Defining and characterising diabetic ketoacidosis in adults

Hyperglycemic Crises in Adults With Diabetes: A Consensus Report

The American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), Joint British Diabetes Societies for Inpatient Care (JBDS), American Association of Clinical Endocrinology (AACE), and Diabetes Technology Society (DTS) convened a panel of internists and diabetologists to update the ADA consensus statement on hyperglycemic crises in adults with diabetes, published in 2001 and last updated in 2009. The objective of this consensus report is to provide up-to-date knowledge about the epidemiology, pathophysiology, clinical presentation, and recommendations for the diagnosis, treatment, and prevention of diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) in adults. A systematic examination of publications since 2009 informed new recommendations. The target audience is the full spectrum of diabetes health care professionals and individuals with diabetes.

Hyperglycaemic crises in adults with diabetes: a consensus report

The American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), Joint British Diabetes Societies for Inpatient Care (JBDS), American Association of Clinical Endocrinology (AACE) and Diabetes Technology Society (DTS) convened a panel of internists and diabetologists to update the ADA consensus statement on hyperglycaemic crises in adults with diabetes, published in 2001 and last updated in 2009. The objective of this consensus report is to provide up-to-date knowledge about the epidemiology, pathophysiology, clinical presentation, and recommendations for the diagnosis, treatment and prevention of diabetic ketoacidosis (DKA) and hyperglycaemic hyperosmolar state (HHS) in adults. A systematic examination of publications since 2009 informed new recommendations. The target audience is the full spectrum of diabetes healthcare professionals and individuals with diabetes.

Analysis of the 2-Bag Method for the Management of Diabetic Ketoacidosis: A Retrospective before and after Study

Purpose: This study aims to assess the efficacy and safety of a two-bag method compared with a one-bag method for the treatment of diabetic ketoacidosis (DKA). We hypothesize that a two-bag method will decrease the incidence of hypoglycemia, when compared with a one-bag method. Methods: A retrospective chart review was conducted on patients treated for DKA at a Trinity Health institution between 2020 and 2022. A total of 1084 adult patients were included. Patients treated with the one-bag protocol were included in the pre-group, while those treated with the two-bag protocol were included in the post-group. The primary outcome was incidence of hypoglycemia (blood glucose <70 mg/dL). Secondary outcomes included time to anion gap closure, insulin infusion duration, time to HCO3 correction, and incidence of hypokalemia. Patients were excluded if they were pregnant or diagnosed with Hyperosmolar Hyperglycemic State (HHS), euglycemic DKA, or ketosis from other causes. Results: The incidence of hypoglycemia was 38% in the pre-group and 15.83% in the post-group (P < .001). Patients in the pre-group were on an insulin infusion longer than the post-group (28.37 hours vs 22.17 hours, P < .001). Patients in the pre-group had a slower time to anion gap closure (8.99 hours vs 8.52 hours, P = .021) and had a slower time to HCO3 correction (10.88 hours vs 10.69 hours, P = .004). Between-group incidence of hypokalemia was similar (66.39% vs 60%, P = .079). Conclusions: The two-bag method for the treatment of DKA resulted in improved safety and efficacy outcomes, compared with the one-bag method.

Development of Machine Learning Models for the Identification of Elevated Ketone Bodies During Hyperglycemia in Patients with Type 1 Diabetes

Aims: Diabetic ketoacidosis (DKA) is a serious life-threatening condition caused by a lack of insulin, which leads to elevated plasma glucose and metabolic acidosis. Early identification of developing DKA is important to start treatment and minimize complications and risk of death. The aim of the present study is to develop and test prediction model(s) that gives an alarm about their risk of developing elevated ketone bodies during hyperglycemia. Methods: We analyzed data from 138 type 1 diabetes patients with measurements of ketone bodies and continuous glucose monitoring (CGM) data from over 30,000 days of wear time. We utilized a supervised binary classification machine learning approach to identify elevated levels of ketone bodies (≥0.6 mmol/L). Data material was randomly divided at patient level in 70%/30% (training/test) dataset. Logistic regression (LR) and random forest (RF) classifier were compared. Results: Among included patients, 913 ketone samples were eligible for modeling, including 273 event samples with ketone levels ≥0.6 mmol/L. An area under the receiver operating characteristic curve from the RF classifier was 0.836 (confidence interval [CI] 90%, 0.783-0.886) and 0.710 (CI 90%, 0.646-0.77) for the LR classifier. Conclusions: The novel approach for identifying elevated ketone levels in patients with type 1 diabetes utilized in this study indicates that CGM could be a valuable resource for the early prediction of patients at risk of developing DKA. Future studies are needed to validate the results.

Wearable Vertical Graphene-Based Microneedle Biosensor for Real-Time Ketogenic Diet Management

Ketogenic diets have attracted substantial interest in the treatment of chronic diseases, but there are health risks with long-term regimes. Despite the advancements in diagnostic and therapeutic methods in modern medicine, there is a huge gap in personalized health management of this dietary strategy. Hence, we present a wearable microneedle biosensor for real-time ketone and glucose monitoring. The microneedle array possesses excellent mechanical properties, allowing for consistent sampling of interstitial biomarkers while reducing the pain associated with skin puncture. Vertical graphene with outstanding electrical conductivity provides the resulting sensor with a high sensitivity of 234.18 μA mM-1 cm-2 and a low limit detection of 1.21 μM. When this fully integrated biosensor was used in human volunteers, it displayed an attractive analytical capability for tracking the dynamic metabolite levels. Moreover, the results of the on-body evaluation established a significant correlation with commercial blood measurements. Overall, this cost-effective and efficient sensing platform can accelerate the application of a ketogenic diet in personal nutrition and wellness management.

