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Krinsley JS, Roberts G, Brownlee M, Schwartz M, Preiser JC, Rule P, Wang Y, Bahgat J, Umpierrez GE, Hirsch IB. Case-control Investigation of Previously Undiagnosed Diabetes in the Critically Ill. J Endocr Soc 2022; 7:bvac180. [PMID: 36532359 PMCID: PMC9753064 DOI: 10.1210/jendso/bvac180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Indexed: 11/27/2022] Open
Abstract
Context The outcome of patients requiring intensive care can be influenced by the presence of previously undiagnosed diabetes (undiagDM). Objective This work aimed to define the clinical characteristics, glucose control metrics, and outcomes of patients admitted to the intensive care unit (ICU) with undiagDM, and compare these to patients with known DM (DM). Methods This case-control investigation compared undiagDM (glycated hemoglobin A1c [HbA1c] ≥ 6.5%, no history of diabetes) to patients with DM. Glycemic ratio (GR) was calculated as the quotient of mean ICU blood glucose (BG) and estimated preadmission glycemia, based on HbA1c ([28.7 × HbA1c] - 46.7 mg/dL). GR was analyzed by bands: less than 0.7, 0.7 to less than or equal to 0.9, 0.9 to less than 1.1, and greater than or equal to 1.1. Risk-adjusted mortality was represented by the Observed:Expected mortality ratio (OEMR), calculated as the quotient of observed mortality and mortality predicted by the severity of illness (APACHE IV prediction of mortality). Results Of 5567 patients 294 (5.3%) were undiagDM. UndiagDM had lower ICU mean BG (P < .0001) and coefficient of variation (P < .0001) but similar rates of hypoglycemia (P = .08). Mortality and risk-adjusted mortality were similar in patients with GR less than 1.1 comparing undiagDM and DM. However, for patients with GR greater than or equal to 1.1, mortality (38.5% vs 10.3% [P = .0072]) and risk-adjusted mortality (OEMR 1.18 vs 0.52 [P < .0001]) were higher in undiagDM than in DM. Conclusion These data suggest that DM patients may develop tolerance to hyperglycemia that occurs during critical illness, a protective mechanism not observed in undiagDM, for whom hyperglycemia remains strongly associated with higher risk of mortality. These results may shed light on the natural history of diabetes.
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Affiliation(s)
- James S Krinsley
- Department of Medicine, Stamford Hospital and Columbia Vagelos Columbia College of Physicians and Surgeons, Stamford, CT 06902, USA
| | - Gregory Roberts
- Department of Pharmacology, Flinders Medical Centre, Bedford Park, SA 5042, Australia
| | - Michael Brownlee
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Michael Schwartz
- Department of Medicine, University of Washington School of Medicine, Seattle, WA 98195, USA
| | - Jean-Charles Preiser
- Department of Intensive Care, Erasme University Hospital, Brussels 1070, Belgium
| | - Peter Rule
- PRI Consultants, Los Altos Hills, CA 94024, USA
| | - Yu Wang
- Department of Medicine, Stamford Hospital and Columbia Vagelos Columbia College of Physicians and Surgeons, Stamford, CT 06902, USA
| | - Joseph Bahgat
- Department of Medicine, Stamford Hospital and Columbia Vagelos Columbia College of Physicians and Surgeons, Stamford, CT 06902, USA
| | | | - Irl B Hirsch
- Department of Medicine, University of Washington School of Medicine, Seattle, WA 98195, USA
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Wang X, Cheng FTF, Lam TYT, Liu Y, Huang D, Liu X, Chen H, Zhang L, Ali Y, Wang MHT, Yu J, Gin T, Chan MTV, Wu WKK, Wong SH. Stress Hyperglycemia Is Associated With an Increased Risk of Subsequent Development of Diabetes Among Bacteremic and Nonbacteremic Patients. Diabetes Care 2022; 45:1438-1444. [PMID: 35275995 DOI: 10.2337/dc21-1682] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 02/21/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Stress hyperglycemia is associated with an increased risk of diabetes among survivors of critical illness. We investigated whether patients without diabetes hospitalized for bacteremia or nonbacteremic diseases with transient stress hyperglycemia would have a higher risk of subsequent diabetes development compared with those who remained normoglycemic. RESEARCH DESIGN AND METHODS This retrospective observational study was conducted on 224,534 in-patients with blood culture records. Stress hyperglycemia was defined based on the highest random glucose level ≥7.8 mmol/L during the index admission period. Diagnosis of diabetes, as the primary end point of interest, was defined based on diagnostic codes, blood test results, or medication records. Differences in cumulative incidence and hazard ratios (HRs) of diabetes between groups were assessed using the Kaplan-Meier estimator and Cox regression. RESULTS After exclusion of patients with preexisting or undiagnosed diabetes or indeterminate diabetes status and propensity score matching, bacteremic patients with stress hyperglycemia had a significantly higher cumulative incidence of diabetes (HR 1.7, 95% CI 1.2-2.4) compared with those who remained normoglycemic. Stress hyperglycemia was further confirmed to be a diabetes predictor independent of age, sex, comorbidity, and other serological markers. For the nonbacteremic patients, stress hyperglycemia was similarly associated with a higher cumulative incidence of diabetes (HR 1.4, 95% CI 1.2-1.7). CONCLUSIONS Hospitalized patients with transient stress hyperglycemia had a higher risk of subsequent diabetes development compared with their normoglycemic counterparts. Recognition of an increased risk of diabetes in these patients can allow early detection and monitoring in their subsequent follow-ups.
