Background: The presence of concomitant diabetic ketoacidosis (DKA) with acute pancreatitis (AP) is not uncommon and is associated with unfavorable outcomes (1,2). However, the diagnosis of AP in DKA patients is often missed because of the overlapping clinical features. Data comparing clinical characteristics and outcomes of patients with co-existing DKA and AP with DKA alone is limited. We conducted a retrospective observational study to compare the clinical characteristics and outcomes of patients with concomitant DKA and AP or DKA alone.

Methods: Data of patients with DKA admitted between January 2015 to August 2021 to four tertiary hospitals of Hamad Medical Corporation, Qatar, was extracted from the electronic health record (Cerner). DKA diagnosis was according to the ADA criteria. Co-existing AP was diagnosed based on the Atlanta criteria. Descriptive statistics, univariate and multivariate regression analyses were conducted as appropriate.

Results: 936 patients with DKA were included in the analysis, of which 84 (8.98%) had co-existing AP. Patients in this group were older (p-value < 0.001). AP was most common in the Asian race (65.47%, p-value < 0.001) despite comprising only 33% of the total study cohort. AP was also more common (75%, p-value < 0.001) in patients with type 2 diabetes (T2D). Patients with DKA and AP had significantly (p < 0.05) higher admission anion gap, white cell count, hemoglobin, neutrophil to lymphocyte ratio (NLR), urea, creatinine, maximum blood glucose during the episode, total cholesterol and triglyceride as compared to DKA patients without AP. They had a lower (p < 0.05) admission venous pH, venous pH and bicarbonate at 6 hours. Patients in the DKA with AP group also had a longer length of stay (LOS) (p-value < 0.001), DKA duration (p-value < 0.001) and a higher rate of ICU admission (p-value 0.001). In-hospital mortality, 3-month all-cause readmission, 6-month and 12-month DKA recurrence did not differ between the two groups. Univariate logistic regression analysis showed age, Asian ethnicity, male gender, T2D, admission WBC count, hemoglobin, urea, creatinine, potassium, venous pH, bicarbonate, anion gap, total cholesterol, triglyceride (TG) and LDL level to be statistically significant (p < 0.05) factors associated with the development of concomitant DKA with AP. However, based on multivariate logistic regression analysis, only age and total cholesterol level were associated with concomitant DKA with AP (p < 0.05).

Conclusions: This study showed that patients with concomitant DKA and AP have more severe derangement in markers of DKA severity, inflammation, kidney injury and metabolic profile, along with a longer DKA duration, LOS and requirement for ICU support as compared to DKA patients without AP. This highlights the clinical significance of diagnosing the coexistence of DKA with AP, as the combination results in significantly worse clinical outcomes and greater healthcare utilization than in patients with only DKA.