Comparison of Diabetic Ketoacidosis in Patients With Type-1 and Type-2 Diabetes Mellitus

Enhancing outcome prediction by applying the 2019 WHO DM classification to adults with hyperglycemic crises: A single-center cohort in Thailand

BACKGROUND AND AIMS

Hyperglycemic crisis is a metabolic catastrophe which can occur in any type of diabetes. In 2019, the World Health Organization (WHO) revised the classification of diabetes mellitus (DM) and established two new hybrid forms, latent autoimmune diabetes in adults (LADA) and ketosis-prone type 2 diabetes (T2D). This study aimed to determine clinical outcomes after a hyperglycemic crisis event in people with diabetes classified subtypes by 2019 WHO DM classification.

METHODS

A five-year (2015-2019) retrospective study of adult patients admitted with hyperglycemic crises was conducted. Types of diabetes were recategorized based on the 2019 WHO DM classification. Clinical characteristics, in-admission treatment and complications, long-term follow-up outcomes, and mortality were collected, analyzed, and compared.

RESULTS

A total of 185 admissions occurred in 136 patients. The mean age was 50.6 ± 18.4 years (49.3 % men). The annual average incidence of hyperglycemic crises was 5.2 events/1000 persons. The proportion of type 1 diabetes, T2D, LADA, ketosis-prone T2D, and pancreatic DM were 15.4 %, 69.1 %, 2.2 %, 11 %, and 2.2 %, respectively. In-hospital mortality was 3.7 % while cumulative mortality totaled 19.1 %. During the 24-month follow-up, ketosis-prone T2D had the highest success of insulin discontinuation (HR 6.59; 95 % CI 6.69-319.4; p < 0.001), while T2D demonstrated the highest mortality compared to others (HR, 2.89; 95%CI 1.15-6.27; p = 0.02).

CONCLUSION

The reclassification of diabetes based on 2019 WHO DM classification helped elucidate differences in long-term outcomes and mortality among DM types. The new classification, which separates ketosis-prone T2D from standard T2D, should be encouraged in clinical practice for precise and individualized management.

Diabetic Ketoacidosis Associated With Second Generation Antipsychotics: A Case Study and Review of Literature

OBJECTIVE

Second-generation antipsychotics (SGAs) have revolutionized the treatment of psychiatric disorders, but are associated with significant metabolic risks, including diabetes and hyperglycemic crises. This review explores the complex interplay between antipsychotics, diabetes, and hyperglycemic crises, highlighting the mechanisms underlying SGA-induced diabetes.

METHODS

We present the case of a patient with schizophrenia who was taking antipsychotic medication and was admitted to the emergency room due to the sudden onset of diabetic ketoacidosis (DKA) without any history of diabetes. We extensively searched databases, including Elsevier, PubMed, IEEE, SpringerLink, and Google Scholar, for papers on the effects of antipsychotic drugs on DKA from 2002 to 2021. We focused on DKA, hyperglycemia, and atypical antipsychotics, and retrieved 117 papers. After full-text review, 32 papers were included in this comprehensive review.

RESULTS

DKA was significantly more frequent in patients taking SGAs. Antipsychotics can induce insulin resistance either directly or through the onset of obesity. Antipsychotics can reduce insulin secretion from pancreatic β-cells, which is associated with absolute insulin deficiency.

CONCLUSION

As the use of antipsychotics continues to increase, understanding their risks and mechanisms is crucial for clinicians to enable informed treatment decisions and prevent potentially life-threatening complications.

Association between elevated lactate and clinical outcomes in adults with diabetic ketoacidosis

PURPOSE

To assess the occurrence of hyperlactatemia among patients admitted to the intensive care unit (ICU) with diabetic ketoacidosis (DKA), and effect on in-hospital mortality.

MATERIALS AND METHODS

A retrospective, multicentre, cohort study of adult patients admitted to ICU with a primary diagnosis of DKA in Australia and New Zealand, utilising a pre-existing dataset. The primary exposure variable was lactate, dichotomised into normolactatemia (lactate <2.0 mmol/L) and hyperlactatemia (lactate ≥ 2.0 mmol/L) groups. The primary outcome was in-hospital mortality. Secondary outcomes included ICU and hospital length of stay (LOS), requirement for ventilation, renal replacement therapy (RRT) and inotropes.

RESULTS

The final dataset included 9061 patients. Hyperlactatemia was associated with in-hospital mortality (Odds Ratio [OR] 1.785 (95% CI 1.122-2.841, p = 0.014), hospital LOS (Geometric mean ratio [GMR] 1.063, 95% CI 1.025-1.103, p = 0.001), ICU LOS (GMR 1.057, 95% CI 1.026-1.09. p < 0.001), RRT (OR 2.198, 95% CI 1.449-3.334, p < 0.001) and inotropes (OR 1.578, 95% CI 1.311-1.899, p < 0.001). These associations persisted in Type 2 but not Type 1 diabetics.

CONCLUSIONS

Hyperlactatemia in patients admitted to ICU with DKA is associated with higher mortality, longer hospital and ICU LOS, and higher rates of mechanical ventilation, RRT and inotropes.

Management of diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is an acute life-threatening emergency in patients with diabetes, it can result in serious morbidity and mortality. Management of DKA requires reversing metabolic derangements, correcting volume depletion, electrolyte imbalances and acidosis while concurrently treating the precipitating illness. There are still controversies regarding certain aspects of DKA management. Different society guidelines have inconsistencies in their recommendations, while some aspects of treatment are not precise enough or have not been thoroughly studied. These controversies may include issues such as optimal fluid resuscitation, rate and type of Insulin therapy, potassium and bicarbonate replacement. Many institutions follow common society guidelines, however, other institutions either develop their own protocols for internal use or do not routinely use any protocols, resulting in inconsistencies in treatment and increased risk of complications and suboptimal outcomes. The objectives of this article are to review knowledge gaps and controversies in the treatment of DKA and provide our perspective on these issues. Moreover, we believe that special patient factors and comorbidities should receive more careful attention and consideration. Factors like pregnancy, renal disease, congestive heart failure, acute coronary syndrome, older age, use of sodium-glucose cotransporter-2 (SGLT2) inhibitors and site of care all impact the treatment approach and require tailored management strategies. However, guidelines often lack sufficient recommendations regarding specific conditions and comorbidities, we aim to address unique circumstances and provide an approach to managing complex patients with specific conditions and co-morbidities. We also sought to examine changes and trends in the treatment of DKA, illuminate on aspects of latest research with a perspective towards future developments and modifications.

Hospitalization of Patients With Diabetes Due to Ketoacidosis Before and After the Initiation of Sodium-Glucose Cotransporter-2 Inhibitors

OBJECTIVE

Diabetic ketoacidosis (DKA) is a rare side effect related to sodium-glucose cotransporter-2 inhibitors (SGLT2I). This study investigated the incidence of people with diabetes hospitalized because of DKA after the implementation of SGLT2I (2015-2019), compared with the pre-SGLT2I era.

METHODS

In this retrospective cohort study, medical records of all adult patients hospitalized with a diagnosis of DKA in a tertiary referral center from 2011-2019 were reviewed. The incidence of DKA was compared between the periods 2011-2014 and 2015-2019. Demographic and clinical data of patients hospitalized with DKA as well as SGLT2I use were extracted.

RESULTS

During 2011-2019, there were 186 hospitalizations because of DKA. The rate of hospitalization was stable during 2011-2019 at 0.22% ± 0.04% (95% CI, 0.18-0.25). The clinical characteristics of people hospitalized with DKA in 2011-2014 were similar to those of people hospitalized during 2015-2019. Only 7 people (6.1%) in the 2015-2019 cohort had SGLT2I-related DKA, and their clinical characteristics were similar to those of the rest of the cohort.

CONCLUSIONS

The rate of hospitalizations because of DKA remained stable before and 5 years after SGLT2I were implemented for the treatment of type 2 diabetes mellitus. Larger, multi-institutional studies with longer follow-ups are needed to study the effect of SGLT2I on the rate of hospitalizations because of DKA among people with diabetes. Although DKA events associated with SGLT2I are rare, they should be strongly considered in the differential diagnosis of people treated with these medications.

Management of Diabetic Ketoacidosis in a Patient With Chronic Kidney Disease Under Maintenance Hemodialysis: A Case Report

Diabetic ketoacidosis (DKA) is a potentially fatal metabolic complication seen in individuals with type 1 diabetes mellitus (DM) or type 2 DM under stress, such as infections and non-compliance with treatment. DKA in chronic kidney disease (CKD) patients undergoing maintenance hemodialysis (HD) presents challenges due to the unique pathophysiology and the absence of specific management guidelines. This case report highlights the importance of tailoring the treatment of DKA based on the specific requirements of CKD patients on HD. The presented case involves a 47-year-old female with type 2 DM and CKD who developed DKA in the context of a urinary tract infection (UTI). Management included insulin infusion, cautious fluid replacement therapy, electrolyte monitoring, and identifying precipitating factors, such as an infection. The case highlights the complexity of DKA management in CKD patients and the necessity of individualized approaches. More studies and guidelines are needed to optimize the proper management of DKA in CKD patients.

