Diabetic Ketoacidosis Prevalence and Clinical Presentation in Diabetic Covid Comorbidity in Nangarhar Afghanistan


Ikramullah Ibrahimi
Hayatullah Ahmadzai
Zakirullah Sarwari
Salam Jan Shams
Mohammad Azim Azimee
Said Mohammad Mohammadi


Background: Diabetic ketoacidosis (DKA) as an acute complication of diabetes mellitus is a life threatening medical emergency causing mortality and morbidity in patients. The aim of the study was to find out DKA prevalence and existing clinical presentation in diabetic-covid comorbidity.
Materials and Methods: The retrospective cross sectional study included 791 both male and female diabetic patients with a confirmed diagnosis of covid 19 based on purposive sampling for a period of one year from Aug 2021 to Aug 2022 from two centers (Corona Center and Nangarhar Regional Hospital) in Nangarhar, Afghanistan.
Findings: The study included 300 (37.9%) male and 491 (62.1%) female patients, 45 (5.7%) Type 1, 746 (94.3%) Type 2 diabetic patients, 511 (64.6%) old diabetes, and 280 (35.4%) new onset diabetes patients. Mean age at the study was 58.7±13, BMI was31.2±4, Systolic BP128.3±24.4, oxygen was 79.1±15.4, glycaemia was 297.5±8, and mean hospital stay was 8.8±8.1 days. In fact, 149 out of 791 patients (19%) had diabetic ketoacidosis (DKA) of which 140 patients out of 149 (93.96%) were hyperglycemic and 9 out of 149 patients (6%) were euglycemic DKA. Furthermore, DKA was more prevalent in males 58.4% vs 41.6% in females, young age (20-39 years) 31.2%, Type 1 diabetes 33.3% vs 21.9% type 2 diabetes, and old diabetes 19.5% vs 17.6% new onset diabetes. Moreover, clinical presentation included dyspnea 143 (96%), abdominal pain 124 (83.2%), nausea/vomiting 121 (81.2%), tachycardia 105 (70.5%), polydipsia of diabetic classic symptoms 70 (47%), and crepitation in chest auscultation though not significant 77 (51.7%). Pneumonia 92 (61.7%), and ARDS 54 (36.2%) were respectively the most prevalent clinical and X-ray findings in DKA patients. In addition, hospitalization duration was comparatively higher for females (10 vs 9), T2DM (10 vs 6), and new onset DM (14 vs 7) and it increased with advancing age (most for patients of ≥ 80 years) in DKA. Death and referral measures were significantly different across DKA positive and DKA negative patients i.e. 37.6% vs 14.8% and 16.1% vs 8.1% respectively. While, discharge status with home rest was more prevalent in DKA negative patients i.e. 46.3% vs 77.1%.
Conclusion: We concluded that DKA prevalence has increased almost two fold in diabetic patients suffering from corona virus affecting in-hospital mortality, hospital stay, morbidity and the preexisting clinical picture. In fact, obesity, hypertension, young age and male gender were significant factors contributing to the prevalence. In addition, mortality and referral rates to specialty specific centers were significantly higher in DKA positive patients with the aforementioned factors being the leading contributors.


Diabetes, Diabetic Ketoacidosis, DKA, Covid 19, Afghanistan


How to Cite
Ibrahimi, I., Ahmadzai, H., Sarwari, Z., Shams, S. J., Azimee, M. A., & Mohammadi, S. M. (2023). Diabetic Ketoacidosis Prevalence and Clinical Presentation in Diabetic Covid Comorbidity in Nangarhar Afghanistan. NUIJB, 2(02), 32–41. Retrieved from http://nuijb.nu.edu.af/index.php/nuijb/article/view/41


