COVID-19 and diabetic ketoacidosis: National outcomes, predictors, and resource utilization in the United States

The impact of COVID-19 infection on diabetic ketoacidosis (DKA) outcomes remains incompletely characterized at a national level.

We analyzed adult DKA hospitalizations in the United States from the 2020-2021 National Inpatient Sample. The primary outcome was in-hospital mortality; secondary outcomes included acute kidney injury (AKI), mechanical ventilation, sepsis, vasopressor use, length of stay (LOS), and hospitalization cost. Multivariable regression and propensity score matching adjusted for patient- and hospital-level variables.

Among 658,675 DKA hospitalizations, 69,005 (10.5%) involved COVID-19. Patients with COVID-19 were older and had a greater comorbidity burden. Crude in-hospital mortality was higher with COVID-19 (21.3% vs 3.4%, P < 0.001). After adjustment, COVID-19 was associated with over sixfold higher mortality (aOR 6.22; 95% CI: 5.85-6.62), increased risks of AKI (aOR 1.15), ventilation (aOR 3.91), sepsis (aOR 1.77), vasopressor use (aOR 2.33), longer LOS (+3.99 days), and higher costs (+$15,248; all P < 0.001). Propensity-matched analysis confirmed these findings. In subgroup analysis, type 1 diabetes was linked to higher mortality (aOR 2.12) vs type 2 diabetes. Predictors of mortality included age, comorbidity burden, hospital size, and Hispanic ethnicity; female sex was protective only in COVID-19 DKA.

In this national analysis, COVID-19 significantly worsened mortality, multiorgan failure, and healthcare utilization in DKA admissions. DKA with COVID-19 represents a high-acuity entity warranting early escalation and resource allocation.