Hemoglobin A1c and Permissive Hyperglycemia in Patients in the Intensive Care Unit with Diabetes

The newly proposed plasma-glycosylated hemoglobin A1c/High-Density lipoprotein cholesterol ratio serves as a simple and practical indicator for screening metabolic associated fatty liver disease: an observational study based on a physical examination population

BACKGROUND

Glycotoxicity and lipotoxicity are key pathophysiological mechanisms underlying the development of metabolic associated fatty liver disease (MAFLD). The primary objective of this study is to investigate the association between the newly proposed Plasma-Glycosylated Hemoglobin A1c/High-Density Lipoprotein Cholesterol Ratio (HbA1c/HDL-C ratio) and the risk of MAFLD.

METHODS

A study population of 14,251 individuals undergoing health examinations was included. The association between the HbA1c/HDL-C ratio and MAFLD was analyzed using multivariable logistic regression and restricted cubic spline (RCS) analysis. Exploratory analyses were conducted to assess variations in this association across subgroups stratified by gender, age, body mass index (BMI), exercise habits, drinking status, and smoking status. The discriminatory value of the HbA1c/HDL-C ratio and its components for screening MAFLD was evaluated using receiver operating characteristic (ROC) curves.

RESULTS

A total of 1,982 (13.91%) subjects were diagnosed with MAFLD. After adjusting for confounding factors, we found a significant positive association between the HbA1c/HDL-C ratio and MAFLD [odds ratio (OR) 1.34, 95% confidence interval (CI): 1.25, 1.44]. No significant differences in this association were observed across all subgroups (All P for interaction > 0.05). Furthermore, through RCS analysis, we observed a nonlinear positive correlation between the HbA1c/HDL-C ratio and MAFLD (P for non-linearity < 0.001), with a potential threshold effect point (approximately 3 for the HbA1c/HDL-C ratio). Beyond this threshold point, the slope of the MAFLD prevalence curve increased rapidly. Additionally, in further ROC analysis, we found that for the identification of MAFLD, the HbA1c/HDL-C ratio was significantly superior to HbA1c and HDL-C, with an area under the curve (AUC) and optimal threshold of 0.81 and 4.08, respectively.

CONCLUSIONS

Our findings suggest that the newly proposed HbA1c/HDL-C ratio serves as a simple and practical indicator for assessing MAFLD, exhibiting well-discriminatory performance in screening for MAFLD.

Association Between Glycemic Gap and Mortality in Critically Ill Patients with Diabetes

OBJECTIVES

Dysglycemia is associated with poor outcomes in critically ill patients,which is uncertain in patients with diabetes regarding to the situation of glucose control before hospitalization. This study was aimed to investigate the effect of the difference between the level of blood glucose during ICU stay and before admission to ICU upon the outcomes of critically ill patients with diabetes.

METHOD

Patients with diabetes expected to stay for more than 24hs were enrolled, HbA1c was converted to A1C-derived average glucose (ADAG) by the equation: ADAG  =  [ (HbA1c * 28.7) - 46.7 ] * 18^-1, blood glucose were measured four times a day during the first 7 days after admission, the mean glucose level(MGL) and SOFA (within 3, 5, and 7days) were calculated for each person, GAP_adm and GAP_mean was calculated as admission blood glucose and MGL minus ADAG, the incidence of moderate hypoglycemia(MH), severe hypoglycemia (SH), total dosage of glucocorticoids and average daily dosage of insulin, duration of renal replacement therapy(RRT), ventilator-free hours, and non-ICU days were also collected. Patients were divided into survival group and nonsurvival group according to survival or not at 28-day, the relationship between GAP and mortality were analyzed.

RESULTS

431 patients were divided into survival group and nonsurvival group. The two groups had a comparable level of HbA1c, the nonsurvivors had greater APACHE II, SOFA, GAP_adm, GAP_mean-3, GAP_mean-5, GAP_mean-7 and higher MH and SH incidences. Less duration of ventilator-free, non-ICU stay and longer duration of RRT were recorded in the nonsurvival group. GAP_mean-5 had the greatest predictive power with an AUC of 0.807(95%CI: 0.762-0.851), the cut-off value was 3.6 mmol/L (sensitivity 77.7% and specificity 76.6%). The AUC was increased to 0.852(95%CI: 0.814-0.889) incorporated with SOFA₅ (NRI  =  11.34%).

CONCLUSION

Glycemic GAP between the MGL within 5 days and ADAG was independently associated with 28-day mortality of critically ill patients with diabetes. The predictive power was optimized with addition of SOFA₅.

Association between stress hyperglycemia ratio and delirium in older hospitalized patients: a cohort study

Background

It remains unclear whether stress hyperglycemia is associated with delirium. We performed this cohort study to determine the association between stress hyperglycemia and delirium.