Ketoacidosis and SGLT2 Inhibitors: A Narrative Review

An acute metabolic complication of diabetes mellitus, especially type 1, is diabetic ketoacidosis (DKA), which is due to an increase in blood ketone concentrations. Sodium/glucose co-transporter-2 inhibitor (SGLT2-i) drugs have been associated with the occurrence of a particular type of DKA defined as euglycemic (euDKA), characterized by glycemic levels below 300 mg/dL. A fair number of euDKA cases in SGLT2-i-treated patients have been described, especially in the last few years when there has been a significant increased use of these drugs. This form of euDKA is particularly insidious because of its latent onset, associated with unspecific symptomatology, until it evolves (progressing) to severe systemic forms. In addition, its atypical presentation can delay diagnosis and treatment. However, the risk of euDKA associated with SGLT2-i drugs remains relatively low, but it is essential to promptly diagnose and manage it to prevent its serious life-threatening complications. In this narrative review, we intended to gather current research evidence on SGLT2i-associated euDKA from randomized controlled trials and real-world evidence studies, its diagnostic criteria and precipitating factors.

Sodium-Glucose Cotransporter 2 Inhibitors Should Be Avoided for the Inpatient Management of Hyperglycemia

OBJECTIVE

Hyperglycemia in patients with type 2 diabetes mellitus is frequently encountered in the hospital setting. The recent guidelines for the management of inpatient hyperglycemia have included the use of dipeptidyl peptidase 4 inhibitors as an alternative to standard insulin therapy in select patients. This raises the question of the inpatient use of sodium-glucose cotransporter 2 inhibitors (SGLT2i), which have gained increasing popularity in the outpatient setting because of beneficial cardiovascular and renal outcomes. This article describes the risks associated with the use of SGLT2i for the management of inpatient hyperglycemia.

METHODS

A literature review was performed using PubMed and Google Scholar for studies assessing the inpatient use of SGLT2i. Search terms included "SGLT2 inhibitors," "euglycemic DKA," "inpatient hyperglycemia," "DPP4 inhibitors," "hypovolemia," and "urinary tract infections." Studies not written in English were excluded. Forty-eight articles were included.

RESULTS

Review of the literature showed significant safety concerns with the use of SGLT2i for the inpatient management of hyperglycemia. Hospitalized patients treated with SGLT2i were at increased risk of diabetic ketoacidosis, euglycemic diabetic ketoacidosis, hypovolemia, and urinary tract infections. When compared head-to-head, SGLT2i were not more effective for inpatient glycemic control than dipeptidyl peptidase 4 inhibitors and did not reduce insulin requirements when used in combination with insulin. Although SGLT2i can be considered for the treatment of congestive heart failure, they should be started close to or at the time of discharge.

CONCLUSION

Although SGLT2i are a preferred pharmacotherapy class for the outpatient management of type 2 diabetes mellitus, there are considerable safety concerns when using them in a hospital setting, and avoidance is recommended.

New advances in type 1 diabetes

Type 1 diabetes is an autoimmune condition resulting in insulin deficiency and eventual loss of pancreatic β cell function requiring lifelong insulin therapy. Since the discovery of insulin more than 100 years ago, vast advances in treatments have improved care for many people with type 1 diabetes. Ongoing research on the genetics and immunology of type 1 diabetes and on interventions to modify disease course and preserve β cell function have expanded our broad understanding of this condition. Biomarkers of type 1 diabetes are detectable months to years before development of overt disease, and three stages of diabetes are now recognized. The advent of continuous glucose monitoring and the newer automated insulin delivery systems have changed the landscape of type 1 diabetes management and are associated with improved glycated hemoglobin and decreased hypoglycemia. Adjunctive therapies such as sodium glucose cotransporter-1 inhibitors and glucagon-like peptide 1 receptor agonists may find use in management in the future. Despite these rapid advances in the field, people living in under-resourced parts of the world struggle to obtain necessities such as insulin, syringes, and blood glucose monitoring essential for managing this condition. This review covers recent developments in diagnosis and treatment and future directions in the broad field of type 1 diabetes.

Epidemiology of Diabetic Ketoacidosis in the Waikato Region of New Zealand: 2000-2019

Aims

Diabetic ketoacidosis (DKA) is not well characterised in New Zealand. This study is aimed at characterising the change in epidemiology and severity of DKA from 2000 to 2019 at a tertiary hospital in the Waikato region of New Zealand.

Methods

A retrospective clinical data review of all patients admitted to Waikato District Health Board hospitals with DKA was undertaken. Characteristics and severity of DKA were assessed by type of DKA admission (diagnosed at admission, nonrecurrent, and recurrent), ethnicity, social deprivation, intensive care unit (ICU) admission, and length of hospital stay, with linear regression reporting on changes over time.

Results

There were 1254 admissions for DKA (564 individual patients), two-thirds being recurrent events. Nonrecurrent DKA patients were younger, whilst recurrent admissions for DKA were associated with T1D, female gender, greater socioeconomic deprivation, and rural living (all P values < 0.01). DKA admission increased 8-fold between 2000 and 2019, mostly due to an increased number of recurrent events, particularly in Māori and female patients (P < 0.001). ICU admissions increased over time (P < 0.001) whilst length of hospital stay trended down (P = 0.031).

Conclusions

The rise in recurrent DKA is concerning, particularly in youth and indigenous Māori. Healthcare inequities need to be addressed, including adequate access to mental health support to ensure optimal outcomes for all patients with diabetes.

