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

Development and validation of a nomogram for screening patients with type 2 diabetic ketoacidosis

OBJECTIVE AND BACKGROUND

The early detection of diabetic ketoacidosis (DKA) in patients with type 2 diabetes (T2D) plays a crucial role in enhancing outcomes. We developed a nomogram prediction model for screening DKA in T2D patients. At the same time, the input variables were adjusted to reduce misdiagnosis.

METHODS

We obtained data on T2D patients from Mimic-IV V0.4 and Mimic-III V1.4 databases. A nomogram model was developed using the training data set, internally validated, subjected to sensitivity analysis, and further externally validated with data from T2D patients in Aviation General Hospital.

RESULTS

Based on the established model, we analyzed 1885 type 2 diabetes patients, among whom 614 with DKA. We further additionally identified risk factors for DKA based on literature reports and multivariate analysis. We identified age, glucose, chloride, calcium, and urea nitrogen as predictors in our model. The logistic regression model demonstrated an area under the curve (AUC) of 0.86 (95%CI: 0.85-0.90]. To validate the model, we collected data from 91 T2D patients, including 15 with DKA, at our hospital. The external validation of the model yielded an AUC of 0.68 (95%CI: 0.67-0.70). The calibration plot confirmed that our model was adequate for predicting patients with DKA. The decision-curve analysis revealed that our model offered net benefits for clinical use.

CONCLUSIONS

Our model offers a convenient and accurate tool for predicting whether DKA is present. Excluding input variables that may potentially hinder patient compliance increases the practical application significance of our model.

Combined hyperglycemic crises in adult patients already exist in Latin America

INTRODUCTION

Diabetes mellitus is one of the most common diseases worldwide, with a high morbidity and mortality rate. Its prevalence has been increasing, as well as its acute complications, such as hyperglycemic crises. Hyperglycemic crises can present with combined features of diabetic ketoacidosis and hyperosmolar state. However, their implications are not fully understood.

OBJECTIVE

To describe the characteristics, outcomes, and complications of the diabetic population with hyperglycemic crises and to value the combined state in the Latin American population.

MATERIALS AND METHODS

Retrospective observational study of all hyperglycemic crises treated in the intensive care unit of the Fundación Valle del Lili between January 1, 2015, and December 31, 2020. Descriptive analysis and prevalence ratio estimation for deaths were performed using the robust Poisson regression method.

RESULTS

There were 317 patients with confirmed hyperglycemic crises, 43 (13.56%) with diabetic ketoacidosis, 9 (2.83%) in hyperosmolar state, and 265 (83.59%) with combined diabetic ketoacidosis and hyperosmolar state. Infection was the most frequent triggering cause (52.52%). Fatalities due to ketoacidosis occurred in four patients (9.30%) and combined diabetic ketoacidosis/hyperosmolar state in 22 patients (8.30%); no patient had a hyperosmolar state. Mechanical ventilation was associated with death occurrence (adjusted PR = 1.15; 95 % CI 95 = 1.06 - 1.24).

CONCLUSIONS

The combined state was the most prevalent presentation of the hyperglycemic crisis, with a mortality rate similar to diabetic ketoacidosis. Invasive mechanical ventilation was associated with a higher occurrence of death.

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.

One third of cases of new-onset diabetic ketosis in adults are associated with ketosis-prone type 2 diabetes-A systematic review and meta-analysis

AIMS

Ketosis-prone type 2 diabetes was defined by the World Health Organization in 2019. According to the literature, the diagnosis is based on the presence of ketosis, islet autoantibody negativity and preserved insulin secretion. Our meta-analysis assessed the prevalence and clinical characteristics of ketosis-prone type 2 diabetes among patients hospitalised with diabetic ketoacidosis (DKA) or ketosis.

METHODS

The systematic search was performed in five main databases as of 15 October 2021 without restrictions. We calculated the pooled prevalence of ketosis-prone type 2 diabetes (exposed group) within the diabetic population under examination, patients with ketoacidosis or ketosis, to identify the clinical characteristics, and we compared it to type 1 diabetes (the comparator group). The random effects model provided pooled estimates as prevalence, odds ratio and mean difference (MD) with 95% confidence intervals.

RESULTS

Eleven articles were eligible for meta-analysis, thus incorporating 2010 patients of various ethnic backgrounds. Among patients presenting with DKA or ketosis at the onset of diabetes, 35% (95% CI: 24%-49%) had ketosis-prone type 2 diabetes. These patients were older (MD = 11.55 years; 95% CI: 5.5-17.6) and had a significantly higher body mass index (BMI) (MD = 5.48 kg/m2 ; 95% CI: 3.25-7.72) than those with type 1 diabetes.

