Clinical characteristics and outcomes of patients with end-stage renal disease hospitalized with diabetes ketoacidosis

Abstract

IntroductionThere is limited evidence to guide management in patients with end-stage renal disease (ESRD) on chronic hemodialysis admitted with diabetes ketoacidosis. Thus, we investigated the clinical characteristics and outcomes of patients with ESRD admitted with diabetic ketoacidosis (DKA).MethodsIn this observational study, we used International Classification of Diseases Ninth/Tenth Revision codes to identify adult (aged 18–80 years) patients admitted to Emory University Hospitals between 1 January 2006 and 31 December 2016. DKA and ESRD diagnoses were confirmed by reviewing medical records and by admission laboratory results.ResultsAmong 307 patients with DKA meeting the inclusion and exclusion criteria, 22.1% (n: 68) had ESRD on hemodialysis and 77.9% (n: 239) had preserved renal function (estimated glomerular filtration rate >60 mL/min/1.73 m2). Compared with patients with preserved renal function, the admission blood glucose was higher (804.5±362.6 mg/dL vs 472.5±137.7 mg/dL) and the mean hemoglobin A1c was lower (9.6%±2.1 vs 12.0%±2.5) in patients with DKA and ESRD, both p<0.001. The rates of hypoglycemia <70 mg/dL (34% vs 14%, p=0.002) and <54 mg/dL (13% vs 5%, p=0.04) were higher in the ESRD group. During hospitalization, more patients with ESRD develop volume overload (28% vs 3%, p<0.001) and require mechanical ventilation (24% vs 3%, p=<0.001). There were no differences in hospital mortality (3% vs 0%, p=0.21), but length of stay (median 7.0 vs 3.0 days, p<0.001) was longer in the ESRD cohort. After adjusting for multiple covariates, patients with DKA and ESRD have higher odds of hypoglycemia (OR 3.3, 95% CI 1.51 to 7.21, p=0.003) and volume overload (OR 4.22, 95% CI 1.37 to 13.05, p=0.01) compared with patients with DKA with preserved renal function.ConclusionsPatients with DKA and ESRD on chronic hemodialysis had worse clinical outcomes including higher rates of hypoglycemia, volume overload, need for mechanical ventilation and longer length of stay, compared with patients with preserved kidney function.

Outcomes of Diabetic Ketoacidosis in Adults With End-Stage Kidney Disease: Retrospective Study Based on a National Database

“…We found a higher incidence of DKA in females in the ESKD group (52.4% vs. 48.97%) than in the patients with no CKD/ ESKD. Other studies supported this finding where DKA with ESKD was more prevalent in females [ 6 ]. Several international studies have shown that the female sex is an independent risk factor for developing DKA regardless of ESKD [ 11 - 14 ].…”

“…Diabetic ketoacidosis (DKA) is one of the most acute complications related to diabetes [ 4 ]. Treatment of DKA with ESKD or CKD has been associated with an increased risk of hypoglycemia and volume overload [ 6 , 7 ]. If not treated promptly, patients can develop severe metabolic acidosis and other complications [ 6 ].…”

“…Treatment of DKA with ESKD or CKD has been associated with an increased risk of hypoglycemia and volume overload [ 6 , 7 ]. If not treated promptly, patients can develop severe metabolic acidosis and other complications [ 6 ]. Data on appropriate management of DKA in the ESKD population are limited.…”

The Corrected Serum Sodium Concentration in Hyperglycemic Crises: Computation and Clinical Applications

“…Table 2 shows presenting values for [Glu], [Na], tonicity, and corrected [Na] in reports of DKA ( 66 – 171 ), HHS ( 3 , 9 , 13 , 75 – 78 , 110 , 129 , 169 , 172 – 251 ), and hyperglycemia in chronic kidney disease (CKD) stage V ( 12 , 16 , 47 – 49 , 156 , 171 , 252 – 277 ), which was included in Table 2 as the control group because it causes limited or no water and electrolyte losses through osmotic diuresis. All but three of the cases in this last group were on maintenance dialysis.…”

“…In DKA the overall mean corrected [Na] was within the normal range of [Na] (137–143 mmol/L). Among DKA series with ≥10 cases, mean corrected [Na] was in the eunatremic range in 45 series ( 66 – 69 , 71 , 74 , 75 , 80 , 83 , 84 , 90 , 91 , 93 , 104 – 106 , 108 , 109 , 112 , 113 , 118 , 120 , 122 , 125 – 127 , 129 , 135 , 137 , 138 , 140 , 143 – 146 , 151 , 155 , 156 , 158 , 160 , 163 – 165 , 168 – 171 ) reporting 6,355 episodes, including the pivotal PECARN study in which mean corrected [Na] was 140.8 mmol/L in one study group and 140.7 mmol/L in each of the other three study groups ( 163 ); and in the hypernatremic range in the remaining 18 series ( 74 , 76 , 78 , 80 , 85 , 91 , 93 , 98 , 100 – 102 , 104 , 116 , 120 , 129 , 133 , 139 , 169 ) reporting 1,301 episodes. Thus, although many patients have water deficits in excess of sodium and potassium deficits, an equal or even larger number of patients do not have excessive water deficits at presentation with DKA.…”