Risk Factors for Adverse Outcomes in Pediatric Diabetic Ketoacidosis

Overview

A multivariable model identified type 2 diabetes, initial hyperglycemia, and acidosis severity as key predictors of adverse outcomes in children with diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS). The model demonstrated excellent predictive accuracy and explained increased adverse events during the COVID-19 pandemic, with risks declining by mid-2023.

Background

Diabetic ketoacidosis (DKA) is a common metabolic complication in pediatric diabetes, characterized by hyperglycemia, acidosis, and ketonemia. Hyperglycemic hyperosmolar state (HHS) is rarer in children but associated with higher mortality and complications. Mortality rates for DKA have decreased over time but remain a concern. The COVID-19 pandemic saw increased frequency and severity of DKA and HHS, but data on complications during this period are limited. Developing a predictive model for adverse outcomes could guide clinical management.

Data Highlights

Key Findings

• Among 4565 pediatric admissions for DKA and/or HHS, 1.5% to 5.0% experienced adverse outcomes defined as death or ICU stay >48 hours.
• Eight deaths (0.18%) occurred, all related to the acute episode.
• Maximum serum glucose, initial venous pH, and diagnosis of type 2 diabetes were the strongest independent predictors of adverse outcomes.
• The proportion of patients with type 2 diabetes was highest during the 2020-2021 COVID-19 pandemic period, correlating with increased adverse outcomes.
• The multivariable model showed excellent discrimination with AUCs of 0.948 (training), 0.960 (2020-2021 validation), and 0.873 (2022-2023 validation).
• Risk of adverse outcomes decreased in the period from January 2022 to June 2023, paralleling the waning of the pandemic.

Clinical Implications

Clinicians should recognize type 2 diabetes and severity of initial hyperglycemia and acidosis as key risk factors for poor outcomes in pediatric DKA and HHS. Early identification of high-risk patients using this validated model can guide intensive monitoring and management decisions. Awareness of increased risks during pandemic periods may inform resource allocation and preventive strategies.

Conclusion

This study presents a robust predictive model for adverse outcomes in pediatric hyperglycemic emergencies, highlighting type 2 diabetes and biochemical severity as critical factors. The model explains temporal variations in complication rates, particularly during the COVID-19 pandemic, and supports targeted clinical interventions.

References

1. Study Authors/Institution/2023 -- Identifying Risk Factors for Negative Outcomes in Pediatric Patients with Diabetic Ketoacidosis