Methods

We consecutively enrolled patients aged ≥70 years who were admitted to the Geriatric Department of West China Hospital between March 2016 and July 2017. Stress hyperglycemia ratio (SHR) was calculated as fasting blood glucose divided by estimated average glucose derived from glycosylated hemoglobin (HbA1c) and was classified into three tertiles. Delirium was screened within 24 h of admission and three times daily thereafter, using the confusion assessment method. The Cox proportional hazards models were used to assess the association of SHR with delirium.

Results

Among 487 included patients (mean age 83.0 years, 72.0% male), 50 (10.3%) patients experienced delirium during hospitalization. Compared to the second tertile, both the lowest and the highest SHR tertiles were independently associated with delirium (hazard ratio [HR] 3.71, 95% confidence interval [CI] 1.45-9.51; and HR 2.97, 95% CI 1.29-6.81, respectively). Similar results were found after further adjusting for statin comedication. Multiple-adjusted restricted cubic splines revealed a nonlinear relationship between SHR and delirium (P_nonlinearity=0.04). Adding SHR to conventional risk factors improved the risk prediction of delirium (net reclassification index 0.39, P=0.01; integrated discrimination improvement 0.07, P=0.03). Subgroup analyses indicated that the relationship between SHR and delirium was more apparent in patients with HbA1c <6.5%, with significantly higher HR in the first (3.65, 95% CI 1.11-11.97) and third (3.13, 95% CI 1.13-8.72) SHR tertiles compared to the second tertile, while there was no significant association between SHR and delirium in those with HbA1c ≥6.5%.

Conclusions

Both lower and higher SHR were associated with increased risk of delirium but only in patients with HbA1c <6.5%. Admission SHR may serve as a promising predictor of delirium, and incorporating this biomarker into prediction algorithms might have potential clinical utility in aiding delirium risk stratification, especially in those with HbA1c <6.5%.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02935-6.

Association between dysglycemia and mortality by diabetes status and risk factors of dysglycemia in critically ill patients: a retrospective study

AIMS

Dysglycemia, including the three domains hyperglycemia, hypoglycemia, and increased glycemic variability (GV), is associated with high mortality among critically ill patients. However, this association differs by diabetes status, and reports in this regard are limited. This study aimed to evaluate the associations between the three dysglycemia domains and mortality in critically ill patients by diabetes status and determined the contributing factors for dysglycemia.

METHODS

This retrospective study included 958 critically ill patients (admitted to the ICU) with or without DM. Dysglycemia was defined as abnormality of any of the three dimensions. We evaluated the effects of the three domains of glucose control on mortality using binary logistic regression and then adjusted for confounders. The associations between dysglycemia and other variables were investigated using cumulative logistic regression analysis.

RESULT

GV independently and similarly affected mortality in both groups after adjustment for confounders (DM: odds ratio [OR], 1.05; 95% confidence interval [CI]: 1.03-1.08; p <0.001; non-DM: OR, 1.07; 95% CI, 1.03-1.11; p = 0.002). Hypoglycemia was strongly associated with ICU mortality among patients without DM (3.12; 1.76-5.53; p <0.001) and less so among those with DM (1.18; 0.49-2.83; p = 0.72). Hyperglycemia was non-significantly associated with mortality in both groups. However, the effects of dysglycemia seemed cumulative. The factors contributing to dysglycemia included disease severity, insulin treatment, glucocorticoid use, serum albumin level, total parenteral nutrition, duration of diabetes, elevated procalcitonin level, and need for mechanical ventilation and renal replacement therapy.

CONCLUSION

The association between the three dimensions of dysglycemia and mortality varied by diabetes status. Dysglycemia in critical patients is associated with excess mortality; however, glucose management in patients should be specific to the patient's need considering the diabetes status and broader dimensions. The identified factors for dysglycemia could be used for risk assessment in glucose management requirement in critically ill patients, which may improve clinical outcomes.

Effect of glycemic gap upon mortality in critically ill patients with diabetes

AIMS/INTRODUCTION

Hyperglycemia, hypoglycemia, and blood glucose fluctuation are associated with the outcome in critically ill patients, but the target of blood glucose control is debatable especially in patients with diabetes regarding the status of blood glucose control before admission to ICU. This study aimed to investigate the association between the glycemic gap which is calculated as the mean blood glucose level during the first 7 days after admission to ICU minus the A1C-derived average glucose and the outcome of critically ill patients with diabetes.

