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Official websites use. Share sensitive information only on official, secure websites. Correspondence to: Beatriz D. This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. To evaluate the precipitating factors of diabetic ketoacidosis DKA in patients with type 1 diabetes hospitalized through the emergency department of a tertiary hospital. Data were collected by reviewing medical records. Only the first hospitalization of each participant in each period was included. In P2, 44 patients Most patients In P1, non-adherence was the main cause of DKA In P2, these rates were Over time, non-adherence remained the main precipitating factor of DKA, followed by infection, and no significant difference was observed between the two study periods. Elevated HbA1c, outside the therapeutic range, indicates suboptimal diabetes care and may explain, at least in part, poor adherence as a precipitating factor of decompensation. Health strategies, such as improved self-management of type 1 diabetes, may contribute to a future reduction in DKA episodes. Keywords: Diabetic ketoacidosis, precipitating factors, type 1 diabetes mellitus. Diabetic ketoacidosis DKA is a potentially life-threatening complication of type 1 diabetes. Its prevalence has increased over the past two decades, with approximately 50 to events per 1, adult patients with type 1 diabetes 1 — 3. The main known DKA precipitating factors are newly diagnosed diabetes, infection, poor adherence to treatment, and problems with interruption of insulin delivery 6 , 7. Approximately one-third of children with type 1 diabetes present with DKA on diagnosis 8. In developed nations, poor adherence to treatment is the leading cause of DKA, followed by infection and newly diagnosed diabetes, whereas infection and limited access to health care are the most prevalent causes in developing countries 9. In , we published an article describing the main triggers of DKA in patients with type 1 diabetes at a public tertiary hospital from January to March , which indicated poor adherence as the main cause of this acute complication, followed by infection and newly diagnosed diabetes 6. The objective of the current study was to determine if there were changes in the precipitating factors of patients presenting to the emergency department with DKA in the same hospital over time. We developed a cross-sectional study to establish the most common precipitating factors of DKA in patients with type 1 diabetes in two different time periods at a public tertiary hospital. The study analysed patients from a tertiary university hospital located in southern Brazil, a middle-income country. The data were divided into two time periods for comparison: period 1 P1 , from January to March ; and period 2 P2 , from April to January After identifying the patients who met the criteria for DKA, their electronic medical records were analysed for precipitating factors of DKA and other associated factors. Patients were identified through a query of electronic medical records. All patients presenting to the emergency department who had blood collected for arterial blood gas analysis and measurement of serum or urine ketones and blood glucose had their medical records reviewed. We retrospectively selected patients with type 1 diabetes who met the diagnostic criteria for DKA, defined by: When patients had been hospitalized more than once during the study periods, only the first hospitalization was counted for each patient in the period. However, the periods were considered independently, i. Considering that approximately one third of people with type 1 diabetes have DKA at diagnosis, for a better assessment of precipitating causes of this complication, we performed the analyses in two ways. First, evaluating all patients diagnosed with DKA, including both patients with a previous diagnosis of type 1 diabetes and patients who received type 1 diabetes diagnosis at the emergency department. Secondly, we evaluated the precipitating causes of DKA only in patients with previously instituted treatment, that is, with a previous diagnosis of type 1 diabetes. The precipitating factors were infection, treatment poor adherence, DKA associated with the diagnosis of type 1 diabetes initial diagnosis , recreational drug use, and others defined as those not belonging to any of the previous groups and, therefore, analysed individually. As in the previous study, treatment poor adherence was considered a precipitating factor if there was non-adherence to insulin therapy or dietary abuse without proper correction with bolus insulin excluding any other clearly identifiable precipitating factor 6. The precipitating factor of DKA was defined by the evaluation of physicians or endocrinologists during hospitalization. Other laboratory and radiological investigations performed for precipitating factors were also analysed, including chest and sinus radiographs and urine and blood cultures. Ketones were measured by reagent strip testing with sodium nitroprusside. The t-test was used for continuous variables, and the chi-square test for categorical variables. Data were analysed using SPSS, version The study was approved by the institution's Research Ethics Committee protocol no. CAEE During the electronic medical record search, potential cases of DKA were identified. After completing the review of medical records, records were excluded for not meeting the criteria for DKA and records were excluded due to other type of diabetes rather than type 1. After selecting all confirmed cases of DKA in patients with type 1 diabetes, only the first DKA hospitalization of each patient was included, leading to the exclusion of 91 records Figure 1. A total of 97 patients were included in the study. The clinical characteristics of patients are described in Table 1. Briefly, 44 Forty-three Seventy-four patients The median duration of diabetes was Eighteen patients In 14 patients Clinical characteristics among individuals with DKA triggered by infection or poor adherence are shown in Table 2. There is no significant difference between groups considering the two main causes. Urinary tract infection was the most common infection, detected in 11 cases DKA: diabetic ketoacidosis. HbA1c: glycated haemoglobin. Regarding the treatment, only one patient was treated with insulin infusion pump, and only one patient used insulin pens. None of the patients