DKA at diagnosis and its effect on long term bg control and the risk of complications

In another thread someone made the statement that kids who have DKA at dx are at "great risk for complications down the road". It was also said that those who have "profound" DKA at dx have more difficulty with blood glucose control.

I have not heard this before and would like to see any studies that discuss these issues, or hear anecdotal evidence from those parents who may (or may not) have experienced this.

 

I would like to read a study on this as well. My son was in severe DKA when diagnosed. We are almost but not quite a year in. He doesn't appear to have a harder time than any other type 1 toddler. Very curious about this...

 

This totally goes against what happened to us! DD came back from a 5 month exchange in Italy having lost 32 lbs and in big-time DKA! However, she has had a relatively easy time maintaining her bgs and good A1C's. I really do think that there are so many variations of this disease (YDMV) that this kind of generalization misses the mark!

 

I was in severe DKA at dx (I had lost close to 50 lbs) and I do struggle with control, it's hard to say if I have a harder time than other people.... I have had some complications though, six months or so after dx I had surgery to have large cataracts removed from both my eyes (so bad I was legally blind in my left eye). We're not sure if that is a result of the DKA or the fact that I had been sick for a REALLY long time before being dx, like a year....

 

Here's one study: "DKA at diagnosis was associated with poor long-term metabolic regulation and residual beta cell function as assessed by HbA1c and IDAA1c, respectively; however, CSII treatment was associated with improvement in glycaemic regulation and residual beta cell function, changing the effect of DKA at onset in our population."

http://www.ncbi.nlm.nih.gov/m/pubmed/23389397/

But it appears this is a complicated question.

DKA at diagnosis is associated with many different factors. Some of them could be related to longterm control, and others not.

For example, researchers report the following in one study:

"After adjusting for the effects of center, age, gender, race or ethnicity, diabetes type, and family history of diabetes, diabetic ketoacidosis at diagnosis was associated with lower family income, less desirable health insurance coverage, and lower parental education."

http://www.ncbi.nlm.nih.gov/m/pubmed/18450868/

It seems likely to me that people who lack health insurance are more likely to present in DKA and to have more difficulty getting the supplies and education required for optimal bg down the road. On the other hand, people who were in dka at diagnosis can erase the risk, as evidenced by the good outcomes for people who went on pumps in the first study. It's probably not just pumps but engaging in treatment generally.

It's also possible that there are different courses of the disease, and that dka at diagnosis represents a more difficult course, but I don't think there is strong evidence for that.

 

I love being the outlier. Chris was diagnosed in severe DKA and spent 24 hours in PICU, then 3 more days in pediatrics in the hospital. I have a Master's degree. My husband has a Bachelor's degree and two semesters towards his Master's. We are both teachers. We went to the doctor not once but twice while he was symptomatic and it was not detected or even considered. Christopher's insurance is pretty good except for the high-ish deductible.

I have no idea about level of our control. Some days we're doing okay. Others, not so much. It doesn't seem to be any different than others that I have seen on this board, though. We're only a year out, but hopefully we won't have any more long term issues than any other child who has T1D and was not diagnosed in DKA.

 

Yes, I agree it is complicated. Like most things associated with diabetes there are so many variables and angles that can influence outcomes. That is why I REALLY don't like it when people make these blanket, generalized statements like....kids who have DKA at dx are at great risk for complications in the future. It just causes unwarranted anxiety and worry when we all have enough of that already in our lives.

So basically what this information you posted seems to be saying is that it is actually not the DKA itself that causes negative future outcomes but it is a persons access to quality medical care, insurance, education, etc. that helps determine outcomes. That makes much more sense to me. Thank you for posting.

 

This is nonsense.

