Association of Diabetic Ketoacidosis at Onset, Diabetes Technology Uptake and Clinical Outcomes after 1 and 2 Years of Follow-up: A Collaborative Analysis of Pediatric Registries Involving 9,269 Children with Type 1 Diabetes from 9 Countries

Objectives: The aim of this study is to examine the association between diabetic ketoacidosis (DKA) at type 1 diabetes diagnosis and long-term glycemic outcomes, insulin requirements, BMI SDS and diabetes technology uptake in youth. Research design and methods: Data from nine countries (Austria, Czechia, Germany, Italy, Luxembourg, New Zealand, Slovenia, Switzerland and USA (Colorado)) including youth (0.5-15.9 years) diagnosed with type 1 diabetes in 2019-2020 and followed for 2 years thereafter. Participants were divided into three groups: no DKA, non-severe, and severe DKA at diagnosis. HbA1c, insulin requirements, BMI SDS, and use of technology, including automated insulin delivery (AID), were assessed. Results: A total of 9,269 individuals (54.8% males, mean age 9.0 years) were included in the analysis. DKA at diagnosis was observed in 34.2% of participants and severe DKA in 12.8%. After one year, adjusted mean HbA1c was higher in the severe DKA group (7.41%) compared to non-severe DKA (7.23%, p=0.001) and no DKA groups (7.14, p<0.001), and this difference persisted after two years (7.58% vs. 7.38%, p<0.001, and vs 7.32%, p<0.001). Higher BMI SDS was observed in both DKA groups compared to no DKA. The use of AID was associated with lower HbA1c levels compared to other treatment modalities and moderated differences between DKA groups after two years of follow up (p=0.072). Conclusions: Both severe and non-severe DKA at type 1 diabetes diagnosis were associated with persistently higher HbA1c and higher BMI SDS. AID use diminishes the association of DKA at diagnosis and higher HbA1c over time.