were using sodium-glucose cotransporter-2 SGLT2 inhibitors. Of the 74 patients with a previous diagnosis of type 1 diabetes, 16 The rates of diabetes complications and comorbidities of P2 patients were similar to those of P1 patients Table 3. In P1, poor adherence was the main cause of DKA When only patients who had a previous diagnosis of diabetes were analysed, poor adherence to treatment accounted for Compared with the first study period up to , when low adherence was identified in Diabetic ketoacidosis is a potentially life-threatening but preventable complication of diabetes and the leading cause of death in children and young adults with type 1 diabetes Better understanding of the precipitating factors of DKA may facilitate the targeting of prevention efforts. However, there is scientific uncertainty about what is actually the most common precipitating factor. In our study, no statistical difference was observed between the two study periods. In the second-period analysis, covering the years from to , no changes were observed in the main causes of DKA, with non-adherence to treatment remaining the main precipitating factor. When only patients with a previous diagnosis of type 1 diabetes were evaluated, there was also no change in the distribution of the causes of DKA: rates were similar between the two study periods, with poor adherence to treatment as the main triggering factor for this acute complication of diabetes. The percentage of patients who did not have their DKA precipitating factor identified increased from 9. Difficulty in identifying the precipitating factor of DKA has also been described in previous studies with a retrospective design 7 , 13 , 14 including the previous study conducted in the same hospital 6. Moreover, incomplete data are not uncommon under such study design, as data entry in electronic medical records is often considered both burdensome and time-consuming by physicians Poor adherence to treatment, especially insulin omission, has been widely reported as an important precipitating factor of DKA 16 , Because it is a modifiable and preventable factor, clarifying and promoting adherence to treatment may reduce morbidity and mortality as well as the costs of diabetes care 18 , Unfortunately, although diabetes care in our institution is provided by a multidisciplinary team dietitians, nurses, psychologists, and endocrinologists and educational initiatives are offered, individually or in groups, to most of our patients with diabetes, the impact on the outcomes measured here was null. This information should be used to develop new approaches to delivery diabetes self-management in order to have an actual impact on our patients in daily practice. Comprehensive strategies and innovative clinical models are needed to engage patients in their own diabetes care by addressing barriers to ideal management and, consequently, improving adherence to treatment; supported by telemedicine, for example Infection remained an important cause of DKA in the present study. This triggering factor appears to be more closely associated with older age and most commonly affects the lungs and urinary tract This is particularly important considering a previous report in the literature of a significant association of infection with increased case-fatality rate of DKA, which indicates that more actions aimed at prompt identification and treatment of infection may be needed On admission, 23 patients Therefore, programs to improve the understanding of the classic symptoms of type 1 diabetes would increase early diagnosis and prevent acute metabolic disorders at presentation. This action may reduce the number of diagnoses of DKA in children at the initial presentation of type 1 diabetes, which is what occurs in centres with a larger number of cases of type 1 diabetes 4 , 8 , These data are in accordance with previous studies correlating DKA events with elevated HbA1c and poor glycaemic control 1 , 26 , 27 , and psychiatric disorders Other factors commonly correlated with DKA events are lower socioeconomic status 27 , 28 and female sex 1 , Most of our patients were male, and their socioeconomic status was not assessed, thus precluding further analysis of these data. Some limitations of our study, such as including only the first hospitalization of the same patient who had more than one admission for DKA, may have interfered with the interpretation of the results, since some patients had several hospitalizations for DKA. In addition, all medical records reviewed were exclusively from patients receiving care through the public health system, who are often of low socioeconomic status and more susceptible to social problems that may interfere with the control of chronic diseases and increase the risk of DKA This was a retrospective cross-sectional study and, therefore, subject to known methodological biases. All information was collected only by medical record review, thus preventing the analysis of some data that were not described in all records. Nevertheless, to our knowledge, this study is one of the first in Latin America to estimate the number of DKA cases at a tertiary hospital in two different time periods, as well as to investigate possible identifiable precipitating factors over time. In conclusions, after almost a decade, poor adherence to treatment remains the most common precipitating factor of DKA in our population. Outpatient follow-up, diabetes care programs, and implementation of initiatives to engage patients in diabetes self-management education and adherence to self-care may be effective strategies to reduce the number of hospitalizations for DKA, thus improving the overall quality of life of patients with type 1 diabetes. All authors have seen and approved the current version of the manuscript. The funders did not have any participation in the study design, in the collection, analysis and interpretation of data, in the writing of the report, or in the decision to submit the article for publication. As a library, NLM provides access to scientific literature. Arch Endocrinol Metab. Find articles by Sheila Piccoli Garcia. Find articles by Leonardo Grabinski Bottino. Find articles by Julia Luchese Custodio. Find articles by Gabriela Heiden Telo. Find articles by Beatriz D Schaan. Disclosure: no potential conflict of interest relevant to this article was reported. PMC Copyright notice. 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