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.

ST-elevation myocardial infarction due to coronary thrombus in a young patient with diabetic ketoacidosis and a new diagnosis of type 2 diabetes

The association between cardiovascular disease and diabetes is increasingly understood and shared therapeutic targets are emerging. We describe the presentation and successful management of ST-elevation myocardial infarction (STEMI) secondary to coronary thrombus in a young patient with a new diagnosis of type 2 diabetes and diabetic ketoacidosis.

Exploring HbA1c variation between Australian diabetes centres: The impact of centre-level and patient-level factors

Background

Increasing global diabetes incidence has profound implications for health systems and for people living with diabetes. Guidelines have established clinical targets but there may be variation in clinical outcomes including HbA1c, based on location and practice size. Investigating this variation may help identify factors amenable to systemic improvement interventions. The aims of this study were to identify centre-specific and patient-specific factors associated with variation in HbA1c levels and to determine how these associations contribute to variation in performance across diabetes centres.

Methods

This cross-sectional study analysed data for 5,872 people with type 1 (n = 1,729) or type 2 (n = 4,143) diabetes mellitus collected through the Australian National Diabetes Audit (ANDA). A linear mixed-effects model examined centre-level and patient-level factors associated with variation in HbA1c levels.

Results

Mean age was: 43±17 years (type 1), 64±13 (type 2); median disease duration: 18 years (10,29) (type 1), 12 years (6,20) (type 2); female: 52% (type 1), 45% (type 2). For people with type 1 diabetes, volume of patients was associated with increases in HbA1c (p = 0.019). For people with type 2 diabetes, type of centre was associated with reduction in HbA1c (p <0.001), but location and patient volume were not. Associated patient-level factors associated with increases in HbA1c included past hyperglycaemic emergencies (type 1 and type 2, p<0.001) and Aboriginal and Torres Strait Islander status (type 2, p<0.001). Being a non-smoker was associated with reductions in HbA1c (type 1 and type 2, p<0.001).

Conclusions

Centre-level and patient-level factors were associated with variation in HbA1c, but patient-level factors had greater impact. Interventions targeting patient-level factors conducted at a centre level including sick-day management, smoking cessation programs and culturally appropriate diabetes education for and Aboriginal and Torres Strait Islander peoples may be more important for improving glycaemic control than targeting factors related to the Centre itself.

Comparisons of biochemical parameters and diabetic ketoacidosis severity in adult patients with type 1 and type 2 diabetes

OBJECTIVE

The aim of this study was to determine the differences in biochemical parameters and diabetic ketoacidosis (DKA) severity in adult patients with type 1 and type 2 diabetes and utilization of serum BHB as a biomarker for DKA resolution was also evaluated.

MATERIALS AND METHODS

This prospective observational study of type 1 or type 2 diabetes mellitus who were diagnosed with DKA between 01 October 2018 and 30 September 2020. The correlations between serum BHB, measured by the Ranbut assay, and pH, bicarbonate, and anion gap were examined.

RESULTS

A total of 99 diabetes patients were diagnosed with DKA (mean age 39.4 years, 63.4% female, 53.6% T2DM). while infection was the most common precipitating factor in T2DM (43.4%), non-compliance with treatment was the most common precipitating factor in T1DM (43.5%). T1DM patients had more severe DKA more hypokalemia during treatment. However, there was no significant difference in mortality between type1 and type2 diabetes. The initial laboratories evaluation of patients did not significant differ between type1 and type2 diabetes. Serum BHB during treatment of DKA was significantly correlated with changes in serum bicarbonate (r = - 0.64), serum anion gap (r = 0.84), and venous pH (r = - 0.6). The serum BHB levels corresponding to HCO₃ levels for DKA severity were 4.5, 5.7, and 5.9 mmol/L in mild, moderate, and severe DKA, respectively. The serum BHB level of < 1 mmol/L had 73.7% sensitivity and 100% specificity to predict DKA resolution. Median time to resolution of DKA was 12 h with an optimized BHB cut-off value of < 1 mmol/L. There were no significant difference in time to resolution of DKA in the patients with type 1 and type 2 diabetes.

CONCLUSIONS

There are no differences in DKA-related biochemical parameters between type 1 and type 2 diabetes patients. The present findings suggest that DKA should be assessed and treated similarly, regardless of its occurrence in type 1 or type 2 diabetes patients.

Beta-Hydroxybutyric Acid Inhibits Renal Tubular Reabsorption via the AKT/DAB2/Megalin Signalling Pathway

AIM

Patients with diabetic ketosis often exhibit albuminuria. We previously found that acute hyperglycaemia can cause nephrotoxic injury. Here, we explored whether an excessive ketone body level causes kidney injury and the potential underlying mechanism.

METHODS

Fifty-six type 2 diabetes without ketosis (NDK group), 81 type 2 diabetes with ketosis (DK group), and 38 healthy controls (NC group) were enrolled. Clinical data were collected before and after controlling diabetic ketosis. Beta-hydroxybutyric acid (BOHB), an AKT activator, an AKT inhibitor, or plasmids encoding DAB2 were transformed into human renal proximal tubule epithelial cells (HK-2 cells).

RESULTS

The urinary albumin-to-creatinine ratio (ACR), transferrin (TF), immunoglobulin G (IgG), Beta2-microglobulin (β2-MG), retinol-binding protein (RBP), N-acetyl-beta-glucosaminidase (NAG), and Beta-galactosidase (GAL) were higher in the DK than NC and NDK groups. The proportion of patients with an increased urinary level of TF, IgG, β2-MG, RBP, NAG, or GAL was higher in the DK group too. After controlling ketosis, urinary microalbumin, TF, IgG, β2-MG, and RBP decreased significantly. In HK-2 cells, albumin endocytosis and megalin expression decreased with increasing BOHB concentration. Compared with BOHB treatment, BOHB with AKT activator significantly increased the DAB2, megalin levels and albumin endocytosis; the AKT inhibitor treatment exhibited the opposite effects. Compared with BOHB treatment, megalin expression and albumin endocytosis were significantly increased after BOHB with DAB2 overexpression treatment.

CONCLUSIONS

Patients with diabetic ketosis may suffer from glomerular and tubular injuries that recover after ketosis control. High concentrations of BOHB downregulate megalin expression by inhibiting the AKT/DAB2/megalin signalling pathway and albumin endocytosis in proximal renal tubules.

Psychosocial factors associated with repeat diabetic ketoacidosis in people living with type 1 diabetes: A systematic review

AIM

To systematically review the literature concerning the psychosocial factors associated with repeat diabetic ketoacidosis for people living with type 1 diabetes.

METHODS

PsycInfo, Web of Science, CINAHL, PubMed and ASSIA were searched according to a registered study protocol (PROSPERO CRD42020167381). Data were extracted into a coding spreadsheet, and findings were synthesised narratively. Included papers were also subject to a quality assessment.

RESULTS

The search yielded 548 unique articles, of which 22 met inclusion criteria for this review. There was considerable variance across studies with regard to design, quality and outcome measured. Nevertheless, there was relatively consistent evidence to suggest that repeat diabetic ketoacidosis in type 1 diabetes is associated with female gender, adolescent to young adult age range, lower socio-economic status and poor mental health. Some evidence was also observed for the role of ethnicity and, for children and young people at least, family, social and behavioural issues. However, this was limited by issues of methodological rigour and scant investigation.

CONCLUSIONS

The review identified four psychosocial factors that appear to play a key role in the cycle of repeat diabetic ketoacidosis. Individuals with these factors present may benefit from targeted support and interventions by specialist healthcare professionals. Knowledge and understanding in this area would be considerably enhanced via increased use of prospective study designs and greater consistency in the operationalisation of variables across studies.

Lifetime risk and health-care burden of diabetic ketoacidosis: A population-based study

OBJECTIVE

Diabetic ketoacidosis (DKA) is a life-threatening complication of both type 1 and type 2 diabetes. We aimed to assess population-based rates, trends and outcomes of patients with DKA.

DESIGN AND METHODS

This is a nationwide cohort study using hospital discharge claims data from 2010 to 2018 in Switzerland. Incidence rates and in-hospital outcomes of DKA were analyzed throughout lifetime for children (0-9 years), adolescents (10-19 years), and adults (20-29, 30-59, and 60-90 years). Analyses were stratified for type of diabetes mellitus and sex.

