Background: Diabetic Ketoacidosis (DKA) is the most common severe acute complication of diabetes, and has shown to be worsened by COVID-191. Several studies have found an association between COVID-19 and worsened outcomes from diabetic ketoacidosis (DKA).2 Vaccination against COVID-19 has led to substantial declines in the frequency, severity, and mortality from acute infection, but little research has examined if COVID-19 vaccines have benefit among people admitted with DKA3. Therefore, we aim to evaluate the association between COVID-19 vaccination and in-hospital outcomes in patients admitted with DKA.

Methods: We conducted a retrospective matched cohort study among 94 patients who presented with DKA and COVID-19 infection in 4 hospitals within Emory Healthcare from 1/1/2021 to 3/1/22 . DKA was confirmed on admission laboratories (pH < 7.3, bicarbonate < 18 mmol/L, and either a beta-hydroxybutyrate >1.5mg/dL or presence of ketonuria). COVID-19 status was also confirmed by laboratory testing. We propensity matched individuals 1:1 on vaccination status, age, sex, race, ethnicity comorbidities and admission labs. Our primary outcome was mortality within the hospitalization, defined as the total number of deaths at discharge. Secondary outcomes included insulin requirement, length of stay, incidence of hypoglycemia (blood glucose < 70 mg/dL) , incidence of acute respiratory failure, thrombosis and pneumonia. For primary outcome analysis , we used logistic regression to compare the odds of complication between the groups

Results: The patient characteristics on admission, including demographic, severity of illness and labs were similar. The mortality in the vaccinated and unvaccinated groups were 19.1% (n=9) and 21.3% (n=10) (p = 1.0) respectively. Similarly, the length of stay for the vaccinated group was 7.0 days (95% CI 3.5-13 .0) vs 9.0 days (95% CI 5.0 – 18.0) for the unvaccinated group. There was also no difference in the rate of hypoglycemia at 59.6% vs 57.4% (p = 1.0). Other than CKD (42.6% vs 17.4%, p = 0.001) other complications such as acute respiratory failure, thrombosis, and pneumonia were not significantly different.

Conclusions: In this observational study, our study did not show a significant improvement in outcomes for patients presenting with DKA who were vaccinated for COVID-19 compared to those who were not vaccinated. It is possible that waning immunity and decreased vaccine effectiveness (especially against Omicron) lead to these results4,5 . It is also likely that incomplete vaccination record on admission found on manual chart review could have contributed to these results. More research is needed to elucidate the effectiveness of vaccines on patients with DKA and COVID-19 infection.