Risk factors for diabetic ketoacidosis in acute pancreatitis patients with type 2 diabetes

BACKGROUND AND PURPOSE

In cinical, some acute pancreatitis patients with diabetes may have diabetic ketoacidosis (DKA). However, the risk factors for DKA in these patients remain unclear. The purpose of this study is to analyze the risk factors for DKA in acute pancreatitis patients with type 2 diabetes.

PATIENTS AND METHODS

Twenty-five patients were included in this prospective single-centre study to analyze the incidence and risk factors for DKA in acute pancreatitis patients with type 2 diabetes.

RESULTS

Seven of the twenty-five patients (28%) developed DKA within 48 h of admission. According to whether they had DKA, the twenty-five AP patients were divided into DKA group and non-DKA group. There were significant differences in age (P = 0.014), BMI (P = 0.034), poor previous blood glucose control (P < 0.001) and uric acid concentration (P = 0.041), but no statistically significant differences in sex (P = 0.597), number of drinkers (P = 0.407), number of smokers (P = 1.000), triglyceride level (P = 0.389) and total cholesterol concentration (P = 0.534) between the two groups. In both groups, 1 patients had severe pancreatitis, and the difference was no statistically significant (P = 0.490).

CONCLUSIONS

The incidence of DKA in AP patients with diabetes is high. Age, BMI, worse glycemic control and uric acid concentration may be predictors of DKA in AP patients with diabetes.

Presentation of Severe Diabetic Ketoacidosis in New-Onset Type One Diabetes Mellitus: The Importance of a Broad Differential in an Otherwise Healthy Population in the Operational Environment

Diabetic ketoacidosis (DKA) is a serious disease entity that must be diagnosed quickly for urgent management in the intensive care unit. Keeping DKA in the differential diagnosis is important, especially in a forward deployed, resource-poor setting. The symptoms and signs of DKA are nonspecific, including fatigue, polydipsia, polyuria, weakness, weight loss, nausea, vomiting, and abdominal pain with tachycardia and tachypnea on exam. The testing capability to evaluate for DKA includes a glucometer, urine dipstick, and basal metabolic panel, all of which can be done in most forward deployed settings. The need for a high index of suspicion for DKA in patients with these symptoms is required due to the lack of life-saving insulin and intensive lab monitoring required. The downstream effects of DKA include diabetic coma and death. We present a case report of a 21-year-old otherwise healthy, active duty, male Marine who presents to the clinic with a chief complaint of 4 days of headache and 1 day of nausea with four episodes of non-bloody, non-bilious emesis along with epigastric abdominal pain. He returned to the clinic 2 days later with evidence of tachycardia and increased work of breathing, at which time there was a concern for a pulmonary embolus. By the time he was transferred to the emergency room, he was in severe DKA. The patient was treated in the intensive care unit and made a full recovery. He was processed for limited duty and medical board upon hospital discharge.

Systematically Treating the Extra Sweet Pediatric Patient, Without Inadvertently Giving Them a Big Head

Treating pediatric patients with diabetic ketoacidosis (DKA) during transport can be complex and multifactorial. Cerebral edema is a frequent occurrence in pediatric patients with DKA; however, the signs often occur in a subtle manner. Overzealous correction of their blood glucose may result in cerebral edema as well as a cascade of electrolyte abnormalities. Pediatric patients with diabetes mellitus are prone to developing DKA. Serious complications from DKA in pediatrics often present acutely and rapidly.

What is the utility of blood beta-hydroxybutyrate measurements in emergency department in patients without diabetes: a systematic review

BACKGROUND

Ketones are synthesised as an alternative fuel source during times of energy restriction. In the absence of a hyperglycemic emergency, ketosis in patients presenting to the emergency department (ED) may indicate reduced carbohydrate intake. In the perioperative setting, excess fasting with ketosis is associated with worse outcomes; however, whether ketosis in patients without diabetes presenting to ED is also associated with worse outcomes is unclear. This systematic review aims to examine the evidence for ketosis in predicting the need for hospital admission in patients without diabetes, presenting to the ED.

METHODS

A systematic review was performed using PRISMA guidelines. We searched electronic bases (OVID-Medline, OVID-EMBASE, Scopus and PubMed) up to December 2022. Eligible studies included children or adults without diabetes presenting to the ED where a point-of-care capillary beta-hydroxybutyrate (BHB) was measured and compared to outcomes including the need for admission. Outcome measures included need for admission and length of stay. Content analysis was performed systematically; bias and certainty assessed using standard tools.

RESULTS

The literature search found 17,133 citations, 14,965 papers were subjected to title and abstract screening. The full text of 62 eligible studies were reviewed. Seven articles met the inclusion criteria. Six studies were conducted solely in the paediatric population, and of these, four were limited to children presenting with gastroenteritis symptoms. Median BHB was higher in children requiring hospital admission with an AUC of 0.64-0.65 across two studies. There was a weak correlation between BHB and dehydration score or duration of symptoms. The single study in adults, limited to stroke presentations, observed no relationship between BHB and neurological deficit at presentation. All studies were at risk of bias using the Newcastle-Ottawa Scale and was assessed of "very low" to "low" quality due to their study design in the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Heterogeneity amongst selected studies precluded meta-analysis.

CONCLUSION

The evidence for any utility of BHB measurement in the ED in absence of diabetes is limited to the paediatric population, specifically children presenting with symptoms of gastroenteritis. Any role in adults remains unexplored.

Incidence of type 1 diabetes in Navarra, 2009-2020. Evidence of a stabilization

INTRODUCTION

The evolution of the incidence of type 1 diabetes (T1D) in all groups is controversial. Our objective is to study the incidence from 2009 to 2020, based on the Type 1 Diabetes Registry of Navarra, and to analyze the clinical presentation as diabetic ketoacidosis (DKA), and HbA1c at onset.

