358 The Impact of COVID-19 on Diabetic Ketoacidosis Patients

Abstract

BackgroundDiabetics have worse outcomes once infected with COVID-19. Diabetic ketoacidosis (DKA), a potentially lethal complication of diabetes, was recently described in 110 COVID-19 patients with a 45% mortality rate in a systematic review by Pal et al. of 19 case series. Yet case series cannot describe an association, much less a cause-and-effect relationship between COVID-19 and DKA.Study ObjectiveDescribe the prevalence/outcomes of DKA patients comparing pre- (March-April 2019) and pandemic (March-April 2020) periods.Methods:DesignRetrospective cohort of admitted pandemic DKA/COVID-19+ patients comparing prevalence/outcomes to pre-pandemic DKA patients using electronic health record Setting: Eleven hospitals of New York City Health & Hospitals. Participants: Inclusion: Pandemic period: admitted COVID-19+ patients (>18 years). Pre-pandemic period: admissions (>18 years) selected through the medical record.Exclusion: transfers during both periods. Exposure(s): COVID-19+ by PCR testing. Main Outcome(s) and Measure(s): Mortality: death during the index hospitalization. Demographics, medical histories and triage vital signs, and laboratory tests. Definition of DKA: Beta-Hydroxybutyrate (BHBA) (> 0.4 mmol/L) and bicarbonate (< 15 mmol/L) or pH (< 7.3). Statistical Analysis: The data were reported as means or counts and percentages with 95% confidence intervals. Group comparisons were analyzed by Student’s t-tests or Fisher’s Exact Test, where appropriate, and odds ratios to predict mortality.ResultsDemographics and past medical histories were similar during the pre-pandemic (n=6938) vs. pandemic (n=7962) periods (Table 1). DKA prevalence was greater during pandemic (3.14%, 2.66-3.68) vs. pre-pandemic period (0.72%, 0.54-0.95) (p>0.001). DKA/COVID-19+ mortality rates were greater (46.3% (38.4-54.3) vs. pre-pandemic period (18%, 8.6-31.4) (p<0.001). Surviving vs. non-surviving DKA/COVID- 19+ patients had more severe DKA with lower bicarbonates by 2.7 mmol/L (1.0–4.5) (p<0.001) and higher both Anion Gaps by 3.0 mmol/L (0.2-6.3) and BHBA by 2.1 mmol/L (1.2–3.1) (p<0.001) (Table 2). There was an increased odds of dying for patients with DKA and COVID-19 for the following parameters: O2 Sat. < 95%, OR 9.27 (4.09 - 21.05) (p<0.001); Sys. BP < 100 mmHg OR 9.98 (4.17 - 23.89) (p< 0.001); BUN > 20 mg/dl OR 2.53 (1.11 - 5.77) (p=0.040); and Cre > 0.9 mg/d OR 5.07 (1.40 - 18.39) (p=0.015).DiscussionWe found that COVID-19 had significant impacts on DKA patients. Comparing our pre- to pandemic periods, we found a greater than a 4+-fold increase in DKA prevalence (0.72% vs. 3.14%) with a 2+times higher DKA/COVID-19+ mortality rate (46.3% vs. 18.0%). Comparing DKA severity pre-and pandemic periods, we found similar pH, bicarbonate, beta-hydroxybutyric acid levels. High mortality rates of DKA/COVID-19+ were associated with COVID-19 biomarkers of lower oxygen saturations and blood pressures, higher degrees of renal insufficiency with higher SOFA and qSOFA scores, not DKA severity.ConclusionWe found a strong association of COVID-19 with the increased prevalence of DKA. We suggest screening all COVID-19+ patients for DKA with Beta-hydroxybutyric acid testing. If another COVID-19 surge occurs and ICU beds are limited, prioritizing DKA/COVID-19+ with renal insufficiency, low oxygen saturation, or blood pressure is reasonable compared to those without these markers.View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT)No, authors do not have interests to disclose BackgroundDiabetics have worse outcomes once infected with COVID-19. Diabetic ketoacidosis (DKA), a potentially lethal complication of diabetes, was recently described in 110 COVID-19 patients with a 45% mortality rate in a systematic review by Pal et al. of 19 case series. Yet case series cannot describe an association, much less a cause-and-effect relationship between COVID-19 and DKA. Diabetics have worse outcomes once infected with COVID-19. Diabetic ketoacidosis (DKA), a potentially lethal complication of diabetes, was recently described in 110 COVID-19 patients with a 45% mortality rate in a systematic review by Pal et al. of 19 case series. Yet case series cannot describe an association, much less a cause-and-effect relationship between COVID-19 and DKA. Study ObjectiveDescribe the prevalence/outcomes of DKA patients comparing pre- (March-April 2019) and pandemic (March-April 2020) periods.Methods: Describe the prevalence/outcomes of DKA patients comparing pre- (March-April 2019) and pandemic (March-April 2020) periods. Methods: DesignRetrospective cohort of admitted pandemic DKA/COVID-19+ patients comparing prevalence/outcomes to pre-pandemic DKA patients using electronic health record Setting: Eleven hospitals of New York City Health & Hospitals. Participants: Inclusion: Pandemic period: admitted COVID-19+ patients (>18 years). Pre-pandemic period: admissions (>18 years) selected through the medical record.Exclusion: transfers during both periods. Exposure(s): COVID-19+ by PCR testing. Main Outcome(s) and Measure(s): Mortality: death during the index hospitalization. Demographics, medical histories and triage