RESULTS

In total, 5,544 hospitalizations with DKA were identified, of whom 3,847 were seen in patients with type 1 diabetes and 1,697 in type 2 diabetes. Incidence rates of DKA among patients with type 1 diabetes were highest during adolescence with 17.67 (girls) and 13.87 (boys) events per 100,000 person-years (incidence rate difference [IRD]: -3.80 [95% CI, -5.59 to -2.02]) and decreased with age in both sexes thereafter. Incidence rates of DKA in patients with type 2 diabetes were low up to an age of 40 years and rose to 5.26 (females) and 6.82 (males) per 100,000 person-years in adults aged 60-90 years. Diabetic ketoacidosis was associated with relevant health-care burden independent of age, sex, or type of diabetes. The population-based incidence rate of DKA increased over time from 7.22 per 100,000 person-years in 2010 to 9.49 per 100,000 person-years in 2018.

CONCLUSIONS

In type 1 diabetes highest incidence rates of DKA hospitalizations were observed among adolescent females. In comparison, in patients with type 2 diabetes the risk for DKA steadily increased with age with higher rates in adult males. Over the 9 year study period, incidence rates of DKA were increasing irrespective of type of diabetes. DKA was associated with a high burden of disease reflected by high rates of intensive care unit admission, prolonged hospital stay and high mortality rates, especially in elderly.

Clinical and biochemical profile of 786 sequential episodes of diabetic ketoacidosis in adults with type 1 and type 2 diabetes mellitus

INTRODUCTION

We explored the clinical and biochemical differences in demographics, presentation and management of diabetic ketoacidosis (DKA) in adults with type 1 and type 2 diabetes.

RESEARCH DESIGN AND METHODS

This observational study included all episodes of DKA from April 2014 to September 2020 in a UK tertiary care hospital. Data were collected on diabetes type, demographics, biochemical and clinical features at presentation, and DKA management.

RESULTS

From 786 consecutive DKA, 583 (75.9%) type 1 diabetes and 185 (24.1%) type 2 diabetes episodes were included in the final analysis. Those with type 2 diabetes were older and had more ethnic minority representation than those with type 1 diabetes. Intercurrent illness (39.8%) and suboptimal compliance (26.8%) were the two most common precipitating causes of DKA in both cohorts. Severity of DKA as assessed by pH, glucose and lactate at presentation was similar in both groups. Total insulin requirements and total DKA duration were the same (type 1 diabetes 13.9 units (9.1-21.9); type 2 diabetes 13.9 units (7.7-21.1); p=0.4638). However, people with type 2 diabetes had significantly longer hospital stay (type 1 diabetes: 3.0 days (1.7-6.1); type 2 diabetes: 11.0 days (5.0-23.1); p<0.0001).

CONCLUSIONS

In this population, a quarter of DKA episodes occurred in people with type 2 diabetes. DKA in type 2 diabetes presents at an older age and with greater representation from ethnic minorities. However, severity of presentation and DKA duration are similar in both type 1 and type 2 diabetes, suggesting that the same clinical management protocol is equally effective. People with type 2 diabetes have longer hospital admission.

Diabetic ketoacidosis in patients with SARS-CoV-2: a systematic review and meta-analysis

BACKGROUND

One possible reason for increased mortality due to SARS-CoV-2 in patients with diabetes is from the complication of diabetic ketoacidosis (DKA).

OBJECTIVES

To re-evaluate the association of SARS-CoV-2 and development of DKA and analyse the demographic and biochemical parameters and the clinical outcomes in COVID-19 patients with DKA.

DESIGN

A systematic review and meta-analysis. Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was followed.

METHODS

Electronic databases (Proquest, Medline, Embase, Pubmed, CINAHL, Wiley online library, Scopus and Nature) were searched from 1 December 2019 to 30 June 2021 in the English language using the following keywords alone or in combination: COVID-19 OR SARS-CoV-2 AND diabetic ketoacidosis OR DKA OR ketosis OR ketonemia OR hyperglycaemic emergency OR hyperglycaemic crisis. We included studies in adults and children of all ages in all healthcare settings. Binary logistic regression model was used to explore the effect of various demographic and biochemical parameters variables on patient's final treatment outcome (survival or death).

RESULTS

Of the 484 papers that were identified, 68 articles were included in the systematic review and meta-analysis (54 case report, 10 case series, and 4 cohort studies). Studies involving 639 DKA patients with confirmed SARS-CoV-2 [46 (7.2%) were children and 334 (52.3%) were adults] were analyzed. The median or mean patient age ranged from < 1 years to 66 years across studies. Most of the patients (n = 309, 48.3%) had pre-existing type 2 diabetes mellitus. The majority of the patients were male (n = 373, 58.4%) and belonged to Hispanic (n = 156, 24.4%) and black (n = 98, 15.3%) ethnicity. The median random blood glucose level, HbA1c, pH, bicarbonate, and anion gap in all included patients at presentation were 507 mg/dl [IQR 399-638 mg/dl], 11.4% [IQR 9.9-13.5%], 7.16 [IQR 7.00-7.22], 10 mmol/l [IQR 6.9-13 mmol/l], and 24.5 mEq/l [18-29.2 mEq/l]; respectively. Mortality rate was [63/243, 25.9%], with a majority of death in patients of Hispanic ethnicity (n = 17, 27%; p = 0.001). The odd ratios of death were significantly high in patients with pre-existing diabetes mellitus type 2 [OR 5.24, 95% CI 2.07-15.19; p = 0.001], old age (≥ 60 years) [OR 3.29, 95% CI 1.38-7.91; p = 0.007], and male gender [OR 2.61, 95% CI 1.37-5.17; p = 0.004] compared to those who survived.

CONCLUSION

DKA is not uncommon in SARS-CoV-2 patients with diabetes mellitus and results in a mortality rate of 25.9%. Mortality key determinants in DKA patients with SARS-CoV-2 infection are individuals with pre-existing diabetes mellitus type 2, older age [≥ 60 years old], male gender, BMI ≥ 30, blood glucose level > 1000 mg/dl, and anion gap ≥ 30 mEq/l.

Ketoacidosis Onset of Diabetes on a Patient with Normal C-Peptide Value

Background:Diabetic ketoacidosis is an acute major life-threatening complication of diabetes, characterized by hyperglycemia, ketoacidosis and ketonuria, which can be life threatening if it is not promptly recognized and treated. This occurs mainly in patients with type 1 diabetes, but stressors like trauma and infection can increase the risk of ketoacidosis in other forms of diabetes such as type 2 diabetes. Type 2 diabetes mellitus is a complex metabolic disorder of heterogeneous etiology with behavioral, social, and environmental risk factors that unmask the effects of genetic susceptibility. Recent studies indicate an increasing prevalence of type 2 diabetes mellitus in children and adolescents around the world in all ethnicities. C-peptide is a useful and widely used method of assessing pancreatic beta cell function given his structure: part of proinsulin which is cleaved prior to co-secretion with insulin from pancreatic beta cells. This is used as a tool in the differentiation of type 1 diabetes from type 2 but also other types of diabetes. We present a 12-year-old previously healthy male who was hospitalized in our clinic for polydipsia, polyuria, weight loss and emesis, with symptom onset 10 days prior to admission. On the admission day, he presented to the emergency room for progressively increasing somnolence, apathy, decreased muscle tone and urinary incontinence. Physical examination was significant for grade I obesity [height 168 cm and weight 90 kg, yielding a body index mass (BMI) of 31.78 kg/m2, percentile >97%], lethargy, slurred speech, high blood pressure (145/90 mmHg), tachycardia (145 beats per minute) and acanthosis nigricans. Considering his physical examination, laboratory tests and clinical evolution, he was diagnosed with type 2 diabetes mellitus complicated with hyperosmolar hyperglycemic state and diabetic ketoacidosis. Diabetic ketoacidosis should be considered in the differential diagnosis of metabolic decompensation in all types of diabetes. Although type 2 diabetes mellitus seems to be still rare in childhood and adolescence, prevention and treatment of type 2 diabetes mellitus should become public awareness and public health intervention programs. The particularity of this case was the unusual onset of diabetes mellitus type 2 in a male child with metabolic syndrome.

Predictors and outcomes of recurrent diabetic ketoacidosis in Israeli adults

AIMS

To identify risk factors for recurrent episodes of DKA that may allow the development of an effective prevention strategies.

METHODS

Retrospective analysis of admissions for DKA in adult patients between 2004, and 2017 in a tertiary hospital. The clinical characteristics and outcomes of DKA of patients were stratified into an isolated episode of DKA (group 1) and recurrent episodes (group 2).

