Diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome after renal transplantation in the United States

Differing Manifestations of Hepatitis C and Tacrolimus on Hospitalized Diabetes Mellitus Occurring after Kidney Transplantation

Acute hyperglycemic emergencies in children with type 2 diabetes

We conducted a retrospective epidemiologic study assessing the incidence of new-onset diabetes mellitus presenting as diabetic ketoacidosis in patients with schizophrenic disorders (ICD-9 295.0-295.9; referred to as "schizophrenia patients" hereafter) treated with atypical antipsychotic agents. The identification of patients and the review of records were achieved by using an electronic database linking administrative and clinical laboratory data between January 1, 1995, and December 31, 2001. The main outcome measure was the incidence of diabetic ketoacidosis or hyperosmolar hyperglycemic syndrome per 10,000 patient years in patients with new-onset or existing diabetes mellitus. We also determined the incidence of diabetic ketoacidosis associated with the use of atypical antipsychotics and calculated the mean hemoglobin A1c (HbA1c) level for all patients. During the 7-year period, 18.4% of schizophrenia patients were diagnosed with diabetes mellitus, compared with 6.6% in the general hospital population (p < .001). After chart review, 23 schizophrenia patients were identified with diabetic ketoacidosis: 11 had diabetes presenting as diabetic ketoacidosis, 8 had diabetic ketoacidosis with known diabetes mellitus, 2 had new-onset diabetes mellitus-hyperosmolar hyperglycemic syndrome, and 2 had hyperosmolar hyperglycemic syndrome with known diabetes mellitus. The incidence of diabetes presenting as diabetic ketoacidosis in schizophrenia patients was more than 10-fold higher than that reported in the general population: 14.93 per 10,000 patient years in schizophrenia patients versus 1.4 per 10,000 patient years in the general population (p < .000001) and versus the 1.98 per 10,000 patient years in the general hospital population (p < .000001). The incidence of diabetic ketoacidosis for each of atypical antipsychotic drugs over the 7-year period was as follows: clozapine, 2.2%; olanzapine, 0.8%; and risperidone, 0.2% (no incidence with ziprasidone or quetiapine). Of the 11 patients with diabetes presenting as diabetic ketoacidosis, the mean HbA1c level at admission was 13.3% +/- 1.9% (10.4%-16.9%). The incidence of diabetes mellitus presenting as diabetic ketoacidosis in schizophrenia patients is higher than in the general hospital population and differs across atypical antipsychotic agents. Elevated HgbA1c levels observed suggests that patients had undiagnosed diabetes mellitus for at least several weeks before the diabetic ketoacidosis episode.

Urinary Tract Infections in Solid Organ Transplant Recipients

Aims: We aimed to analyze incidence and characteristics of patients with diabetic ketosis (DK) and diabetic ketoacidosis (DKA) in Caucasian adults with type 2 diabetes mellitus (T2DM). Methods: Studied population included 261, 749 adults. DK criteria included plasma glucose >13.9 mmol/L and ketonuria >2, while in DKA bicarbonate <18 mEq/L or pH<7.30 was also required. Hyperglycemic crises without these criteria were defined as non-ketotic hyperglycemia (NKH). Results: During a 5-year period, we observed 630 episodes of DK and 215 episodes of DKA. Only 8.6% of DK episodes and 34.4% of DKA were attributed to type 1 diabetes mellitus (T1DM). Patients with T1DM were younger, leaner, majority had newly diagnosed disease, and hyperglycemia was the main cause of admission. Standardized incidence ratio for DK was 48.1 (95% confidence interval [CI] 44.5-52.1) and 17.0 (95% CI 14.9-19.4) for DKA. Incidence for both DK and DKA was increasing with age. In patients younger than 50, the incidence of DK and DKA was similar. However, dramatic rise in the incidence of DK was observed in both sexes after the age of 50. When compared with patients with NKH, the patients with DK had higher serum pH and bicarbonates. Patients with T2DM had a risk of 0.8% for developing DKA and 2.9% for DK over 5- year period. Conclusions: Our study showed that DK and DKA are not uncommon in Caucasian adults and the majority of episodes were contributed to T2DM. Incidence of DK is far more higher than the incidence of DKA in patients older than 50, who predominantly have T2DM. Moreover, patients with DK have higher serum pH and bicarbonates, both of which imply that DK and DKA are distinct clinical entities in patients with T2DM. Further studies are needed to assess the impact of these clinical entities.

