longer than that started in adulthood.

Type 2 Diabetes in Youth: New Lessons from the SEARCH Study

PURPOSE OF REVIEW

The purpose of this review is to provide an update on the recent body of evidence emerging for type 2 diabetes as identified through the SEARCH for Diabetes in Youth study.

RECENT FINDINGS

This body of evidence illustrates that type 2 diabetes continues to increase in incidence, although this increase may be partially attributable to increased surveillance. Disease management is influenced by the transition from adolescent to adult care and psychosocial factors may also contribute. This evidence also describes a high prevalence of disease-associated complications and comorbidities. Risk factors for cardiovascular disease are also highly prevalent. The SEARCH for Diabetes in Youth study continues to inform our understanding of the descriptive epidemiology and natural history of type 2 diabetes in youth. As the cohort matures, new opportunities emerge for building on our understanding of how youth-onset type 2 diabetes impacts future health.

Racial/Ethnic Minority Youth With Recent-Onset Type 1 Diabetes Have Poor Prognostic Factors

OBJECTIVE

To compare races/ethnicities for characteristics, at type 1 diabetes diagnosis and during the first 3 years postdiagnosis, known to influence long-term health outcomes.

RESEARCH DESIGN AND METHODS

We analyzed 927 Pediatric Diabetes Consortium (PDC) participants <19 years old (631 non-Hispanic white [NHW], 216 Hispanic, and 80 African American [AA]) diagnosed with type 1 diabetes and followed for a median of 3.0 years (interquartile range 2.2-3.6). Demographic and clinical data were collected from medical records and patient/parent interviews. Partial remission period or "honeymoon" was defined as insulin dose-adjusted hemoglobin A_1c (IDAA1c) ≤9.0%. We used logistic, linear, and multinomial regression models, as well as repeated-measures logistic and linear regression models. Models were adjusted for known confounders.

RESULTS

AA subjects, compared with NHW, at diagnosis, were in a higher age- and sex-adjusted BMI percentile (BMI%), had more advanced pubertal development, and had higher frequency of presentation in diabetic ketoacidosis, largely explained by socioeconomic factors. During the first 3 years, AA subjects were more likely to have hypertension and severe hypoglycemia events; had trajectories with higher hemoglobin A_1c, BMI%, insulin doses, and IDAA1c; and were less likely to enter the partial remission period. Hispanics, compared with NHWs, had higher BMI% at diagnosis and over the three subsequent years. During the 3 years postdiagnosis, Hispanics had higher prevalence of dyslipidemia and maintained trajectories of higher insulin doses and IDAA1c.

CONCLUSIONS

Youth of minority race/ethnicity have increased markers of poor prognosis of type 1 diabetes at diagnosis and 3 years postdiagnosis, possibly contributing to higher risk of long-term diabetes complications compared with NHWs.

Nephrolithiasis: A complication of pediatric diabetic ketoacidosis

OBJECTIVE

To determine the frequency of nephrolithiasis as a complication of diabetic ketoacidosis (DKA) in pediatrics.

METHODS

We performed a retrospective chart review of patients with DKA admitted to a pediatric hospital between January 2009 and July 2016. We identified patients with nephrolithiasis during admission for DKA.

RESULTS

We identified 395 episodes of DKA over 7.5 years. Nephrolithiasis developed as a complication of DKA in 3 of those admissions (0.8%). All three patients with nephrolithiasis were males with new onset type 1 diabetes, aged 11 to 16.5 years. They all developed symptoms of nephrolithiasis after transition to subcutaneous insulin. One patient had subsequent worsening acidosis that required an additional 24 hours of IV insulin administration.

CONCLUSIONS

Nephrolithiasis is a rare complication of pediatric DKA, and should be considered in children with DKA who develop hematuria, flank pain, or suprapubic pain. Nephrolithiasis can increase insulin resistance due to increased pain and inflammation, so these patients should be monitored closely for recurrence of DKA. As patients with diabetes have increased risk of chronic kidney disease and nephrolithiasis can cause kidney injury, risk factors for nephrolithiasis should be identified and addressed to avoid subsequent kidney damage.

