Prognostic Implications of Diabetic Ketoacidosis in Adults on Long-term Mortality and Diabetes-related Complications.

OBJECTIVES: Diabetic ketoacidosis (DKA) occurring after diabetes diagnosis is often associated with risk factors for other diabetes-related complications. In this study we aimed to determine the prognostic implications of DKA on all-cause mortality and complications in type 1 diabetes (T1D). METHODS: Previously collected data from the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) study were obtained through the the National Institute of Diabetes and Digestive and Kidney Diseases Central Repository. Using Cox proportional hazards models with time-dependent covariates, we examined age- and sex-adjusted, glycated hemoglobin-adjusted, and fully adjusted associations of DKA with all-cause mortality, cardiovascular disease, microvascular, and acute complications over 34 years. RESULTS: Of the 1,441 study participants, 297 had 488 DKA events. Prior DKA was associated with a higher risk of age- and sex-adjusted all-cause mortality (hazard ratio [HR] 8.28, 95% confidence interval [CI] 3.74 to 18.32, p<0.001), major adverse cardiovascular events (MACEs) (HR 2.05, 95% CI 1.34 to 3.13, p<0.001), and all advanced microvascular and acute complications compared with no prior DKA. Most associations except retinopathy were significant even after adjustment for covariates. In our fully adjusted analysis, prior DKA was associated with a significantly higher risk of subsequent all-cause mortality (HR 9.13, 95% CI 3.87 to 21.50, p<0.001), MACEs (HR 1.66, 95% CI 1.07 to 2.59, p=0.03), advanced kidney disease (HR 2.10, 95% CI 1.00 to 4.22, p=0.049), advanced neuropathy (HR 1.49, 95% CI 1.05 to 2.13, p=0.03), severe hypoglycemia (HR 1.53, 95% CI 1.28 to 1.81, p<0.001), and recurrent DKA (HR 3.24, 95% CI 2.41 to 4.36, p<0.001) compared with person-time without DKA. CONCLUSIONS: DKA is a prognostic marker for diabetes complications, including excess all-cause mortality. Intensified clinical interventions, such as cardiovascular prevention strategies, may be warranted after diagnosis of DKA.

Associations Between Socioeconomic Status and Patient Experience With Type 1 Diabetes Management and Complications: Cross-sectional Analysis of a Cohort From Québec, Canada.

BACKGROUND: Low socioeconomic status (SES) may add to the challenges of type 1 diabetes (T1D) management and be an independent risk factor for chronic and acute diabetes complications. Our aim in this study was to evaluate the association between SES and TID management and risk of complications in a universal health-care system using data from a registry of people living with T1D (PWT1D) in Québec, Canada (the BETTER registry). METHODS: This study was a cross-sectional analysis describing the association between SES factors (education, income, employment and insurance coverage) and T1D outcomes (glycated hemoglobin [A1C], acute and chronic complications and comorbidities), using chi-square tests and regression analyses (adjusted for diabetes duration, sex, ethnicity and diabetes technology use). RESULTS: In a sample of 1,333 PWT1D, lower education level was associated with cardiovascular disease (odds ratio [OR], 2.44; p=0.002), depression (OR, 1.56; p=0.020), nephropathy (OR, 2.10; p=0.001) and higher A1C (OR, 1.79; p<0.001). Low-income groups were more likely to report higher A1C (OR, 2.16; p=0.001), retinopathy (OR, 1.84; p=0.038), neuropathy (OR, 1.89; p=0.043), nephropathy (OR, 2.23; p=0.024), severe hypoglycemia (OR, 1.87; p=0.022) and depression (OR, 1.87; p=0.012). Unemployment was associated with retinopathy (OR, 2.37; p=0.009) and neuropathy (OR, 1.96; p=0.035). Diabetic ketoacidosis (OR, 2.81; p=0.001) and neuropathy (OR, 1.67; p=0.020) were more likely to be reported by participants with public insurance. CONCLUSIONS: PWT1D from lower SES, particularly those with low income and low education, were more likely to report T1D-related complications and comorbidities. Further longitudinal investigations are needed to better understand the nature and directionality of these associations.

Skin autofluorescence is associated with past glycaemic control and complications in type 1 diabetes mellitus.

As skin autofluorescence (AF) can assess subcutaneous accumulation of fluorescent advanced glycation end-products (AGEs), this study aimed to investigate whether it was linked to glycaemic control and complications in patients with type 1 diabetes mellitus (T1DM). Using the AGE Reader™, AF was measured in T1DM patients referred to Haut-Levêque Hospital (Bordeaux, France); data on their HbA1c levels measured every 6months as far back as the last 5years were also collected. The association of AF with the patients' past glucose control, based on their latest HbA1c values, and the means of the last five and 10 HbA1c values, and with diabetic complications was also examined by linear regression analysis. The sample included 300 patients: 58% were male; the mean age was 49 (SD 17) years and the mean diabetes duration was 21 (SD 13) years. The median skin AF measurement was 2.0 [25th-75th percentiles: 1.7-2.4] arbitrary units (AU), and this was associated with age (ß=0.15 per 10years, P<0.001) and diabetes duration (ß=0.17 per 10years, P<0.001). After adjusting for age and estimated glomerular filtration rate (eGFR), the skin AF measurement was also related to the means of the last five and 10 HbA1c values (ß=0.10 per 1% of HbA1c, P=0.005, and ß=0.13 per 1% of HbA1c, P=0.001, respectively). In addition, the skin AF was associated with retinopathy (P<0.001), albuminuria (P<0.001) and decreased eGFR (P<0.001). In conclusion, the skin AF is related to the long-term glucose control and diabetic complications.