Characteristics Patients with Diabetic Ketoacidosis Before and During COVID-19 Pandemic Era at Regional Public Hospital Abdul Wahab SJahranie Samarinda

  • Muhammad Wiryansyah Fakultas Kedokteran Universitas Mulawarman
  • Yuliana Rahmah Retnaningrum Laboratorium Ilmu Penyakit Dalam, Fakultas Kedokteran, Universitas Mulawarman
Keywords: diabetes mellitus, diabetic ketoacidosis, COVID-19


Background: The Corona Virus Disease-19 (COVID-19) pandemic has put obstacles in management of diabetes mellitus (DM) thus making patients more susceptible to complications, including diabetic ketoacidosis (DKA). DKA cases during the pandemic have been reported to increase and could be precipitated by COVID-19. This study aims to determine the characteristics of DKA patients before and during pandemic at Regional Public Hospital Abdul Wahab Sjahranie Samarinda

Methods: This study uses a descriptive observasional design with total sampling method. The variables studied were demography, clinical, laboratory examination, and type of infection.

Result: 59 patients were met the criteria (17 during pandemic vs 42 before pandemic). Adult age group (58,82% & 71,43%), female (64,7% & 66,67%), and DM type 2 (58,82% & 71,43%) were dominant in both groups. During the pandemic, cases of severe DKA were relatively high (82,35% vs 76,19%). Mortality was relatively decreased (23,52% & 45,23%), but still higher than other studies. Blood glucose levels, HbA1c, HCO3-, pCO2, anion gap, and leukocytes were relatively higher before the pandemic. Even so, we found higher levels of pH, ketonuria, urea, and creatinine during the pandemic. Among both group, almost all patients had history of infection that precipitate DKA (94,11% & 92,85%) with sepsis as the most common type of infection. However, we not found that Severe Acute Respiratory Syndrome-Corona Virus-2 (SARS-CoV-2) infection triggers DKA in this study.

Conclusion: The COVID-19 pandemic has an impact on clinical and outcome of DKA patients


