High risk for venous thromboembolism in diabetics with hyperosmolar state: comparison with other acute medical illnesses

Abstract

Summary. Background: Diabetes mellitus is generally not recognized as an important risk factor for venous thromboembolism (VTE). However, clinical observations and case reports have suggested that patients with diabetes and hyperosmolarity may be at increased risk for VTE. Objectives: To determine the risk of VTE in patients hospitalized for diabetes with hyperosmolar state compared to patients with other acute medical illnesses. Patients/methods: The California Patient Discharge Data Set was used to determine the incidence of first-time VTE in all patients admitted between 1995 and 2000 for diabetes with hyperosmolarity and 11 other acute medical conditions. Proportional hazard modeling was used to adjust for age, race, gender, and prior hospitalization within 3 months. Results: Among 2859 patients with diabetes and hyperosmolarity, 34 (1.2%) developed VTE during the hospitalization and 14 (0.5%) developed VTE within 91 days after discharge. In an adjusted multivariate model comparing the risk of VTE to cases with depression, patients with hyperosmolarity had a significantly higher risk of VTE [hazard ratio (HR) = 16.3; 95% confidence interval (CI): 10-25] comparable to the risk associated with sepsis (HR = 19.3; 95% CI: 13-29) or acute connective tissue disease (HR = 21; 95% CI: 15-31). Compared to uncomplicated diabetes, patients with hyperosmolarity had a significantly higher risk of VTE (HR = 3.0; 95% CI: 2.1-4.5) whereas patients with ketoacidosis were not at higher risk (HR = 1.2; 95% CI: 0.8-1.7). Conclusions: Patients hospitalized for diabetes with hyperosmolarity are at increased risk for developing VTE both during their inpatient stay and in the 3 months after discharge. Thromboprophylaxis in these patients appears warranted, and extended prophylaxis for after hospital discharge should be studied.

Secretion of von Willebrand factor by endothelial cells links sodium to hypercoagulability and thrombosis

“…Our findings identify the mechanism probably involved in the thrombosis seen in cases of hypernatremic dehydration (12)(13)(14), hyperosmolality associated with diabetes (15), and heatstroke (16). In clinical practice, infusion of hypertonic saline to elevate plasma sodium up to 155 mmol/L, and even higher, is routinely used in head injury, ischemic stroke, and intracerebral hemorrhage and is the subject of heated debate (28,29).…”

“…Dehydration and hypernatremia are often accompanied by thrombosis. Thus, complications owing to thrombosis, such as disseminated intravascular coagulation, intracranial thrombosis, and peripheral thrombosis are commonly encountered during the hypernatremia associated with dehydration (12)(13)(14), the hyperosmolality associated with diabetes (15), and heatstroke (16). Increased sodium concentration is a common feature of the thrombosis in these studies.…”

The management of the hyperosmolar hyperglycaemic state in adults with diabetes: a summary of a report from the Joint British Diabetes Societies for Inpatient Care

“…Patients in HHS are at elevated thrombotic risk [40][41][42][43][44][45] and should receive prophylactic treatment for this (LMWH) throughout admission, unless contraindicated. Consider full anticoagulation for patients with suspected thrombosis or acute coronary syndrome and consider extending prophylaxis beyond the duration of admission in patients deemed to be at high risk.…”

“…Consider full anticoagulation for patients with suspected thrombosis or acute coronary syndrome and consider extending prophylaxis beyond the duration of admission in patients deemed to be at high risk. 43 Hypophosphataemia and hypomagnesaemia are common in HHS. These patients are often elderly and may be malnourished, and the re-feeding syndrome could be precipitated once the person begins to eat.…”

Managing hyperglycaemic emergencies: an illustrative case and review of recent British guidelines

“…Another important aspect of the management of HHS that is not relevant to DKA is the use of full anti-coagulation because of the high risk of thrombotic events resulting from severe dehydration. 12 The recently published JBDS guidelines on the management of HHS have highlighted the important differences in management of DKA and HHS. 13 They state that the diagnosis of HHS is based on characteristic features of hypovolaemia, marked hyperglycaemia (>30 mmol/l) without significant ketonaemia or acidosis, and hyperosmolality (>320 mOsm/kg), but that some patients can present with a mixed picture of DKA and HHS, or with lactic acidosis if sepsis, metformin therapy or renal failure are apparent.…”