RESULTS

385 patients were included in the study, 281 had a single admission of DKA, and 104 had recurrent admissions. There were no statistically significant differences between the two groups in demographic or clinical variables. Patients in the recurrent DKA group had a younger age at diabetes diagnosis, 32.1 ± 17.08 vs. 36.13 ± 19.52 (p = 0.05). Patients with A1C greater than 9.0% were associated with recurrent DKA in cox regression analysis (HR 2.023; 95% Cl 1.112-3.679; p = 0.021). Recurrent DKA was a significant predictor of one-year mortality in cox regression analysis (HR 0.172; 95% CI 0.04-0.742; p = 0.018).

CONCLUSION

High A1C levels, which account for poorly controlled diabetes, was identified as the strongest predictor of recurrent DKA. This patient population warrants particular attention and the development of intervention strategies in further studies.

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.

Effect of short-term ketogenic diet on end-tidal carbon dioxide

BACKGROUND & AIMS

Previous studies have shown that end-tidal carbon dioxide (EtCO₂) is lower with the presence of supraphysiological ketones as in the case of chronic ketogenic diet (KD) and diabetic ketoacidosis (DKA). This study aimed to determine changes in EtCO₂ upon short term KD.

METHODS

Healthy subjects were screened not to have conditions that exerts abnormal EtCO₂ nor contraindicated for KD. Subjects underwent seven days of KD while the EtCO2 and blood ketone (beta-hydroxybutyrate; β-OHB) parameters were sampled at day zero (t0) and seven (t7) of ketosis respectively. Statistically, the t-test and Pearson's coefficient were conducted to determine the changes and correlation of both parameters.

RESULTS

12 subjects completed the study. The mean score ± standard deviation (SD) for EtCO₂ were 35.08 ± 3.53 and 35.67 ± 3.31 mm Hg for t0 and t7 respectively. The mean score ±SD for β-OHB were 0.07 ± 0.08 and 0.87 ± 0.84 mmol/L for t0 and t7 respectively. There was no significant difference of EtCO₂ between the period of study (p > 0.05) but the β-OHB increased during t7 (p < 0.05). There was also no correlation between the parameters.

CONCLUSIONS

These findings suggest that EtCO₂ may not be utilized to determine short term nutritional ketosis.

Factors affecting in-hospital mortality of diabetic ketoacidosis patients: A retrospective cohort study

AIMS

With advances in the diagnosis and treatment of diabetic ketoacidosis (DKA), its rate of in-hospital mortality has declined. However, the risk factors for in-hospital mortality in patients with DKA remain to be elucidated.

METHODS

Using a Japanese national inpatient database from 01 July 2010 to 31 March 2018, we performed multivariable logistic regression analyses to identify factors associated with in-hospital mortality of DKA patients.

RESULTS

We identified 25,627 DKA patients and 839 (3.3%) in-hospital deaths. Factors associated with increased in-hospital mortality included higher Charlson comorbidity index (≥4) (odds ratio, 3.38; 95% confidence interval, 2.30-4.96; p < 0.001), sepsis (odds ratio, 3.09; 95% confidence interval, 2.38-4.00; p < 0.001), type 2 diabetes mellitus (odds ratio, 2.67; 95% confidence interval, 2.09-3.41; p < 0.001), and obesity (odds ratio, 2.51; 95% confidence interval, 2.05-3.07; p < 0.001). Other factors positively associated with in-hospital mortality included male sex, age ≥ 60 years, consciousness disturbance, lower activities of daily living score at admission, admission requiring ambulance, and admission at non-academic hospital.

CONCLUSIONS

The present findings may help clinicians to identify DKA patients at higher risk of in-hospital mortality.

Prolonged Glucosuria With Sodium-Glucose Cotransporter-2 (SGLT2) Inhibitors: A Case Report and Review of Literature

Sodium-glucose cotransporter-2 (SGLT2) inhibitors assert their role as an anti-diabetic medication by reversibly inhibiting sodium-glucose cotransporters in the renal proximal tubules and resulting in enhanced glucose excretion. Due to their reversible effect on the transporters in the proximal tubule, it is expected that all their metabolic effects, including glucose excretion, should also cease in two to three days, as per their half-life of 10-15 hours. However, it is increasingly being observed that the glycosuric effect of SGLT2 inhibitors persists beyond this duration and, in many cases, exceeds their other known metabolic effects, which resolve sooner. We present a case report of a 53-year-old diabetic male who developed SGLT2 inhibitor-related euglycemic diabetic ketoacidosis (EuDKA) two days after being discharged post a laparoscopic appendectomy procedure. The patient was treated as per the recommended protocols, after which ongoing metabolic acidosis abated, but the patient’s urinary glucose remained on the higher end. We present an up-to-date review of existing evidence on this rare but serious side effect of SGLT2 inhibitors.

Clinical and Epidemiological Characteristics of Diabetic Ketoacidosis in Older Adults

OBJECTIVES

Much of the research previously done on diabetic ketoacidosis (DKA) was based on a young population with type 1 diabetes mellitus (type 1 DM). But substantial numbers of DKA episodes occur in patients with a prior history of type 2 diabetes mellitus (type 2 DM). There is a lack of Data are lacking about DKA in older adults. The aims of this study were to analyze the clinical characteristics and outcomes of older adult patients with DKA.

DESIGN

Retrospective matched cohort study of adult patients hospitalized with DKA between 2004 and 2017.

SETTING

Soroka University Medical Center, Be'er Sheva, Israel.

PARTICIPANTS

The clinical characteristics of DKA patients 65 years and older were compared with patients younger than 65 years.

MEASUREMENTS

The primary outcome was in-hospital mortality.

RESULTS

The study cohort included 385 consecutive patients for whom the admission diagnosis was DKA: 307 patients (79.7%) younger than 65 years (group 1), and 78 patients (20.3%) older than 65 years (group 2). Patients in group 2 compared with group 1 had a significantly higher Charlson index (6 [6-6] vs 6 [6-7]; P < .0001) and DM with target organ damage (24.4% vs 6.2%; P < .0001). Patients in group 2 compared with group 1 had more serious disease according to results of laboratory investigations. The total in-hospital mortality rate of patients in group 2 was 16.7% compared with 1.6% in patients in group 1 in a sex and co-morbidities matched analysis (P = .001).

CONCLUSIONS

DKA in older adults is a common problem. The serious co-morbidities and precipitating factors such as infection/sepsis, myocardial infarction, and cerebrovascular accidents, may explain the severity of the problem of DKA in older adults and the high rate of mortality of these patients. DKA appears to be a lifethreatening condition in older adults. The alertness of physicians to DKA in older adults, timely diagnosis, proper treatment, and prevention are cornerstones of care. J Am Geriatr Soc 68:1256-1261, 2020.

Incidence and associates of diabetic ketoacidosis in a community-based cohort: the Fremantle Diabetes Study Phase II

OBJECTIVE

To assess the incidence and associates of diabetic ketoacidosis (DKA) in a representative community-based cohort.

METHODS

All hospitalizations of 1724 participants in the Fremantle Diabetes Study Phase II for/with DKA (plasma glucose >13.8 mmol/L, urinary/serum ketones, serum bicarbonate <18 mmol/L and/or arterial/venous pH <7.30) were identified between study entry from 2008 to 2011 and end-2013. Details of each episode were categorized by chart review as confirmed/probable DKA, possible DKA or not DKA. Incidence rates by diabetes type were calculated. Cox proportional hazards modeling determined predictors of first episode, and negative binomial regression identified predictors of frequency.

RESULTS

There were 53 coded DKA episodes (41 first episodes, 12 recurrences), of which 19 (35.8%) were incorrectly coded, 9 (17.0%) had possible DKA and 25 (47.2%) had confirmed/probable DKA. Of this latter group, 44% had type 1 diabetes, 32% had type 2 diabetes, 12% had latent autoimmune diabetes of adults (LADA) and 12% had secondary diabetes. The overall incidence of confirmed/probable DKA (95% CI) was 35.6 (23.0 to 52.6)/10 000 person-years (178.6 (85.7 to 328.5)/10 000 person-years for type 1 diabetes, 13.3 (5.7 to 26.1)/10 000 person-years for type 2 diabetes, 121.5 (33.1 to 311.0)/10 000 person-years for LADA and 446.5 (92.1 to 1304.9)/10 000 person-years for secondary diabetes). Baseline ln(fasting serum C-peptide) (inversely), glycated hemoglobin and secondary diabetes predicted both incident first confirmed/probable DKA episode and the frequency of DKA (p<0.001).

CONCLUSIONS

These data highlight the contribution of poor glycemic control and limited pancreatic beta cell function to incident DKA, and show that people with types of diabetes other than type 1, especially secondary diabetes, are at risk.

