Skip to main content
SpringerLink
Log in

Mortality after discharge from hospital following an episode of diabetic ketoacidosis

  • Original Article
  • Published:
Acta Diabetologica Aims and scope Submit manuscript

Abstract

Aims

The rate of inpatient mortality associated with diabetic ketoacidosis (DKA) has steadily decreased in recent decades. However, there remains a significantly increased outpatient death rate following an episode of survived DKA. We undertook this study to investigate the observed increase in mortality following an episode of DKA.

Methods

We completed a retrospective cohort study to investigate rates and causes of death in people admitted to our hospital with DKA between 2013 and 2018. DKA was confirmed by pre-defined biochemical parameters and cause of death data was extracted from multiple sources. Follow-up was for two years after discharge for all participants with one-year mortality being the main time point for analysis.

Results

We identified 818 admissions to hospital with DKA, affecting 284 people. Twenty people died as inpatients and a further 40 people died during the two-year follow-up. Of these 60 participants, cause of death was able to be determined for 41 (68%), with most deaths occurring due to infection or macrovascular disease. Risk factors for death within a year of hospital discharge included older age, vascular complications of diabetes, intellectual impairment and residential care living. Those who survived an episode of DKA had a one-year age-corrected mortality rate 13 times higher than the general population. This was more marked in the younger cohort with those aged 15–39 years being 49 times more likely to die in the year after surviving a DKA admission compared to their general population counterparts.

Conclusion

An episode of diabetic ketoacidosis is associated with a significant outpatient mortality risk with most deaths due to infectious or macrovascular causes. This study should prompt investigation of predictive scoring tools to identify those at increased mortality risk after DKA and encourage the development of targeted interventions to reduce mortality.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

Data availability

This study reports confidential health data on patients that cannot be made available in a public repository, even if anonymised, as per conditions of the ethics approval. Nonetheless, the anonymised data on which this manuscript was based could be made available to other investigators upon bona fide request, and following all the necessary approvals (including ethics approval) of the detailed study proposal and statistical analyses plan. Any queries should be directed to the corresponding author.

References

  1. Cooper H, Tekiteki A, Khanolkar M, Braatvedt G (2016) Risk factors for recurrent admissions with diabetic ketoacidosis: a case-control observational study. Diabet Med 33(4):523–528

    Article  CAS  Google Scholar 

  2. Bagg W, Sathu A, Streat S, Braatvedt GD (1998) Diabetic ketoacidosis in adults at Auckland Hospital, 1988–1996. Aust N Z J Med 28(5):604–608

    Article  CAS  Google Scholar 

  3. Skrivarhaug T, Bangstad HJ, Stene LC, Sandvik L, Hanssen KF, Joner G (2006) Long-term mortality in a nationwide cohort of childhood-onset type 1 diabetic patients in Norway. Diabetologia 49(2):298–305

    Article  CAS  Google Scholar 

  4. Secrest AM, Becker DJ, Kelsey SF, LaPorte RE, Orchard TJ (2010) All-cause mortality trends in a large population-based cohort with long-standing childhood-onset type 1 diabetes. Diabetes Care 33(12):2573–2579

    Article  Google Scholar 

  5. Ramaesh A (2016) Incidence and long-term outcomes of adult patients with diabetic ketoacidosis admitted to intensive care: a retrospective cohort study. J Intensive Care Soc 17(3):222–233

    Article  Google Scholar 

  6. Huang CC, Weng SF, Tsai KT, Chen PJ, Lin HJ, Wang JJ et al (2015) Long-term mortality risk after hyperglycemic crisis episodes in geriatric patients with diabetes: a national population-based cohort study. Diabetes Care 38(5):746–751

    Article  CAS  Google Scholar 

  7. Kao Y, Hsu CC, Weng SF, Lin HJ, Wang JJ, Su SB et al (2016) Subsequent mortality after hyperglycemic crisis episode in the non-elderly: a national population-based cohort study. Endocrine 51(1):72–82

    Article  CAS  Google Scholar 

  8. Stats NZ (2021) Subnational population estimates (DHB, DHB constituency), by age and sex, at 30 June 1996–2021 (2021 boundaries) [Internet]. Available from http://nzdotstat.stats.govt.nz/wbos/Index.aspx?DataSetCode=TABLECODE7509. Accessed 13 Jan 2022

  9. Secrest AM, Becker DJ, Kelsey SF, LaPorte RE, Orchard TJ (2010) Cause-specific mortality trends in a large population-based cohort with long-standing childhood-onset type 1 diabetes. Diabetes 59(12):3216–3222