MATERIALS AND METHODS

Descriptive study of all cases diagnosed as T1D and included in the Population Registry of T1D of Navarra in the period 1/1/2009 to 12/31/2020. Data are obtained from primary and secondary sources with an ascertainment rate of 96%. Incidence rates are expressed per 100,000 person-years of risk, by age group and sex. Likewise, a descriptive analysis of the HbA1c and DKA at diagnosis of each patient is performed.

RESULTS

627 new cases are registered, which represents an incidence of 8.1 (10 in men, 6.3 in women), without differences throughout the analyzed period. The group with the highest incidence is the 10-14 years old children (27.8), followed by that of 5-9 years old (20.6). The incidence in people older than 15 years is 5.8. Twenty six percent of patients present DKA at onset. The global mean of HbA1c is 11.6%, without changes throughout the studied period.

CONCLUSIONS

The population registry of T1D of Navarra shows a stabilization in the incidence of T1D at all ages in the 2009-2020 period. The percentage of presentation as severe forms is high, even in adulthood.

Predicting the risk factors of diabetic ketoacidosis-associated acute kidney injury: A machine learning approach using XGBoost

Objective

The purpose of this study was to develop and validate a predictive model based on a machine learning (ML) approach to identify patients with DKA at increased risk of AKI within 1 week of hospitalization in the intensive care unit (ICU).

Methods

Patients diagnosed with DKA from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database according to the International Classification of Diseases (ICD)-9/10 code were included. The patient's medical history is extracted, along with data on their demographics, vital signs, clinical characteristics, laboratory results, and therapeutic measures. The best-performing model is chosen by contrasting the 8 Ml models. The area under the receiver operating characteristic curve (AUC), sensitivity, accuracy, and specificity were calculated to select the best-performing ML model.

Results

The final study enrolled 1,322 patients with DKA in total, randomly split into training (1,124, 85%) and validation sets (198, 15%). 497 (37.5%) of them experienced AKI within a week of being admitted to the ICU. The eXtreme Gradient Boosting (XGBoost) model performed best of the 8 Ml models, and the AUC of the training and validation sets were 0.835 and 0.800, respectively. According to the result of feature importance, the top 5 main features contributing to the XGBoost model were blood urea nitrogen (BUN), urine output, weight, age, and platelet count (PLT).

Conclusion

An ML-based individual prediction model for DKA-associated AKI (DKA-AKI) was developed and validated. The model performs robustly, identifies high-risk patients early, can assist in clinical decision-making, and can improve the prognosis of DKA patients to some extent.

Overlap of diabetic ketoacidosis and hyperosmolar hyperglycemic state

Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemia state (HHS) are two life-threatening metabolic complications of diabetes that significantly increase mortality and morbidity. Despite major advances, reaching a uniform consensus regarding the diagnostic criteria and treatment of both conditions has been challenging. A significant overlap between these two extremes of the hyperglycemic crisis spectrum poses an additional hurdle. It has well been noted that a complete biochemical and clinical patient evaluation with timely diagnosis and treatment is vital for symptom resolution. Worldwide, there is a lack of large-scale studies that help define how hyperglycemic crises should be managed. This article will provide a comprehensive review of the pathophysiology, diagnosis, and management of DKA-HHS overlap.

The management of diabetic ketoacidosis in adults-An updated guideline from the Joint British Diabetes Society for Inpatient Care

This article summarises the Joint British Diabetes Societies for Inpatient Care guidelines on the management of ketoacidosis; available at https://abcd.care/resource/management-diabetic-ketoacidosis-dka-adults. The document explicitly states that when a person aged 16-18 is under the care of the paediatric team, then the paediatric guideline should be used, and if they are cared for by an adult team, then this guideline should be used. The guideline takes into account new evidence on the use of the previous version of this document, particularly the high prevalence of hypoglycaemia and hypokalaemia, and recommends that when the glucose concentration drops below 14 mmol/L, that de-escalating the insulin infusion rate from 0.1 to 0.05 units/kg/h should be considered. Furthermore, a section has been added to address the recognition that use of sodium glucose co-transporter 2 inhibitors is associated with an increased risk of euglycaemic ketoacidosis. The management of ketoacidosis in people with end-stage renal failure or on dialysis is also mentioned. Finally, the algorithms to illustrate the guideline have been updated.

Aminoaciduria and metabolic dysregulation during diabetic ketoacidosis: Results from the diabetic kidney alarm (DKA) study

OBJECTIVE

We examined changes in the excretion of various amino acids and in glycolysis and ketogenesis-related metabolites, during and after diabetic ketoacidosis (DKA) diagnosis, in youth with known or new onset type 1 diabetes (T1D).

METHODS

Urine samples were collected from 40 youth with DKA (52% boys, mean age 11 ± 4 years, venous pH 7.2 ± 0.1, blood glucose 451 ± 163 mg/dL) at 3 time points: 0-8 h and 12-24 h after starting an insulin infusion, and 3 months after hospital discharge. Mixed-effects models evaluated the changes in amino acids and other metabolites in the urine.

RESULTS

Concentrations of urine histidine, threonine, tryptophan, and leucine per creatinine were highest at 0-8 h (148.8 ± 23.5, 59.5 ± 12.3, 15.4 ± 1.4, and 24.5 ± 2.4% of urine creatinine, respectively), and significantly decreased over 3 months (p = 0.028, p = 0.027, p = 0.019, and p < 0.0001, respectively). Urine histidine, threonine, tryptophan, and leucine per urine creatinine decreased by 10.6 ± 19.2, 0.7 ± 0.9, 1.3 ± 0.9, and 0.5 ± 0.3-fold, respectively, between 0 and 8 h and 3 months.

