Causes of diabetic ketoacidosis among adults with type 1 diabetes mellitus: insulin pump users and non-users
Open accessAbstract
Introduction: Insulin pumps are increasingly being used as a method of insulin delivery in patients with type 1 diabetes mellitus (T1DM). Diabetic ketoacidosis (DKA) is a serious complication of T1DM. This study aims to identify the causes of DKA in patients with T1DM on continuous subcutaneous insulin infusion (CSII) and to compare these with patients with T1DM on multiple daily insulin injections (MDIIs). Research design and methods: This is a prospective observational study between January and June 2019 at the Cleveland Clinic Fairview Hospital. Demographic, clinical, and biochemical data were obtained from chart review. A questionnaire to explore additional clinical data relating to DKA was administered, with additional items for patients on the insulin pump. Results: Seventy-four patients were admitted with a diagnosis of DKA between the period of January and June 2019. Of these, 45 met the inclusion criteria and 43 consented. These were divided into two groups: group 1 included patients on MDII and group 2 included CSII. Overall, the most common precipitating factor for developing DKA was insulin non-adherence, seen in 51.2% of the cases. The most common cause of DKA in group 2 was pump/tubing related to 55% of the cases. Conclusion: Despite non-adherence being common in both CSII and MDII, a combination of social factors, education and insulin pump malfunction, such as pump/tubing problems, might be playing a pivotal role in DKA etiology in young adults with T1DM, especially in CSII users. Continued education on pump use may reduce the rate of DKA in pump users.
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Infusion failures are the leading cause of hospitalizations for diabetes-related ketoacidosis among people with diabetes who use CSII therapy, in some cases resulting in fatal outcomes.
“Notably, infusion failures are the leading cause of hospitalizations for diabetes-related ketoacidosis (DKA) hospitalization among PWD who use CSII therapy, in some cases resulting in fatal outcomes.8,9”
From Development of a Real-time Force-based Algorithm for Infusion Failure Detection (2024) · cites this paper as [8]
The Results (Etiology of DKA; page not provided) report that pump/tubing defects were associated with 55% of DKA cases among the study’s CSII users, making them the leading cause in that hospitalized group. The Discussion describes DKA as potentially fatal but does not link any fatal outcome specifically to an infusion failure. The claim also generalizes the finding beyond the adults with type 1 diabetes studied. (LLM, conf=0.88)
Experimental — accuracy not yet measuredIIS failures are the primary contributor to DKA development and the leading cause of DKA-related hospitalizations among insulin pump users.
“Correspondingly, IIS failures are the primary contributor to DKA development and the leading cause of DKA-related hospitalizations among insulin pump users.[9][10][11][12]”
From Frequency and Detection of Insulin Infusion Site Failure in the Type 1 Diabetes Exchange Online Community (2023) · cites this paper as [10]
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
The self-check needs the paper’s full text.
Cites
Miller, K. M., Foster, N. C., Beck, R. W., Bergenstal, R. M., DuBose, S. N., DiMeglio, L. A., Maahs, D. M., & Tamborlane, W. V. (2015) · Diabetes Care · doi:10.2337/dc15-0078 · Cited by 1,254 · see citing works
Flagged first, then by citations
Research works printed but not linked: 25
- [1]Realsen J, Goettle H, Chase HP Morbidity and mortality of diabetic ketoacidosis with and without insulin pump care. Diabetes Technol Ther 2012; 14: 1149– 54. 10.1089/dia.2012.0161 23009106 · DOI
- [2]Fazeli Farsani S, Brodovicz K, Soleymanlou N, et al Incidence and prevalence of diabetic ketoacidosis (DKA) among adults with type 1 diabetes mellitus (T1D): a systematic literature review. BMJ Open 2017; 7: e016587. 10.1136/bmjopen-2017-016587 PMC5642652 28765134 · DOI
