Here’s a startling fact: despite common assumptions, new research reveals that lower kidney function levels, as measured by eGFR rates, do not inherently increase the risk of diabetic ketoacidosis (DKA) in adults with type 1 diabetes (T1D). But here’s where it gets controversial—this finding challenges previous beliefs and could reshape how we approach kidney-protective treatments in this population. Let’s dive deeper.
In a groundbreaking study published in Diabetes Care, researchers found no significant link between reduced estimated glomerular filtration rate (eGFR) and DKA risk in T1D patients, regardless of whether they were using kidney-protective medications like SGLT inhibitors. This is particularly intriguing because, while SGLT inhibitors have proven effective in reducing late-stage kidney outcomes in type 2 diabetes, they’ve also been associated with a higher risk of DKA. And this is the part most people miss—the study’s implications could pave the way for safer use of these medications in T1D patients, a group where they’re currently not routinely approved.
Lead researcher Abdulmohsen Bakhsh, MD, an endocrinologist at Mount Sinai Hospital in Toronto, Canada, emphasized that chronic kidney disease affects about 3 in 10 people with T1D. Yet, the impact of reduced eGFR on DKA risk has remained unclear. To address this gap, the team analyzed 35 years of data from the DCCT/EDIC study, involving 1,441 adults with T1D. Their goal? To determine whether kidney function alone is a risk factor for DKA, which could inform future trials of SGLT inhibitors in T1D.
The results were striking. Over a 34-year follow-up, 297 participants experienced at least one DKA event, totaling 488 events. However, unadjusted and adjusted analyses showed no statistical difference in DKA rates among individuals with varying eGFR levels, even those below 30 mL/min/1.73 m². Bakhsh noted that while the findings weren’t entirely surprising given the study’s limitations—such as a relatively young and healthy cohort—they still carry significant weight due to the study’s large size and long duration.
Here’s the bold part: these findings contrast sharply with the FinnDiane study, which reported higher DKA risk in individuals with baseline eGFR ≤ 60 mL/min/1.73 m². Bakhsh and his team argue that their time-updated analysis, which tracked eGFR levels immediately before each DKA event, may provide a more accurate risk assessment. But does this settle the debate? Not quite.
Charles Leonard, PharmD, MSCE, MPH, an associate professor at the University of Pennsylvania, cautioned that while the study is noteworthy, it’s not entirely convincing. He highlighted the wide confidence intervals at very low eGFR levels and stressed the need for further research to distinguish causation from correlation. So, here’s the question for you: Should we reconsider the use of SGLT inhibitors in T1D patients based on this study, or do we need more evidence? Let’s hear your thoughts in the comments.
Looking ahead, Bakhsh suggested that ongoing trials and emerging tools like continuous ketone monitors could enable safer, targeted use of SGLT inhibitors in T1D. Future studies, he added, should focus on patients with advanced chronic kidney disease, use central adjudication for DKA confirmation, and explore strategies like education and ketone monitoring to mitigate risks. If successful, these efforts could lead to regulatory changes in medication approvals.
In conclusion, while this study doesn’t provide all the answers, it opens the door to important conversations about kidney function, DKA risk, and treatment options in T1D. What’s your take? Are we on the brink of a paradigm shift, or is this just the beginning of a much longer journey? Share your perspective below—let’s keep the discussion going.
