Incidence of Diabetic Ketoacidosis of New-Onset Type 1 Diabetes in Children and Adolescents in Different Countries Correlates with Human Development Index (HDI): An Updated Systematic Review, Meta-Analysis, and Meta-Regression

Abstract

Type 1 diabetes mellitus (T1DM) is usually diagnosed by insulin deficiency at a young age. Diabetic ketoacidosis (DKA) represents a severe complication occurring before the first diagnosis of T1DM. Actually, the data situation is still unsettled in assessing the current state of diagnosis. This study summarizes the latest rates of DKA of new-onset T1DM in children and adolescents in different countries available over the last five years. Different T1DM-related, geographical and socioeconomic moderators are suitable to explain the heterogeneity of observed DKA rates. A systematic literature search using PubMed, EMBASE*, and MedLine* (*via OVID) was conducted to extract worldwide DKA rates covering publications from April 2011 to May 2016. We define DKA consistently by pH<7.3 or bicarbonate<15 mmol/l. We identified 34 suitable studies covering DKA rates in 25 countries. Overall DKA rates were compared to earlier studies to identify a temporal trend. We further applied a random effects meta-analysis and used meta-regression to reveal moderators of DKA rate heterogeneity. This review evaluating 34 studies includes 47 000 children and adolescents in total. DKA rates varied from 14.7% (Denmark) to 79.8% (Saudi Arabia). DKA rates are still high but a decline can also be recognized. The meta-regression shows that latitude (p<0.000) and human development index (HDI) (p<0.000) are moderators of DKA rates. The frequency of DKA rates occurrence varies widely for different countries. Both latitude and HDI partially explain the observed heterogeneity, while other moderators such as density of physicians showed no obvious correlation.

Diabetic ketoacidosis at the onset of disease during a national awareness campaign: a 2-year observational study in children aged 0–18 years

“…Only 68% of centres reported adoption of the ISPAD guidelines to manage DKA, and there was great variation in the approach to management 1. These data were consistent with a comprehensive study of DKA incidence during a 10-year follow-up in Italy by Cherubini et al ,2 and with studies published in the same period in other European3–5 and Extra European countries 6 7…”

Diabetic ketoacidosis

“…Mortality increases substantially in those with comorbidities and with ageing, reaching 8-10% in those aged >65-75 years 1,37 . The highest rates of DKA have been suggested to occur in regions least able to afford health care 38 . Mortality might also be higher in these populations; for example, data from India showed a 30% mortality in those presenting with DKA 39 , and studies from sub-Saharan Africa have reported similarly high mortality (26-41.3%), whereas a study from Jamaica reported a mortality of 6.7% [39][40][41] .…”

Temporal trends in diabetic ketoacidosis at diagnosis of paediatric type 1 diabetes between 2006 and 2016: results from 13 countries in three continents

“…Reported prevalence estimates of DKA at diabetes diagnosis vary between countries and there is some evidence that prevalence is associated with a country's socioeconomic factors [22]. However, the definitions of DKA, reporting of venous pH in medical records, inclusion criteria, age ranges of individuals included and statistical analyses differ considerably between studies [22].…”