Prevalence and clinical characteristics of diabetic retinopathy in patients newly diagnosed with ketosis-onset diabetes: A real-world study

doi:10.4239/wjd.v17.i3.115465

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World Journal of Diabetes

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

Observational Study

Copyright: ©Author(s) 2026. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution-NonCommercial (CC BY-NC 4.0) license. No commercial re-use. See permissions. Published by Baishideng Publishing Group Inc.

World J Diabetes. Mar 15, 2026; 17(3): 115465
Published online Mar 15, 2026. doi: 10.4239/wjd.v17.i3.115465

Prevalence and clinical characteristics of diabetic retinopathy in patients newly diagnosed with ketosis-onset diabetes: A real-world study

Man-Rong Xu, Meng-Han Li, Jun-Wei Wang, Ya-Wen Zhang, Jun-Xi Lu, Jiang-Feng Ke, Lian-Xi Li

Man-Rong Xu, Meng-Han Li, Ya-Wen Zhang, Jun-Xi Lu, Lian-Xi Li, Department of Endocrinology and Metabolism, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai Clinical Center for Diabetes, Shanghai Diabetes Institute, Shanghai Key Laboratory of Diabetes Mellitus, Shanghai Key Clinical Center for Metabolic Disease, Shanghai 200233, China

Jun-Wei Wang, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Third Hospital of Shanxi Medical University, Tongji Shanxi Hospital, Taiyuan 030032, Shanxi Province, China

Jiang-Feng Ke, Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fuzhou 350014, Fujian Province, China

Co-first authors: Man-Rong Xu and Meng-Han Li.

Co-corresponding authors: Jiang-Feng Ke and Lian-Xi Li.

Author contributions: Xu MR undertook data curation, formal analysis, software, visualization, and writing original draft; Xu MR and Li MH contributed equally to this article, they are the co-first authors of this manuscript; Lu JX, Ke JF, and Li LX handled funding acquisition; Li MH, Wang JW, Zhang YW, Lu JX, and Li LX managed methodology, validation, and writing review and editing; Ke JF and Li LX were responsible for conceptualization, resources, project administration, supervision, and investigation, they contributed equally to this article, they are the co-corresponding authors of this manuscript; and all authors contributed to the article and approved the submitted version.

Supported by the National Natural Science Foundation of China, No. 81770813 and No. 82070866; the Joint Funds for the Innovation of Science and Technology, Fujian Province, No. 2023Y9453; Shanxi Research Program of Application Foundation, No. 202403021212199; and China Postdoctoral Science Foundation, No. 2024M751910.

Institutional review board statement: This study was approved by the Medical Ethics Committee of Shanghai Sixth People’s Hospital, approval No. 2018-KY-018(K).

Informed consent statement: Each subject gave written consent prior to participating in this study.

Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.

STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.

Data sharing statement: All data generated or analyzed during this study are included in this article. Further enquiries can be directed to the corresponding author.

Corresponding author: Lian-Xi Li, MD, PhD, Department of Endocrinology and Metabolism, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai Clinical Center for Diabetes, Shanghai Diabetes Institute, Shanghai Key Laboratory of Diabetes Mellitus, Shanghai Key Clinical Center for Metabolic Disease, No. 600 Yishan Road, Shanghai 200233, China. lilx@sjtu.edu.cn

Received: October 17, 2025
Revised: November 23, 2025
Accepted: January 6, 2026
Published online: March 15, 2026
Processing time: 146 Days and 8.2 Hours

Abstract

BACKGROUND

The classification of ketosis-onset diabetes is controversial, and the prevalence and clinical characteristics of diabetic retinopathy (DR) in ketosis-onset diabetes mellitus remain unclear.

AIM

To compare the prevalence and risk factors of DR among patients with type 1 diabetes mellitus (T1DM), ketosis-onset diabetes, and non-ketotic type 2 diabetes mellitus (T2DM).

METHODS

This real-world observational study enrolled 1777 patients with newly diagnosed diabetes between January 2003 and December 2012, including 211 with T1DM, 673 with ketosis-onset diabetes, and 893 with non-ketotic T2DM. DR was assessed using digital nonmydriatic fundus photography, and its severity was graded based on the ETDRS classification. Clinical characteristics and risk factors of DR were compared across the three groups.

RESULTS

After controlling for age and sex, DR prevalence was significantly higher in ketosis-onset diabetes (9.5%) than in T1DM (5.7%, P = 0.034), but not significantly different from non-ketotic T2DM (12.3%, P = 0.105). Risk factors for DR in ketosis-onset diabetes and non-ketotic T2DM included increased estimated glomerular filtration rate (eGFR) and urinary albumin excretion. In contrast, elevated eGFR and 2-hour postprandial C-peptide were independent risk factors for DR in T1DM. The prevalence and risk factors for DR in ketosis-onset diabetes were similar to those in non-ketotic T2DM, but differed from T1DM.

CONCLUSION

These findings further support classifying ketosis-onset diabetes as a subtype of T2DM rather than idiopathic T1DM. However, the distinctive clinical features of ketosis-onset diabetes should not be ignored.

Keywords: Diabetic classification; Ketosis-onset diabetes; Diabetic retinopathy; Type 1 diabetes; Type 2 diabetes

Core Tip: This study demonstrates that the clinical features and risk profile of diabetic retinopathy in ketosis-onset diabetes resemble those of non-ketotic type 2 diabetes rather than type 1 diabetes. The similarity in diabetic retinopathy patterns supports the classification of ketosis-onset diabetes as a subtype of type 2 diabetes. Nonetheless, ketosis-onset diabetes presents with distinct clinical characteristics that should be carefully considered in clinical decision-making and individualized management.