IDF21-0243 Clinical characteristics and outcomes in adult patients with hyperglycemic crises based on WHO classification 2019

Abstract

Background: Hyperglycemic crises composed of diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar syndrome (HHS) are metabolic catastrophes and could occur in any type of diabetes. Recently, the World Health Organization (WHO) revised the classification of diabetes and established the hybrid forms of diabetes mellitus, latent autoimmune diabetes in adults (LADA) and ketosis-prone type 2 diabetes (KPD). Although many clinical trials demonstrated the clinical characteristics and outcomes of hyperglycemic crises, few studies investigated the outcome of care in patients with hyperglycemic crises using the new WHO diabetic classification. Aim: To examine the clinical characteristics, outcomes of hyperglycemic crisis treatment, and post-discharged diabetic complications in the referral hospital in Bangkok, Thailand, of which diabetic subtypes were re-classified by the WHO diabetic classification 2019. Method: A retrospective study of patients with hyperglycemic crisis over 5 years (2015-2019) was done. Patients were re-classified into new DM subtypes according to the WHO diabetic classification 2019. The clinical characteristics, laboratory data, in-hospital outcomes, and long-term macrovascular and microvascular diabetic complications were collected and analyzed. Results: A total of 185 hyperglycemic crisis episodes in 138 patients with diabetes were included. DKA occurred more frequently than HHS and overlapped DKA and HHS (88.4%, 5.1%, and 6.1%, respectively). The mean age was 50.7±18.3 years old (51.4% female). The baseline A1c was 11.9±3.4%. Subjects were classified as follows: T1DM 15.9%, T2DM 68.8%, LADA 2.2%, KPD 10.9%, and pancreatic DM 2.2%. The most common precipitating causes of hyperglycemic crises were different among subtypes, i.e. medication noncompliance for T1DM, first diagnosis of DM for KPD, and infection for T2DM, LADA, and pancreatic DM (p=0.013). Forty-seven percent of all subjects developed hypokalemia during hyperglycemic crisis management, which was no different among DM subtypes. Five T2DM patients expired due to infection, the precipitating cause, which accounted for a mortality rate of 3.62% in our study. By the median follow-up of 25 months, insulin therapy had successfully been discontinued up to 71.4% in KPM and 24.4% in T2DM. The median time at insulin discontinuation was 7.2±4.3 months after hospital discharge. The last follow-up A1c was lowest in KPM, 6.5±1.4% (p=0.02). The new-onset macrovascular diabetic complications occurred in only T2DM and KPD, of which 55.5% occurred beyond 12 months. The microvascular complication occurred in all subtypes, of which 67.4% occurred within 12 months. Discussion: The KPD and LADA, the new hybrid subtypes of DM, accounted for 13% of hyperglycemic crisis patients in our center. Among diabetic subtypes, the acute outcomes of care were comparable but the long-term consequences were different. The KPD patients were more successful in discontinuing insulin therapy and had better glycemic control than other diabetic types. However, all DM subtypes were not different in developing macrovascular and microvascular complications. We encourage using the WHO diabetic classification 2019 to predict long-term clinical outcomes and insulin management in patients presenting with hyperglycemic crises.