Clinical Outcomes in Patients With Isolated or Combined Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State: A Retrospective, Hospital-Based Cohort Study

• Type of Material: Article
• Authors: Francisco Pasquel, Emory University; K Tsegka, Emory University; H Wang, Emory University; S Cardona, Emory University; Rodolfo Galindo, Emory University; Maya Fayfman, Emory University; Georgia Davis, Emory University; Priyathama Vellanki, Emory University; Alexandra Migdal, Emory University; Unjali Gujral, Emory University; Kabayam Venkat Narayan, Emory University; Guillermo Umpierrez, Emory University
• Language: English
• Date: 2020-02-01
• Publisher: American Diabetes Association
• Publication Version: Final Published Version
• Copyright Statement: © 2019 by the American Diabetes Association.
• License: Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.2337/dc19-1168
• Title of Journal or Parent Work: Diabetes Care
• Volume: 43
• Issue: 2
• Start Page: 349
• End Page: 357
• Grant/Funding Information: This study was supported by a clinical research grant from the Jacobs Research Funds to Emory University.; F.J.P., P.V., K.M.V.N., and G.E.U. are partially supported by National Institutes of Health grants from the National Institute of General Medical Sciences (1K23-GM-128221-01A1 [F.J.P.]), the Eunice Kennedy ShriverNational Institute of Child Health and Human Development (3K12-HD-085850-03S1; [P.V.]); National Institute of Diabetes and Digestive and Kidney Diseases (1P30-DK-111024-01; [K.M.V.N. and G.E.U.]), and the National Center for Advancing Translational Sciences (UL1-TR-002378 [G.E.U.]).
• Keywords: Mechanisms; Mortality; Admissions; Therapy; Life Sciences & Biomedicine; Crises; Endocrinology & Metabolism; Coma; Science & Technology; Management; Insulin; Adults; Hypokalemia
• Research Categories: Health Sciences, Public Health; Health Sciences, Medicine and Surgery; Health Sciences, Rehabilitation and Therapy

Abstract

OBJECTIVE: Many patients with hyperglycemic crises present with combined features of diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). The implications of concomitant acidosis and hyperosmolality are not well known. We investigated hospital outcomes in patients with isolated or combined hyperglycemic crises. RESEARCH DESIGN AND METHODS: We analyzed admissions data listing DKA or HHS at two academic hospitals. We determined 1) the frequency distributions of HHS, DKA, and combined DKA-HHS (DKA criteria plus elevated effective osmolality); 2) the relationship of markers of severity of illness and clinical comorbidities with 30-day all-cause mortality; and 3) the relationship of hospital complications associated with insulin therapy (hypoglycemia and hypokalemia) with mortality. RESULTS: There were 1,211 patients who had a first admission with confirmed hyperglycemic crises criteria, 465 (38%) who had isolated DKA, 421 (35%) who had isolated HHS, and 325 (27%) who had combined features of DKA-HHS. After adjustment for age, sex, BMI, race, and Charlson Comorbidity Index score, subjects with combined DKA-HHS had higher in-hospital mortality compared with subjects with isolated hyperglycemic crises (adjusted odds ratio [aOR] 2.7; 95% CI 1.4, 4.9; P = 0.0019). In all groups, hypoglycemia (<40 mg/dL) during treatment was associated with a 4.8fold increase in mortality (aOR 4.8; 95% CI 1.4, 16.8). Hypokalemia ≤3.5 mEq/L was frequent (55%). Severe hypokalemia (≤2.5 mEq/L) was associated with increased inpatient mortality (aOR 4.9; 95% CI 1.3, 18.8; P = 0.02). CONCLUSIONS: Combined DKA-HHS is associated with higher mortality compared with isolated DKA or HHS. Severe hypokalemia and severe hypoglycemia are associated with higher hospital mortality in patients with hyperglycemic crises.