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Affiliation(s)
- Xiansong Wang
- Department of Anaesthesia and Intensive Care and Peter Hung Pain Research Institute, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Frankie T F Cheng
- Department of Anaesthesia and Intensive Care and Peter Hung Pain Research Institute, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Thomas Y T Lam
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Yingzhi Liu
- Department of Anaesthesia and Intensive Care and Peter Hung Pain Research Institute, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Dan Huang
- Department of Anaesthesia and Intensive Care and Peter Hung Pain Research Institute, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Xiaodong Liu
- Department of Anaesthesia and Intensive Care and Peter Hung Pain Research Institute, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Huarong Chen
- Department of Anaesthesia and Intensive Care and Peter Hung Pain Research Institute, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Lin Zhang
- Department of Anaesthesia and Intensive Care and Peter Hung Pain Research Institute, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China.,Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Yusuf Ali
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Maggie H T Wang
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Jun Yu
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China.,State Key Laboratory of Digestive Diseases, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China.,Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China.,CUHK Shenzhen Research Institute, Shenzhen, China
| | - Tony Gin
- Department of Anaesthesia and Intensive Care and Peter Hung Pain Research Institute, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Matthew T V Chan
- Department of Anaesthesia and Intensive Care and Peter Hung Pain Research Institute, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - William K K Wu
- Department of Anaesthesia and Intensive Care and Peter Hung Pain Research Institute, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China.,State Key Laboratory of Digestive Diseases, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China.,Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China.,CUHK Shenzhen Research Institute, Shenzhen, China
| | - Sunny H Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.,State Key Laboratory of Digestive Diseases, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China.,Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
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4
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Are point-of-care measurements of glycated haemoglobin accurate in the critically ill? Aust Crit Care 2018; 32:465-470. [PMID: 30591312 DOI: 10.1016/j.aucc.2018.11.064] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 11/13/2018] [Accepted: 11/16/2018] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Critically ill patients with type 2 diabetes mellitus (T2DM) and chronic hyperglycaemia may benefit from a more liberal approach to glucose control than patients with previously normal glucose tolerance. It may therefore be useful to rapidly determine HbA1c concentrations. Point-of-care (POC) analysers offer rapid results but may be less accurate than laboratory analysis. AIM(S) The aim of this study was to determine agreement between POC and laboratory HbA1c testing in critically ill patients with T2DM. METHODS Critically ill patients with T2DM had concurrent laboratory, capillary-, and arterial-POC HbA1c measurements performed. Data are presented as mean (standard deviation) or median [interquartile range]. Measurement agreement was assessed by Lin's concordance correlation coefficient, Bland-Altman 95% limits of agreement, and classification by Cohen's kappa statistic. RESULTS HbA1c analysis was performed for 26 patients. The time to obtain a result from POC analysis took a median of 9 [7, 10] minutes. Laboratory analysis took a median of 328 [257, 522] minutes from the time of test request to the time of report. Lin's correlation coefficient showed almost perfect agreement (0.99%) for arterial- vs capillary-POC and both POC methods vs arterial laboratory analysis. Bland-Altman plots showed a mean difference of 2.0 (3.7) with 95% limits of agreement of -5.4 to 9.3 for capillary vs laboratory, 1.6 (3.4) and -5.1 to 8.4 for arterial vs laboratory, and -0.137 (2.6) and -5.2 to 4.9 for capillary vs arterial. Patient classification as having inadequately controlled diabetes (>53 mmol/mol) showed 100% agreement across all tests. CONCLUSIONS HbA1c values can be accurately and rapidly obtained using POC testing in the critically ill.