CONCLUSIONS

In our study, DKA was associated with profound aminoaciduria, suggestive of proximal tubular dysfunction analogous to Fanconi syndrome.

Characteristics of newly diagnosed type 1 diabetes in paediatric and adult population from Reims University Hospital, France from 1997 to 2019

French health insurance data showed that the incidence of type 1 diabetes mellitus (T1DM) in children increased over the years to 2015. The objective of our study was to assess the evolution of the number of incident cases of paediatric and adult type 1 diabetes in our institution, and to describe their clinical presentation and its evolution. All patients with T1DM managed at diagnosis at Reims University Hospital between 1997 and 2019 were included. The clinical and biological data were extracted from the Champagne-Ardenne Diabetes Network database. Included were 847 patients with a median age of 10.3 years. Diagnosis was established in 71% of cases before 15 years, 7.4% after 35 years. The number of newly diagnosed cases was 3.6-times higher in 2019 compared to 1997. Ketoacidosis, the frequency of which decreased with age (P < 0.0001), revealed diabetes in a total of 32% of cases and in 46% of children under 5 years. It was more severe in children than in adults (P = 0.03), and its frequency increased over the study period. Hypotrophy was found in 23% of children under 15 years of age, and was more pronounced before 5 years of age, with no improvement over time. We saw an increase in the frequency of obesity or overweight among adults. Our study showed an increase in incident cases of diabetes in our hospital that continued over time for both children and adults. Clinical features at diagnosis deteriorated during this period for those under 15 years of age with an increase in ketoacidosis frequency.

Controversies Around the Measurement of Blood Ketones to Diagnose and Manage Diabetic Ketoacidosis

The measurement of blood ketones in preference to urine ketones has become a well-established tool in the diagnosis and management of diabetic ketoacidosis (DKA). However, there remains considerable disparity between diabetes guidelines regarding if, how, and when this test should be used. While recent guidelines now mainly emphasize blood measurement, several issues nonetheless remain. Many laboratories still measure blood ketones using a semiquantitative test that does not measure the predominant ketone, β-hydroxybutyrate (BOHB), which may hinder patient management. Even when BOHB is measured, the evidence for cutoffs used in DKA diagnosis or exclusion is limited, while its use in gauging severity, treatment progress, and resolution is not fully clear. Lastly, although employing point-of-care meters instead of a laboratory for BOHB measurement brings undoubted benefits, this approach has its own challenges. This article provides a perspective on these topics to complement current recommendations and to suggest how future research may improve its use in the DKA context.

Base excess measured at hospital admission is useful for predicting diabetic ketoacidosis severity and resolution time in adult patients

BACKGROUND AND AIMS

This study aimed to identify the biochemical factors measured at hospital admission that could predict diabetes ketoacidosis (DKA) resolution time in adult patients.

MATERIALS AND METHODS

This retrospective study included 79 patients >18 years of age. Multivariate analyses were performed to determine which variables might predict DKA resolution time. Biochemical parameters between the two DKA resolution time groups were compared.

RESULTS

Using multiple linear regression models, acidosis time was found to decrease by 29 h if the pH value increased by one unit, 0.64 h if the base excess (BE) value increased by 1 mmol, and 1.09 h if the bicarbonate (HCO3^-) value increased by 1 mmol. The biochemical parameters that differed between the two groups were pH, HCO3^-, and BE. Patients with delayed resolution of DKA had a blood pH of 7.1 (±0.18), HCO3^- of 5.1 mmol (2.9-11.6 mmol), and BE of -21.5 mmol (-28.2 to -14.4 mmol) at hospital admission.

CONCLUSIONS

Lower pH, HCO3^-, and BE values at hospital admission may predict longer DKA resolution times in adult patients. In addition, BE may predict DKA severity.

New Therapeutic Horizons in Chronic Kidney Disease: The Role of SGLT2 Inhibitors in Clinical Practice

Chronic kidney disease (CKD) is a serious, progressive condition associated with significant patient morbidity. Hypertension control and use of renin-angiotensin system blockers are the cornerstones of treatment for CKD. However, even with these treatment strategies, many individuals will progress towards kidney failure. Recently, sodium-glucose cotransporter 2 (SGLT2) inhibitor clinical trials with primary renal endpoints have firmly established SGLT2 inhibition, in addition to standard of care, as an effective strategy to slow down the progression of CKD and reduce some of its associated complications. The emergence of this new clinical evidence supports the use of SGLT2 inhibitors in the management of CKD in people with and without diabetes. As licensing and guidelines for SGLT2 inhibitors are updated, there is a need to adapt CKD treatment pathways and for this class of drugs to be included as part of standard care for CKD management. In this article, we have used consensus opinion alongside the available evidence to provide support for the healthcare community involved in CKD management, regarding the role of SGLT2 inhibitors in clinical practice. By highlighting appropriate prescribing and practical considerations, we aim to encourage greater and safe use of SGLT2 inhibitors for people with CKD, both with and without diabetes.

Clinical study of autoantibodies in type 1 diabetes mellitus children with ketoacidosis or microalbuminuria

Aims

The study aimed to investigate the value of autoantibodies in predicting the risk of ketoacidosis or microalbuminuria in children with type 1 diabetes mellitus.

Methods

Clinical data and laboratory indicators of 80 patients with type 1 diabetes admitted to the Department of Endocrinology in Tianjin Children's Hospital, from June 2017 to March 2019, were retrospectively analyzed. The patients were divided into two groups: diabetes without ketoacidosis group (n = 20) and diabetes with ketoacidosis group (n = 60). The differences in general data, laboratory test indexes, and autoantibodies between the two groups were analyzed. Finally, ROC curves and multivariate logistic regression analysis were used to explore the value of autoantibodies in patients with ketoacidosis or microalbuminuria.

