Association of hyperglycemic crisis with an increased risk of end-stage renal disease: A nationwide population-based cohort study

Risk of chronic kidney disease in patients with a hyperglycemic crisis as the initial presentation of type 2 diabetes

Limited data exist on long-term renal outcomes in patients with hyperglycemic crisis (HC) as initial type 2 diabetes presentation. We evaluated the risk of chronic kidney disease (CKD) development in those with concurrent HC at diagnosis. Utilizing Taiwan's insurance claims from adults newly diagnosed with type 2 diabetes during 2006-2015, we created HC and matched non-HC cohorts. We assessed incident CKD/diabetic kidney disease (DKD) by 2018's end, calculating the hazard ratio (HR) with the Cox model. Each cohort comprised 13,242 patients. The combined CKD and DKD incidence was two-fold higher in the HC cohort than in the non-HC cohort (56.47 versus 28.49 per 1000 person-years) with an adjusted HR (aHR) of 2.00 (95% confidence interval [CI] 1.91-2.10]). Risk increased from diabetic ketoacidosis (DKA) (aHR:1.69 [95% CI 1.59-1.79]) to hyperglycemic hyperosmolar state (HHS) (aHR:2.47 [95% CI 2.33-2.63]) and further to combined DKA-HHS (aHR:2.60 [95% CI 2.29-2.95]). Subgroup analysis in individuals aged ≥ 40 years revealed a similar trend with slightly reduced incidences and HRs. Patients with HC as their initial type 2 diabetes presentation face a higher CKD risk than do those without HC. Enhanced medical attention and customized interventions are crucial to reduce this risk.

Clinical characteristics and outcomes of care in patients hospitalized with diabetic ketoacidosis

AIMS

To assess the clinical characteristics and outcomes of patients hospitalized with DKA.

METHODS

We examined the hospital database for patients admitted with DKA to all government hospitals in Qatar over 6 years.

RESULTS

We evaluated a total of 1330 patients [(37.3 % with type 1 diabetes (T1DM) and 62.7 % with type 2 diabetes (T2DM)] with 1613 episodes of DKA. Patients with T2DM were older than those with T1DM [48.0 (38.0-60.0), 26.0 (21.0-31.0) years] while there was no difference in DKA severity and laboratory values on admission or time to resolution of DKA. Admission to the intensive care unit was higher (38.9 % vs. 26.6 %; P < 0.001) with a longer hospital stay [5 (2.0-9.0) vs. 2 (2.0-4.0) days, P < 0.001] and markedly higher mortality (7.4 % vs. 1 %; P < 0.001) in patients with T2DM compared to T1DM. On multivariable logistic regression analysis, significant predictors of mortality were older age (odds ratio, 1.11; 95 % CI, 1.07-1.15; P = 0.0001), and admission to the intensive care unit (odds ratio, 3.61; 95 % CI, 1.69-7.72;P = 0.001).

CONCLUSION

In this national cohort of patients hospitalized with DKA, those with T2DM had a 7-fold increase in inpatient mortality associated with older age and admission to the intensive care unit.

Predicting readmission due to severe hyperglycemia after a hyperglycemic crisis episode

AIM

This study aimed to investigate the readmission pattern and risk factors for patients who experienced a hyperglycemic crisis.

METHODS

Patients admitted to MacKay Memorial Hospital for diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar state (HHS) between January 2016 and April 2019 were studied. The timing of the first readmission for hyperglycemia and other causes was recorded. Kaplan-Meier analysis was used to compare patients with hyperglycemia and all-cause readmissions. Cox regression was used to identify independent predictors for hyperglycemia and all-cause readmission post-discharge.

RESULTS

The study cohort included 410 patients, and 15.3 % and 46.3 % of them had hyperglycemia and all-cause readmissions, respectively. The DKA and HHS group showed a similar incidence for hyperglycemia, with the latter group showing a higher incidence of all-cause readmissions. The significant predictors of hyperglycemia readmissions included young age, smoking, hypoglycemia, higher effective osmolality, and hyperthyroidism in the DKA group and higher glycated hemoglobin level in the HHS group.

CONCLUSIONS

Patients who experienced DKA and HHS had similar hyperglycemia readmission rates; however, predictors in the DKA group were not applicable to the HHS group. Designing different strategies for different types of hyperglycemic crisis is necessary for preventing readmission.

Impact of acute hyperglycemic crisis episode on survival in individuals with diabetic foot ulcer using a machine learning approach

Objective

The outcome of DFUs concomitant with HCE remains unknown. This study aimed to investigate mortality rates and identify risk factors of mortality in patients with DFUs-HCE.

Methods

27 inpatients with DFUs-HCE were retrospectively enrolled in a cohort design, they were compared to 93 inpatients with DFUs in a city designated emergency center, between January 2016 and January 2021. After a 6-year followed-up, clinical characteristic, amputation and survival rates were compared. Extreme gradient boosting was further used to explore the relative importance of HCE and other risk factors to all-cause mortality in DFUs.

Results

Patients with DFUs-HCE were more likely to havedementia, acute kidney injury and septic shock, whereas DFUs were more likely to have diabetic peripheral neuropathy and ulcer recurrence (P<0.05). No significant difference was observed on the amputation rate and diabetes duration. Both Kaplan-Meier curves and adjusted Cox proportional model revealed that DFUs-HCE was associated with a higher mortality compared with DFUs (P<0.05). HCE significantly increased the risk of mortality in patients with DFUs (hazard ratio, 1.941; 95% CI 1.018-3.700; P = 0.044) and was independent from other confounding factors (age, sex, diabetes duration, Wagner grades and Charlson Comorbidity Index). The XGBoost model also revealed that HCE was one of the most important risk factors associated with all-cause mortality in patients with DFUs.