Aims: We aimed to analyze incidence and characteristics of patients with diabetic ketosis (DK) and diabetic ketoacidosis (DKA) in Caucasian adults with type 2 diabetes mellitus (T2DM).&#13;\n&#13;\nMethods: Studied population included 261,749 adults. DK criteria included plasma glucose &gt;13.9 mmol/L and ketonuria &gt;2, while in DKA bicarbonate &lt;18 mEq/L or pH&lt;7.30 was also required. Hyperglycemic crises without these criteria were defined as non-ketotic hyperglycemia (NKH).&#13;\n&#13;\nResults: During a 5-year period, we observed 630 episodes of DK and 215 episodes of DKA. Only 8.6% of DK episodes and 34.4% of DKA were attributed to type 1 diabetes mellitus (T1DM). Patients with T1DM were younger, leaner, majority had newly diagnosed disease, and hyperglycemia was the main cause of admission. Standardized incidence ratio for DK was 48.1 (95% confidence interval [CI] 44.5-52.1) and 17.0 (95% CI 14.9-19.4) for DKA. Incidence for both DK and DKA was increasing with age. In patients younger than 50, the incidence of DK and DKA was similar. However, dramatic rise in the incidence of DK was observed in both sexes after the age of 50. When compared with patients with NKH, the patients with DK had higher serum pH and bicarbonates. Patients with T2DM had a risk of 0.8% for developing DKA and 2.9% for DK over 5-year period.&#13;\n&#13;\nConclusions: Our study showed that DK and DKA are not uncommon in Caucasian adults and the majority of episodes were contributed to T2DM. Incidence of DK is far more higher than the incidence of DKA in patients older than 50, who predominantly have T2DM. Moreover, patients with DK have higher serum pH and bicarbonates, both of which imply that DK and DKA are distinct clinical entities in patients with T2DM. Further studies are needed to assess the impact of these clinical entities.

Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar syndrome (HHS) are life-threatening complications of diabetes mellitus. Their clinical profiles have not been fully investigated. A multicenter retrospective cohort study was conducted in 21 acute care hospitals in Japan. Patients included were adults aged 18 or older who had been hospitalized from January 1, 2012, to December 31, 2016 due to DKA or HHS. The data were extracted from patient medical records. A four-group comparison (mild DKA, moderate DKA, severe DKA, and HHS) was performed to evaluate outcomes. A total of 771 patients including 545 patients with DKA and 226 patients with HHS were identified during the study period. The major precipitating factors of disease episodes were poor medication compliance, infectious diseases, and excessive drinking of sugar-sweetened beverages. The median hospital stay was 16days [IQR 10-26days]. The intensive care unit (ICU) admission rate was 44.4% (mean) and the rate at each hospital ranged from 0 to 100%. The in-hospital mortality rate was 2.8% in patients with DKA and 7.1% in the HHS group. No significant difference in mortality was seen among the three DKA groups. The mortality rate of patients with DKA in Japan is similar to other studies, while that of HHS was lower. The ICU admission rate varied among institutions. There was no significant association between the severity of DKA and mortality in the study population. This study is registered in the UMIN clinical Trial Registration System (UMIN000025393, Registered 23th December 2016).

Management of acute hyperglycemic emergencies: focus on diabetic ketoacidosis.