CONCLUSIONS

Ketosis-prone type 2 diabetes accounts for one third of DKA or ketosis at the onset of diabetes in adults. These patients are characterised by islet autoantibody negativity and preserved insulin secretion. They are older and have a higher BMI compared with type 1 diabetes. C-peptide and diabetes-related autoantibody measurement is essential to identify this subgroup among patients with ketosis at the onset of diabetes.

Development and validation of a novel nomogram for prediction of ketosis-prone type 2 diabetes

Background

Ketosis-prone type 2 diabetes (KPD), as a unique emerging clinical entity, often has no clear inducement or obvious clinical symptoms at the onset of the disease. Failure to determine ketosis in time may lead to more serious consequences and even death. Therefore, our study aimed to develop and validate a novel nomogram to predict KPD.

Methods

In this retrospective study, clinical data of a total of 398 newly diagnosed type 2 diabetes in our hospital who met our research standards with an average age of 48.75 ± 13.86 years years old from January 2019 to December 2022 were collected. According to the occurrence of ketosis, there were divided into T2DM groups(228 cases)with an average age of 52.19 ± 12.97 years, of whom 69.74% were male and KPD groups (170cases)with an average age of 44.13 ± 13.72 years, of whom males account for 80.59%. Univariate and multivariate logistic regression analysis was performed to identify the independent influencing factors of KPD and then a novel prediction nomogram model was established based on these independent predictors visually by using R4.3. Verification and evaluation of predictive model performance comprised receiver-operating characteristic (ROC) curve, corrected calibration curve, and clinical decision curve (DCA).

Results

4 primary independent predict factors of KPD were identified by univariate and multivariate logistic regression analysis and entered into the nomogram including age, family history, HbA1c and FFA. The model incorporating these 4 predict factors displayed good discrimination to predict KPD with the area under the ROC curve (AUC) of 0.945. The corrected calibration curve of the nomogram showed good fitting ability with an average absolute error =0.006 < 0.05, indicating a good accuracy. The decision analysis curve (DCA) demonstrated that when the risk threshold was between 5% and 99%, the nomogram model was more practical and accurate.

Conclusion

In our novel prediction nomogram model, we found that age, family history, HbA1c and FFA were the independent predict factors of KPD. The proposed nomogram built by these 4 predictors was well developed and exhibited powerful predictive performance for KPD with high discrimination, good accuracy, and potential clinical applicability, which may be a useful tool for early screening and identification of high-risk population of KPD and therefore help clinicians in making customized treatment strategy.

Detecting Diabetic Ketoacidosis with Infection: Combating a Life-Threatening Emergency with Practical Diagnostic Tools

BACKGROUND

Diabetic ketoacidosis (DKA) is a life-threatening acute complication of diabetes mellitus and can lead to patient demise if not immediately treated. From the recent literature, the diabetic ketoacidosis mortality rate, depending on age, is 2-5%. Insulin discontinuation and infection remain the two most common triggers for diabetic ketoacidosis. About 50% of cases of ketoacidosis result from bacterial infections like urinary tract infections and pneumonia. It is also important to diagnose the presence of infection in diabetic ketoacidosis patients to prevent the excessive use of antibiotics, which may lead to antibiotic resistance. Although performing bacterial culture is confirmatory for the presence or absence of bacterial infection, the time required to obtain the result is long. At the same time, emergency treatment needs to be started as early as possible.

METHODS

This narrative review examines various septic markers to identify the appropriate tools for diagnosis and to distinguish between diabetic ketoacidosis with and without infection. Electronic databases were searched using the Google engine with the keywords "Diabetes Mellitus", "Diabetic Ketoacidosis", "Infection with Diabetic Ketoacidosis", "biomarkers for infection in Diabetic Ketoacidosis", "Procalcitonin", "Inflammatory cytokines in DKA", "Lactic acidosis in DKA", and "White blood cell in infection in DKA".