METHOD

This study was undertaken in two intensive care units (ICUs) with a total of 30 beds. Patients with diabetes who were expected to stay for more than 24 h were enrolled, the HbA1c was tested within 3 days after admission and converted to the A1C-derived average glucose (ADAG) by the equation: ADAG = [(HbA1c * 28.7) - 46.7 ] * 18-1 , arterial blood glucose measurements were four per day routinely during the first 7 days after admission, the APACHE II score within the first 24 h, the mean blood glucose level (MGL), standard deviation (SD), and coefficient of variation (CV) during the first 7 days were calculated for each person, the GAPadm and GAPmean were calculated as the admission blood glucose and MGL minus the ADAG, respectively, the incidence of moderate hypoglycemia (MH) and severe hypoglycemia (SH), the total dosage of glucocorticoids and average daily dosage of insulin within 7 days, the duration of renal replacement therapy (RRT), ventilator-free hours, and non-ICU stay days within 28 days were also collected. The enrolled patients were divided into a survival group and a nonsurvival group according to survival or not at 28 days and 1 year after admission, and the relationship between parameters derived from blood glucose and mortality in the enrolled critically ill patients was explored.

RESULTS

Five hundred and two patients were enrolled and divided into a survival group (n = 310) and a nonsurvival group (n = 192). It was shown that the two groups had a comparable level of HbA1c, the nonsurvivors had a greater APACHE II, MGL, SD, CV, GAPadm , GAPmean , and a higher incidence of hypoglycemia. A lesser duration of ventilator-free, non-ICU stay, and a longer duration of RRT were recorded in the nonsurvival group, who received a lower carbohydrate intake, a higher daily dosage of insulin and glucocorticoid. GAPmean had the greatest predictive power with an AUC of 0.820 (95%CI: 0.781-0.850), the cut-off value was 3.60 mmol/L (sensitivity 78.2% and specificity 77.3%). Patients with a low GAPmean tended to survive longer than the high GAPmean group 1 year after admission.

CONCLUSIONS

Glycemic GAP between the mean level of blood glucose within the first 7 days after admission to ICU and the A1C-derived average glucose was independently associated with a 28 day mortality of critically ill patients with diabetes, the predictive power extended to 1 year. The incidence of hypoglycemia was associated with mortality either.

Glycemic lability index and mortality in critically ill patients-A multicenter cohort study

BACKGROUND

Emerging evidence indicates a relationship between glycemic variability during intensive care unit (ICU) admission and death. We assessed whether mean glucose, hypoglycemia occurrence, or premorbid glycemic control modified this relationship.

METHODS

In this retrospective, multicenter cohort study, we included adult patients admitted to five ICUs in Australia and Sweden with available preadmission glycated hemoglobin A1c (HbA1c) and three or more glucose readings. We calculated the glycemic lability index (GLI), a measure of glycemic variability, and the time-weighted average blood glucose (TWA-BG) from all glucose readings. We used logistic regression analysis with adjustment for hypoglycemia and admission characteristics to assess the independent association of GLI (above vs. below cohort median) and TWA-BG (above vs. below cohort median) with hospital mortality.

RESULTS

Among 2305 patients, 859 (37%) had diabetes, median GLI was 40 [mmol/L]² /h/week, median TWA-BG was 8.2 mmol/L, 171 (7%) developed hypoglycemia, and 371 (16%) died. The adjusted odds ratio for death was 1.61 (95% CI, 1.19-2.15; P = .002) for GLI above versus below median and 1.06 (95% CI, 0.80-1.41; P = .67) for TWA-BG above versus below median. The relationship between GLI and mortality was not modified by TWA-BG (P [interaction] = 0.66), a history of diabetes (P [interaction] = 0.89) or by HbA1c ≥52 mmol/mol (vs. <52 mmol/mol) (P [interaction] = 0.29).

CONCLUSION

In adult patients admitted to an ICU in Sweden and Australia, a high GLI was associated with increased hospital mortality irrespective of the level of mean glycemia, hypoglycemia occurrence, or premorbid glycemic control. These findings support the assessment of interventions to reduce glycemic variability during critical illness.

Study of visual acuity and contrast sensitivity in diabetic patients with and without non-proliferative diabetic retinopathy

PURPOSE

To analyze high and low contrast visual acuity and contrast sensitivity in diabetic patients without clinically significant macular edema associated or not with non-proliferative diabetic retinopathy.

METHODS

Cross-sectional study of 368 eyes of 368 patients classified into three groups: a) disease-free patients, b) patients with diabetes mellitus (DM) without diabetic retinopathy, c) DM patients with non-proliferative diabetic retinopathy. All patients underwent a complete ophthalmological examination that included high and low contrast visual acuity with 1.25%, 2.5% and 5% contrast chart and Pelli-Robson type contrast sensitivity test.