Results

A total of 80 children with type 1 diabetes were assessed, including 35 boys and 45 girls, ranging in age from 10 months to 15 years. The concentration of GADA, IA2A, and ZnT8A was not statistically different between the two groups, but the positive rate of ZnT8A was statistically significant (p = 0.038) and had a diagnostic value for the occurrence of ketoacidosis (p = 0.025). ZnT8A‐positive patients had a higher titer of IA2A and a more frequent prevalence of GADA and IA2A than ZnT8A‐negative patients (p < 0.01). In multivariate logistic regression analyses, the presence of positive ZnT8A was associated with a higher risk of microalbuminuria independent of age, sex, and BMI (OR = 4.184 [95% CI 1.034~16.934], p = 0.045).

Conclusions

The positive ZnT8A had diagnostic value for ketoacidosis in children with type 1 diabetes and had the highest specificity among the three kinds of autoantibodies. Moreover, ZnT8A positivity was related to a higher titer of IA2A and more frequent occurrence of multiple diabetes‐related autoantibodies. Besides, the presence of positive ZnT8A was an independent risk factor of microalbuminuria in children with type 1 diabetes. Therefore, we can infer that positive ZnT8A may be related to ketoacidosis and microalbuminuria, accelerating the progression of T1DM.

Clinical and endoscopic characteristics of acute esophageal necrosis and severe reflux esophagitis

The similarities and differences between acute esophageal necrosis and severe reflux esophagitis have not been elucidated. We compared Los Angeles classification Grade C reflux esophagitis, Grade D reflux esophagitis, and acute esophageal necrosis to consider the similarities and differences between acute esophageal necrosis and severe reflux esophagitis.We retrospectively reviewed records of patients who underwent esophagogastroduodenoscopy at a tertiary referral center from January 2012 to December 2019. Data on patients diagnosed as Grade C reflux, Grade D reflux, or acute esophageal necrosis for the first time were extracted for analysis.A total of 213 patients were enrolled in the study, composed of 130 Grade C reflux, 74 Grade D reflux, and 9 acute esophageal necrosis patients. Compared to Grade C reflux patients, Grade D reflux and acute esophageal necrosis patients were more likely to be transfused (P = .013 and P = .011, respectively), to have duodenal ulcers (P = .025 and P = .049, respectively), and to have psychiatric illnesses (P = .022 and P = .018, respectively). Compared to both Grade C and D reflux, acute esophageal necrosis patients were more likely to present with shock (P = .003 and P < .001, respectively), have type 1 diabetes (P = .030 and P = .004, respectively), and present in winter (P < .001 and P < .001, respectively). Significant step-wise differences (Grade C < Grade D < acute esophageal necrosis) were observed in the need for admission (P < .001 and P = .009), coffee ground emesis (P < .001 and P = .022), and stigmata of hemorrhage on endoscopy (P = .002 and P < .001). Admission (P = .003) and coffee ground emesis (P = .003) independently predicted either Grade D reflux or acute esophageal necrosis over Grade C reflux on multivariate analysis.Shock, type 1 diabetes, and winter may predict acute esophageal necrosis, while the need for admission and coffee ground emesis may predict Grade D reflux or acute esophageal necrosis.

Biochemical and immunological changes in obesity

Obesity is a syndemia that promotes high expenditures for public health, and is defined by the excess of adipose tissue that is classified according to its function and anatomical distribution. In obese people, this tissue generates oxidative stress associated with a chronic inflammatory response, in which there is an imbalance in relation to the release of hormones and adipokines that cause loss of body homeostasis and predisposition to the development of some comorbidities. The purpose of this review is to summarize the main events that occur during the onset and progression of obesity with a special focus on biochemical and immunological changes. Hypertrophied and hyperplasia adipocytes have biomarkers and release adipokines capable of regulating pathways and expressing genes that culminate in the development of metabolic changes, such as changes in energy balance and intestinal microbiota, and the development of some comorbidities, diabetes mellitus, dyslipidemias, arterial hypertension, liver disease, cancer, allergies, osteoporosis, sarcopenia and obstructive sleep apnea. Thus, it is necessary to treat and/or prevent pathology, using traditional methods based on healthy eating, and regular physical and leisure activities.

Rising Rates and Widening Socioeconomic Disparities in Diabetic Ketoacidosis in Type 1 Diabetes in Scotland: A Nationwide Retrospective Cohort Observational Study

OBJECTIVE

Whether advances in the management of type 1 diabetes are reducing rates of diabetic ketoacidosis (DKA) is unclear. We investigated time trends in DKA rates in a national cohort of individuals with type 1 diabetes monitored for 14 years, overall and by socioeconomic characteristics.

RESEARCH DESIGN AND METHODS

All individuals in Scotland with type 1 diabetes who were alive and at least 1 year old between 1 January 2004 and 31 December 2018 were identified using the national register (N = 37,939). DKA deaths and hospital admissions were obtained through linkage to Scottish national death and morbidity records. Bayesian regression was used to test for DKA time trends and association with risk markers, including socioeconomic deprivation.

RESULTS

There were 30,427 DKA admissions and 472 DKA deaths observed over 393,223 person-years at risk. DKA event rates increased over the study period (incidence rate ratio [IRR] per year 1.058 [95% credibility interval 1.054-1.061]). Males had lower rates than females (IRR male-to-female 0.814 [0.776-0.855]). DKA incidence rose in all age-groups other than 10- to 19-year-olds, in whom rates were the highest, but fell over the study. There was a large socioeconomic differential (IRR least-to-most deprived quintile 0.446 [0.406-0.490]), which increased during follow-up. Insulin pump use or completion of structured education were associated with lower DKA rates, and antidepressant and methadone prescription were associated with higher DKA rates.