Omics-based biomarkers in the diagnosis of diabetes

Diabetes mellitus (DM) is a group of metabolic diseases related to the dysfunction of insulin, causing hyperglycaemia and life-threatening complications. Current early screening and diagnostic tests for DM are based on changes in glucose levels and autoantibody detection. This review evaluates recent studies on biomarker candidates in diagnosing type 1, type 2 and gestational DM based on omics classification, whilst highlighting the relationship of these biomarkers with the development of diabetes, diagnostic accuracy, challenges and future prospects. In addition, it also focuses on possible non-invasive biomarker candidates besides common blood biomarkers.

The translational network for metabolic disease - from protein interaction to disease co-occurrence

Background

The recent advances in human disease network have provided insights into establishing the relationships between the genotypes and phenotypes of diseases. In spite of the great progress, it yet remains as only a map of topologies between diseases, but not being able to be a pragmatic diagnostic/prognostic tool in medicine. It can further evolve from a map to a translational tool if it equips with a function of scoring that measures the likelihoods of the association between diseases. Then, a physician, when practicing on a patient, can suggest several diseases that are highly likely to co-occur with a primary disease according to the scores. In this study, we propose a method of implementing ‘n-of-1 utility’ (n potential diseases of one patient) to human disease network—the translational disease network.

Results

We first construct a disease network by introducing the notion of walk in graph theory to protein-protein interaction network, and then provide a scoring algorithm quantifying the likelihoods of disease co-occurrence given a primary disease. Metabolic diseases, that are highly prevalent but have found only a few associations in previous studies, are chosen as entries of the network.

Conclusions

The proposed method substantially increased connectivity between metabolic diseases and provided scores of co-occurring diseases. The increase in connectivity turned the disease network info-richer. The result lifted the AUC of random guessing up to 0.72 and appeared to be concordant with the existing literatures on disease comorbidity.

Young adult patients with type 1 diabetes have a higher risk of mortality than those of similar age with type 2 diabetes: A nationwide analysis in Hungary

BACKGROUND

There are few papers comparing complications of type 1 diabetes with those of a similarly young age with type 2 diabetes. The aim of our nationwide study was to compare the risks of mortality and morbidities between the two types of diabetes (age ≤ 40).

METHODS

We identified all young adult patients with type 1 diabetes who were recorded in the database of the Hungarian National Health Insurance Fund between 2001 and 2014 (n = 11 863) and compared them with a population of similar age with young adult type 2 diabetes (n = 47 931). The incidence of all-cause mortality, myocardial infarction, stroke, any type of cancer, diabetic ketoacidosis, and hypoglycemia was followed from the onset of diabetes to the date of death or end of study period.

RESULTS

The risks of all-cause mortality were significantly higher in patients with type 1 compared with patients with type 2 diabetes (hazard ratio, 95%CI; 2.17, 1.95-2.41; P < .0001). The risks of myocardial infarction (0.90, 0.71-1.13; P = 0.36) and stroke (1.06, 0.87-1.29; P = .582) were not significantly different in type 1 compared with type 2. In contrast, the risk of cancer (1.35, 1.15-1.59; P = .0003), dialysis (2.20, 1.76-2.75; P < .0001), hypoglycemia (7.70, 6.45-9.18; P < .0001), and ketoacidosis (22.12, 19.60-25.00; P < .0001) was higher among patients with type 1 compared with those with type 2 diabetes.

CONCLUSIONS

A comparatively higher incidence of diabetic ketoacidosis and hypoglycemia and higher risk of cancer and dialysis in patients with type 1 diabetes than in those with type 2 may play a role in the higher risk of mortality.

Hospital admissions for hyperglycemic emergencies in young adults at an inner-city hospital

AIMS

There is limited information characterizing young adults (18-35 years) (YA) with diabetes, especially those admitted for hyperglycemic emergencies. The study aims were to examine associations of patient-level characteristics with hyperglycemic emergency hospitalization and to identify variations based on diabetes type and glycemic control.

METHODS

We conducted retrospective analysis of 273 YA admitted to an inner-city hospital with diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic nonketotic syndrome (HHS). T-tests, Chi-Square tests, and ANOVA identified differences in demographics, diabetes history, clinical indicators, complications/comorbidities, and hospital admission stratified separately by diabetes type (1 vs 2) and admission HbA1c < 9% (75 mmol/mol), ≥9% to 12% (108 mmol/mol), ≥12%).

RESULTS

Mean admission HbA1c was 12.4% (112 mmol/ml). HbA1c was ≥9.0% for 90.5%. The main DKA/HHS trigger was medication nonadherence (57.9%), with 35.6% presenting with new-onset type 2 diabetes. Only 3.7% utilized outpatient diabetes clinics, 38.8% were re-hospitalized within the year, and 69% lacked insurance. Diabetes complications (44.7%) and psychiatric co-morbidities (35.5%) were common. Significantly more YA with type 1 diabetes had insurance, whereas YA with type 2 diabetes had higher admission HbA1c. YA with HbA1c ≥12% were more likely to be Black and lack insurance.

CONCLUSIONS

YA hospitalized for DKA/HHS in an inner-city hospital tended to have severely uncontrolled diabetes. Many already had comorbidities and diabetes complications, high use of acute care services and low use of diabetes specialty services. YA characteristics varied by diabetes type and HbA1c. Overall, a substantial percentage lacked insurance, potentially impacting healthcare utilization patterns and medication adherence, and leading to DKA/HHS admissions.

Initial management of diabetic ketoacidosis and prognosis according to diabetes type: a French multicentre observational retrospective study

Background

Guidelines for the management of diabetic ketoacidosis (DKA) do not consider the type of underlying diabetes. We aimed to compare the occurrence of metabolic adverse events and the recovery time for DKA according to diabetes type.

Methods

Multicentre retrospective study conducted at five adult intermediate and intensive care units in Paris and its suburbs, France. All patients admitted for DKA between 2013 and 2014 were included. Patients were grouped and compared according to the underlying type of diabetes into three groups: type 1 diabetes, type 2 or secondary diabetes, and DKA as the first presentation of diabetes. Outcomes of interest were the rate of metabolic complications (hypoglycaemia or hypokalaemia) and the recovery time.

Results

Of 122 patients, 60 (49.2%) had type 1 diabetes, 28 (22.9%) had type 2 or secondary diabetes and 34 (27.9%) presented with DKA as the first presentation of diabetes (newly diagnosed diabetes). Despite having received lower insulin doses, hypoglycaemia was more frequent in patients with type 1 diabetes (76.9%) than in patients with type 2 or secondary diabetes (50.0%) and in patients with newly diagnosed diabetes (54.6%) (p = 0.026). In contrast, hypokalaemia was more frequent in the latter group (82.4%) than in patients with type 1 diabetes (57.6%) and type 2 or secondary diabetes (51.9%) (p = 0.022). The median recovery times were not significantly different between groups.

Conclusions

Rates of metabolic complications associated with DKA treatment differ significantly according to underlying type of diabetes. Decreasing insulin dose may limit those complications. DKA treatment recommendations should take into account the type of diabetes.

Electronic supplementary material

The online version of this article (10.1186/s13613-019-0567-y) contains supplementary material, which is available to authorized users.

DKA cases over the last three years: has anything changed?

BACKGROUND

Diabetic ketoacidosis (DKA) has been related mainly to type 1 diabetes mellitus (T1DM). However, it is not solely related to T1DM. The purpose of this study was to assess the prevalence of DKA among type 1 and type 2 patients with diabetes mellitus, who were hospitalized in our Clinic due to DKA, as well as to determine the etiology beyond DKA.

PATIENTS AND METHODS

A cohort of 109 patients with DKA, 17-86 years of age, who were hospitalized in the Department of Endocrinology, Diabetes and Metabolism of our hospital between 2015 and 2017, were included in the study.

RESULTS

Among the 109 patients, 50 (45.9%) had mild DKA, 48 (44.1%) had moderate DKA, whereas 11 patients (10%) had severe DKA. Sixty-five patients (60%) developed DKA as the first manifestation of T1DM, 30 patients (27%) developed DKA in the context of type 2 diabetes (T2DM), mainly due to the co-existence of serious infections, 11 patients (10%) had T1DM, but had omitted their insulin dosages, and 3 patients (3%) developed DKA due to unknown reasons.

CONCLUSIONS

Most patients with DKA presented with mild and moderate DKA and only a minority presented with the severe form of the disease. The etiology of DKA was mainly T1DM and less frequent uncontrolled T2DM, usually due to the co-existence of severe infections, while only in a tiny minority, the causes remained unidentifiable.

Comparison of two glycemic discharge goals in ED patients with hyperglycemia, a randomized trial

STUDY OBJECTIVE

Hyperglycemia is commonly encountered in the ED; the importance of glucose reduction in patients well enough to be discharged is unknown.

