Background: Monitoring the trends in the presentation of T1D over decades cannot be underestimated as it provides a rich source of information on diabetes-related complications like DKA. DKA represents a medical emergency, with potentially fatal outcome, and thus the prevention of DKA is a priority in diabetes care. The aim of this study is to report on trends in the presentation of DKA in children newly diagnosed with T1D in Kuwait.
Material and methods: This study is based on a retrospective review of children newly diagnosed with T1D aged 14 years or less at three Governmental Hospitals representing three health sectors out of the total six health sectors in the country during the period 2011-2017.
Results: A total of 799 children (376 males and 423 females) were newly diagnosed with T1D. 287 children presented with DKA (35.9%) with only 73 children (9.1%) classified as severe. During the years 2011 to 2017, we note that the percentage of children older than 6 years of age presenting with severe DKA has decreased significantly (p=0.022). Unfortunately, this has not been replicated in children younger than 6 years.
Conclusion: This study highlights the importance of continued monitoring of clinical characteristics of children at diagnosis of T1D specifically presenting with DKA to enable diabetes care professionals to appreciate the multifaceted aspects of T1D, in particular the importance of raising awareness of the early signs of the onset of T1D with special attention to DKA and its severe consequences.
Keywords: Kuwait; childhood; diabetic ketoacidosis; type 1 diabetes; type 1 – child – adolescent.
Rahmati M, Keshvari M, Mirnasuri S, Yon DK, Lee SW, Il Shin J, Smith L.J Med Virol. 2022 Nov;94(11):5112-5127. doi: 10.1002/jmv.27996. Epub 2022 Jul 22.PMID: 35831242 Free PMC article. Review.
Patterson C, Guariguata L, Dahlquist G, Soltesz G, Ogle G, Silink M. Diabetes in the young - a global view and worldwide estimates of numbers of children with type 1 diabetes. Diabetes Res Clin Pract (2014) 103(2):161–75. doi: 10.1016/j.diabres.2013.11.005 - DOI - PubMed
Soltesz G, Patterson CC, Dahlquist G, Group ES. Worldwide childhood type 1 diabetes incidence–what can we learn from epidemiology? Pediatr Diabetes (2007) 8 Suppl 6:6–14. doi: 10.1111/j.1399-5448.2007.00280.x - DOI - PubMed
Shaltout AA, Wake D, Thanaraj TA, Omar DM, Al-AbdulRazzaq D, Channanath A, et al. . Incidence of type 1 diabetes has doubled in Kuwaiti children 0-14 years over the last 20 years. Pediatr Diabetes. (2017) 18(8):761–6. doi: 10.1111/pedi.12480 - DOI - PubMed
al Khawari M, Shaltout A, Qabazard M, Abdella N, Moemen J, Al-Mazidi Z, et al. . Incidence and severity of ketoacidosis in childhood-onset diabetes in kuwait. Kuwait diabetes study group. Diabetes Res Clin Pract (1997) 35(2-3):123–8. doi: 10.1016/S0168-8227(96)01365-4 - DOI - PubMed
Al Shaikh A, Farahat F, Saeedi M, Bakar A, Al Gahtani A, Al-Zahrani N, et al. . Incidence of diabetic ketoacidosis in newly diagnosed type 1 diabetes children in western Saudi Arabia: 11-year experience. J Pediatr Endocrinol Metab (2019) 32(8):857–62. doi: 10.1515/jpem-2018-0548 - DOI - PubMed
Deylami R, Townson J, Mann M, Gregory JW. Systematic review of publicity interventions to increase awareness amongst healthcare professionals and the public to promote earlier diagnosis of type 1 diabetes in children and young people. Pediatr Diabetes. (2018) 19(3):566–73. doi: 10.1111/pedi.12565 - DOI - PubMed