- [3]Mecklenburg RS, Benson EA, Benson JW, et al Acute complications associated with insulin infusion pump therapy. Report of experience with 161 patients. JAMA 1984; 252: 3265– 9. 6439896
- [4]Peden NR, Braaten JT, McKendry JB Diabetic ketoacidosis during long-term treatment with continuous subcutaneous insulin infusion. Diabetes Care 1984; 7: 1– 5. 10.2337/diacare.7.1.1 6423352 · DOI
- [5]Jeitler K, Horvath K, Berghold A, et al Continuous subcutaneous insulin infusion versus multiple daily insulin injections in patients with diabetes mellitus: systematic review and meta-analysis. Diabetologia 2008; 51: 941– 51. 10.1007/s00125-008-0974-3 18351320 · DOI
- [6]Pettus JH, Zhou FL, Shepherd L, et al Incidences of severe hypoglycemia and diabetic ketoacidosis and prevalence of microvascular complications stratified by age and glycemic control in U.S. adult patients with type 1 diabetes: a real-world study. Diabetes Care 2019; 42: 2220– 7. 10.2337/dc19-0830 31548241 · DOI
- [7]Kitabchi AE, Umpierrez GE, Murphy MB, et al Hyperglycemic crises in diabetes. Diabetes Care 2004; 27 Suppl 1: S94– 102. 10.2337/diacare.27.2007.s94 14693938 · DOI
- [8]Ejaz S, Wilson T Managing type 1 diabetes ‑ a journey from starvation to insulin pump. Minerva Endocrinol 2013; 38: 123– 31. 23732367
- [9]Giessmann LC, Kann PH Risk and relevance of insulin pump therapy in the aetiology of ketoacidosis in people with type 1 diabetes. Exp Clin Endocrinol Diabetes 2020; 128: 745-751. 10.1055/a-0654-5134 30049002 · DOI
- [10]Benoit SR, Zhang Y, Geiss LS, et al Trends in Diabetic Ketoacidosis Hospitalizations and In-Hospital Mortality - United States, 2000-2014. MMWR Morb Mortal Wkly Rep 2018; 67: 362– 5. 10.15585/mmwr.mm6712a3 29596400 PMC5877353 · DOI
- [11]Randall L, Begovic J, Hudson M, et al Recurrent diabetic ketoacidosis in inner-city minority patients: behavioral, socioeconomic, and psychosocial factors. Diabetes Care 2011; 34: 1891– 6. 10.2337/dc11-0701 21775761 PMC3161256 · DOI · Paper page
- [12]Dabelea D, Rewers A, Stafford JM, et al Trends in the prevalence of ketoacidosis at diabetes diagnosis: the search for diabetes in youth study. Pediatrics 2014; 133: e938– 45. 10.1542/peds.2013-2795 24685959 PMC4074618 · DOI · Paper page
- [13]Wolfsdorf J, Glaser N, Sperling MA, et al Diabetic ketoacidosis in infants, children, and adolescents: a consensus statement from the American diabetes association. Diabetes Care 2006; 29: 1150– 9. 10.2337/dc06-9909 16644656 · DOI
- [14]Kitabchi AE, Umpierrez GE, Miles JM, et al Hyperglycemic crises in adult patients with diabetes. Diabetes Care 2009; 32: 1335– 43. 10.2337/dc09-9032 19564476 PMC2699725 · DOI · Paper page
- [16]Foster NC, Beck RW, Miller KM, et al State of type 1 diabetes management and outcomes from the T1D exchange in 2016-2018. Diabetes Technol Ther 2019; 21: 66– 72. [published correction appears in Diabetes Technol Ther. 2019 Apr;21(4):230]. 10.1089/dia.2018.0384 30657336 PMC7061293 · DOI · Paper page
- [17]Stratigou T, Vallianou N, Vlassopoulou B, et al DKA cases over the last three years: has anything changed? Diabetes Metab Syndr 2019; 13: 1639– 41. 10.1016/j.dsx.2019.03.022 31336534 · DOI
- [18]Dogan ADA, Jørgensen UL, Gjessing HJ Diabetic ketoacidosis among patients treated with continuous subcutaneous insulin infusion. J Diabetes Sci Technol 2017; 11: 631– 2. 10.1177/1932296816668375 27595713 PMC5505411 · DOI · Paper page
- [19]Hanas R, Lindgren F, Lindblad B A 2-yr national population study of pediatric ketoacidosis in Sweden: predisposing conditions and insulin pump use. Pediatr Diabetes 2009; 10: 33– 7. 10.1111/j.1399-5448.2008.00441.x 18761647 · DOI · Paper page
- [20]Gibb FW, Teoh WL, Graham J, et al Risk of death following admission to a UK hospital with diabetic ketoacidosis. Diabetologia 2016; 59: 2082– 7. 10.1007/s00125-016-4034-0 27397023 PMC5016550 · DOI · Paper page
