Prognosis

An improved understanding of the pathophysiology of diabetic ketoacidosis (DKA), together with close monitoring and correction of electrolytes, has resulted in a significant reduction in the overall mortality rate from this life-threatening condition. From 2000 to 2014, in-hospital mortality rates among people with DKA consistently decreased in the US, from 1.1% to 0.4%.[15]​ Mortality rates reported in low- and middle-income countries are much higher, potentially because of delayed diagnosis and treatment.[1]​ Data from India have shown a 30% mortality rate in those presenting with DKA, and studies from sub-Saharan Africa have reported similarly high mortality (26% to 41.3%).[11]

Death is rarely caused by the metabolic complications of hyperglycaemia or ketoacidosis but rather relates to the underlying illness. Mortality increases substantially in those with comorbidities and with ageing, reaching 8% to 10% in those aged 65-75 years in developed countries.[11]

Mortality rates remain increased even after recovery. One New Zealand-based cohort study found that people discharged after an episode of DKA had a 1-year age-corrected mortality rate that was 13 times higher than that of the general population.[164]​ This was more pronounced among younger individuals (aged 15-39 years), in whom the mortality rate was 49 times higher than that of the general population.[164] In a US-based cohort study, all-cause mortality within 30 days of a hyperglycaemic crisis was 0.1% in patients with type 1 diabetes and 2% in individuals with type 2 diabetes. The 1-year mortality rate was 0.9% in patients with type 1 diabetes and 9.5% in those with type 2 diabetes.[165]

A substantial proportion of individuals hospitalised with DKA experience recurrent episodes.[1]​ In one US-based study conducted between 2006 and 2012, 21.6% of people hospitalised for DKA had more than one episode over 6 years, with 5.8% of individuals accounting for 26.3% of DKA hospitalisations.[166]​ In one US nationwide analysis conducted between 2010 and 2014, up to 22% of people admitted with DKA had at least one readmission within 30 days or the same calendar year.[39]​ Among those readmitted within 30 days, 40.8% represented recurrent DKA episodes, with approximately 50% being readmitted within 2 weeks.[39][40]​ Among those readmitted within the same calendar year, 86% and 14% had 1-3 and ≥4 readmissions for DKA, respectively.[40]​ In another study conducted in the UK, patients with 2-5 admissions had a threefold higher risk of death compared with those with a single DKA admission, while those with six or more admissions had a sixfold higher risk of death.[167]

Extensive evidence indicates that mental health conditions, particularly eating disorders, depression, or schizophrenia, are independent risk factors for poor glycaemic control and recurrent admissions with DKA.[1][168]​ Furthermore, individuals with type 1 diabetes and a history of DKA have been found to be at increased risk of hospitalisation for suicide attempts, with the highest risk occurring within 12 months following a DKA episode.[1]​ Hospital admission with DKA, and recurrent admissions in particular, should be considered a potential 'red flag' for triggering psychiatric assessment, so that mental health problems can be addressed.[36]

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