Worldwide prevalence of diabetic ketoacidosis at diagnosis of type 1 diabetes: A systematic review and meta-analysis.

Abstract

Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes (T1D) and a marker of delayed diagnosis, associated with significant morbidity, mortality, and healthcare costs. Global estimates of DKA at T1D onset remain inconsistent. We conducted a systematic review and meta-analysis, searching PubMed (1996), Web of Science (1966), Embase (1947), and Scopus (1980), each from its inception to October 2025, without restrictions. Studies reporting DKA prevalence at diagnosis in individuals <19 years with newly diagnosed T1D were included. Pooled prevalence was calculated using random-effects meta-analysis. Subgroup analyses explored variations by country, region, World Bank income level, and pre- versus post-COVID-19 period; meta-regression examined continuous moderators. A total of 233 studies from 58 countries (380,191 participants) were included. The pooled global prevalence was 41.9% (CI = 39.7, 44.0; I² = 99.3%; prediction interval: 12.9, 74.3), ranging from 15.6% (Sweden) to 78.5% (Thailand). Rates were lower in high-income (38.6%) countries (p < 0.001). Younger age and higher female proportion were independently associated with higher prevalence. Approximately two in five children with new-onset T1D present in DKA. The rising trend is indicative of ongoing challenges in achieving timely diagnosis, demanding urgent public health strategies encompassing clinical vigilance and innovative early detection approaches.