Introduction: Diabetic ketoacidosis (DKA) is one of the serious complications that is often found in pediatric cases of type 1 diabetes mellitus (DM). Diabetic ketoacidosis mostly occurs in patients with low glycemic control. Currently, many studies are assessing risk factors for recurrent ketoacidosis, including young age, male gender, patients with comorbidities (psychiatric diseases, alcohol or substance abuse, other chronic diseases), and patients with socioeconomic factors. The incidence of recurrent diabetic ketoacidosis in children and adolescents is becoming more frequent. Risk factors that often trigger the incidence of diabetic ketoacidosis are important to understand to reduce the incidence of recurrent DKA. Case Presentation: This study reported a 17-year-old adolescent patient with a history of type 1 diabetes mellitus who had recurrent diabetic ketoacidosis. Patients come with complaints of nausea and vomiting, accompanied by a feeling of weakness. The results of the blood glucose test were 565 mg/dL. In urinalysis, a reduction of glucose was obtained (+3), and ketonuria with urinary ketones was obtained with a result of +3. A blood gas analysis showed a blood pH of 7,367 mmHg with HCO3 of 16.6 mmol/L and PCO2 of 28.6 mmHg. The initial management of the patient was given a loading of 0.9% NaCl fluid as much as 500 cc/hour for 2 hours, then 0.9% NaCl fluid as much as 500 cc mixed with KCL 10 meq at a rate of 75 ml/hour. The patient was also given an insulin drip to correct blood glucose levels in the form of 5 IU of insulin diluted with 0.9% NaCl, as much as 50 cc. During treatment, the patient's condition tends to stabilize, and the patient is discharged from the hospital by continuing with routine treatment with subcutaneous insulin. Conclusion: Diabetic ketoacidosis is one of the complications with high morbidity and mortality, especially in patients with type 1 diabetes mellitus. There are several risk factors associated with recurrent DKA in patients. Known risk factors for DKA allow health workers to prevent the occurrence of a recurrence of DKA.

This study characterized incidence, patient profiles, risk factors and outcomes of in-hospital diabetic ketoacidosis (DKA) in patients with COVID-19 compared with influenza and pre-pandemic data. This study consisted of 13 383 hospitalized patients with COVID-19 (March 2020-July 2022), 19 165 hospitalized patients with influenza (January 2018-July 2022) and 35 000 randomly sampled hospitalized pre-pandemic patients (January 2017-December 2019) in Montefiore Health System, Bronx, NY, USA. Primary outcomes were incidence of in-hospital DKA, in-hospital mortality, and insulin use at 3 and 6 months post-infection. Risk factors for developing DKA were identified. The overall incidence of DKA in patients with COVID-19 and influenza, and pre-pandemic were 2.1%, 1.4% and 0.5%, respectively (p < .05 pairwise). Patients with COVID-19 with DKA had worse acute outcomes (p < .05) and higher incidence of new insulin treatment 3 and 6 months post-infection compared with patients with influenza with DKA (p < .05). The incidence of DKA in patients with COVID-19 was highest among patients with type 1 diabetes (12.8%), followed by patients with insulin-dependent type 2 diabetes (T2D; 5.2%), non-insulin dependent T2D (2.3%) and, lastly, patients without T2D (1.3%). Patients with COVID-19 with DKA had worse disease severity and higher mortality [odds ratio = 6.178 (4.428-8.590), p < .0001] compared with those without DKA. Type 1 diabetes, steroid therapy for COVID-19, COVID-19 status, black race and male gender were associated with increased risk of DKA. The incidence of DKA was higher in COVID-19 cohort compared to the influenza and pre-pandemic cohort. Patients with COVID-19 with DKA had worse outcomes compared with those without. Many COVID-19 survivors who developed DKA during hospitalization became insulin dependent. Identification of risk factors for DKA and new insulin-dependency could enable careful monitoring and timely intervention.

Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycaemic syndrome (HHS) are the most commonly occurring metabolic medical emergencies. They are seldom the first presentation of diabetes, but most frequently occur due to infection, or non-concordance with prescribed medications. The diagnosis of DKA should only be made if all three components (the ‘D’, the ‘K’, and the ‘A’) are present—with a history of diabetes or a glucose concentration of ≥11.1 mmol/L; a ketone concentration of ≥3.0 mmol/L; and a pH &amp;lt;7.3 and/or a serum bicarbonate of &amp;lt;15.0 mmol/L. HHS has no formal diagnostic criteria but should have a glucose of &amp;gt;30.0 mmol/L, a calculated serum osmolality of &amp;gt;320 mOsmol/Kg and the absence of ketones. The management of DKA and HHS are different, and national guidelines exist for both. Both conditions require the administration of intravenous fluid with 0.9% sodium chloride solution to treat the dehydration frequently seen. In DKA, aggressive fluid replacement should accompany a weight based, fixed rate intravenous insulin infusion given at 0.1 units/kg/hour, as well as potassium replacement after the first litre of fluid has been administered. In HHS, fluid and electrolyte replacement are the mainstay of initial treatment, with insulin only being added at 0.05 units/kg/hour once the glucose concentration and osmolality has stopped falling. For both conditions, the early involvement of the specialist diabetes inpatient team is strongly recommended to help guide treatment and also to provide ongoing care and support once the DKA or HHS has resolved and the patient is discharged.