METHODS

We conducted a prospective, randomized trial of ED patients with hyperglycemia with a glucose value 400-600 mg/dL who were discharged from the ED, excluding those with type 1 diabetes mellitus. Patients were randomly assigned to a discharge glucose goal, <350 mg/dL (moderate control) or < 600 mg/dL (loose control). The primary outcome was ED length of stay.

RESULTS

Among 110 enrolled patients, 57 were assigned to moderate and 53 to loose glycemic control. Median (IQR) length of stay was 211 min (177-288 min) for the moderate group and 216 min (151-269 min) for the loose group (difference, 17 min [95% CI -15 to 49 min]). ED length of stay for those with an actual discharge glucose <350 mg/dL was 29 min longer (95% CI -1 to 59 min). Repeat ED visits for hyperglycemia (7% vs 6%), hospitalization for hyperglycemia (0% vs 2%), and hospitalization for any reason (4% vs 8%) did not differ significantly between groups.

CONCLUSION

In the intention-to-treat analysis, ED length of stay and 7-day outcomes were not significantly different whether moderate or loose glycemic control was pursued. However, the length of stay for those with discharge glucose <350 mg/dL was approximately 29 min longer. ED glycemic control did not appear to be associated negative short-term outcomes. Glucose reduction in well-appearing ED patients may consume time and resources without conferring short- or long-term benefits.

TRIAL REGISTRATION

Clinicaltrials.govNCT02478190.

Validation of data from electronic data warehouse in diabetic ketoacidosis: Caution is needed

AIMS

This study validated enterprise data warehouse (EDW) data for a cohort of hospitalized patients with a primary diagnosis of diabetic ketoacidosis (DKA).

METHODS

247 patients with 319 admissions for DKA (ICD-9 code 250.12, 250.13, or 250.xx with biochemical criteria for DKA) were admitted to Northwestern Memorial Hospital from 1/1/2010 to 9/1/2013. Validation was performed by electronic medical record (EMR) review of 10% of admissions (N = 32). Classification of diabetes type (Type 1 vs. Type 2) and DKA clinical status were compared between the EMR review and EDW data.

RESULTS

Key findings included incorrect classification of diabetes type in 5 of 32 (16%) admissions and indeterminable classification in 5 admissions. DKA was not present, based on the review, in 11 of 32 (34%) admissions. DKA was not present, based on biochemical criteria, in 15 of 32 (47%) admissions.

CONCLUSIONS

This study found that EDW data have substantial errors. Some discrepancies can be addressed by refining the EDW query code, while others, related to diabetes classification and DKA diagnosis, cannot be corrected without improving clinical coding accuracy, consistency of medical record documentation, or EMR design. These results support the need for comprehensive validation of data for complex clinical populations obtained through data repositories such as the EDW.

The management of diabetic ketoacidosis at a rural regional hospital in KwaZulu-Natal

Background

Diabetic ketoacidosis (DKA) is a biochemical triad of hyperglycaemia, ketoacidosis and ketonaemia and one of the potentially life-threatening acute metabolic complications of diabetes mellitus. This study aimed at describing the clinical profile of patients presenting with DKA to a busy rural regional hospital in KwaZulu-Natal.

Methods

A retrospective review of clinical notes of patients presenting with DKA to the Emergency Department was performed over a 10-month period. Data included patients’ demographic profile, clinical presentation, precipitating factors, comorbidities, biochemical profile, length of hospital stay and outcome.

Results

One hundred and five black South African patients above the age of 12 years were included in the study. Sixty-four (60.95%) patients had type 1 diabetes mellitus (T1DM) and 41 (39.05%) patients had type 2 diabetes mellitus (T2DM). Patients with T2DM were significantly older than those with T1DM (52.1 ± 12.4 years vs. 24.4 ± 9.5 years, p < 0.0001). The acute precipitant was identified in 68 (64.76%) cases with the commonest precipitant in T1DM patients being poor adherence to treatment, whereas in T2DM, the most common precipitant was infection. Nausea and vomiting were the most common presenting symptoms with the majority of patients presenting with non-specific symptoms. Fifty-seven (54.29%) cases had pre-existing comorbidities, with higher prevalence in T2DM than T1DM patients. Glycated haemoglobin was severely elevated in the majority of patients. Patients remained hospitalised for an average of 8.9 ± 7.5 days. The mortality rate was 17.14%, and 12 of the 18 deaths occurred in patients with T2DM.

Conclusion

The prevalence of DKA was higher in patients with T1DM and those with pre-existing comorbidities. The mortality rate remains alarmingly high in older patients with T2DM.

The value of venous blood gas analysis in the diagnosis of diabetic ketoacidosis

BACKGROUND & AIM

Newer blood gas analyzers have the ability to report electrolyte values and glucose in addition to pH, so this diagnostic process could be condensed in diagnosing diabetic ketoacidosis (DKA). We aimed to assess the accuracy of the venous blood gas (VBG) analysis with electrolytes for diagnosing DKA.

METHODS

This study prospectively identified a convenience sample of (60 patients) presented with DKA and tested their VBG and serum electrolytes. The diagnosis of DKA was made according to American Diabetes Association criteria. Serum chemistry electrolyte values were considered to be the criterion standard. Sensitivity and specificity of VBG electrolytes results were compared against this standard. In addition, correlation coefficients for individual electrolytes between VBG electrolytes and laboratory chemistry electrolytes were calculated.

RESULTS

Paired VBG and serum chemistry panels were available for 60 patients, only 49 patients were included, In this study; 20% of cases were newly diagnosed diabetes mellitus. The total number of diabetic ketoacidosis was 14 patients (28.5%). The sensitivity and specificity of the VBG and electrolytes for diagnosing DKA was 92.9% (95% confidence interval [CI]=89% to 99%) and 97.1% (95% CI=92% to 100%), respectively. Correlation coefficients between VBG and serum chemistry were 0.91, 0.47, 0.61, 0.65, and 0.58 for blood sugar, sodium, potassium, chloride, and creatinine respectively.

CONCLUSIONS

Findings of this study offer preliminary support for the possibility of using VBG sample rather than VBG sample and serum chemistry electrolytes together to rule out diabetic ketoacidosis.

SGLT2 Inhibitor-associated Diabetic Ketoacidosis: Clinical Review and Recommendations for Prevention and Diagnosis

PURPOSE

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are the newest class of antihyperglycemic agents available on the market. Regulator warnings and concerns regarding the risk of developing diabetic ketoacidosis (DKA), however, have dampened enthusiasm for the class despite the combined glycemic, blood pressure, and occasional weight benefits of SGLT2 inhibitors. With the goal of improving patient safety, a cross-Canada expert panel and writing group were convened to review the evidence to-date on reported SGLT2 inhibitor-related DKA incidents and to offer recommendations for preventing and recognizing patients with SGLT2 inhibitor-associated DKA.

METHODS

Reports covering DKA events in subjects taking SGLT2 inhibitors that were published in PubMed, presented at professional conferences, or in the public domain from January 2013 to mid-August 2016 were reviewed by the group independently and collectively. Practical recommendations for diagnosis and prevention were established by the panel.

FINDINGS

DKA is rarely associated with SGLT2 inhibitor therapy. Patients with SGLT2 inhibitor-associated DKA may be euglycemic (plasma glucose level <14 mmol/L). DKA is more likely in patients with insulin-deficient diabetes, including those with type 2 diabetes, and is typically precipitated by insulin omission or dose reduction, severe acute illness, dehydration, extensive exercise, surgery, low-carbohydrate diets, or excessive alcohol intake. SGLT2 inhibitor-associated DKA may be prevented by withholding SGLT2 inhibitors when precipitants develop, avoiding insulin omission or inappropriate insulin dose reduction, and by following sick day protocols as recommended.

IMPLICATIONS

Preventive strategies should help avoid SGLT2 inhibitor-associated DKA. All SGLT2 inhibitor-treated patients presenting with signs or symptoms of DKA should be suspected to have DKA and be investigated for DKA, especially euglycemic patients. If DKA is diagnosed, SGLT2 inhibitor treatment should be stopped, and the DKA should be treated with a traditional treatment protocol.

Incidence of diabetic ketoacidosis among patients with type 2 diabetes mellitus treated with SGLT2 inhibitors and other antihyperglycemic agents

AIMS

To estimate and compare incidence of diabetes ketoacidosis (DKA) among patients with type 2 diabetes who are newly treated with SGLT2 inhibitors (SGLT2i) versus non-SGLT2i antihyperglycemic agents (AHAs) in actual clinical practice.

METHODS

A new-user cohort study design using a large insurance claims database in the US. DKA incidence was compared between new users of SGLT2i and new users of non-SGLT2i AHAs pair-matched on exposure propensity scores (EPS) using Cox regression models.

