The outcome of brittle type 1 diabetes--a 20 year study

Cartwright, Anne; Wallymahmed, M; MacFarlane, I A; Wallymahmed, Akhtar; Williams, Gareth; Gill, Geoff

doi:10.1093/qjmed/hcr010

Cited by 20 publications

(14 citation statements)

References 7 publications

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“…A potentially complementary strategy, targeting patients with persistently suboptimal HbA 1c levels (in type 1 and 2 diabetes), employs a combined medical, psychological and social support approach (‘3 Dimensions of Care for Diabetes’); this has been reported to result in significant reductions in emergency department attendances and inpatient admissions [ 19 ]. Longitudinal studies of ‘brittle diabetes’ suggest that patients eventually cease presenting with recurrent DKA, anecdotally often following positive life events, but frequently develop a significant burden of chronic diabetes complications [ 11 , 12 ]. Considerable challenges remain in preventing early death and later complications in this vulnerable group.…”

Section: Discussionmentioning

confidence: 99%

Risk of death following admission to a UK hospital with diabetic ketoacidosis

et al. 2016

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Aims/hypothesisThe aim of this study was to assess the risk of death during hospital admission for diabetic ketoacidosis (DKA) and, subsequently, following discharge. In addition, we aimed to characterise the risk factors for multiple presentations with DKA.MethodsWe conducted a retrospective cohort study of all DKA admissions between 2007 and 2012 at a university teaching hospital. All patients with type 1 diabetes who were admitted with DKA (628 admissions of 298 individuals) were identified by discharge coding. Clinical, biochemical and mortality data were obtained from electronic patient records and national databases. Follow-up continued until the end of 2014.ResultsCompared with patients with a single DKA admission, those with recurrent DKA (more than five episodes) were diagnosed with diabetes at an earlier age (median 14 [interquartile range 9–23] vs 24 [16–34] years, p < 0.001), had higher levels of social deprivation (p = 0.005) and higher HbA1c values (103 [89–108] vs 79 [66–96] mmol/mol; 11.6% [10.3–12.0%] vs 9.4% [8.2–10.9%], p < 0.001), and tended to be younger (25 [22–36] vs 31 [23–42] years, p = 0.079). Antidepressant use was greater in those with recurrent DKA compared with those with a single episode (47.5% vs 12.6%, p = 0.001). The inpatient DKA mortality rate was no greater than 0.16%. A single episode of DKA was associated with a 5.2% risk of death (4.1 [2.8–6.0] years of follow-up) compared with 23.4% in those with recurrent DKA admissions (2.4 [2.0–3.8] years of follow-up) (HR 6.18, p = 0.001).Conclusions/interpretationRecurrent DKA is associated with substantial mortality, particularly among young, socially disadvantaged adults with very high HbA1c levels.Electronic supplementary materialThe online version of this article (doi:10.1007/s00125-016-4034-0) contains peer-reviewed but unedited supplementary material, which is available to authorised users.

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Section: Discussionmentioning

confidence: 99%

Risk of death following admission to a UK hospital with diabetic ketoacidosis

et al. 2016

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“…These data may also provide a measure of ongoing improvements in the quality of paediatric diabetes care which may lead to reduced rates of ketoacidosis and its associated mortality. 9 …”

Section: Introductionmentioning

confidence: 99%

Evidence for a persistent, major excess in all cause admissions to hospital in children with type-1 diabetes: results from a large Welsh national matched community cohort study

