# Differentiating diabetes type in children and adolescents with ketosis or ketoacidosis at onset: a retrospective analysis of clinical and biochemical markers

## TL;DR

This study identifies key clinical and biochemical markers to help distinguish between type 1 and type 2 diabetes in children and adolescents with ketosis or ketoacidosis at diagnosis.

## Contribution

The study provides new diagnostic cut-off values for C-peptide, BMI, blood pressure, and fatty liver to classify diabetes in pediatric patients with ketosis or ketoacidosis.

## Key findings

- C-peptide levels at fasting, 1-h, and 2-h showed high diagnostic accuracy with AUCs up to 0.96.
- BMI and systolic blood pressure were significant discriminators between type 1 and type 2 diabetes.
- Fatty liver and islet auto-antibody status also contributed to effective diabetes classification.

## Abstract

Distinguishing diabetes diagnosis is fundamental to ensuring proper management of individuals with diabetes, but has been challenging, especially in newly diagnosed diabetes onset with ketosis or ketoacidosis in pediatrics.

A retrospective analysis was conducted on medical records from 2017/1/1 to 2020/4/30 in pediatrics with new-onset diabetes accompanied with ketosis or ketoacidosis. Data was collected at diabetes onset and two years after discharge. Persons with diabetes were classified as type 1 or 2 diabetes (T1DM; T2DM) based on the person’s medication and final diagnosis. The best diagnostic cut-off point was determined using receiver operating characteristic curves (ROCs) between T1DM and T2DM.

Among 153 children and adolescent with diabetes, 78 (51.0%) were diagnosed as T1DM and 75 (49.0%) were diagnosed as T2DM after two years of follow-up. There were significant differences in sex, age, family history, BMI, systolic and diastolic blood pressure, lipids, uric acid (UA), C-peptide, combined fatty liver ratio and any islet auto-antibody-positive ratio at the time of onset (P < 0.05). Key discriminators identified by ROC analysis included fatty liver, SBP, BMI, and C-peptide levels (fasting, 1-h, and 2-h), with AUCs of 0.79, 0.83, 0.92, 0.94, 0.96, and 0.95 and optimal cut-offs value of 110.5 mmHg, 20.95 kg/m², 0.47 nmol/L (fasting), 0.98 nmol/L (1-h), and 2.03 nmol/L (2-h), respectively.

Overall, the most sensitive and specific clinical and biochemical criteria for the diagnostic classification of newly diagnosed diabetes onset with ketosis or ketoacidosis in pediatrics should consider C-peptide, BMI, SBP and fatty liver at the time of onset, which have effective diagnostic values.

Not applicable.

The online version contains supplementary material available at 10.1186/s12902-025-02077-x.

Distinguishing diabetes diagnosis is fundamental to ensuring proper management of individuals with diabetes, but has been challenging, especially in newly diagnosed diabetes onset with ketosis or ketoacidosis.

The current study retrospectively collected the clinical data from 153 newly diagnosed diabetes onset with DK/DKA among children and adolescents and followed up for two years, and further figures out the effective diagnostic metrics in effort to shed light on better classifying diabetes.

The results indicate that C-peptide, BMI, SBP and fatty liver at onset possess significant diagnostic value. These readily available clinical parameters provide a practical approach for classifying newly diagnosed diabetes onset with ketosis or ketoacidosis in pediatric populations.

The online version contains supplementary material available at 10.1186/s12902-025-02077-x.