 

this one seems to point clearly to DKA at dx being an indicator of poorer control
http://www.ncbi.nlm.nih.gov/pubmed/24152206
" Diabetic ketoacidosis at onset was associated with greater insulin requirements over the first 2 years of follow-up and with poorer glycemic control during the course of the illness. "
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This seems somewhat inconclusive to me:
http://www.plosone.org/article/info:doi/10.1371/journal.pone.0025251

First it says:
Neither the presence nor severity of DKA at diagnosis influenced HbA1c 6mo.

but then later it says:
We also found that the prevalence and severity of DKA at diagnosis was considerably greater among girls. Further, girls had worse glycaemic control than boys, a pattern that has been previously observed [29]. Differences in metabolism and/or pubertal status between the sexes may account for these differences, and Hoffman et al. showed that early pubertal girls were less insulin sensitive than boys, but that this difference was compensated by increased insulin secretion [55].

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This one talks about Ketosis Prone Diabetes as a subset of type 1 and talks about outcomes. (I don't think you'd actually know if you had this version of diabetes without testing, so I think it might be relevant)
http://europepmc.org/articles/PMC2888957/reload=0;jsessionid=rOBvpiePkECNI0OxmMFg.58

 

Being in DKA at diagnosis makes it a lot less likely that a person is earlier in the disease process and therefore less likely that they will have a honeymoon, so it is a predictor of blood sugar control during that time period where a honeymoon is expected.
http://www.ncbi.nlm.nih.gov/pubmed/18547233
http://www.ncbi.nlm.nih.gov/pubmed/16629716
http://www.ncbi.nlm.nih.gov/pubmed/23389397

Also, some of us who were in DKA have had long term impacts of the DKA. Personally, I developed issues with my memory while I was in DKA and they have not cleared up. My cognitive abilities have not returned to their pre-DKA levels, and I lost a lot of my memories of things before and for about one year after the DKA. I no longer have clear memories of ANYTHING from before age 19 or so (I am now 25, and was diagnosed a month before turning 18- I was in moderate DKA).

A statement that people who have been in DKA are at greater risk of whatever is not a statement that we will develop those things. It is also not a statement that those who haven't been in DKA are not at risk.

 

I agree with LantusFiend. I think the connection is that if you are in DKA then it was not caught early, there is probably less of a honey moon and it is more likely the body is still producing some of its own insulin.

My dd was in DKA. We had good insurance; that wasnt an issue. I think her being 1yo was more of an issue since we just weren't expecting it. Coincidentally our CDE told us recently that our dd is a less stable kid, a statement which I found oddly comforting (we have known her 10 yrs and she knows us well and there was a context to the statement; she doesn't just say these things recklessly).

 

This one only looked at 300 people and only looked at them for 6 years. It also doesn't talk about other variables that could contribute to poor bg control so I guess I would need more information on this one. Regardless, it still seems irrelevant to the point of this thread.

This one only looked at 229 people and only for 2 years. You are correct that it is contradictory and inconclusive, so again, irrelevant to the point of this thread.

Again, this one is irrelevant to the point of this thread.

The main reason I created this thread was that I was concerned that parents would see the statement that "Kids with DKA at dx are at great risk for complictions down the road" and worry for no reason. It appears there are a lot of parents on this site who's children presented with DKA. So I know an irresponsible statement like that could negatively effect a lot of people here. It seemed like a blanket, generalized comment that had no basis in fact or science. If there is solid, relevant reseach out there that proves that statement, then I would like to see it.

 

Phillip wasn't in DKA at diagnosis. He struggles with control, and always has. He also didn't have a honeymoon. They think he had a slow onset over quite a few months.

 

Well, until they do a study looking at every person with DKA at diagnosis and follow those people forever, I guess your criteria for relevance won't be met.

Many studies have been listed, by myself and others, pointing out various aspects of DKA at diagnosis and the subsequent glycemic control, which may or may not indicate future outcomes. No one yet has found exact studies using your very specific terms, but the studies cited may be useful to forming a educated opinion. And isn't that what we do here; Form educated opinions, based on the science at hand. Not just "say so." Whatever way that turns out.

 

I don't see how we could provide a study that looks at what you want. We would need a longitudinal study of a few thousand people over a period of at least 20 years. Considering that the diabetes technology even 10 years ago was no where near as advanced as it is now any study like that would be irrelevant.