Ketoacidosis at diagnosis of type 1 diabetes: Effect of prospective studies with newborn genetic screening and follow up of risk children

We studied the frequency of diabetic ketoacidosis (DKA) in children at diagnosis of type 1 diabetes (T1D) in a region where newborn infants have since 1995 been recruited for genetic screening for human leukocyte antigen (HLA)-conferred disease susceptibility and prospective follow up. The aim was to study whether participation in newborn screening and follow up affected the frequency of DKA, and to follow the time trends in DKA frequency. We first included children born in Oulu University Hospital since 1995 when the prospective studies have been ongoing and diagnosed with T1D <15 years by 2015 (study cohort 1, n = 517). Secondly, we included all children diagnosed with T1D <15 years in this center during 2002-2014 (study cohort 2, n = 579). Children who had an increased genetic risk for T1D and participated in prospective follow up had low frequency of DKA at diagnosis (5.0%). DKA was present in 22.7% of patients not screened for genetic risk, 26.7% of those who were screened but had not an increased risk and 23.4% of children with increased genetic risk but who were not followed up. In study cohort 2 the overall frequency of DKA was 18.5% (13.0% in children <5 years, 14.0% in children 5-10 years and 28.6% in children ≥10 years at diagnosis; P<.001). In children <2 years the frequency of DKA was 17.1%. Participation in prospective follow-up studies reduces the frequency of DKA in children at diagnosis of T1D, but genetic screening alone does not decrease DKA risk.

Ketoacidosis at onset of type 1 diabetes is a predictor of long-term glycemic control

BACKGROUND

Few studies have evaluated the impact of diabetic ketoacidosis (DKA) at diabetes onset on long-term glycemic control in patients with type 1 diabetes (T1D).

OBJECTIVE

We aimed to determine any differences in long-term glycemic control between children/adolescents with T1D presenting with DKA at diabetes onset and those without.

METHODS

This retrospective study comprised 335 patients diagnosed with T1D from September 2007 to December 2012, among which 132 (39.4%) presented with DKA. Variables compared between patients with DKA at onset and those without: yearly hemoglobin A1c (HbA1c) levels, daily insulin dose, yearly rates of severe hypoglycemia and DKA, percent of patients achieving target HbA1c levels.

RESULTS

After the first year of diabetes, the mean daily insulin dose and HbA1c level were significantly higher in the group with DKA at onset (0.74 ± 0.26 vs 0.69 ± 0.27 units/kg/d, P = .049, and 7.85 ± 1.13% vs 7.49 ± 0.94%, P = .01, respectively), despite similarity of therapy (multiple daily injections or continuous subcutaneous insulin infusion), with a similar but not statistically significant trend subsequently. Mean HbA1c since onset was significantly higher in the DKA group (8.08 ± 0.95% vs 7.86 ± 0.95%, P = .025). A significantly higher percentage of patients in the group without DKA at onset achieved a mean level of HbA1c since onset within glycemic targets (32% vs 20.5%, P = .02). In the DKA group, the frequency of subsequent DKA episodes per diabetes years was significantly higher (P = .042).

CONCLUSIONS

DKA at diagnosis was associated with less favorable long-term glycemic control as assessed by HbA1c and the rate of DKA episodes. T1D patients presenting with DKA may therefore need stricter treatment and tight follow-up.

Congenital forms of diabetes: the beta-cell and beyond

The majority of patients diagnosed with diabetes less than 6 months of age, and many cases diagnosed between 6 and 12 months of age, have a gene mutation that causes permanent or transient hyperglycemia. Recent research advances have allowed for the discovery of new causes of congenital diabetes, including genes involved in pancreatic development (GATA4, NKX2-2, MNX1) and monogenic causes of autoimmune dysregulation (STAT3, LRBA). Ongoing follow-up of patients with KCNJ11 and ABCC8 mutations has supported the safety and efficacy of sulfonylureas, as well as the use of insulin pumps and continuous glucose monitors in infants with insulin-requiring forms of monogenic diabetes. Future studies are needed to improve clinical care and outcomes for these patients and their families.

