Association of diabetic ketoacidosis and retinopathy in patients with type 2 diabetes: a nationwide cohort study

Diabetic ketoacidosis (DKA) is the most common acute complication in people with diabetes. We aimed to assess the association of DKA with the risk of diabetic retinopathy (DR) and related ophthalmic interventions in individuals with type 2 diabetes (T2D). To ensure similar T2D management and severity at baseline between groups, we enrolled 1,007 T2D patients with and without DKA matched by anti-diabetic combination within the initial 3 months of diabetes diagnosis, gender, birth and diabetes diagnosis year in Taiwan National Health Insurance Research Database from 2000 to 2019. We employed Fine and Gray competing risk model to assess the risk of non-proliferative DR (NPDR), proliferative DR (PDR) and panretinal photocoagulation (PRP). Our results showed that patients with DKA had an increased risk of DR (adjusted subdistribution hazard ratio [SHR] 1.64 [95% CI, 1.34-2.01]) and PRP (SHR 1.43 [1.11-1.86]). The risk of NPDR is elevated when diabetes-to-DKA duration exceeded 24 months (SHR 2.15 [1.52-3.05]), while 1-24 months duration increased PDR risk (SHR 3.72 [1.76-7.88]). Patients with DKA onset at ages 46-55 and 56-65 showed specific PDR (SHR 1.82 [0.99-3.33]) and NPDR susceptibilities (SHR 6.52 [2.30-18.49]), respectively. Our study showed that DKA was associated with a higher risk of developing DR and requiring related ophthalmic interventions compared to a matched cohort with similar T2D baseline characteristics.