Clinical profiles, Outcomes and Risk Factors among Type 2 Diabetic Inpatients with Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State: A Hospital-Based Analysis over a 6-Year Period

Abstract

Objective：Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are the two most common hyperglycemic emergencies (HEs) associated with diabetes mellitus. Individuals with HEs can present with combined features of DKA and HHS. The objective of this study is to assess the clinical characteristics, therapeutic outcomes, and associated predisposing factors of type 2 diabetic patients with isolated or combined HEs in China. Methods: We performed a retrospective analysis of 158 patients with type 2 diabetes (T2DM), complicated with DKA, HHS, or DKA combined with HHS (DKA-HHS) in Shanghai Tongji Hospital, China from 2010 to 2015. Admission clinical features, therapeutic approaches and treatment outcomes of those patients were extracted and analyzed.Results: Of the 158 patients with T2DM, 65 (41.1%) patients were DKA, 74 (46.8%) were HHS, and 19 (12.0%) were DKA-HHS. The most common precipitants were infections (111, 70.3%), newly diagnosed diabetes (28,17.7%) and non-compliance to medications (9, 5.7%). DKA patients were divided into mild, moderate and severe group, based on arterial blood gas. Spearman correlation analysis revealed that C-reaction protein (CRP) was positively correlated with severity of DKA, whereas age and fasting C peptide were inversely correlated with severity of DKA (P<0.05). The mortality was 10.8% (17/158) in total and 21.6% (16/74) in the HHS group, 5.9% (1/17) in DKA-HHS. Spearman correlation analysis indicated that lethal outcome of HHS patients was positively correlated to effective plasma osmolality (EPO), renal function indicators and hepatic enzymes, while inversely associated with the continuous subcutaneous insulin infusion (CSII) therapy. Logistic regression analysis suggested that elevated blood urea nitrogen (BUN) on admission was an independent predisposing factor of mortality in HHS, while CSII might be a protective factor for patients with HHS. Furthermore, the receiver-operating characteristic (ROC) curve analysis indicated that BUN had the largest area under the ROC curves for predicting lethal outcome in patients with HHS.Conclusions: Our findings showed elevated CRP and decreased fasting C-peptide might serve as indicator for severe DKA. Elevated BUN might be an independent predictor of mortality in patients with HHS, whereas CSII might be a protective factor against lethal outcome in HHS.

Clinical and biochemical characteristics of diabetic ketoacidosis in adults with type 1 or type 2 diabetes at a tertiary hospital in the United Arab Emirates

“…Although speculative, the factors likely associated with the increased risk of mortality in our patients with T2DM when compared to those with T1DM are older age, the presence of comorbidities (macrovascular complications and CKD), high ICU admission rates, long lengths of stay, long times to recovery, and extended mechanical ventilation needs. Similar results were obtained from a study in Pakistan reporting higher mortality in older patients with concomitant comorbidities and T2DM (24). Interestingly, the presence of severe comorbidities has been found to be a significant independent predictor for mortality in patients with DKA (25, 27).…”

“…Interestingly, all the patients with T2DM and DKA who died were classified as having moderate DKA. The overall mortality rates varied across different regions of the world, with some documenting lower rates than those in our study (23,24) and others reporting higher rates (25, 26). Although speculative, the factors likely associated with the increased risk of mortality in our patients with T2DM when compared to those with T1DM are older age, the presence of comorbidities (macrovascular complications and CKD), high ICU admission rates, long lengths of stay, long times to recovery, and extended mechanical ventilation needs.…”

Pediatric management challenges of hyperglycemic hyperosmolar state: case series of Korean adolescents with type 2 diabetes

“…9,15) In HHS or mixed HHS and DKA, several studies have pointed to hyperosmolality and consequent profound hypovolemia as a major factor that influences outcomes, including altered mental status and complications such as acute kidney injury. [15][16][17][18] As observed in patients 4 and 8, who arrived in a comatose state, had significantly higher effective osmolalities than other patients did, at over 400 mOsm/kg. These results suggest that hyperosmolality should be emphasized in the diagnosis of patients with hyperglycemic crisis and highlighted as an important factor during treatment.…”

“…In the literature, we found that mixed HHS and DKA have been diagnosed during hyperglycemic crises in 14% children and 12-30% adults. [15][16][17][18] Although the diagnostic criteria for HHS and DKA are distinguishable due to differences in their pathogenesis, 1,11) the basic mechanism of the reduced action of insulin (insulin deficiency in DKA and insulin resistance in HHS) and the consequential increase in the levels of circulating counter-regulatory hormones is a pathophysiology common to both these conditions. Accordingly, clinical features frequently overlap and can lead to confusion during diagnosis.…”

Is acid suppression associated with the increased length of stay in diabetic ketoacidosis patients? A nationwide analysis

“…After controlling for confounding factors, the mean adjusted LOS was 0.28 days more in the PUD group. Historically, predictors known to prolong LOS in DKA independently include age, concurrent infection, hypokalemia, lower pH on presentation, precipitating cause as infection including urinary tract infection and pneumonia, and severity of DKA based on biochemical markers including serum osmolality, anion gap apart from many others [14–18]. Studies reporting the association of quantitative $${\rm{HCO}}_{3}^{-} $$ on presentation found contradictory results with both positive and no association reported [14, 17].…”