    Article  CAS  Google Scholar 

  10. Stats NZ (2022) Infoshare Population death rates [Internet]. Available from: https://infoshare.stats.govt.nz/. Accessed 5 Feb 2022

  11. Coggon D, Rose G, Barker DJP (2003) Chapter 3 Comparing disease rates. In: Epidemiology for the unititiated [Internet], 5th edn. London: BMJ books. Available from https://www.bmj.com/about-bmj/resources-readers/publications/epidemiology-uninitiated/3-comparing-disease-rates. Accessed 28 Apr 2022]

  12. Newcombe RG (1998) Two-sided confidence intervals for the single proportion: comparison of seven methods. Stat Med 17(8):857–872

    Article  CAS  Google Scholar 

  13. Armitage P, Berry G (1994) Statistical methods in medical research [Internet], 3rd edn. England: Blackwell Scientific Publications. Available from https://www.ncbi.nlm.nih.gov/nlmcatalog/9309522. Accessed 28 Apr 2022

  14. Rothman KJ (1990) No adjustments are needed for multiple comparisons. Epidemiol Camb Mass 1(1):43–46

    Article  CAS  Google Scholar 

  15. Ministry of Health (2022) Population of Auckland DHB [Internet]. Ministry of Health NZ. Available from https://www.health.govt.nz/new-zealand-health-system/my-dhb/auckland-dhb/population-auckland-dhb. Accessed 25 Apr 2022

  16. Heald A, Stedman M, Robinson A, Davies M, Livingston M, Alshames R et al (2022) Mortality rate associated with diabetes: outcomes from a general practice level analysis in England using the royal college of general practitioners (RCGP) database indicate stability over a 15 year period. Diabetes Ther 13(3):505–516

    Article  Google Scholar 

  17. Thunander M, Lindgren A, Petersson C, Landin-Olsson M, Holmberg S (2020) Standard mortality rates and years of life lost for serologically defined adult-onset type 1 and type 2 diabetes—a fifteen year follow-up. Diabetes Res Clin Pract 1(160):107943

    Article  Google Scholar 

  18. Yang JJ, Yu D, Wen W, Saito E, Rahman S, Shu XO et al (2019) Association of diabetes with all-cause and cause-specific mortality in Asia: a pooled analysis of more than 1 million participants. JAMA Netw Open 2(4):e192696

    Article  Google Scholar 

  19. Gibb FW, Teoh WL, Graham J, Lockman KA (2016) Risk of death following admission to a UK hospital with diabetic ketoacidosis. Diabetologia 59(10):2082–2087

    Article  CAS  Google Scholar 

  20. Elsheikh A, Abdullah A, Wahab A, Eigbire GE, Salama A, Rajamani K (2018) Impact of obesity on outcomes of diabetic ketoacidosis—results from the national inpatient sample. Diabetes 67:2085

    Article  Google Scholar 

  21. Hamman RF (2010) Mortality risk in long-standing type 1 diabetes: hope and concern. Diabetes 59(12):2997–2998

    Article  CAS  Google Scholar 

Download references

Acknowledgements

The authors acknowledge the receipt of the Fiona Wu Research Grant awarded by the Auckland Diabetes Centre. We also acknowledge the work of Dr José Derraik and Dr Jo Secher who provided assistance with statistical analysis.

Funding

Auckland Diabetes Centre.

Author information

Authors and Affiliations

  1. Auckland City Hospital, 2 Park Road, Grafton, Auckland, New Zealand

    James A. D. Shand, Paul Morrow & Geoff Braatvedt

Authors
  1. James A. D. Shand
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Paul Morrow
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Geoff Braatvedt
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All authors contributed to the study conception and design; JS and PM: data collection was performed; GB: provided supervision; JS: the first draft of the manuscript was written and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to James A. D. Shand.

Ethics declarations

Conflict of interest

The authors were awarded the Fiona Wu Research Grant awarded by the Auckland Diabetes Centre.

Ethical approval

This retrospective chart review study involving human participants was conducted in accordance with the ethical standards of our institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

The requirement for individual informed consent was waived due to the nature of this study.

Additional information

Managed by Massimo Porta.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Shand, J.A.D., Morrow, P. & Braatvedt, G. Mortality after discharge from hospital following an episode of diabetic ketoacidosis. Acta Diabetol 59, 1485–1492 (2022). https://doi.org/10.1007/s00592-022-01953-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00592-022-01953-5

Keywords

Search

Navigation