RESULTS

We observed no statistically significant differences regarding age, intraocular pressure, duration of diabetes or high contrast visual acuity. The eyes of patients with non-proliferative diabetic retinopathy had worse contrast sensitivity (p = 0.03, in both cases) and low contrast visual acuity at 1.5% (p = 0.03 and p = 0.01), 2.5% (p = 0.01, in both cases) and 5% (p = 0.02 and p = 0.04) than patients free of disease or without diabetic retinopathy.

CONCLUSIONS

Analysis of contrast sensitivity and low contrast visual acuity could be considered as markers of visual function impairment in the eyes of patients with non-proliferative diabetic retinopathy.

Prevalence and impact of chronic dysglycemia in intensive care unit patients-A retrospective cohort study

BACKGROUND

The prevalence of chronic dysglycemia (diabetes and prediabetes) in patients admitted to Swedish intensive care units (ICUs) is unknown. We aimed to determine the prevalence of such chronic dysglycemia and asses its impact on blood glucose control and patient-centered outcomes in critically ill patients.

METHODS

In this retrospective observational cohort study, we obtained glycated hemoglobin A1c (HbA1c) in patients admitted to four tertiary ICUs in Sweden between March and August 2016. Based on previous diabetes history and HbA1c we determined the prevalence of chronic dysglycemia. We used multivariable regression analyses to study the association of chronic dysglycemia with the time-weighted average blood glucose concentration, glycemic lability index (GLI), and development of hypoglycemia (co-primary outcomes), and with ICU length of stay, mechanical ventilation duration, renal replacement therapy (RRT) use, vasopressor use, ICU-acquired infections, and mortality (exploratory clinical outcomes).

RESULTS

Of 943 patients, 312 (33%) had chronic dysglycemia. Of these 312 patients, 84 (27%) had prediabetes, 43 (14%) had undiagnosed diabetes and 185 (59%) had known diabetes. Chronic dysglycemia was independently associated with higher time-weighted average blood glucose concentration (P < .001), higher GLI (P < .001), and hypoglycemia (P < .001). Chronic dysglycemia was independently associated with RRT use (adjusted odds ratio 1.97, 95% CI 1.24-3.13, P = .004) but not with other exploratory clinical outcomes.

CONCLUSIONS

In four tertiary Swedish ICUs, measurement of HbA1c showed that one-third of patients had chronic dysglycemia. Chronic dysglycemia was associated with marked derangements in glycemic control, and a greater need for renal replacement therapy.

Relative Hyperglycemia Is an Independent Determinant of In-Hospital Mortality in Patients With Critical Illness

OBJECTIVES

To determine whether relative hyperglycemia was associated with in-hospital mortality in critically ill patients independent of other prognostic variables and whether this association is affected by background glycemia.

DESIGN

Prospective observational study.

SETTING

Mixed medical-surgical ICU in a metropolitan teaching hospital.

PATIENTS

From 2,617 admissions to ICU between January 27, 2016, and March 30, 2017, 1,262 consecutive patients who met inclusion and exclusion criteria were studied.

INTERVENTIONS

Glycosylated hemoglobin was used to estimate average glucose concentration over the prior 3 months. Glucose concentration on ICU admission was divided by estimated average glucose concentration to calculate the stress hyperglycemia ratio, an index of relative glycemia. Risk of death score was calculated using data submitted to the Australia and New Zealand Intensive Care Society.

MEASUREMENTS AND MAIN RESULTS

In this study, there were 186 deaths (14.7%). Admission glucose was significantly associated with mortality in univariate analysis (odds ratio = 1.08 per mmol/L glucose increment; p < 0.001) but not after adjustment for risk of death score (odds ratio = 1.01; p = 0.338). In contrast, stress hyperglycemia ratio was significantly associated with mortality both in univariate analysis (odds ratio = 1.09 per 0.1 stress hyperglycemia ratio increment; p < 0.001) and after adjustment for risk of death score (odds ratio = 1.03; p = 0.014). Unlike admission glucose concentration, stress hyperglycemia ratio was significantly associated with mortality in patients with glycosylated hemoglobin less than 6.5% (odds ratio = 1.08 per 0.1 stress hyperglycemia ratio increment; p < 0.001) and glycosylated hemoglobin greater than or equal to 6.5% (48 mmol/mol) (odds ratio = 1.08 per 0.1 stress hyperglycemia ratio increment; p = 0.005).

CONCLUSIONS

Unlike absolute hyperglycemia, relative hyperglycemia, as assessed by the stress hyperglycemia ratio, independently predicts in-hospital mortality in critically ill patients across the glycemic spectrum. Future studies should investigate whether using measures of relative hyperglycemia to determine individualized glycemic treatment targets improves outcomes in ICU.