Clinical characteristics and outcomes of patients with end-stage renal disease hospitalized with diabetes ketoacidosis

• Authors: Rodolfo Galindo, Emory University; Francisco Pasquel, Emory University; Maya Fayfman, Emory University; Katerina Tsegka, Emory University; Neil Dhruv, Emory University; Saumeth Cardona, Emory University; Heqiong Wang, Emory University; Priyathama Vellanki, Emory University; Guillermo Umpierrez, Emory University
• Journal Title: BMJ Open Diabetes Research & Care
• Volume: Volume 8, Number 1
• Publisher: BMJ Publishing House | 2020-01-01
• Type of Work: Article | Final Publisher PDF
• Publisher DOI: http://doi.org/10.1136/bmjdrc-2019-000763
• Subjects: Health Sciences, Health Care Management; Health Sciences, Public Health; Biology, Physiology
• Keywords: Science & Technology; Life Sciences & Biomedicine; Endocrinology & Metabolism; ketoacidosis; dialysis; ESRD; hypoglycemia; Severe hyperglycemia; Chronic dialysis; Adult patients; Potassium; Insulin

Abstract

Introduction: There is limited evidence to guide management in patients with end-stage renal disease (ESRD) on chronic hemodialysis admitted with diabetes ketoacidosis. Thus, we investigated the clinical characteristics and outcomes of patients with ESRD admitted with diabetic ketoacidosis (DKA). Methods: In this observational study, we used International Classification of Diseases Ninth/Tenth Revision codes to identify adult (aged 18-80 years) patients admitted to Emory University Hospitals between 1 January 2006 and 31 December 2016. DKA and ESRD diagnoses were confirmed by reviewing medical records and by admission laboratory results. Results: Among 307 patients with DKA meeting the inclusion and exclusion criteria, 22.1% (n: 68) had ESRD on hemodialysis and 77.9% (n: 239) had preserved renal function (estimated glomerular filtration rate >60 mL/min/1.73 m 2). Compared with patients with preserved renal function, the admission blood glucose was higher (804.5±362.6 mg/dL vs 472.5±137.7 mg/dL) and the mean hemoglobin A1c was lower (9.6%±2.1 vs 12.0%±2.5) in patients with DKA and ESRD, both p<0.001. The rates of hypoglycemia <70 mg/dL (34% vs 14%, p=0.002) and <54 mg/dL (13% vs 5%, p=0.04) were higher in the ESRD group. During hospitalization, more patients with ESRD develop volume overload (28% vs 3%, p<0.001) and require mechanical ventilation (24% vs 3%, p=<0.001). There were no differences in hospital mortality (3% vs 0%, p=0.21), but length of stay (median 7.0 vs 3.0 days, p<0.001) was longer in the ESRD cohort. After adjusting for multiple covariates, patients with DKA and ESRD have higher odds of hypoglycemia (OR 3.3, 95% CI 1.51 to 7.21, p=0.003) and volume overload (OR 4.22, 95% CI 1.37 to 13.05, p=0.01) compared with patients with DKA with preserved renal function. Conclusions: Patients with DKA and ESRD on chronic hemodialysis had worse clinical outcomes including higher rates of hypoglycemia, volume overload, need for mechanical ventilation and longer length of stay, compared with patients with preserved kidney function.