Current Clinical Features of Diabetic Ketoacidosis in Adults: A German Multicenter Study 2022-2023

To obtain clinical features of diabetic ketoacidosis (DKA) in adults leading to hospital admission.

Multicenter observational study investigating DKAs treated in five German tertiary hospitals between 2022 and 2023.

A total of 179 patients with 203 episodes of DKA were registered: 64% of cases in pre-existing type 1 diabetes mellitus (T1DM), 14% in new-onset T1DM, 14% in pre-existing type 2 diabetes mellitus (T2DM), 3% in new-onset T2DM, 6% in latent autoimmune diabetes in adults, and 6% in pancreatogenic diabetes. Seven cases of SGLT 2 inhibitor (SGLT 2-I)-associated euglycemic DKA (EDKA) were encountered. In pre-existing T1DM, DKA occurred despite continuous glucose monitoring in 51% of patients and insulin pumps or automated insulin delivery in 24%. Only 21% of individuals with T1DM were in possession of ketone test and only 6% applied ketone testing. In total, 71% of patients with pre-existing T1DM experienced recurrent episodes of DKA. Suboptimal adherence to diabetes therapy was the most common triggering factor for DKA in known T1DM (56%), whereas infections contributed most in pre-existing T2DM (32%). The entirety of patients pretreated with SGLT2-Is and particularly also those with SGLT2-I associated EDKA were not educated concerning sick-day-rules. The inpatient mortality risk of DKA was 2.3% and restricted to multimorbid patients with known T2DM.

The clinical and etiological pattern of DKA is heterogeneous. Patients with pre-existing T1DM showed educational deficits concerning diagnostic and therapeutic measures to prevent DKA. Individuals with recurrent episodes of DKA require individual therapeutic concepts within the multidisciplinary diabetes care team. Emphasizing sick-day-rules in patients being treated with SGLT 2-Is is indispensable to prevent EDKA. Individuals with pre-existing T2DM represent a vulnerable group with severe comorbidities and high mortality risk due to DKA.