RESULTS

Overall, crude incidence rates (95% CI) per 1000 patient-years for DKA were 1.69 (1.22-2.30) and 1.83 (1.58-2.10) among new users of SGLT2i (n=34,442) and non-SGLT2i AHAs (n=126,703). These rates more than doubled among patients with prior insulin prescriptions but decreased by more than half in analyses that excluded potential autoimmune diabetes (PAD). The hazard ratio (95% CI) for DKA comparing new users of SGLT2i to new users of non-SGLT2i AHAs was 1.91 (0.94-4.11) (p=0.09) among the 30,196 EPS-matched pairs overall, and 1.13 (0.43-3.00) (p=0.81) among the 27,515 EPS-matched pairs that excluded PAD.

CONCLUSIONS

This was the first observational study that compared DKA risk between new users of SGLT2i and non-SGLT2i AHAs among patients with type 2 diabetes, and overall no statistically significant difference was detected.

Distinct clinical characteristics and therapeutic modalities for diabetic ketoacidosis in type 1 and type 2 diabetes mellitus

AIMS

Patients with type 1 diabetes often develop diabetic ketoacidosis (DKA). Reportedly, DKA in type 2 diabetes has higher mortality despite its limited occurrence. The exact clinical characteristics and therapeutic modalities yielding successful outcomes in DKA type 2 diabetes remain unknown.

METHODS

This retrospective study compared the clinical features and detailed treatment of consecutive type 1 and type 2 diabetes patients hospitalized with DKA between January 2001 and December 2014.

RESULTS

We report on 127 patients with type 1 and 74 patients with type 2 diabetes whose DKA was successfully treated. The most frequent precipitating cause for DKA was infectious disease for patients with type 1 diabetes and consumption of sugar-containing beverages for those with type 2 diabetes. Type 2 diabetes patients showed higher mean plasma glucose levels than those with type 1 diabetes (48.4±21.6, vs. 37.1±16.4mmol/l, P<0.01) and higher serum creatinine, blood urea nitrogen, and hemoglobin levels, which normalized after DKA resolution. Compared with type 1 diabetes patients, those with type 2 diabetes required distinctly higher daily total insulin dosage (35.9±37.0U, vs. 20.2±23.3U, P<0.01), larger replacement fluid volumes (4.17±2.69L, vs. 2.29±1.57L, P<0.01) and greater potassium supplementation (23.9±36.5mEq, vs. 11.2±17.9mEq, P<0.01) to resolve DKA and reduce plasma glucose level to ≤16.7mmol/l.

CONCLUSIONS

DKA patients with type 2 diabetes required management with a modified treatment protocol to resolve their profound hyperglycemia and dehydration compared with those with type 1 diabetes.

HbA1c as a Screening tool for Ketosis in Patients with Type 2 Diabetes Mellitus

Ketosis in patients with type 2 diabetes mellitus (T2DM) is overlooked due to atypical symptoms. The objective of this study is to evaluate the value of hemoglobin A_1c (HbA_1c) as a screening tool for ketosis in T2DM patients. This retrospective study consisted of 253 T2DM patients with ketosis at Shanghai 10th People’s Hospital during a period from January 1, 2011 to June 30, 2015. A control group consisted of 221 T2DM patients without ketosis randomly selected from inpatients during the same period. Receiver operating characteristic curve (ROC) analysis was used to examine the sensitivity and specificity of HbA_1c as an indicator for ketosis. Higher HbA_1c levels were correlated with ketosis. In patients with newly diagnosed T2DM, the area under the curve (AUC) was 0.832, with 95% confidence interval (CI) 0.754–0.911. The optimal threshold was 10.1% (87 mmol/mol). In patients with previously diagnosed T2DM, the AUC was 0.811 (95% CI: 0.767–0.856), with an optimal threshold of 8.6% (70 mmol/mol). HbA_1c is a potential screening tool for ketosis in patients with T2DM. Ketosis is much more likely with HbA_1c values at ≥10.1% in patients with newly diagnosed T2DM and HbA_1c values at ≥8.6% in patients with previously diagnosed T2DM.

Prognostic Factors in Patients Hospitalized with Diabetic Ketoacidosis

BACKGROUND

Diabetic ketoacidosis (DKA) is characterized by a biochemical triad of hyperglycemia, acidosis, and ketonemia. This condition is life-threatening despite improvements in diabetic care. The purpose of this study was to evaluate the clinical and biochemical prognostic markers of DKA. We assessed correlations in prognostic markers with DKA-associated morbidity and mortality.

METHODS

Two hundred and seventy patients that were hospitalized with DKA over a period of 2 years were evaluated clinically and by laboratory tests. Serial assays of serum electrolytes, glucose, and blood pH were performed, and clinical outcome was noted as either discharged to home or death.

RESULTS

The analysis indicated that significant predictors included sex, history of type 1 diabetes mellitus or type 2 diabetes mellitus, systolic blood pressure, diastolic blood pressure, total leukocyte count, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, blood urea nitrogen, serum creatinine, serum magnesium, serum phosphate, serum osmolality, serum glutamic oxaloacetic transaminases, serum glutamic pyruvic transaminases, serum albumin, which were further regressed and subjected to multivariate logistic regression (MLR) analysis. The MLR analysis indicated that males were 7.93 times more likely to have favorable outcome compared with female patients (odds ratio, 7.93; 95% confidence interval, 3.99 to 13.51), while decreases in mean APACHE II score (14.83) and serum phosphate (4.38) at presentation may lead to 2.86- and 2.71-fold better outcomes, respectively, compared with higher levels (APACHE II score, 25.00; serum phosphate, 6.04).

CONCLUSION

Sex, baseline biochemical parameters such as APACHE II score, and phosphate level were important predictors of the DKA-associated mortality.

Discharge Glucose Is Not Associated With Short-Term Adverse Outcomes in Emergency Department Patients With Moderate to Severe Hyperglycemia

STUDY OBJECTIVE

Hyperglycemia is frequently encountered in the emergency department (ED), and there is no consensus on optimal care before discharge. The importance of glucose reduction in the ED is unknown. We seek to determine whether an association exists between discharge glucose and 7-day adverse outcomes.

METHODS

A cohort design with retrospective chart review was conducted at a high-volume urban ED. Patients were included if any glucose level was greater than or equal to 400 mg/dL and they were discharged from the ED. Generalized estimating equation models were created for the 7-day outcomes with a primary predictor of discharge glucose.

RESULTS

The cohort consisted of 422 patients with 566 ED encounters. Mean arrival and discharge glucose were 491 mg/dL (SD 82 mg/dL) and 334 mg/dL (SD 101 mg/dL), respectively. In the 7-day follow-up period, 62 (13%) and 36 (7%) patients had a repeat ED visit for hyperglycemia and were hospitalized, respectively. Two patients had diabetic ketoacidosis. After adjustment for arrival glucose, whether a chemistry panel was obtained, amount of intravenous fluids administered, and amount of subcutaneous insulin administered, discharge glucose was not associated with repeat ED visit for hyperglycemia (adjusted odds ratio 0.997; 95% confidence interval 0.993 to 1.001) or hospitalization for any reason (adjusted odds ratio 0.998; 95% confidence interval 0.995 to 1.002).

CONCLUSION

ED discharge glucose in patients with moderate to severe hyperglycemia was not associated with 7-day outcomes of repeat ED visit for hyperglycemia or hospitalization. Attaining a specific glucose goal before discharge in patients with hyperglycemia may be less important than traditionally thought.

Hyperketonemia and ketosis increase the risk of complications in type 1 diabetes

Diets that boost ketone production are increasingly used for treating several neurological disorders. Elevation in ketones in most cases is considered favorable, as they provide energy and are efficient in fueling the body's energy needs. Despite all the benefits from ketones, the above normal elevation in the concentration of ketones in the circulation tend to illicit various pathological complications by activating injurious pathways leading to cellular damage. Recent literature demonstrates a plausible link between elevated levels of circulating ketones and oxidative stress, linking hyperketonemia to innumerable morbid conditions. Ketone bodies are produced by the oxidation of fatty acids in the liver as a source of alternative energy that generally occurs in glucose limiting conditions. Regulation of ketogenesis and ketolysis plays an important role in dictating ketone concentrations in the blood. Hyperketonemia is a condition with elevated blood levels of acetoacetate, 3-β-hydroxybutyrate, and acetone. Several physiological and pathological triggers, such as fasting, ketogenic diet, and diabetes cause an accumulation and elevation of circulating ketones. Complications of the brain, kidney, liver, and microvasculature were found to be elevated in diabetic patients who had elevated ketones compared to those diabetics with normal ketone levels. This review summarizes the mechanisms by which hyperketonemia and ketoacidosis cause an increase in redox imbalance and thereby increase the risk of morbidity and mortality in patients.