vital signs, and laboratory tests. Definition of DKA: Beta-Hydroxybutyrate (BHBA) (> 0.4 mmol/L) and bicarbonate (< 15 mmol/L) or pH (< 7.3). Statistical Analysis: The data were reported as means or counts and percentages with 95% confidence intervals. Group comparisons were analyzed by Student’s t-tests or Fisher’s Exact Test, where appropriate, and odds ratios to predict mortality. Retrospective cohort of admitted pandemic DKA/COVID-19+ patients comparing prevalence/outcomes to pre-pandemic DKA patients using electronic health record Setting: Eleven hospitals of New York City Health & Hospitals. Participants: Inclusion: Pandemic period: admitted COVID-19+ patients (>18 years). Pre-pandemic period: admissions (>18 years) selected through the medical record.Exclusion: transfers during both periods. Exposure(s): COVID-19+ by PCR testing. Main Outcome(s) and Measure(s): Mortality: death during the index hospitalization. Demographics, medical histories and triage vital signs, and laboratory tests. Definition of DKA: Beta-Hydroxybutyrate (BHBA) (> 0.4 mmol/L) and bicarbonate (< 15 mmol/L) or pH (< 7.3). Statistical Analysis: The data were reported as means or counts and percentages with 95% confidence intervals. Group comparisons were analyzed by Student’s t-tests or Fisher’s Exact Test, where appropriate, and odds ratios to predict mortality. ResultsDemographics and past medical histories were similar during the pre-pandemic (n=6938) vs. pandemic (n=7962) periods (Table 1). DKA prevalence was greater during pandemic (3.14%, 2.66-3.68) vs. pre-pandemic period (0.72%, 0.54-0.95) (p>0.001). DKA/COVID-19+ mortality rates were greater (46.3% (38.4-54.3) vs. pre-pandemic period (18%, 8.6-31.4) (p<0.001). Surviving vs. non-surviving DKA/COVID- 19+ patients had more severe DKA with lower bicarbonates by 2.7 mmol/L (1.0–4.5) (p<0.001) and higher both Anion Gaps by 3.0 mmol/L (0.2-6.3) and BHBA by 2.1 mmol/L (1.2–3.1) (p<0.001) (Table 2). There was an increased odds of dying for patients with DKA and COVID-19 for the following parameters: O2 Sat. < 95%, OR 9.27 (4.09 - 21.05) (p<0.001); Sys. BP < 100 mmHg OR 9.98 (4.17 - 23.89) (p< 0.001); BUN > 20 mg/dl OR 2.53 (1.11 - 5.77) (p=0.040); and Cre > 0.9 mg/d OR 5.07 (1.40 - 18.39) (p=0.015). Demographics and past medical histories were similar during the pre-pandemic (n=6938) vs. pandemic (n=7962) periods (Table 1). DKA prevalence was greater during pandemic (3.14%, 2.66-3.68) vs. pre-pandemic period (0.72%, 0.54-0.95) (p>0.001). DKA/COVID-19+ mortality rates were greater (46.3% (38.4-54.3) vs. pre-pandemic period (18%, 8.6-31.4) (p<0.001). Surviving vs. non-surviving DKA/COVID- 19+ patients had more severe DKA with lower bicarbonates by 2.7 mmol/L (1.0–4.5) (p<0.001) and higher both Anion Gaps by 3.0 mmol/L (0.2-6.3) and BHBA by 2.1 mmol/L (1.2–3.1) (p<0.001) (Table 2). There was an increased odds of dying for patients with DKA and COVID-19 for the following parameters: O2 Sat. < 95%, OR 9.27 (4.09 - 21.05) (p<0.001); Sys. BP < 100 mmHg OR 9.98 (4.17 - 23.89) (p< 0.001); BUN > 20 mg/dl OR 2.53 (1.11 - 5.77) (p=0.040); and Cre > 0.9 mg/d OR 5.07 (1.40 - 18.39) (p=0.015). DiscussionWe found that COVID-19 had significant impacts on DKA patients. Comparing our pre- to pandemic periods, we found a greater than a 4+-fold increase in DKA prevalence (0.72% vs. 3.14%) with a 2+times higher DKA/COVID-19+ mortality rate (46.3% vs. 18.0%). Comparing DKA severity pre-and pandemic periods, we found similar pH, bicarbonate, beta-hydroxybutyric acid levels. High mortality rates of DKA/COVID-19+ were associated with COVID-19 biomarkers of lower oxygen saturations and blood pressures, higher degrees of renal insufficiency with higher SOFA and qSOFA scores, not DKA severity. We found that COVID-19 had significant impacts on DKA patients. Comparing our pre- to pandemic periods, we found a greater than a 4+-fold increase in DKA prevalence (0.72% vs. 3.14%) with a 2+times higher DKA/COVID-19+ mortality rate (46.3% vs. 18.0%). Comparing DKA severity pre-and pandemic periods, we found similar pH, bicarbonate, beta-hydroxybutyric acid levels. High mortality rates of DKA/COVID-19+ were associated with COVID-19 biomarkers of lower oxygen saturations and blood pressures, higher degrees of renal insufficiency with higher SOFA and qSOFA scores, not DKA severity. ConclusionWe found a strong association of COVID-19 with the increased prevalence of DKA. We suggest screening all COVID-19+ patients for DKA with Beta-hydroxybutyric acid testing. If another COVID-19 surge occurs and ICU beds are limited, prioritizing DKA/COVID-19+ with renal insufficiency, low oxygen saturation, or blood pressure is reasonable compared to those without these markers.View Large Image Figure ViewerDownload Hi-res image Download (PPT)No, authors do not have interests to disclose We found a strong association of COVID-19 with the increased prevalence of DKA. We suggest screening all COVID-19+ patients for DKA with Beta-hydroxybutyric acid testing. If another COVID-19 surge occurs and ICU beds are limited, prioritizing DKA/COVID-19+ with renal insufficiency, low oxygen saturation, or blood pressure is reasonable compared to those without these markers.