At the end of five years follow up, about 207 (58.4%) developed DKA with the median survival time of 35.6 months (IQR: 18.6, 49.2). In this study, the overall incidence of DKA was 2.27 cases per 100 children per month (27.24 cases per 100 child-years) observation. The incidence rate of DKA is much higher than studies done in Saudi Arabia which were 6.2% per year , international society of pediatric and adolescent diabetes 2014 report which was 1–10% per patient per year  and Austria which was 8.4 to 18.4 per 100,000 per year . These controversies might be due to in studies done at Saudi Arabia the age of participants was 14 to 40, but in this study, participants were < 15 years old and study done in Austria was population-based study and for a long time (twenty years) ago.
Regarding cumulative incidence, this finding is consistent with studies done in north-western Nigeria which was 62.2%  and 55.5% in Iran . However, this finding is much lower than studies done in Tikur-Abesa specialized hospital which was 80% , 77.1% in Benin teaching hospital . This discrepancy might be due to methodological differences, in those two studies the incidence was calculated based on newly diagnosed DM, but in the current study, the incidence was estimated based on known diabetes diagnosed children. This finding is much higher than studies done in the US which was 25.5% , 40.3% in Italy , 27% in New Zealand  in Poland 28% , 40% in southern Iraq . This discrepancy might be due to methodological differences, in the US the incidence was calculated based on newly diagnosed DM, in others the incidence was calculated based on both newly diagnosed DM and known diabetes children but in the current study, the incidence was estimated based on known Diabetes. Another explanation might be due to different population characteristics and qualities of health care service.
Children age < 5 years were more likely to develop DKA compared to age > 10 years. This is consistent with other previous studies conducted in the US , Italy , Southern Iraq . This might be the age group < 5-year might be more dependent on their caregiver thus not take on time and not collaborate to take medication. Children who have medication non-adherence were more likely to develop DKA as compared to adhere to medication. This finding is supported by other previous studies conducted in sub-Saharan Africa , north India , Saudi Arabia , New Zealand , Southern Iraq . This might be since DM is chronic illness after taking medication symptoms may disappear for some times so, the children may not take their medication on time. Also, children having a history of inappropriate insulin storage at home were more likely to develop DKA. This might be most of the participants were from rural areas and may not have an appropriate storage material like refrigerator and may have inadequate knowledge about the storage of insulin. Children who have preceding gastroenteritis and upper respiratory tract infection at the time of DKA development were more likely to develop DKA as compared to those who have not. This is supported by study in Tikur Ambesa hospital , Nigeria , sub-Saharan Africa , Malaysia , north India  and Saudi Arabia . This might be infection can cause high levels of counteracting hormones which triggering an episode of DKA
Since the data were collected from medical records, patients’ charts lost and incomplete data were found. These may affect the outcome of the study. Also, this study did not include the recurrence of diabetic ketoacidosis (trend) and the lack of some variables like parental factors that can't be addressed through card review