Paediatric diabetic ketoacidosis-associated acute liver failure in the post-COVID era: A case series.

Following Coronavirus disease 2019 (COVID-19) paediatric diabetic ketoacidosis (DKA) incidence and severity rose. We report a 2020-2024 cluster of four DKA-associated acute liver failure (ALF) cases at the largest UK paediatric hepatology unit. None had known diabetes. Presentations: one perianal abscess; three reduced consciousness, requiring intubation. Standard UK DKA protocol was started. Admission liver functions were normal. By day 4, all developed cardiovascular instability and ALF with liver injury, coagulopathy, metabolic acidosis, and hyperlactataemia. All required inotropes and haemofiltration. Three arrested; two died. Both autopsies showed centriacinar necrosis, with macro- and micro-vesicular steatosis. The two survivors normalised liver function. Viral, immune, and metabolic studies were unremarkable. This cluster suggests a novel, severe hepatic phenotype complicating paediatric DKA. Plausible mechanisms include ischaemic hepatitis and drug injury on a background of diabetes-related mitochondrial vulnerability. Earlier recognition of type 1 diabetes and awareness of hepatic complications may reduce morbidity and mortality.