Risk Factors for Adverse Outcomes in Children With Diabetic Ketoacidosis

Objective: Develop a multivariable model to identify children with diabetic ketoacidosis (DKA) and/or hyperglycemic hyperosmolar state (HHS) at increased risk of adverse outcomes and apply it to analyze adverse outcomes during and after the COVID-19 pandemic. Methods: Retrospective review of clinical data from 4565 admissions (4284 with DKA alone, 31 [0.7%] only HHS, 250 [5.4%] hyperosmolar DKA) to a large academic children's hospital from January 2010 to June 2023. Data from 2010-2019 (N = 3004) were used as a training dataset, and 2020-2021 (N = 903) and 2022-2023 (N = 658) data for validation. Death or intensive care unit stays > 48 hours comprised a composite "Adverse Outcome" group. Risks for this composite outcome were assessed using generalized estimating equations. Results: There were 47 admissions with Adverse Outcomes (1.5%) in 2010-2019, 46 (5.0%) in 2020-2021, and 16 (2.4%) in 2022-2023. Eight patients died (0.18%). Maximum serum glucose, initial pH, and diagnosis of type 2 diabetes most strongly predicted Adverse Outcomes. The proportion of patients with type 2 diabetes was highest in 2020-2021. A multivariable model incorporating these factors had excellent discrimination (area under receiver operator characteristic curve [AUC] of 0.948) for the composite outcome in the training dataset, and similar predictive power (AUC 0.960 and 0.873) in the 2020-2021 and 2022-2023 validation datasets, respectively. In the full dataset, AUC for death was 0.984. Conclusion: Type 2 diabetes and severity of initial hyperglycemia and acidosis are independent risk factors for Adverse Outcomes and explain the higher frequency of Adverse Outcomes during the COVID-19 pandemic. Risks decreased in January 2022 to June 2023.