Clinical profile of diabetic ketoacidosis in tertiary hospitals in China: a multicentre, clinic-based study

AIMS

To evaluate the clinical profile of patients with diabetic ketoacidosis in tertiary hospitals in China.

METHODS

A retrospective study of patients hospitalized with diabetic ketoacidosis between 2010 and 2012 was carried out in 15 tertiary hospitals around China. Clinical and laboratory data were collected. Patients were classified based on clinical diagnosis and treatment history. Groups were compared for differences in vital statistics and biochemical profiles at presentation.

RESULTS

The study comprised 643 patients with diabetic ketoacidosis: 308 patients (47.9%) with Type 1 diabetes, 294 patients (45.7%) with Type 2 diabetes and 41 patients (6.4%) with atypical diabetes. Three hundred and eighty-eight diabetic ketoacidosis episodes (60.3%) were in patients with known diabetes. The most common precipitating factor was infection (40.1%), followed by unknown causes (36.9%) and non-compliance with anti-diabetes treatment (16.8%). At presentation, gastrointestinal symptoms and dehydration were more common in the Type 1 diabetes group. For new-onset diabetes, only 74.4% and 55.9% of patients were evaluated for β-cell function and autoantibodies for classification. Only 67% of patients with diabetic ketoacidosis received appropriate fluid therapy and 56% patients with severe acidosis received bicarbonate therapy. The length of hospital stay was 10.0 (7.0-14.0) days. The mortality rate was 1.7%, and was much higher in Type 2 diabetes than that in Type 1 diabetes (3.2% vs. 0.4%, P < 0.01).

CONCLUSIONS

Type 2 and Type 1 diabetes contribute to a similar proportion of cases presenting with diabetic ketoacidosis in China. Admissions with diabetic ketoacidosis are still associated with significant mortality and prolonged hospitalization. The efficiency of diabetic ketoacidosis management needs to be improved by implementing the updated guidelines.

Comparison between New-Onset and Old-Diagnosed Type 2 Diabetes with Ketosis in Rural Regions of China

Objectives. Type 2 diabetes (T2D) with ketosis was common because of late diagnosis and lacking adequate treatment in rural regions of China. This study aimed to provide the data of T2D with ketosis among inpatients in a south-west border city of China. Methods. Data of 371 patients of T2D with ketosis who were hospitalized between January 2011 and July 2015 in Baoshan People's Hospital, Yunnan, China, were analyzed. New-onset and old-diagnosed T2D patients presenting with ketosis were compared according to clinical characteristics, laboratory results, and chronic diabetic complications. Results. Overall, the blood glucose control was poor in our study subjects. Male predominated in both groups (male prevalence was 68% in new-onset and 64% in old-diagnosed groups). Overweight and obesity accounted for 50% in new-onset and 46% in old-diagnosed cases. Inducements of ketosis were 13.8% in new-onset and 38.7% in old-diagnosed patients. Infections were the first inducements in both groups. The prevalence of chronic complications of diabetes was common in both groups. Conclusions. More medical supports were needed for the early detection and adequate treatment of diabetes in rural areas of China.

Severe Ketoacidosis (pH ≤ 6.9) in Type 2 Diabetes: More Frequent and Less Ominous Than Previously Thought

Diabetic ketoacidosis is a life-threatening acute metabolic complication of uncontrolled diabetes. Severe cases of DKA (pH ≤ 7.00, bicarbonate level ≤ 10.0, anion gap > 12, positive ketones, and altered mental status) are commonly encountered in patients with type 1 diabetes and are thought to carry an ominous prognosis. There is not enough information on the clinical course of severely acidotic type 2 diabetes (pH ≤ 6.9) patients with DKA, possibly because this condition is rarely seen in developed countries. In this series, we present 18 patients with type 2 diabetes, DKA, and a pH ≤ 6.9 that presented to a tertiary university hospital over the past 11 years. The objective was to describe their clinical characteristics, the triggering cause, and emphasis on treatment, evolution, and outcomes. The majority of the patients were female (61%). Mean age was 40.66 years (23–59). The patients had been first diagnosed with type 2 diabetes on average 5.27 ± 3.12 years before admission. Glutamic acid decarboxylase (GAD65) antibodies were negative in all patients. The origin of DKA could be attributed to two main causes: treatment omission in 8 (44.4%) patients and infections in 7 (38.8%) patients. The most common symptoms described were general malaise, dyspnea, altered mental status, and abdominal pain. Mean serum glucose on admission was 613.8 ± 114.5 mg/dL. Mean venous pH was 6.84 ± 0.03 with an anion gap of 30.3 ± 2.9 and a venous HCO₃ level of 3.62 ± 1.35 mmol/L. All patients had acute renal failure on admission, with a mean serum creatinine of 1.57 ± 0.35 mg/dL compared to 0.55 ± 0.21 mg/dL at discharge. All patients received regular insulin infusion, aggressive fluid repletion, and 12 patients (66%) received bicarbonate infusion. Mean total insulin infusion dose was 181.7 ± 90.4 U (on average 0.14 ± 0.05 U/Kg/h). Mean time on infusion was 24.4 ± 12.6 hours. We recorded no mortality in this case series. Mean in-hospital stay was 5.0 ± 4.1 days. In conclusion, very severe DKA in type 2 diabetes is not uncommon in our population, shares many features with non-very-severe cases of DKA (bicarbonate therapy did not make a difference in mortality), and can be managed following standard published or institutional guidelines.

Clinical Profile of Diabetic Ketoacidosis: A Prospective Study in a Tertiary Care Hospital

BACKGROUND

Diabetic ketoacidosis, a well-known and major acute metabolic complication classically occurs in young patients with type 1 diabetes. However, it may occur in patients with type 2 Diabetes Mellitus too.

OBJECTIVE

Aim of this study was to look into the clinical profile, precipitating factors and clinical outcome in the patients presenting with Diabetic ketoacidosis in the Emergency of a Tertiary care hospital.

DESIGN

The study was a prospective study conducted over a period of two years in Kasturba Medical College, Manipal Karnataka, India.

MATERIALS AND METHODS

Clinical profile of 60 diabetic patients admitted in the Emergency with the diagnosis of Diabetic ketoacidosis were analysed.

RESULTS

Out of 60 patients, 12 were of Type 1 and 48 were Type 2 Diabetes Mellitus. Mean duration of diabetes was 8.65 years. Only 14 (23.3%) patients were taking regular treatment for Diabetes Mellitus whereas 32 (53.33%) patients were on irregular treatment and eight (13.33%) were not on any treatment at all. Among 12 Type 1 Diabetic patients, six patients were freshly diagnosed to be diabetic when they presented with Diabetic ketoacidosis complication. Nausea and vomiting (63.33%) were the most common symptoms of these patients. Infections (73.33%) were the most common precipitating factor for Diabetic ketoacidosis. Mean fluid requirement on first day of therapy was 3.51 liters. Mortality of 10% was seen.

CONCLUSION

Diabetic ketoacidosis is a fatal acute metabolic complication of Diabetes Mellitus with heterogeneous clinical presentation. Early diagnosis and treatment can avoid morbidity & mortality.

Clinical features, mortality, hospital admission, and length of stay of a cohort of adult patients with diabetic ketoacidosis attending the emergency room of a tertiary hospital in Spain

AIM

To assess the clinical features, length of stay, incidence rate, mortality, and hospital admissions of patients with episodes of diabetic ketoacidosis (DKA).

PATIENTS

It was conducted retrospective, cross-sectional study of 164 consecutive admissions of adult patients (2008-August 2012), with type 1 or type 2 diabetes already known or new onset.

RESULTS

Mortality rate was 1.2%. The DKA episodes were mild (18.9%), moderate (31.7%), or severe (49.4%). The cumulative incidence was 2.66 cases/1000 patients with diabetes (DM) in 4.5 years. The most common causes triggering DKA were infection (33.2%) and dietary transgression and/or insulin dose omission (30.7%). A total of 12.8% of patients had new onset DM, 56.7% type 1, and 26.8% type 2 DM. Patients with type 2 DM were older and had at admission higher creatinine, BUN, osmolality, sodium, and anion gap levels. Patients with new-onset of DM had higher levels of glucose and sodium, but lower potassium levels. No differences were found in pH or bicarbonate. Admission to the intensive care unit (ICU) was required in >50% of cases (p<0.001), and 86.6% of patients were finally admitted to a medical ward (p=0.005). The length of stay at the ICU (p<0.001) and hospital (p=0.013) was significantly different depending on DKA severity.

CONCLUSIONS

Most DKA episodes require hospital admission, but mortality is <2%, and length of stay at the ER and medical ward depends on type of DM and initial severity of the episode.