ContextHyperglycemic emergencies such as diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS) and new-onset diabetes mellitus (DM) have been reported in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections. Hyperglycemia is a predictor of poor prognosis in COVID-19 disease.ObjectivesThe objective of this work is to describe a case series of HHS and/or DKA likely triggered by the COVID-19 vaccine. The aim is to alert physicians of the potential hyperglycemic complications from the COVID-19 vaccination and to provide further insight into the underlying mechanism of the bidirectional relationship between SARS-CoV-2 and DM.Case DescriptionsAll 3 patients developed HHS and/or DKA within 2 to 10 days of the COVID-19 vaccination. PCR testing for SARS-CoV-2 was negative and other clinical precipitating factors were excluded. Two patients had a history of type 2 DM (T2DM) with pre-admission HbA1c levels of 7.0% to 7.5% while 1 patient was newly diagnosed with T2DM during the hospitalization. They were each treated with insulin infusion and were discharged on subcutaneous insulin therapy. Due to the rapid resolution of the hyperglycemia, insulin was discontinued in all patients within 8 weeks and they remain well-controlled on oral DM medications.ConclusionSevere hyperglycemia including HHS and DKA may be triggered by COVID-19 vaccination. Early evaluation and screening of patients with hyperglycemic symptoms after COVID-19 vaccination is recommended. The vaccine-induced hyperglycemia may provide further insight into the underlying pathogenesis caused by the SARS-CoV-2 infection itself. The underlying robust inflammatory response and “cytokine storm” may be the primary precipitant.

Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS) are 2 acute metabolic crisis of uncontrolled diabetes mellitus. DKA usually occurs in patients with type 1 diabetes and HHS is seen mostly in those with type 2. In DKA, hyperglycemia, metabolic acidosis, and dehydration are the most prominent clinical symptoms and HHS is identified by hyperglycemia, severe dehydration without acidosis, and alterations in level of consciousness from sleepiness to confusion, seizure and coma. Treatment for both conditions is based on correction of dehydration and hyperglycemia, and establishing homeostasis of electrolytes. In the present review, we decided to present a comprehensive picture of the pathology and clinical manifestations, diagnosis and treatment of these 2 important conditions.

Diabetes mellitus complicated by mixed diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome presents a special challenge to physicians. There is no standard protocol for the management of mixed hyperglycemic hyperosmolar syndrome and diabetic ketoacidosis in children. The commonest cause of neurological deterioration during an episode of diabetic ketoacidosis is cerebral edema, whereas hyperosmolality often leads to thrombosis. The risks for these complications are further increased in diseases associated with vasculopathies. We present the first case of complex cerebral arteriovenous thrombosis leading to stroke in a child with Adams-Oliver syndrome, a genetic condition that is associated with abnormal vasculogenesis. He presented with new-onset double diabetes complicated by a combination of diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome. Magnetic resonance imaging, magnetic resonance angiography, and magnetic resonance venography provided evidence for an ischemic stroke. Children and adolescents who present with a combination of hyperglycemic hyperosmolar syndrome and diabetic ketoacidosis should be monitored for neurologic deficits and must be investigated for both stroke and cerebral edema in the event of neurological deterioration.

A recent study by Desai et al. (1) showed that the incidence and economic burden of hospitalizations due to diabetic ketoacidosis (DKA) in the U.S. increased between 2003 and 2014 (1). We sought to understand the most recent impact of the disease in the U.S. using the 2017 National Inpatient Sample (NIS) (www.hcup-us.ahrq.gov/nisoverview.jsp). A total of 220,340 patients were identified with a primary diagnosis of DKA (61.6 cases of DKA per 10,000 admissions) (Table 1). The incidence of DKA per 10,000 admissions was higher in males (71.2) than females (54.1), and the majority of DKA patients were covered by Medicaid (79,175 patients [36.0%], P < 0.01). Of all DKA patients, 53.3% were of ages 18–44 years. However, a higher incidence per 10,000 admissions was noted in patients of ages 1–17 years. The mean age of patients with DKA was 38.4 years. The total charges among DKA patients in 2017 were $6,757,748,178, with a mean of $30,836.19. The mean length of stay was 3.22 days. A total of 835 deaths were found among DKA patients, with a mortality rate of 0.38%. The overall …