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Author Notes:

Correspondence: Francisco J. Pasquel, fpasque@emory.edu

Author contributions: F.J.P. designed the study and wrote the first draft of the manuscript. K.T. and S.C. extracted and organized the data and reviewed the manuscript. H.W. conducted the statistical analysis. R.J.G., M.F., G.D., P.V., A.M., U.G., and K.M.V.N. critically reviewed the manuscript.

G.E.U. critically reviewed the study design and the manuscript. F.J.P. is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Acknowledgements: The authors would like to thank Shailesh Nair from the Research and Woodruff Health Sciences Information Technology (R-WIT) Department at Emory University and Dr. Darin Olson from the Department of Medicine/Endocrinology at Emory University for helpful comments on an earlier draft of the manuscript.

Disclosures: No potential conflicts of interest relevant to this article were reported.


Research Funding:

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.]).


  • Science & Technology
  • Life Sciences & Biomedicine
  • Endocrinology & Metabolism
  • Management
  • Insulin
  • Crises
  • Therapy
  • Coma
  • Hypokalemia
  • Mechanisms
  • Mortality
  • Admissions
  • Adults

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

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Journal Title:

Diabetes Care


Volume 43, Number 2


, Pages 349-357

Type of Work:

Article | Final Publisher PDF


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.

Copyright information:

© 2019 by the American Diabetes Association.

This is an Open Access work distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (https://creativecommons.org/licenses/by-nc-nd/4.0/rdf).
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