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Diabetic ketoacidosis in patients with type 2 diabetes: Risk factors for mortality and adverse outcomes
Vishnu Chandrabalan, Timothy Howcroft, Mohammed Khalid Alkhalifah, Noorulanne Younis, Ebrahim Aldhafiri, Joseph M Pappachan
Vishnu Chandrabalan, Timothy Howcroft, Department of Data Science, Lancashire Teaching Hospitals NHS Trust, Preston PR2 9HT, United Kingdom
Mohammed Khalid Alkhalifah, Department of Endocrinology and Metabolism, Lancashire Teaching Hospitals NHS Trust, Preston PR2 9HT, United Kingdom
Mohammed Khalid Alkhalifah, Department of Family Medicine and Polycliniccs, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia
Noorulanne Younis, Ebrahim Aldhafiri, Department of Endocrinology and Metabolism, Lancashire Teaching Hospitals NHS Trust, Preston PR2 9HT, Lancashire, United Kingdom
Joseph M Pappachan, Faculty of Science, Manchester Metropolitan University, Manchester M15 6BH, United Kingdom
Joseph M Pappachan, Department of Endocrinology and Metabolism, Kasturba Medical College, Manipal Academy of Higher Education, Manipal 576104, India
Joseph M Pappachan, Department of Endocrinology and Metabolism, Countess of Chester Hospital NHS Trust, Chester CH2 1UL, United Kingdom
Author contributions: Chandrabalan V and Pappachan JM conceptualized the study; Howcroft T and Alkhalifah MK formulated the methodology; Younis N, Aldhafiri E, and Howcroft T were involved in the literature search, study selection, and data extraction; Chandrabalan V and Howcroft T performed statistical analysis; Alkhalifah MK, Younis N, and Aldhafiri E drafted the initial manuscript under supervision of Pappachan JM; all authors contributed to the revision and approved the final manuscript.
Institutional review board statement: The study was approved by the Institutional Review Board (No. DIAB/CA/2021-22/03).
Informed consent statement: The study is based on a retrospective data analysis and therefore, no patient consent is required.
Conflict-of-interest statement: Authors have no competing interests to declare in relation to 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: Technical appendix, statistical code, and dataset available from the corresponding author on email request.
Corresponding author: Joseph M Pappachan, MD, FRCP, MRCP, Professor, Senior Researcher, Faculty of Science, Manchester Metropolitan University, All-Saints Building, Manchester M15 6BH, United Kingdom.
drpappachan@yahoo.co.in
Received: December 24, 2025
Revised: January 11, 2026
Accepted: February 5, 2026
Published online: March 20, 2026
Processing time: 97 Days and 16 Hours
BACKGROUND
Diabetic ketoacidosis (DKA) resulting from type 2 diabetes mellitus (T2DM) is less common, and the factors associated with adverse outcomes and mortality are not well established based on large-scale studies.
AIM
To identify the risk factors for adverse outcomes and mortality in treated patients with DKA in T2DM.
METHODS
Retrospective analysis of patients admitted to a tertiary-care hospital in the United Kingdom with DKA and T2DM for inpatient management between January 2010 to September 2024 to identify the clinical profile, demographic features, and laboratory parameters impacting treatment outcomes and survival.
RESULTS
Four hundred and sixty-four patients were included. Of these 395 (85.13%) were White, 266 (57.3%) were males with a mean age at presentation of 61.3 (17.6) years, median inpatient hospital stay of 5 (interquartile range: 3-10.3) days, and a mean glycated HbA1c of 89.3 (30) mmol/mol. The 30-day and 90-day mortality were 13.4% and 11% respectively after the index DKA event. The long-term survival after the DKA event was only 58.6%. Presence of cerebrovascular disease [odds ratio (OR): 6.75; 95%CI: 0.76-12.74], use of sodium glucose cotransporter 2 inhibitors (OR: 5.8; 95%CI: 1.32-9.62), chronic obstructive pulmonary disease (OR: 3.6; 95%CI: 2.14-6.44), higher national early warning score 2 score (OR: 1.14; 95%CI: 0.10-2.18) and low systolic blood pressure (OR: -0.18; 95%CI: -0.32 to -0.04) at admission were the significant predictors of longer inpatient stay. Coexistent peripheral vascular disease (PVD; OR: 46.43) and congestive heart failure (CHF; OR: 30.83), and lower estimated glomerular filtration rate (eGFR; OR: 0.98) were the important predictors of mortality during the hospital treatment. The significant predictors on 30-day mortality were: Age (OR: 1.06), eGFR (0.97) and index of multiple deprivation (IMD) decile (0.74). The factors associated with long-term mortality risk were dementia (20.54-fold higher), continued use of sulfonylurea/metformin, and older age (4% higher with each additional year).
CONCLUSION
DKA carries a serious risk of mortality in both the short and long term in T2DM patients. Factors such as older age, dementia, PVD, CHF, low eGFR define the riskiest groups. These groups of patients may benefit from closer follow-up and more aggressive metabolic and comorbidity management after discharge.
Core Tip: Diabetic ketoacidosis (DKA) resulting from type 2 diabetes mellitus (T2DM) is less common. A retrospective analysis of 464 patients from a tertiary-care United Kingdom hospital with DKA and T2DM identified that mortality rates at 30 and 90 days were 13.4% and 11% respectively after the index DKA event. The survival after the DKA event was only 58.6% on long-term follow-up. Coexistent peripheral vascular disease, congestive heart failure, and lower estimated glomerular filtration rate were the important predictors of inpatient mortality. Factors associated with long-term mortality risk were dementia, and older age at presentation and continued use of older antidiabetic agents like sulfonylurea/metformin.