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Gifford RM, Chathuranga U, Lamb T, Verma V, Sattar MA, Thompson A, Siribaddana S, Ghose A, Forbes S, Reynolds RM, Eddleston M. Short-term glucose dysregulation following acute poisoning with organophosphorus insecticides but not herbicides, carbamate or pyrethroid insecticides in South Asia. Clin Toxicol (Phila) 2018; 57:254-264. [PMID: 30306807 DOI: 10.1080/15563650.2018.1515438] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Ingestion of organophosphorus (OP) insecticides is associated with acute hyperglycaemia. We conducted a prospective study to determine whether glucose dysregulation on admission associated with ingestion of OP insecticides or other pesticides is sustained to hospital discharge or to 3-12 months later. METHODS We recruited participants to two similar studies performed in parallel in Anuradhapura, Sri Lanka, and Chittagong, Bangladesh, following hospitalisation for OP insecticide, herbicide or other pesticide self-poisoning. Two-hour 75 g oral glucose tolerance testing (OGTT) was performed after recovery from the acute poisoning, at around the time of discharge. In Sri Lanka, a four time-point OGTT for area-under-the-curve (AUC), C-peptide and homeostatic modelling of insulin resistance (HOMA-IR) was undertaken, repeated after 1 year. In Bangladesh, a 2-h OGTT for glucose was undertaken and repeated after 3 months in participants with initial elevated 2-h glucose. We compared glucose homeostasis by poison group and adjusted findings for age, BMI and sex. FINDINGS Seventy-three Sri Lankan and 151 Bangladeshi participants were recruited. We observed higher mean [SD] fasting (4.91 [0.74] vs. 4.66 [0.46] mmol/L, p = .003) and 2-h glucose (7.94 [2.54] vs. 6.71 [1.90] mmol/L, p < .0001) in OP-poisoned groups than pyrethroid, carbamate, herbicide or 'other poison' groups at discharge from hospital. In Sri Lanka, HOMA-IR, glucose and C-peptide AUC were higher in OP than carbamate or herbicide groups. Adjusted analyses remained significant except for fasting glucose. Follow-up analysis included 92 participants. There was no significant difference in OGTT results between OP-poisoned and other participants at follow-up (mean [SD] 2-h fasting glucose 4.67 [0.92] vs. 4.82 [0.62], p = .352; 2-h glucose 6.96 [2.31] mmol/L vs. 6.27 [1.86] mmol/L, p = .225). CONCLUSION We found in this small prospective study that acute OP insecticide poisoning caused acute glucose dysregulation that was sustained to hospital discharge but had recovered by 3-12 months. Acute glucose dysregulation was related to defects in insulin action and secretion. This study did not address long-term risk of diabetes following acute OP insecticide poisoning, but could provide the data for a power calculation for such a study.
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Affiliation(s)
- Robert M Gifford
- a University/BHF Centre for Cardiovascular Science, University of Edinburgh , Edinburgh , UK.,b South Asian Clinical Toxicology Research Collaboration , Faculty of Medicine , University of Peradeniya , Sri Lanka
| | - Umesh Chathuranga
- b South Asian Clinical Toxicology Research Collaboration , Faculty of Medicine , University of Peradeniya , Sri Lanka
| | - Thomas Lamb
- b South Asian Clinical Toxicology Research Collaboration , Faculty of Medicine , University of Peradeniya , Sri Lanka
| | - Vasundhara Verma
- b South Asian Clinical Toxicology Research Collaboration , Faculty of Medicine , University of Peradeniya , Sri Lanka
| | - Md Abdus Sattar
- c Department of Medicine, Faculty of Medicine , Chittagong Medical College , Chittagong , Bangladesh
| | - Adrian Thompson
- a University/BHF Centre for Cardiovascular Science, University of Edinburgh , Edinburgh , UK
| | - Sisira Siribaddana
- d Department of Medicine, Faculty of Medicine , Rajarata University of Sri Lanka , Saliyapura , Sri Lanka
| | - Aniruddha Ghose
- c Department of Medicine, Faculty of Medicine , Chittagong Medical College , Chittagong , Bangladesh
| | - Shareen Forbes
- a University/BHF Centre for Cardiovascular Science, University of Edinburgh , Edinburgh , UK
| | - Rebecca M Reynolds
- a University/BHF Centre for Cardiovascular Science, University of Edinburgh , Edinburgh , UK
| | - Michael Eddleston
- a University/BHF Centre for Cardiovascular Science, University of Edinburgh , Edinburgh , UK.,b South Asian Clinical Toxicology Research Collaboration , Faculty of Medicine , University of Peradeniya , Sri Lanka.,e Centre for Pesticide Suicide Prevention , University of Edinburgh , Edinburgh , UK
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