Diabetic Ketoacidosis at Onset of Type 1 Diabetes and Long-term HbA_1c in 7,961 Children and Young Adults in the Australasian Diabetes Data Network

The relationship between diabetic ketoacidosis (DKA) at diagnosis of type 1 diabetes and long-term glycemic control varies between studies. We aimed, firstly, to characterize the association of DKA and its severity with long-term HbA_1c in a large contemporary cohort, and secondly, to identify other independent determinants of long-term HbA_1c.

Participants were 7,961 children and young adults diagnosed with type 1 diabetes by age 30 years from 2000 to 2019 and followed prospectively in the Australasian Diabetes Data Network (ADDN) until 31 December 2020. Linear mixed-effect models related variables to HbA_1c.

DKA at diagnosis was present in 2,647 participants (33.2%). Over a median 5.6 (interquartile range 3.2, 9.4) years of follow-up, participants with severe, but not moderate or mild, DKA at diagnosis had a higher mean HbA_1c (+0.23%, 95% CI 0.11,0.28; [+2.5 mmol/mol, 95% CI 1.4,3.6]; P < 0.001) compared with those without DKA. Use of continuous subcutaneous insulin infusion (CSII) was independently associated with a lower HbA_1c (−0.28%, 95% CI −0.31, −0.25; [−3.1 mmol/mol, 95% CI −3.4, −2.8]; P < 0.001) than multiple daily injections, and CSII use interacted with severe DKA to lower predicted HbA_1c. Indigenous status was associated with higher HbA_1c (+1.37%, 95% CI 1.15, 1.59; [+15.0 mmol/mol, 95% CI 12.6, 17.4]; P < 0.001), as was residing in postcodes of lower socioeconomic status (most vs. least disadvantaged quintile +0.43%, 95% CI 0.34, 0.52; [+4.7 mmol/mol, 95% CI 3.4, 5.6]; P < 0.001).

Severe, but not mild or moderate, DKA at diagnosis was associated with a marginally higher HbA_1c over time, an effect that was modified by use of CSII. Indigenous status and lower socioeconomic status were independently associated with higher long-term HbA_1c.