Gesuita R, Maffeis C, Bonfanti R, Cardella F, Citriniti F, D'Annunzio G, et al. . Socioeconomic inequalities increase the probability of ketoacidosis at diagnosis of type 1 diabetes: A 2014-2016 nationwide study of 2,679 Italian children. Front Pediatr (2020) 8:575020. doi: 10.3389/fped.2020.575020 - DOI - PMC - PubMed
Cherubini V, Grimsmann JM, Akesson K, Birkebaek NH, Cinek O, Dovc K, et al. . Temporal trends in diabetic ketoacidosis at diagnosis of paediatric type 1 diabetes between 2006 and 2016: Results from 13 countries in three continents. Diabetologia (2020) 63(8):1530–41. doi: 10.1007/s00125-020-05152-1 - DOI - PMC - PubMed
Rewers A, Klingensmith G, Davis C, Petitti DB, Pihoker C, Rodriguez B, et al. . Presence of diabetic ketoacidosis at diagnosis of diabetes mellitus in youth: the search for diabetes in youth study. Pediatrics (2008) 121(5):e1258–66. doi: 10.1542/peds.2007-1105 - DOI - PubMed
Hekkala A, Reunanen A, Koski M, Knip M, Veijola R, Finnish Pediatric Diabetes R . Age-related differences in the frequency of ketoacidosis at diagnosis of type 1 diabetes in children and adolescents. Diabetes Care (2010) 33(7):1500–2. doi: 10.2337/dc09-2344 - DOI - PMC - PubMed
Usher-Smith JA, Thompson MJ, Sharp SJ, Walter FM. Factors associated with the presence of diabetic ketoacidosis at diagnosis of diabetes in children and young adults: A systematic review. BMJ (2011) 343:d4092. doi: 10.1136/bmj.d4092 - DOI - PMC - PubMed
Group WHOMGRS . WHO child growth standards based on length/height, weight and age. Acta Paediatr Suppl. (2006) 450:76–85. - PubMed
Mayer-Davis EJ, Kahkoska AR, Jefferies C, Dabelea D, Balde N, Gong CX, et al. . ISPAD clinical practice consensus guidelines 2018: Definition, epidemiology, and classification of diabetes in children and adolescents. Pediatr Diabetes. (2018) 19(Suppl 27):7–19. doi: 10.1111/pedi.12773 - DOI - PMC - PubMed
Wolfsdorf JI, Glaser N, Agus M, Fritsch M, Hanas R, Rewers A, et al. . ISPAD clinical practice consensus guidelines 2018: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state. Pediatr Diabetes. (2018) 19(Suppl 27):155–77. doi: 10.1111/pedi.12701 - DOI - PubMed
Abdul-Rasoul M, Al-Mahdi M, Al-Qattan H, Al-Tarkait N, Alkhouly M, Al-Safi R, et al. . Ketoacidosis at presentation of type 1 diabetes in children in Kuwait: frequency and clinical characteristics. Pediatr Diabetes. (2010) 11(5):351–6. doi: 10.1111/j.1399-5448.2009.00600.x - DOI - PubMed
Shaltout AA, Channanath AM, Thanaraj TA, Omar D, Abdulrasoul M, Zanaty N, et al. . Ketoacidosis at first presentation of type 1 diabetes mellitus among children: A study from Kuwait. Sci Rep (2016) 6:27519. doi: 10.1038/srep27519 - DOI - PMC - PubMed
Hong J, Jalaludin MY, Mohamad Adam B, Fuziah MZ, Wu LL, Rasat R, et al. . Diabetic ketoacidosis at diagnosis of type 1 diabetes mellitus in Malaysian children and adolescents. Malays Fam Physician. (2015) 10(3):11–8. - PMC - PubMed
Segerer H, Wurm M, Grimsmann JM, Karges B, Neu A, Sindichakis M, et al. . Diabetic ketoacidosis at manifestation of type 1 diabetes in childhood and adolescence-incidence and risk factors. Dtsch Arztebl Int (2021) 118(22):367–72. doi: 10.3238/arztebl.m2021.0133 - DOI - PMC - PubMed
Klingensmith GJ, Tamborlane WV, Wood J, Haller MJ, Silverstein J, Cengiz E, et al. . Diabetic ketoacidosis at diabetes onset: still an all too common threat in youth. J Pediatr (2013) 162(2):330–4 e1. doi: 10.1016/j.jpeds.2012.06.058 - DOI - PubMed
