Diabetes Mellitus as an Independent Predictor of Severe COVID-19 Disease: A Kenyan Hospital Study

BACKGROUND: Global evidence establishes diabetes mellitus (DM) as a significant risk factor for severe COVID-19, but data from specific sub-Saharan African settings remain limited. AIM: To determine the independent association between DM and COVID-19 severity in western Kenya and to investigate acute metabolic decompensation as a potential mediating pathway.METHODS: A retrospective cohort study analyzed 157 participants (44 with DM, 113 without). The primary outcome was severe/critical COVID-19. Causal mediation analysis estimated the proportion of the effect mediated by diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS). Multivariable logistic regression adjusted for age, sex, hypertension, and cardiovascular disease. The E-value assessed robustness to unmeasured confounding. RESULTS: The median age was 57 years; 57% were male. Patients with DM had significantly higher rates of severe/critical infection (50.0% vs. 23.0%, P<0.001). After adjustment, DM was independently associated with severe/critical disease (aOR: 3.15, 95% CI: 1.52-6.54, P=0.002). While mortality was higher in the DM group (22.7% vs. 15.9%), the study was underpowered to detect a statistically significant difference in death (aOR: 1.48, P=0.380). Mediation analysis estimated that 38% (95% CI: 12% to 75%) of the total effect was mediated through acute metabolic decompensation (DKA/HHS). CONCLUSION: Diabetes is a strong independent predictor of severe COVID-19 in this Kenyan cohort. A substantial portion of this risk is statistically consistent with mediation through acute glycemic crises.