Conclusions

DFUs-HCE had significantly lower immediate survival rates (first 1-6 month) than DFUs alone. HCE is an important risk factor for death in DFUs patients.

The impact of hyperglycaemic crisis episodes on long-term outcomes for inpatients presenting with acute organ injury: A prospective, multicentre follow-up study

BACKGROUND

The long-term clinical outcome of poor prognosis in patients with diabetic hyperglycaemic crisis episodes (HCE) remains unknown, which may be related to acute organ injury (AOI) and its continuous damage after hospital discharge. This study aimed to observe the clinical differences and relevant risk factors in HCE with or without AOI.

METHODS

A total of 339 inpatients were divided into an AOI group (n=69) and a non-AOI group (n=270), and their differences and risk factors were explored. The differences in clinical outcomes and prediction models for evaluating the long-term adverse events after hospital discharge were established.

RESULTS

The mortality among cases complicated by AOI was significantly higher than that among patients without AOI [8 (11.59%) vs. 11 (4.07%), Q = 0.034] during hospitalization. After a 2-year follow-up, the mortality was also significantly higher in patients with concomitant AOI than in patients without AOI after hospital discharge during follow-up [13 (21.31%) vs. 15 (5.8%), Q < 0.001]. The long-term adverse events in patients with concomitant AOI were significantly higher than those in patients without AOI during follow-up [15 (24.59%) vs. 31 (11.97%), Q = 0.015]. Furthermore, Blood β-hydroxybutyric acid (P = 0.003), Cystatin C (P <0.001), serum potassium levels (P = 0.001) were significantly associated with long-term adverse events after hospital discharge.

CONCLUSIONS

The long-term prognosis of HCE patients complicated with AOI was significantly worse than that of HCE patients without AOI. The laboratory indicators were closely correlated with AOI, and future studies should explore the improvement of clinical outcome in response to timely interventions.

Risk of Dementia in Diabetic Patients with Hyperglycemic Crisis: A Nationwide Taiwanese Population-Based Cohort Study

BACKGROUND

A hyperglycemic crisis episode (HCE) signifies poor control of diabetes and may increase the risk of dementia via microvascular and macrovascular injuries.

OBJECTIVES

We conducted this study to clarify this issue, which remains unclear.

METHODS

Using the Taiwan National Health Insurance Database, we identified 9,466 diabetic patients with HCE and the identical number of diabetic patients without HCE who were matched by age and sex for this nationwide population-based cohort study. The risk of dementia was compared between the 2 cohorts by following up until 2014. Investigation of independent predictors of dementia was also done.

RESULTS

In the overall analysis, the risk of dementia between the 2 cohorts was not different. However, stratified analyses showed that patients with HCE had a higher risk of subsequent dementia in the age subgroup of 45-54 and 55-64 years (adjusted odds ratio [AOR]: 2.4, 95% confidence interval [CI]: 1.6-3.6, and AOR: 1.2, 95% CI: 1.0-1.5, respectively). In the overall analysis, older age, female sex, ≥3 HCEs, hypertension, hyperlipidemia, depression, cerebrovascular disease, Parkinson's disease, and head injury were independent predictors.

CONCLUSIONS

HCE increased the risk of dementia in diabetic patients aged 45-64 years. Dementia was predicted by ≥3 HCEs. Prevention of recurrent HCE, control of comorbidities, and close follow-up of cognitive decline and dementia are suggested in patients with HCE.

Association of postoperative glycemic control with outcomes after carotid procedures

Objective

There are limited data evaluating the impact of postoperative hyperglycemia in patients undergoing vascular procedures. This study evaluated the relationship between suboptimal glucose control and adverse outcomes after carotid artery stenting and carotid endarterectomy.

Methods

Patients admitted for elective carotid procedures were selected from the Cerner Health Facts® (2008–2015) database using ICD-9-CM diagnosis and procedure codes. We examined the relationship between patient characteristics, postoperative hyperglycemia (any value > 180 mg/dL), and complications with chi-square analysis. A multivariable model examined the association between patient characteristics, procedure type, and glucose control with infection, renal failure, stroke, respiratory and cardiac complications, and length of stay over 10 days.

Results

Of the 4287 patients admitted for an asymptomatic carotid procedure, 788 (18%) underwent carotid artery stenting and 3499 (82%) underwent carotid endarterectomy. Most patients (87%) had optimal postoperative glucose control (80–180 mg/dL); 13% had suboptimal glucose control. On average, patients with suboptimal glucose control experienced: higher stroke rates (6.2% vs. 2.7%; p <  0.001); more cardiac complications (5.1% vs. 2.0%; p <  0.001); longer hospital stays (3.1 vs. 1.8 days; p < .001); higher rates of post-procedure infection (4.0% vs. 1.8%; p = .001); and more complications than patients with optimal glucose control. Multivariable logistic regression demonstrated that patients with suboptimal glucose control had higher odds of having an infectious (pneumonia, cellulitis, surgical site, etc.) complication (OR 1.91, 95% CI 1.10–3.34), renal failure (OR 3.36, 95% CI 1.95–5.78), respiratory complications (OR 1.81, 95% CI 1.21–2.71), stroke (OR 1.82, 95% CI 1.15–2.88), or length of stay > 10 days (OR 4.07, 95% CI 2.02–8.20).

Conclusions

Suboptimal glucose control was associated with adverse events after carotid artery stenting and carotid endarterectomy, independent of a diabetes diagnosis. Several adverse outcomes were associated with hyperglycemia, including stroke. Given the singular role of carotid procedures in preventing stroke, we suggest that incorporating rigorous post-operative glucose control into best medical treatment of carotid disease should be considered as a standard practice.