Zucchini S, Scaramuzza AE, Bonfanti R, Buono P, Cardella F, Cauvin V, et al. . A multicenter retrospective survey regarding diabetic ketoacidosis management in Italian children with type 1 diabetes. J Diabetes Res (2016) 2016:5719470. doi: 10.1155/2016/5719470 - DOI - PMC - PubMed
Jensen ET, Stafford JM, Saydah S, D'Agostino RB, Dolan LM, Lawrence JM, et al. . Increase in prevalence of diabetic ketoacidosis at diagnosis among youth with type 1 diabetes: The SEARCH for diabetes in youth study. Diabetes Care (2021) 44(7):1573–8. doi: 10.2337/dc20-0389 - DOI - PMC - PubMed
de Vries L, Oren L, Lazar L, Lebenthal Y, Shalitin S, Phillip M. Factors associated with diabetic ketoacidosis at onset of type 1 diabetes in children and adolescents. Diabetes Med (2013) 30(11):1360–6. doi: 10.1111/dme.12252 - DOI - PubMed
Redondo MJ, Rodriguez LM, Escalante M, O'Brian Smith E, Balasubramanyam A, Haymond MW. Beta cell function and BMI in ethnically diverse children with newly diagnosed autoimmune type 1 diabetes. Pediatr Diabetes. (2012) 13(7):564–71. doi: 10.1111/j.1399-5448.2012.00875.x - DOI - PubMed
Kao KT, Islam N, Fox DA, Amed S. Incidence trends of diabetic ketoacidosis in children and adolescents with type 1 diabetes in British Columbia, Canada. J Pediatr (2020) 221:165–73.e2. doi: 10.1016/j.jpeds.2020.02.069 - DOI - PubMed
Maahs DM, Hermann JM, Holman N, Foster NC, Kapellen TM, Allgrove J, et al. . Rates of diabetic ketoacidosis: International comparison with 49,859 pediatric patients with type 1 diabetes from England, Wales, the U.S., Austria, and Germany. Diabetes Care (2015) 38(10):1876–82. doi: 10.2337/dc15-0780 - DOI - PubMed
Wolfsdorf J, Glaser N, Sperling MA, American Diabetes A. Diabetic ketoacidosis in infants, children, and adolescents: A consensus statement from the American diabetes association. Diabetes Care (2006) 29(5):1150–9. doi: 10.2337/dc06-9909 - DOI - PubMed
Choleau C, Maitre J, Elie C, Barat P, Bertrand AM, de Kerdanet M, et al. . [Ketoacidosis at time of diagnosis of type 1 diabetes in children and adolescents: Effect of a national prevention campaign]. Arch Pediatr (2015) 22(4):343–51. doi: 10.1016/j.arcped.2014.11.001 - DOI - PubMed
Vanelli M, Chiari G, Lacava S, Iovane B. Campaign for diabetic ketoacidosis prevention still effective 8 years later. Diabetes Care (2007) 30(4):e12. doi: 10.2337/dc07-0059 - DOI - PubMed
Cangelosi AM, Bonacini I, Serra RP, Di Mauro D, Iovane B, Fainardi V, et al. . Spontaneous dissemination in neighboring provinces of DKA prevention campaign successfully launched in nineties in parma's province. Acta Biomed (2017) 88(2):151–5. doi: 10.23750/abm.v88i2.6553 - DOI - PMC - PubMed
Knip M. Natural course of preclinical type 1 diabetes. Horm Res (2002) 57(Suppl 1):6–11. doi: 10.1159/000053305 - DOI - PubMed
Mallare JT, Cordice CC, Ryan BA, Carey DE, Kreitzer PM, Frank GR. Identifying risk factors for the development of diabetic ketoacidosis in new onset type 1 diabetes mellitus. Clin Pediatr (Phila). (2003) 42(7):591–7. doi: 10.1177/000992280304200704 - DOI - PubMed
Rosenbauer J, Icks A, Giani G. Clinical characteristics and predictors of severe ketoacidosis at onset of type 1 diabetes mellitus in children in a north Rhine-westphalian region, Germany. J Pediatr Endocrinol Metab (2002) 15(8):1137–45. doi: 10.1515/JPEM.2002.15.8.1137 - DOI - PubMed