  1. Wang, D., Hu, B., Hu, C., Zhu, F., Liu, X., Zhang, J., Wang, B., Xiang, H., Cheng, Z., Xiong, Y., Zhao, Y., Li, Y., Wang, X., & Peng, Z. (2020). Clinical Characteristics of 138 Hospitalized Patients with 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA - Journal of the American Medical Association, 323(11), 1061–1069. https://doi.org/10.1001/jama.2020.1585
  2. Saeedzai, S. A., Sahak, M. N., Arifi, F., Aly, E. A., Gurp, M. Van, White, L. J., Chen, S., Barakat, A., Azim, G., Rasoly, B., Safi, S., Flegg, J. A., Ahmed, N., Ahadi, M. J., Achakzai, N. M., & Abouzeid, A. (2022). COVID-19 morbidity in Afghanistan: a nationwide, population-based seroepidemiological study. BMJ Open, 12(7). https://doi.org/10.1136/bmjopen-2021-060739
  3. Shah, J., Essar, M. Y., Qaderi, S., Rackimuthu, S., Nawaz, F. A., Qaderi, F., & Shah, A. (2022). Respiratory health and critical care concerns in Afghanistan. The Lancet Respiratory Medicine, 10(3), 229–231. https://doi.org/10.1016/S2213-2600(21)00583-X
  4. Erratum regarding missing Declaration of Competing Interest statements in previously published articles (Diabetes & Metabolic Syndrome: Clinical Research & Reviews (2020) 14(5) (881–885), (S1871402120301508), (10.1016/j.dsx.2020.05.031)). (2022). Diabetes and Metabolic Syndrome: Clinical Research and Reviews, 16(5), 102505. https://doi.org/10.1016/j.dsx.2022.102505
  5. Roca-Ho, H., Riera, M., Palau, V., Pascual, J., & Soler, M. J. (2017). Characterization of ACE and ACE2 expression within different organs of the NOD mouse. International Journal of Molecular Sciences, 18(3). https://doi.org/10.3390/ijms18030563
  6. Fernandez, C., Rysä, J., Almgren, P., Nilsson, J., Engström, G., Orho-Melander, M., Ruskoaho, H., & Melander, O. (2018). Plasma levels of the proprotein convertase furin and incidence of diabetes and mortality. Journal of Internal Medicine, 284(4), 377–387. https://doi.org/10.1111/joim.12783
  7. Kulcsar, K. A., Coleman, C. M., Beck, S. E., & Frieman, M. B. (2019). Comorbid diabetes results in immune dysregulation and enhanced disease severity following MERS-CoV infection. JCI Insight, 4(20). https://doi.org/10.1172/jci.insight.131774
  8. Maddaloni, E., & Buzzetti, R. (2020). Covid-19 and diabetes mellitus: unveiling the interaction of two pandemics. Diabetes/Metabolism Research and Reviews, 36(7), 19–20. https://doi.org/10.1002/dmrr.3321
  9. Yang, J. K., Lin, S. S., Ji, X. J., & Guo, L. M. (2010). Binding of SARS coronavirus to its receptor damages islets and causes acute diabetes. Acta Diabetologica, 47(3), 193–199. https://doi.org/10.1007/s00592-009-0109-4
  10. Dhatariya, K. K. (2007). Diabetic ketoacidosis. British Medical Journal, 334(7607), 1284–1285. https://doi.org/10.1136/bmj.39237.661111.80
  11. Heaney, A. I., Griffin, G. D., & Simon, E. L. (2020). Newly diagnosed diabetes and diabetic ketoacidosis precipitated by COVID-19 infection. American Journal of Emergency Medicine, 38(11), 2491.e3-2491.e4. https://doi.org/10.1016/j.ajem.2020.05.114
  12. Khan, F., Paladino, L., & Sinert, R. (2022). The impact of COVID-19 on Diabetic Ketoacidosis patients. Diabetes and Metabolic Syndrome: Clinical Research and Reviews, 16(1), 102389. https://doi.org/10.1016/j.dsx.2022.102389
  13. Pal, R., Banerjee, M., Yadav, U., & Bhattacharjee, S. (2020). Clinical profile and outcomes in COVID-19 patients with diabetic ketoacidosis: A systematic review of literature. Diabetes and Metabolic Syndrome: Clinical Research and Reviews, 14(6), 1563–1569. https://doi.org/10.1016/j.dsx.2020.08.015
  14. Vitale, R. J., Valtis, Y. K., McDonnell, M. E., Palermo, N. E., & Fisher, N. D. L. (2021). Euglycemic Diabetic Ketoacidosis With COVID-19 Infection in Patients With Type 2 Diabetes Taking SGLT2 Inhibitors. AACE Clinical Case Reports, 7(1), 10–13. https://doi.org/10.1016/j.aace.2020.11.019
  15. Chamorro-Pareja, N., Parthasarathy, S., Annam, J., Hoffman, J., Coyle, C., & Kishore, P. (2020). Letter to the editor: Unexpected high mortality in COVID-19 and diabetic ketoacidosis. Metabolism: Clinical and Experimental, 110, 154301. https://doi.org/10.1016/j.metabol.2020.154301
  16. Pasquel, F. J., Messler, J., Booth, R., Kubacka, B., Mumpower, A., Umpierrez, G., & Aloi, J. (2021). Characteristics of and Mortality Associated With Diabetic Ketoacidosis Among US Patients Hospitalized With or Without COVID-19. 4(3), 28–31. https://doi.org/10.1001/jamanetworkopen.2021.1091
  17. Zhang, S., Li, L., Shen, A., Chen, Y., & Qi, Z. (2020). Rational Use of Tocilizumab in the Treatment of Novel Coronavirus Pneumonia. Clinical Drug Investigation, 40(6), 511–518. https://doi.org/10.1007/s40261-020-00917-3
  18. Moosazadeh, M., & Mousavi, T. (2022). Combination therapy of tocilizumab and steroid for COVID-19 patients: A meta-analysis. Journal of Medical Virology, 94(4), 1350–1356. https://doi.org/10.1002/jmv.27489
  19. Tchesnokov, E. P., Gordon, C. J., Woolner, E., Kocinkova, D., Perry, J. K., Feng, J. Y., Porter, D. P., & Götte, M. (2020). Template-dependent inhibition of coronavirus RNA-dependent RNA polymerase by remdesivir reveals a second mechanism of action. Journal of Biological Chemistry, 295(47), 16156–16165. https://doi.org/10.1074/jbc.AC120.015720

Similar Articles

You may also start an advanced similarity search for this article.

Most read articles by the same author(s)