DKA Hospitalization Is on the Rise, Mortality Declining

Diana Phillips

April 02, 2018

Hospitalization rates for diabetic ketoacidosis (DKA) are on the rise, according to new data from the Centers for Disease Control and Prevention (CDC).

After a nearly 10-year period of slight decline, age-adjusted rates of hospitalization for the life-threating, preventable diabetes complication increased nearly 55% between 2009 and 2014, Stephen R. Benoit, MD, from the CDC's National Center for Chronic Disease Prevention and Health Promotion, Division of Diabetes Translation, and colleagues report in an article published in the March 30 issue of the Morbidity and Mortality Weekly Report.

However, the increasing hospitalization rate has not led to higher in-hospital mortality, which decreased consistently during the period of study, the authors stress.

Data from the CDC's US Diabetes Surveillance System indicated a rise in DKA hospitalizations from 2009 through 2014. To further investigate that trend, the authors sought to estimate rates of DKA hospitalization and in-hospital case fatality using 2000 to 2014 data from the Agency for Healthcare Research and Quality's National Inpatient Sample.

"Overall, age-adjusted DKA hospitalization rates decreased slightly from 2000 to 2009, then reversed direction, steadily increasing from 2009 to 2014 at an average annual rate of 6.3%," they report.

Overall, the rate increased 54.9%, climbing from 19.5 per 1000 persons in 2009 to 30.2 in 2014. The increase was seen across all age groups, but was highest in adults younger than 45 years (44.3 per 1000 persons in 2014) and lowest in those 65 years and older (less than 2.0 per 1000 persons in 2014).

Meanwhile, in-hospital case-fatality rates declined 63.6% overall, at an annual average rate of 6.8% (from 1.1% to 0.4%, and the decline was observed across all age groups and both sexes, the authors report. "Although the highest case-fatality rates were observed among persons aged ≥75 years, this group experienced the largest absolute decrease across the entire period," they note.

Although the causes of the increase in DKA-related hospitalizations are not clear, the authors hypothesize that the jump might reflect changes in case definition, lower thresholds for hospitalization, and the introduction of new medications such as sodium-glucose cotransporter 2 (SGLT2) inhibitors for type 2 diabetes that potentially increase DKA risk, as reported previously by Medscape Medical News.

Similarly, the causes of the declining in-hospital mortality rates have not been established but may be the result of better management and treatment thanks to an improved understanding of DKA pathophysiology and the adoption of treatment guidelines, the authors say. "Another possibility is that hospital admission of less severe cases has resulted in higher admission rates and contributed to the lower in-hospital case-fatality rates over time," they write.

The fact that, in 2014, DKA hospitalization rates among persons with diabetes younger than 45 years was approximately 27 times higher than in adults 65 or older points to the importance of considering demographic and clinical characteristics of younger diabetes patients when looking to understand the increase in DKA hospitalizations. "Information from studies among these groups might help determine whether factors such as symptom recognition, adherence to therapy, self-management skills, access to care, or cost of treatment should be a focus of DKA prevention strategies."

Further research might also identify populations at increased risk for DKA hospitalization. "Evidence-based, targeted prevention measures, such as diabetes self-management education and support might help reverse the trend in this potentially life-threatening but avoidable complication of diabetes," the authors conclude.

The authors have disclosed no relevant financial relationships.

Morb Mortal Wkly Rep. 2018;67:362-365. Full text

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