Risk Factors for Recurrent DKA in Children and Adolescents with Established Diabetes: A Systematic Review and Meta-Analysis

Abstract

Despite advances in diabetes management, recurrent diabetic ketoacidosis (DKA) remains a common and largely preventable complication in paediatric patients with type 1 diabetes mellitus (T1DM). This systematic review and meta-analysis aimed to synthesise available evidence on risk factors associated with recurrent DKA in children and adolescents. We systematically searched PubMed, Scopus, Web of Science, and the Cochrane Library from inception to October 2025. Observational studies involving children and adolescents (< 21 years) with established type 1 diabetes mellitus and biochemically confirmed DKA were included. Random-effects meta-analyses were performed for predefined predictors, reporting pooled odds ratios (ORs) with 95% confidence intervals (CI). Twelve observational studies comprising 58,911 paediatric patients were included. A prior episode of DKA was the strongest predictor of recurrence, conferring an almost eightfold increased risk (OR = 7.97, 95% CI 4.33–14.67). Longer diabetes duration of 12–15 years was also associated with increased recurrence risk (OR = 1.94, 95% CI 1.21–3.11), whereas duration of 5–11 years was not (OR = 1.13, 95% CI 0.76–1.69). Female sex was not significantly associated with recurrence in the primary analysis. Overall risk of bias was moderate across studies. Prior DKA episodes and longer disease duration are key predictors of recurrent DKA in paediatric T1DM. Targeted prevention strategies following an initial DKA episode are urgently needed, supported by future prospective research.