1. World Health Organization. WHO Coronavirus (COVID-19) Dashboard [Internet]. 2021 [cited 2021 Jun 18]. Available from:
2. Komite Penanganan Covid-19 dan Pemulihan Ekonomi Nasional (KPCPEN). Peta Sebaran COVID-19 [Internet]. 2021 [cited 2021 Jun 18]. Available from:
3. Kementerian Kesehatan RI. Pedoman Pencegahan dan Pengendalian Coronavirus Disease (COVID-19). Revisi 5. 2020.
4. Singh AK, Gupta R, Ghosh A, Misra A. Diabetes in COVID-19: Prevalence, pathophysiology, prognosis and practical considerations. Diabetes Metab Syndr Clin Res Rev [Internet]. 2020;14(4):303–10. Available from:
5. Yang J, Zheng Y, Gou X, Pu K, Chen Z. Prevalence of comorbidities and its effects in patients infected with SARS-CoV-2: a systematic review and meta-analysis. Int J Infect Dis [Internet]. 2020;94(March):91–5. Available from:
6. Guo W, Li M, Dong Y, Zhou H, Zhang Z, Tian C, et al. Diabetes is a risk factor for the progression and prognosis of COVID-19. Diabetes Metab Res Rev. 2020;36(7):1–9.
7. Kshanti IA, Epriliawati M, Mokoagow MI, Nasarudin J, Magfira N. The Impact of Coronavirus Disease 2019 Pandemic on People with Diabetes in Indonesia: A Cross Sectional National Scale Web-Survey. medRxiv. 2020;(165):1–13. Available from:
8. Verma A, Rajput R, Verma S, Balania VKB, Jangra B. Impact of Lockdown in COVID 19 on glycemic control in patients with type 1 Diabetes Mellitus. Diabetes Metab Syndr Clin Res Rev. 2020;14(January):1213–6. Available from:
9. Ledford CJW, Roberts C, Whisenant E, Walters C, Akamiro K, Butler J, et al. Quantifying Worsened Glycemic Control during the COVID-19 Pandemic. J Am Board Fam Med. 2021;34(February):S192–5. Available from:
10. Tanji Y, Sawada S, Watanabe T, Mita T, Kobayashi Y, Murakami T, et al. Impact of COVID-19 pandemic on glycemic control among outpatients with type 2 diabetes in Japan: A hospital-based survey from a country without lockdown. Diabetes Res Clin Pract [Internet]. 2021;176:108840. Available from:
11. Dey RK, Hilmy AI, Imad HA, Yoosuf AA, Latheef AA. COVID-19 and emergencies in patients with diabetes: two case reports. J Med Case Rep. 2021;15(1):1–5. Available from:
12. Forde R, Arente L, Ausili D, De Backer K, Due-Christensen M, Epps A, et al. The impact of the COVID-19 pandemic on people with diabetes and diabetes services: A pan-European survey of diabetes specialist nurses undertaken by the Foundation of European Nurses in Diabetes survey consortium. Diabet Med. 2021;38(5):1–10. Available from:
13. Nyenwe EA, Kitabchi AE. The evolution of diabetic ketoacidosis: An update of its etiology, pathogenesis and management. Metabolism. 2016;65(4):507–21. Available from:
14. Reddy PK, Kuchay MS, Mehta Y, Mishra SK. Diabetic ketoacidosis precipitated by COVID-19: A report of two cases and review of literature. Diabetes Metab Syndr Clin Res Rev. 2020;14(July). Available from:
15. Chee YJ, Ng SJH, Yeoh E. Diabetic ketoacidosis precipitated by Covid-19 in a patient with newly diagnosed diabetes mellitus. Diabetes Res Clin Pract. 2020;164(April). Available from:
16. Parwanto E, Digambiro RA, Nusantara DU, Rarasati T. Coronavirus disease 2019 (COVID-19): A case report in a patient with diabetic ketoacidosis and hypertension. Bali Med J. 2020;9(3):624–9.
17. Centers for Disease Control and Prevention. National Diabetes Statistics Report 2020. Atlanta: GA: Centers for Disease Control and Prevention, U.S. Dept of Health and Human Services; 2020.
18. Benoit SR, Zhang Y, Geiss LS, Gregg EW, Albright A. Trends in Diabetic Ketoacidosis Hospitalizations and In-Hospital Mortality — United States, 2000–2014. MMWR Morb Mortal Wkly Rep. 2018;67(12):362–5.
19. Zavaleta MJC, Florez CDA, Duenas EAP, Arroyo JCC. Diabetic ketoacidosis during COVID-19 pandemic in a developing country. Diabetes Res Clin Pract. 2020;168. Available from:
20. Entwistle A, Edwards AE, Benjamin A, Gelding S V, Gunangah K. Diabetic ketoacidosis (DKA) admissions during and before the covid-19 pandemic. Diabetic Medicine : Diabetes care During covid-19. 2021;5.
21. Jacob R, Weiser G, Krupik D, Takagi D, Peled S, Pines N, et al. Diabetic Ketoacidosis at Emergency Department Presentation During the First Months of the SARS-CoV-2 Pandemic in Israel: A Multicenter Cross-Sectional Study. Diabetes Ther. 2021;12(5):1569–74. Available from:
22. Kamrath C, Mönkemöller K, Biester T, Rohrer TR, Warncke K, Hammersen J, et al. Ketoacidosis in Children and Adolescents with Newly Diagnosed Type 1 Diabetes during the COVID-19 Pandemic in Germany. JAMA - J Am Med Assoc. 2020;324(8):801–4.
23. Chao LC, Vidmar AP, Georgia S. Spike in Diabetic Ketoacidosis Rates in Pediatric Type 2 Diabetes During the COVID-19 Pandemic. Diabetes Care. 2021;44(6):1451–3. Available from:
24. Han MJ, Heo JH. Increased incidence of pediatric diabetic ketoacidosis after covid-19: A two-center retrospective study in Korea. Diabetes, Metab Syndr Obes Targets Ther. 2021;14:783–90. Available from:
25. Rabbone I, Schiaffini R, Cherubini V, Maffeis C, Scaramuzza A. Has covid-19 delayed the diagnosis and worsened the presentation of type 1 diabetes in children? Diabetes Care. 2020;43(11):2870–2. Available from:
26. Arslanoglu I, Akcali F, Yavuzyilmaz F, Sungur MA. Short time effect of Covid 19 pandemic on HbA1c nad acute metabolic complications in children with type 1 diabetes. 2021;6. Available from: :
27. Alshareef R, Al Zahrani A, Alzahrani A, Ghandoura L. Impact of the COVID-19 lockdown on diabetes patients in Jeddah, Saudi Arabia. Diabetes Metab Syndr Clin Res Rev [Internet]. 2020;14(5):1583–7. Available from:
28. Fisher L, Polonsky W, Asuni A, Jolly Y, Hessler D. The early impact of the COVID-19 pandemic on adults with type 1 or type 2 diabetes: A national cohort study. J Diabetes Complications [Internet]. 2020;34(12):107748. Available from:
29. Koliaki C, Tentolouris A, Eleftheriadou I, Melidonis A, Dimitriadis G, Tentolouris N. Clinical Management of Diabetes Mellitus in the Era of COVID-19: Practical Issues, Peculiarities and Concerns. J Clin Med. 2020;9(7):2288.
30. Dewata DGUB, Novida H, Aryati A. Profile of Diabetic Ketoacidosis Patients At Regional Public Hospital Dr. Soetomo in 2017. J Berk Epidemiol. 2020;8(3):301.
31. Hamed ZS, Gawaly A, Abbas K, El Ahwal L. Epidemiology of infection as a precipitating factor for diabetic ketoacidosis at Tanta University Hospital. Tanta Med J. 2017;45(2):68.
32. Goldman N, Fink D, Cai J, Lee YN, Davies Z. High prevalence of COVID-19-associated diabetic ketoacidosis in UK secondary care. Diabetes Res Clin Pract [Internet]. 2020;166:108291. Available from:
33. Kempegowda P, Melson E, Johnson A, Wallett L, Thomas L, Zhou D, et al. Effect of covid-19 on the clinical course of diabetic ketoacidosis (Dka) in people with type 1 and type 2 diabetes. Endocr Connect. 2021;10(4):371–7. Available from:
34. Gera S, Longendyke RL, Minich NM, Malay S, Wood JR. The COVID-19 Pandemic and Associated Worsening of Diabetic Ketoacidosis Presentation in Youth. Diabet Med [Internet]. 2021;(March):e14610. Available from: