Presence of Diabetic Ketoacidosis at Diagnosis of Diabetes Mellitus in Youth: The Search for Diabetes in Youth Study

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Presence of Diabetic Ketoacidosis at Diagnosis of Diabetes Mellitus in Youth: The Search for Diabetes in Youth Study
May 2008
Arleta Rewers, MD, PhDa, Georgeanna Klingensmith, MDa, Cralen Davis, PhDb, Diana B. Petitti, MDc, Catherine Pihoker, MDd, Beatriz Rodriguez, MDe, I. David Schwartz, MDf, Giuseppina Imperatore, MD, PhDg, Desmond Williams, MDg, Lawrence M. Dolan, MDh and Dana Dabelea, MD, PhDi
PEDIATRICS Vol. 121 No. 5

OBJECTIVE. The purpose of this work was to determine the prevalence and predictors of diabetic ketoacidosis at the diagnosis of diabetes in a large sample of youth from the US population.

PATIENTS AND METHODS. The Search for Diabetes in Youth Study, a multicenter, population-based registry of diabetes with diagnosis before 20 years of age, identified 3666 patients with new onset of diabetes in the study areas in 2002Ò2004. Medical charts were reviewed in 2824 (77%) of the patients in a standard manner to abstract the results of laboratory tests and to ascertain diabetic ketoacidosis at the time of diagnosis. Diabetic ketoacidosis was defined by blood bicarbonate <15 mmol/L and/or venous pH < 7.25 (arterial/capillary pH < 7.30), International Classification of Diseases, Ninth Revision, code 250.1, or listing of diabetic ketoacidosis in the medical chart.

RESULTS. More than half (54%) of the patients were hospitalized at diagnosis, including 93% of those with diabetic ketoacidosis and 41% without diabetic ketoacidosis. The prevalence of diabetic ketoacidosis at the diagnosis was 25.5%. The prevalence decreased with age from 37.3% in children aged 0 to 4 years to 14.7% in those aged 15 to 19 years. Diabetic ketoacidosis prevalence was significantly higher in patients with type 1 (29.4%) rather than in those with type 2 diabetes (9.7%). After adjusting for the effects of center, age, gender, race or ethnicity, diabetes type, and family history of diabetes, diabetic ketoacidosis at diagnosis was associated with lower family income, less desirable health insurance coverage, and lower parental education.

CONCLUSION. At the time of diagnosis, 1 in 4 youth presents with diabetic ketoacidosis. Those with diabetic ketoacidosis were more likely to be hospitalized. Diabetic ketoacidosis was a presenting feature of <10% of youth with type 2. Young and poor children are disproportionately affected.

Key Words: ketoacidosis Ô adolescent Ô children Ô diabetes Ô type 1 diabetes Ô type 2 diabetes


Abbreviations: DKAÛdiabetic ketoacidosis Ô SEARCHÛSearch for Diabetes in Youth Ô IRBÛinstitutional review board Ô AICÛAkaike information criterion Ô CIÛconfidence interval Ô ORÛodds ratio

In the United States, >150 000 children have diabetes mellitus,1 and 21 000 are diagnosed annually.2 Over the past 40 years, the incidence of type 1 diabetes in children has been increasing worldwide by 3% to 5% per year.3,4 In addition, recent reports have suggested that type 2 diabetes in youth has become more common.5Ò7 Diabetic ketoacidosis (DKA), the metabolic outcome of very low levels of effective insulin action, can be a life-threatening complication present in 15% to 67% of youth at the time of diagnosis.8 Despite the high morbidity and cost of DKA at diagnosis of diabetes, there are no recent estimates of its prevalence in the US population. Although predictors of DKA in children with established type 1 diabetes have been studied,9 little is known about predictors of DKA that precede diagnosis. Previous studies have suggested that DKA at the diagnosis of diabetes is more frequent in younger patients, in populations with lower socioeconomic status, and in countries with a lower incidence of type 1 diabetes where diabetes awareness is low.10Ò12 Type 2 diabetes may also present with DKA, but the prevalence and predictors of such a severe presentation of type 2 diabetes in youth have not been systematically studied.

To address these issues, the Search for Diabetes in Youth (SEARCH) Study ascertained the prevalence of DKA at diagnosis of diabetes in a large multiracial sample of US youth with diabetes diagnosed before 20 years of age. The spectrum of severity of presentation and the potentially preventable causes of DKA were explored. We hypothesized that lower socioeconomic status and insufficient insurance coverage at the time of diagnosis would both independently increase the risk of DKA. This report also provides preliminary data concerning patterns of the initial delivery of diabetes care to US children and adolescents.

Complete article is available online.