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J Clin Endocrinol Metab. 2019 Sep 14. pii: dgz003. doi: 10.1210/clinem/dgz003. [Epub ahead of print]

The long-term incidence of hospitalization for ketoacidosis in adults with established T1D - a prospective cohort study.

Thomas M1, Harjutsalo V2,3,4,5, Feodoroff M2,3,4, Forsblom C2,3,4,5, Gordin D2,3,4, Groop PH1,2,3,4.

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Department of Diabetes, Central Clinical School, Monash University, Melbourne, Australia.
Folkhälsan Institute of Genetics, Folkhälsan Research Center, Biomedicum Helsinki, Helsinki, Finland.
Department of Nephrology, Department of Medicine Helsinki University Central Hospital, Biomedicum Helsinki, Finland.
Research Programs Unit, Diabetes and Obesity, University of Helsinki, Helsinki, Finland.
National Institute for Health and Welfare, The Chronic Disease Prevention Unit, Helsinki, Finland.



The long-term natural history of diabetic ketoacidosis (DKA) and its risk factors are poorly understood.


To determine the long-term incidence and predictors of DKA in adults with longstanding type 1 diabetes (T1D).


All hospitalizations and deaths due to DKA between 1996 and 2016 were identified in 4758 adults with T1D from the Finnish Diabetic Nephropathy Study (FinnDiane), and a cohort of 16224 adults with T1D from the Finnish general population.


Between 1996 and 2015, there were 1228 DKA events in the FinnDiane participants (1.4/100 person-years) and 4914 DKA events (1.8/100 person-years) in the adults with T1D from the general population. The majority were hospitalized only once. There was a modest increase in the frequency of DKA in the FinnDiane over the follow-up (~2.4%/year [95% CI 0.3-4.5%]; p=0.03). Predictors of DKA were glucose control, CSII, smoking and alcohol consumption, raised HDL cholesterol and triacylglycerides. Diabetic nephropathy and renal impairment were associated with DKA; patients with end-stage renal disease, macroalbuminuria and microalbuminuria had 2.09- (95% CI 1.40-3.12), 1.65- (1.23-2.19) and 0.87- (0.61-1.24) fold risk of DKA, compared to patients with normal albumin excretion rate, respectively. Patients with an eGFR<60 ml/min/1.73m2 were also more likely to be hospitalized for DKA (HR 1.71, [1.26-2.67]).


DKA remains a common cause of hospitalization in individuals with longstanding T1D. These data suggest that the goal to use SGLT2 inhibitors for their vasculo- and renoprotective actions may be problematic, as those most likely to benefit may also have the highest risk for DKA.


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