Incidence of type 1 diabetes in China, 2010-13: population based study

OBJECTIVE

To estimate the incidence of type 1 diabetes in all age groups in China during 2010-13.

DESIGN

Population based, registry study using data from multiple independent sources.

SETTING

National registration system in all 505 hospitals providing diabetes care, and communities of patients with diabetes in 13 areas across China, covering more than 133 million person years at risk, approximately 10% of the whole population.

PARTICIPANTS

5018 people of all ages with newly diagnosed type 1 diabetes and resident in the study areas from 1 January 2010 to 31 December 2013.

MAIN OUTCOME MEASURES

Incidence of type 1 diabetes per 100 000 person years by age, sex, and study area. Type 1 diabetes was doctor diagnosed and further validated by onsite follow-up. Completeness of case ascertainment was assessed using the capture mark recapture method.

RESULTS

5018 cases of newly diagnosed type 1 diabetes were ascertained: 1239 participants were aged <15 years, 1799 were aged 15-29 years, and 1980 were aged ≥30 years. The proportion of new onset cases in participants aged ≥20 years was 65.3%. The estimated incidence of type 1 diabetes per 100 000 persons years for all ages in China was 1.01 (95% confidence interval 0.18 to 1.84). Incidence per 100 000 persons years by age group was 1.93 (0.83 to 3.03) for 0-14 years, 1.28 (0.45 to 2.11) for 15-29 years, and 0.69 (0.00 to 1.51) for ≥30 years, with a peak in age group 10-14 years. The incidence in under 15s was positively correlated with latitude (r=0.88, P<0.001), although this association was not observed in age groups 15-29 years or ≥30 years.

CONCLUSION

Most cases of new onset type 1 diabetes in China occurred among adults. The incidence of type 1 diabetes in Chinese children was among the lowest reported in the study.

Resolution of ketoacidosis in children with new onset diabetes: Evaluation of various definitions

AIMS

Data are sparse concerning use of serum electrolyte parameters as compared to venous blood gas (VBG) measurements to monitor acid-base status during treatment of diabetic ketoacidosis (DKA). We explored the utility of various parameters to define DKA resolution by investigating the relationship of venous pH (vpH), anion gap (AG), serum bicarbonate (HCO₃), and glucose concentration during management of DKA in children with new onset diabetes mellitus (NODM).

METHODS

We included all patients with NODM presenting with DKA to Boston Children's Hospital from 10/1/07-7/1/13. DKA was defined as serum glucose ≥ 200 mg/dL (11.1 mmol/L) and vpH<7.30; severity as mild <7.30, moderate<7.20, severe<7.10; resolution of DKA as vpH≥7.30 and AG≤18 mmol/L. We used Cox regression to determine time to DKA resolution, and logistic regression to evaluate different serum HCO₃ cut-off values as predictors of DKA resolution.

RESULTS

263 patients (133F, mean age 9.9±4.4 years, 74% White) were included. DKA was mild in 134 (51%), moderate in 75 (28%) and severe in 54 (20%). In mild DKA, AG closed after normalization of vpH; in moderate and severe DKA, AG closed before normalization of vpH. HCO₃>15mmol/L correlated with vpH≥7.30, and had 76% sensitivity and 85% specificity to predict DKA resolution. Median times to DKA resolution were similar using two different definitions: vpH and AG (8.4h [IQR 6.3-11.9]) vs. HCO₃>15 mmol/L (7.9 h [IQR 5.0-11.8]), p=.42.

CONCLUSIONS

During management of pediatric DKA, HCO₃ > 15 mmol/L reliably predicts resolution of DKA. In low-resource settings where VBG is unavailable, electrolyte parameters alone may be used to determine DKA resolution.