et al. 2015

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ObjectivesTo estimate the excess in admissions associated with type1 diabetes in childhood.DesignMatched-cohort study using anonymously linked hospital admission data.SettingBrecon Group Register of new cases of childhood diabetes in Wales linked to hospital admissions data within the Secure Anonymised Information Linkage Databank.Population1577 Welsh children (aged between 0 and 15 years) from the Brecon Group Register with newly-diagnosed type-1 diabetes between 1999–2009 and 7800 population controls matched on age, sex, county, and deprivation, randomly selected from the local population.Main outcome measuresDifference in all-cause hospital admission rates, 30-days post-diagnosis until 31 May 2012, between participants and controls.ResultsChildren with type-1 diabetes were followed up for a total of 12 102 person years and were at 480% (incidence rate ratios, IRR 5.789, (95% CI 5.34 to 6.723), p<0.0001) increased risk of hospital admission in comparison to matched controls. The highest absolute excess of admission was in the age group of 0–5 years, with a 15.4% (IRR 0.846, (95% CI 0.744 to 0.965), p=0.0061) reduction in hospital admissions for every 5-year increase in age at diagnosis. A trend of increasing admission rates in lower socioeconomic status groups was also observed, but there was no evidence of a differential rate of admissions between men and women when adjusted for background risk. Those receiving outpatient care at large centres had a 16.1% (IRR 0.839, (95% CI 0.709 to 0.990), p=0.0189) reduction in hospital admissions compared with those treated at small centres.ConclusionsThere is a large excess of hospital admissions in paediatric patients with type-1 diabetes. Rates are highest in the youngest children with low socioeconomic status. Factors influencing higher admission rates in smaller centres (eg, “out of hours resources”) need to be explored with the aim of targeting modifiable influences on admission rates.

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“…Recurrent DKA is often avoidable and there is a need to concentrate on those with higher risk for targeted interventions. Children with recurrent DKA have the increased burden of microvascular complications and increased mortality . Identifying those at risk can allow for intensive multidisciplinary intervention early in their disease.…”

Section: Discussionmentioning

confidence: 99%

Using population data to understand the epidemiology and risk factors for diabetic ketoacidosis in Australian children with type 1 diabetes

et al. 2019

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Background Children with type 1 diabetes (T1D) are at risk of diabetic ketoacidosis (DKA) at T1D diagnosis and/or subsequently. Objective The objective is to determine the incidence and prevalence of T1D by the presence of DKA and identify the characteristics of subsequent DKA episodes. Subjects The study population included all children aged <15 years with T1D during a hospital/day‐stay admission in New South Wales, Australia, from 1 January 2001 to 31 December 2013. T1D and DKA were identified using International Classification of Diseases Australian Modification codes. Methods Data sources included routinely collected longitudinally linked population hospitalization and birth records. Chi‐squared analyses, logistic, and multinomial regression were used to determine the association between child characteristics and admissions with and without DKA. Results The point prevalence of T1D among 0‐14‐year olds on 31 December 2013 was 144.2 per 100 000. For children aged 0‐12 years, the incidence of T1D was 16.3 per 100 000 child‐years. One‐third had DKA at T1D diagnosis and were more likely to be readmitted with DKA than those without DKA at T1D diagnosis. Children with more than one readmission for DKA were more likely to be female, reside in an inner regional area or an area of socioeconomic disadvantage, and be Australian‐born. Among all hospitalizations of children with T1D, those with DKA were more likely to be aged 10‐14 years, require intensive care, have longer length of stay, and admitted outside school days. Conclusion Routinely collected administrative health data are a reliable source to monitor incidence and health service use of childhood T1D. Children at risk of repeated DKA, particularly females, adolescents, and those from inner regional or socioeconomically disadvantaged areas, should be targeted during education and follow‐up.

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The outcome of brittle type 1 diabetes--a 20 year study

Abstract: We conclude that brittle diabetes characterized by recurrent DKA has high long-term outcome mortality. These deaths were premature and almost all diabetes related. Those who survived had resolution of brittleness, but suffered a significant complication burden.

Cited by 20 publications

References 7 publications

Risk of death following admission to a UK hospital with diabetic ketoacidosis

Risk of death following admission to a UK hospital with diabetic ketoacidosis

Evidence for a persistent, major excess in all cause admissions to hospital in children with type-1 diabetes: results from a large Welsh national matched community cohort study

Using population data to understand the epidemiology and risk factors for diabetic ketoacidosis in Australian children with type 1 diabetes

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