Type 1 diabetes (T1D) is one of the most common metabolic diseases in the pediatric population worldwide. The global increase in the incidence of type 1 diabetes among children still remains at the level of 3% to 5% annually.[1,2] The alarming epidemiological situation may also be observed in Poland with the tendency toward younger age groups.[3] In children aged 0-14 the disease frequency boosted approximately six-fold from 4.2 per 100 000 persons/year in the early 1970s to 24.3 per 100 000 persons/year in 2013 with regular, sinusoidal fluctuations and a slight levelling-off over the past few years.[3,4,5]
The International Society for Pediatric and Adolescent Diabetes (ISPAD) stated that diabetic ketoacidosis (DKA) was the most common, but potentially preventable life-threatening complication related to newly diagnosed T1D.[6] The incidence of this problem is still unacceptably high, especially in the youngest group (below 5 years) and has not changed over the last 20 years despite a sharp increase in T1D diagnoses and improvement in medical care.[1,2,7] Overall, more than one-third of newly diagnosed children are affected by DKA.[2,7,8,9] A large global variation is observed in DKA prevalence, with the values varying from 14.7% (Denmark) to 79,8% (Saudi Arabia) depending on a geographic location, the socioeconomic factors of the country and the incidence of diabetes (the awareness is poorer in countries with a lower incidence).[2] The socioeconomic inequalities play a crucial and important role in the DKA rate at diabetes diagnosis.[2,7,8,9] The frequency of DKA in Poland was estimated to be between 22 to 36% [1,10,11,12] and the incidence of coma due to DKA was around 4.7% of children.[12] DKA is the most common cause of diabetes-related death and has an associated mortality rate from 0.15 to 0.35% in developed countries and from 3.4 to 24% in developing countries.[7]
Cerebral edema is the leading cause of DKA-related death. It occurs in 0.3–1% people at disease onset.[3] Some authors suggested that when clinically cerebral edema was not observed mild brain injuries were present in at least 50% of children during DKA treatment.[13]
Negative neurological complications were associated with persistent alterations in attention and memory 6 months following a DKA episode. Moreover, DKA severity and younger age were the greatest risk factors for changes in the cerebral structure.[14] Aye et al. reported that a single episode of moderate or severe DKA in young children at diabetes diagnosis contributed to lowering the cognitive function and altering brain growth.[2,15] DKA was also correlated with a longer hospitalization and higher baseline insulin requirements.[16] Moreover, ketoacidosis at diabetes onset was associated with a poor residual β-cell function and, thereby, a shorter remission period.[1,3] Data concerning long-term glycemic control depending on DKA presence on diabetes diagnosis are contradictory. The majority of authors supported the concept of metabolic tracking and reported a negative influence on metabolic control if diabetes was accompanied by DKA at onset.[2,3] The discussion regarding health care in diabetes attracts attention to numerous differences observed worldwide in terms of the access to medical services, education level, approach to new insulin and diabetes technologies.
The major objective of our study was to assess whether long-term glycemic control in children and adolescents with T1D who had DKA at diabetes onset was poorer than in T1D people without DKA during a 5-year observation period.