CONCLUSIONS

DKA incidence has risen since 2004, except in 10- to 19-year-olds. Of particular concern are the strong and widening socioeconomic disparities in DKA outcomes. Efforts to prevent DKA, especially in vulnerable groups, require strengthening.

Characteristics of post-mortem beta-hydroxybutyrate-positivet cases - A retrospective study on age, sex and BMI in 1407 forensic autopsies

BACKGROUND

Post-mortem biochemistry, including the analysis of beta-hydroxybutyrate (BHB), is increasingly employed in forensic medicine, especially in conditions such as diabetes and chronic alcoholism. However, not much is known about the associations between age, body mass index (BMI), and sex and BHB concentrations in ketoacidotic conditions.

AIM

To retrospectively study the association between age, BMI and sex in several conditions, such as diabetic ketoacidosis (DKA), alcoholic ketoacidosis (AKA), and elevated post-mortem BHB concentrations.

METHODS

1407 forensic autopsy cases analysed for BHB were grouped by diagnosis: DKA, AKA, HHS [hyperosmolar hyperglycaemic state], acidosis NOS [not otherwise specified], or hypothermia. Age, sex, BMI and the concentrations of blood alcohol, vitreous glucose and blood BHB were recorded.

RESULTS

Cases of AKA and DKA were most numerous (184 and 156, respectively). In DKA and in its male subgroup, cases with severe ketosis (BHB>1000 µg/g) were younger and had a lower BMI than those with moderate ketosis (BHB 250-1000 µg/g) and controls (P<0.001). In DKA and in its female subgroup, cases with moderate ketosis cases were older (P = 0.0218 and P = 0.0083) than controls. In AKA and in its male subgroup, cases with severe ketosis had a lower BMI than those with moderate ketosis (P = 0.0391 and P = 0.0469) and controls (P<0.001). Cases with moderate ketosis had a lower BMI than controls (P<0.001).

CONCLUSIONS

BHB concentration is associated with BMI in DKA and AKA, and with both BMI and age in DKA. Constitutional factors should, therefore, be considered in potential AKA and DKA cases.

Early prediction models for prognosis of diabetic ketoacidosis in the emergency department: A protocol for systematic review and meta-analysis

BACKGROUND

Diabetic ketoacidosis (DKA) is one of the most serious complications after diabetes poor control, which seriously threatens human life, health, and safety. DKA can rapidly develop within hours or days leading to death. Early evaluation of the prognosis of DKA patients and timely and effective intervention are very important to improve the prognosis of patients. The combination of several variables or characteristics is used to predict the poor prognosis of DKA, which can allocate resources reasonably, which is beneficial to the early classification intervention and clinical treatment of the patients.

METHODS

For the acquisition of required data of eligible prospective/retrospective cohort study or randomized controlled trials (RCTs), we will search for publications from PubMed, Web of science, EMBASE, Cochrane Library, Google scholar, China national knowledge infrastructure (CNKI), Wanfang and China Science and Technology Journal Database (VIP). Two independent reviewers will read the full English text of the articles, screened and selected carefully, removing duplication. Then we evaluate the quality and analyses data by Review Manager (V.5.4). Results data will be pooled and meta-analysis will be conducted if there's 2 eligible studies considered.

RESULTS

This systematic review and meta-analysis will evaluate the value of the prediction models for the prognosis of DKA in the emergency department.

CONCLUSIONS

This systematic review and meta-analysis will provide clinical basis for predicting the prognosis of DKA. It helps us to understand the value of predictive models in evaluating the early prognosis of DKA. The conclusions drawn from this study may be beneficial to patients, clinicians, and health-related policy makers.

STUDY REGISTRATION NUMBER

INPLASY202150023.

Should We Be Concerned about the Association of Diabetes Mellitus and Periodontal Disease in the Risk of Infection by SARS-CoV-2? A Systematic Review and Hypothesis

The objective of this article was to conduct a systematic review of the literature to contrast the existing evidence regarding the relationship between periodontal disease (PD) and diabetes mellitus (DM) with the possibly increased risk of SARS-CoV-2 infection, as well as to establish a hypothesis that explains the ways in which this interaction could take place. A literature search up from 1 January 2020 to 21 March 2021 was conducted in three electronic databases, namely, PubMed, Web of Science, and Scopus, in order to identify studies on periodontal disease alone or in conjunction with diabetes mellitus, reporting any relation with SARS-CoV-2 infection as a primary outcome. Only articles published in the English language were included. Due to the lack of studies, we decided to collect all the theoretical and clinical evidence suggesting a possible biological pathway evidencing the relationship among PD, DM, and SARS-CoV-2 infection. From a total of 29 articles, 12 were included for final review studies (five reviews, two hypotheses, one Special Issue, one perspective, one commentary, one case–control study, and one case report). In addition, this systematic review article hypothesizes the correlation between PD and type 2 diabetes mellitus (T2DM) by expression of angiotensin-converting enzyme 2 (ACE2) in periodontal tissue and the risk of SARS-CoV-2 infection. T2DM is a metabolic disorder characterized by high blood glucose levels resulting from altered insulin secretion or action. Likewise, periodontitis and T2DM are inflammatory disorders with a bidirectional association, and both diseases have a similar immunomodulatory cascade and cytokine profile. ACE2 is a crucial component of the renin–angiotensin system (RAS) and the key factor of entry in the cells by the new SARS-CoV-2. ACE2 is widely distributed in the lung and kidneys, and interestingly has a great distribution in the oral cavity, principally in the tongue and periodontal tissue. ACE2 in periodontal tissue plays a crucial role between health and disease. Moreover, the ACE2/Ang-(1-7)/MasR axis is downregulated in the dysbiotic and inflammatory periodontal environment. Nevertheless, the balance of ACE2 activity is modified in the context of concurrent diabetes, increasing the expression of ACE2 by the uncontrolled glycemia chronic in T2DM. Therefore, the uncontrolled hyperglycemia possibly increases the risk of developing periodontitis and triggering overexpression of ACE2 in periodontal tissue of T2DM patients, with these events potentially being essential to SARS-CoV-2 infection and the development of mild-to-severe form of COVID-19. In this sense, we would like to point out that the need for randomized controlled trials is imperative to support this association.