However, I think it would be reasonable to consider and discuss the fact that the presence of DKA at diagnosis may increase the risk of complications. There seems to be some evidence that individuals who were in DKA at diagnosis have lower c-peptide levels post diagnosis than individuals who did not. Considering the fact that c-peptide has been established as a protective factor with regards to complications it seems conceivable that DKA-> lower c-peptide -> greater risk of complications.

I don't have the time or scientific knowledge to address this but metabolic memory is another area that would be interesting to consider.

I do agree that the statement that "children in DKA at diagnosis are at a great risk of complications" is broad and inaccurate. I don't think we can say that any children with type 1 (diagnosed in DKA or not) using modern insulin therapy (MDI or insulin pumps) and ideally a CGM are at a great risk of complications.

DKA and c-peptide articles:
http://www.ncbi.nlm.nih.gov/pubmed/24152206
http://www.ncbi.nlm.nih.gov/pubmed/16629716
http://www.ncbi.nlm.nih.gov/pubmed/23389397

C-peptide and complications articles:
http://care.diabetesjournals.org/content/32/2/301.full
http://onlinelibrary.wiley.com/doi/10.1111/j.1399-5448.2010.00729.x/abstract
http://care.diabetesjournals.org/content/27/6/1506.full.pdf

 

Well, since we're talking complications I concur that a 2 or 6 year "study" is insufficient to address "greater risk of complications". IMO.

The couple of studies I read, meaning the summaries, seem to infer that DKA at diagnosis could be a result of ignorance and that continued ignorance could be causal to continued poor control. It may not be biological and could easily be educational. I would wager a tidy sum that the most educated, meaning those that educate themselves on the disease, have far fewer complications.

Just to be clear, I am not casting aspersions on those that are diagnosed with DKA. I personally do not think it has an effect in later control nor complications.

 

Statistically, I would guess people with the awareness to catch the dx earlier would also be more vigilant about control. It's more a personality trait, not a cause and effect relationship. But because many factors go into catching the dx, and many factors go into better control, I would also think it is a very loose relationship. But perhaps a relationship does exist.

I'm not labeling or judging anyone. Just throwing out a plausible explanation.

For the record, my son did not go into DKA. But if my wife were out of town that week and he were solely under my care, he most certainly would have.

Moreover, while he didn't go into DKA, our control post honeymoon has been a very big challenge.

So not everyone meets my explanation above, but statistically the relationship might exist.

Flame away.

 

This is the most incredibly judgmental, naive, and stupid thing I have ever read on this forum. You have no idea how many people here almost lost their children, and the few that actually did lose their children to DKA. It had nothing to do with vigilance. Do you know how many children are misdiagnosed or just how quickly it can go from looking like the flu to your child almost dying? No you don't. And It wasn't because you were more vigilant. Rather you were just damn lucky.

 

No, I've had the same thought. It's logical, and my daughter was in moderate DKA at dx. I can remove myself from the statistical reasoning.

In other words. I'm not one of the ones for whom that was the reasoning but it could very well be that people who are more attentive from the beginning are more attentive about follow up care as well. I won't flame you for that. It occurred to me too, and I'm in that population. It's simply science.

 

Lee -
Go back and read my post. Slowly. It's not long, read it again. Are you still hyperventilating? I'm guessing you are. So I'll type pretty much the same thing I did before, reword it a bit, and see if you're still completely missing the boat.

I am extremely lucky. My wife was there. Without my wife, my son would have been in serious trouble. So using my definition of the word vigilant, that's not me. Not even close.

Now, do I research, stress and obsess over my son's care now? Yes. Same guy. Under my definition of the word vigilant, I would say that describes me nicely.

Was I vigilant for dx? No. Am I vigilant now? Yes. Do I fit the profile of the subjects described in my hypothetical study? No. I would not be in the hypothetical statistical majority. I'm only suggesting there MIGHT be a loose relationship due to lots of different factors.

Maybe my use of the word "vigilant" is out of place. But within its context, you should have understood my meaning.