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

Xiao-Yan Wu,Ling Li,Ran Li,Gang Guo,Ping Fang,Yun Zhou,Dun-Min She,Fang Wang,Ke-Qin Zhang,Ying Xue

doi:10.1186/s12902-020-00659-5

Abstract

ObjectiveDiabetic 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.MethodsWe 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.ResultsOf 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 death in patients with HHS 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 death in patients with HHS.ConclusionsOur 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 death in HHS.

Highlights

Diabetes mellitus is a globally prevalent systemic metabolic disease which is the fifth most common cause of death worldwide [1]
Our findings showed elevated C-reaction protein (CRP) and decreased fasting C-peptide might serve as indicator for severe Diabetic ketoacidosis (DKA)
Elevated blood urea nitrogen (BUN) might be an independent predictor of mortality in patients with hyperosmolar hyperglycemic state (HHS), whereas continuous subcutaneous insulin infusion (CSII) might be a protective factor against death in HHS

Summary

Introduction

Diabetes mellitus is a globally prevalent systemic metabolic disease which is the fifth most common cause of death worldwide [1]. Previous researches on DKA were often conducted in developed countries such as Europe, America, or Japan [4,5,6], so far research data of patients with HEs from mainland China were limited, especially on the overall precipitants, clinical features, treatment outcomes and risk factors. Data on the exact predisposing risk factors are still lacking in Chinese patients. Previous studies have reported that some patients with HEs could have combined features of HHS and DKA [12, 13]. Forth, our study sought to identify potential predictors of mortality for Chinese patients with HHS in order to effectively improve their in-hospital management and decrease associated mortality

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Results

Conclusion