Hospital care: improving outcomes in type 1 diabetes

PURPOSE OF REVIEW

Caring for patients with type 1 diabetes (T1D) in the hospital presents unique challenges. This review provides an update on significant issues relevant to the inpatient management of T1D. Topics include trends in diabetic ketoacidosis (DKA), hypoglycemia, and adapting ambulatory technologies for inpatient use.

RECENT FINDINGS

Rates of DKA in the United States are rising. Although socioeconomic status, health insurance coverage, and hemoglobin A1c are persistently associated with DKA in individuals with T1D, newer risk factors have also emerged. These include the off-label use of sodium-glucose cotransporter inhibitor medications, immune checkpoint inhibitor-induced diabetes, and infection with severe acute respiratory syndrome coronavirus 2. Hypoglycemia is common among hospitalized patients with T1D. Use of validated hypoglycemia risk prediction models and multidisciplinary care initiatives can reduce the risk of inpatient hypoglycemia. Finally, continuous glucose monitoring is being adapted for use in the hospital setting and has shown promise during the coronavirus disease 2019 (COVID-19) pandemic.

SUMMARY

Evidence-based treatment algorithms, risk prediction calculators, multidisciplinary interventions, and wearable technology hold promise for improved outcomes in hospitalized patients with T1D.

Diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is the most common acute hyperglycaemic emergency in people with diabetes mellitus. A diagnosis of DKA is confirmed when all of the three criteria are present - 'D', either elevated blood glucose levels or a family history of diabetes mellitus; 'K', the presence of high urinary or blood ketoacids; and 'A', a high anion gap metabolic acidosis. Early diagnosis and management are paramount to improve patient outcomes. The mainstays of treatment include restoration of circulating volume, insulin therapy, electrolyte replacement and treatment of any underlying precipitating event. Without optimal treatment, DKA remains a condition with appreciable, although largely preventable, morbidity and mortality. In this Primer, we discuss the epidemiology, pathogenesis, risk factors and diagnosis of DKA and provide practical recommendations for the management of DKA in adults and children.

Risk factors and prevention strategies for diabetic ketoacidosis in people with established type 1 diabetes

Diabetic ketoacidosis (DKA) is a serious acute complication of type 1 diabetes, which is receiving more attention given the increased DKA risk associated with SGLT inhibitors. Sociodemographic and modifiable risk factors were identified with strong evidence for an increased risk of DKA, including socioeconomic disadvantage, adolescent age (13-25 years), female sex, high HbA_1c, previous DKA, and psychiatric comorbidities (eg, eating disorders and depression). Possible prevention strategies, which include the identification of people at risk based on non-modifiable sociodemographic risk factors, are proposed. As a second risk mitigation strategy, structured diabetes self-management education that addresses modifiable risk factors can be used. Evidence has found that structured education leads to reduced DKA rates. Knowledge of these risk factors and potent risk mitigation strategies are important to identify subgroups of people with an elevated DKA risk. This knowledge should also be used when adjunct therapy options with an increased DKA risk are considered. Prevention of DKA in people with type 1 diabetes is an important clinical task, which should also be addressed when SGLT inhibitors are part of therapy.

Utilizing End-Tidal Carbon Dioxide to Diagnose Diabetic Ketoacidosis in Prehospital Patients with Hyperglycemia

Background:

Early identification of diabetic ketoacidosis (DKA) may improve clinical outcomes. Prior studies suggest exhaled end tidal carbon dioxide (ETCO2) provides a non-invasive, real-time method to screen for DKA in the emergency department (ED).

Methods:

This a retrospective cohort study among patients who activated Emergency Medical Services (EMS) during a one-year period. Initial out-of-hospital vital signs documented by EMS personnel, including ETCO2 and first recorded blood glucose level (BGL), as well as in-hospital records, including laboratory values and diagnosis, were collected. The main outcome was the association between ETCO2 and the diagnosis of DKA.

Results:

Of the 118 patients transported with hyperglycemia (defined by BGL >200), six (5%) were diagnosed with DKA. The mean level of ETCO2 in those without DKA was 35mmHg (95% CI, 33-38mmHg) compared to mean levels of 15mmHg (95% CI, 8-21mmHg) in those with DKA (P <.001). The Area Under the Receiver Operating Characteristics (ROC) Curve (AUC) for ETCO2 identifying DKA was 0.96 (95% CI, 0.92-1.00). The correlation coefficient between ETCO2 and serum bicarbonate (HCO3) was 0.436 (P <.001) and the correlation coefficient between ETCO2 and anion gap was -0.397 (P <.001).

Conclusion:

Among patients with hyperglycemia, prehospital levels of ETCO2 were significantly lower in patients with DKA compared to those without and were predictive of the diagnosis of DKA. Furthermore, out-of-hospital ETCO2 was significantly correlated with measures of metabolic acidosis.