- [21]Hurtado CR, Lemor A, Vallejo F, et al Causes and predictors for 30-day re-admissions in adult patients with diabetic ketoacidosis in the United States: a nationwide analysis, 2010-2014. Endocr Pract 2019; 25: 242– 53. 10.4158/EP-2018-0457 30913009 · DOI
- [22]Heinemann L, Krinelke L Insulin infusion set: the Achilles heel of continuous subcutaneous insulin infusion. J Diabetes Sci Technol 2012; 6: 954– 64. 10.1177/193229681200600429 22920824 PMC3440169 · DOI · Paper page
- [23]Kannan S, Satra A, Calogeras E, et al Insulin pump patient characteristics and glucose control in the hospitalized setting. J Diabetes Sci Technol 2014; 8: 473– 8. 10.1177/1932296814522809 24876608 PMC4455446 · DOI
- [24]Delgado-Hurtado JJ, Armstrong A, Correa RR, et al Perception of graduating endocrinology, diabetes, and metabolism fellows on the benefits of wearing a continuous glucose monitor and/or insulin pump for their education. Endocr Pract 2019; 25: 423– 6. 10.4158/EP-2018-0357 30720336 · DOI
- [25]Marks BE, Wolfsdorf JI, Waldman G, et al Pediatric endocrinology trainees' education and knowledge about insulin pumps and continuous glucose monitors. Diabetes Technol Ther 2019; 21: 105– 9. 10.1089/dia.2018.0331 30681363 PMC6434593 · DOI
- [26]Sweeney TJ, Kenny DJ, Schubert CC Inpatient insulin pump therapy: assessing the effectiveness of an educational program. J Nurses Prof Dev 2013; 29: 84– 9. 10.1097/NND.0b013e318286c5da 23657039 · DOI
Cited by
Sorted by citations
Grunberger, G., Sherr, J., Allende, M., Blevins, T., Bode, B., Handelsman, Y., Hellman, R., Lajara, R., Roberts, V. L., Rodbard, D., et al. (2021) · Endocrine Practice · doi:10.1016/j.eprac.2021.04.008 · Cited by 288 · see citing works
Russell-Jones, D., Babazono, T., Cailleteau, R., Engberg, S., Irace, C., Kjaersgaard, M. I. S., Mathieu, C., Rosenstock, J., Woo, V., & Klonoff, D. C. (2023) · The Lancet · doi:10.1016/s0140-6736(23)02179-7 · Cited by 115 · see citing works
Diabetic ketoacidosis in pregnancy: clinical risk factors, presentation, and outcomes
Dhanasekaran, M., Mohan, S., Erickson, D., Shah, P., Szymanski, L., Adrian, V., & Egan, A. M. (2022) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/clinem/dgac464 · Cited by 50 · see citing works
Ekberg, N. R., Hartvig, N. V., Kaas, A., Møller, J. B., & Adolfsson, P. (2024) · Journal of Diabetes Science and Technology · doi:10.1177/19322968221104142 · Cited by 33 · see citing works
Hughes, M. S., Douvas, J. L., Layfield-Bryan, M., Blanco, L. E., Gray, J. C., Zapotoczny, G., Espinoza, J., Wilcox, J. H., & Lal, R. A. (2023) · Diabetes Technology & Therapeutics · doi:10.1089/dia.2023.0005 · Cited by 16 · see citing works
Development of a Real-time Force-based Algorithm for Infusion Failure Detection
Blanco, L. E., Wilcox, J. H., Hughes, M. S., & Lal, R. A. (2024) · Journal of Diabetes Science and Technology · doi:10.1177/19322968241247530 · Cited by 2 · see citing works
- Authors
- Flores, M., Amir, M., Ahmed, R., Alashi, S., Li, M., Wang, X., Lansang, M. C., & Al-Jaghbeer, M. J.
- Affiliations
- Cleveland Clinic (US)
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Venue
- BMJ Open Diabetes Research & Care
- Publisher
- BMJ
- Published
- 2020-12
- Volume
- 8
- Issue
- 2
- Pages
- e001329
- ISSN
- 2052-4897 (ISSN-L)
- PMC
- PMC7737023
- OpenAlex
- W3117919811
- Cited by
- 43
- References
- 1
- Citations by year
- 2026: 5 · 2025: 11 · 2024: 12 · 2023: 4 · 2022: 6 · 2021: 4
- FWCI
- 2.64
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- BMJ Open Diabetes Research & Care (publishedVersion, cc-by-nc)
- PubMed Central (publishedVersion, cc-by-nc)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Genetics › Diabetes and associated disorders
- Keywords
- diabetic ketoacidosis, type 1 diabetes, insulin pump therapy, multiple daily insulin injections, pump failure, precipitating factors, young adults, diabetes education
- MeSH terms
- Diabetes Mellitus, Type 1, Humans, Insulin, Insulin Infusion Systems, Surveys and Questionnaires, Diabetic Ketoacidosis
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