RESULTS

This narrative review article presents the options for diagnosis and also aims to create awareness regarding the gravity of diabetic ketoacidosis with infection and emphasizes the importance of early diagnosis for appropriate management. Diabetes mellitus is a clinical condition that may lead to several acute and chronic complications. Acute diabetic ketoacidosis is a life-threatening condition in which an excess production of ketone bodies results in acidosis and hypovolemia. Infection is one of the most common triggers of diabetic ketoacidosis. When bacterial infection is present along with diabetic ketoacidosis, the mortality rate is even higher than for patients with diabetic ketoacidosis without infection. The symptoms and biomarkers of diabetic ketoacidosis are similar to that of infection, like fever, C reactive protein, and white blood cell count, since both create an environment of systemic inflammation. It is also essential to distinguish between the presence and absence of bacterial infection to ensure the appropriate use of antibiotics and prevent antimicrobial resistance. A bacterial culture report is confirmatory for the existence of bacterial infection, but this may take up to 24 h. Diagnosis needs to be performed approximately in the emergency room upon admission since there is a need for immediate management. Therefore, researching the possible diagnostic tools for the presence of infection in diabetic ketoacidosis patients is of great importance. Several of such biomarkers have been discussed in this research work.

Characteristics of adult-onset auto-immune type 1 diabetes

BACKGROUND

Classically described as a disease of childhood and adolescence, diabetes mellitus type 1 (T1DM) can occur in adulthood. Adult-onset T1DM is poorly documented and is often misdiagnosed. This study aims to describe the epidemiological aspect of T1DM with adult-onset and detail its clinical, paraclinical, and therapeutic characteristics.

MATERIALS AND METHODS

A 9-year retrospective longitudinal study (2011-2019) was conducted including adult patients (age >20 years) with confirmed diabetes and at least one of the auto-antibodies (auto-Abs) to glutamic-acid-decarboxylase (GAD), to islet-tyrosine-phosphatase 2 (IA2) or islet-cell-antibodies (ICA) positive.

RESULTS

A total of 166 patients were included (sex-ratio M/F: 1.34; mean age: 28.6 years [20-56 years]). At the onset, 50.6% of patients presented with diabetic ketosis and 13.3% with diabetic ketoacidosis. Cardinal symptoms of diabetes were present in 30.7% of patients only at diagnosis, while the discovery was fortuitous in 5.4% of cases. 27.7% of patients developed an additional auto-immune disease mainly autoimmune thyroid disease. The risk of developing another AUTO-IMMUNE DISEASE was highest in females (p = 0.010) and increased with age (p = 0.011). GAD-Abs, IA2-Abs, and ICA were positive in 98.2%, 13.3%, and 17.4% of cases respectively. Only GAD-Abs were found positive in 73.1%. Upon diagnosis, 75.9% of patients were treated with insulin, while 24.1% of patients were initially put on oral anti-diabetic drugs before requiring insulin within an average of 7.42 months.

CONCLUSIONS

Adult-onset T1DM has a different clinical course (slower onset, less abrupt symptoms, more insidious presentation, and more prolonged progression to insulin) that has to be known. Misdiagnosis of adult-onset T1DM can have serious consequences.

Clinical and biochemical predictors of intensive care unit admission among patients with diabetic ketoacidosis

BACKGROUND

Diabetic ketoacidosis (DKA) contributes to 94% of diabetes-related hospital admissions, and its incidence is rising. Due to the complexity of its management and the need for rigorous monitoring, many DKA patients are managed in the intensive care unit (ICU). However, studies comparing DKA patients managed in ICU to non-ICU settings show an increase in healthcare costs without significantly affecting patient outcomes. It is, therefore, essential to identify suitable candidates for ICU care in DKA patients.

AIM

To evaluate factors that predict the requirement for ICU care in DKA patients.

METHODS

This retrospective study included consecutive patients with index DKA episodes who presented to the emergency department of four general hospitals of Hamad Medical Corporation, Doha, Qatar, between January 2015 and March 2021. All adult patients (> 14 years) fulfilling the American Diabetes Association criteria for DKA diagnosis were included.

RESULTS

We included 922 patients with DKA in the final analysis, of which 229 (25%) were managed in the ICU. Compared to non-ICU patients, patients admitted to ICU were older [mean (SD) age of 40.4 ± 13.7 years vs 34.5 ± 14.6 years; P < 0.001], had a higher body mass index [median (IQR) of 24.6 (21.5-28.4) kg/m² vs 23.7 (20.3-27.9) kg/m²; P < 0.030], had T2DM (61.6%) and were predominantly males (69% vs 31%; P < 0.020). ICU patients had a higher white blood cell count [median (IQR) of 15.1 (10.2-21.2) × 10³/uL vs 11.2 (7.9-15.7) × 10³/uL, P < 0.001], urea [median (IQR) of 6.5 (4.6-10.3) mmol/L vs 5.6 (4.0-8.0) mmol/L; P < 0.001], creatinine [median (IQR) of 99 (75-144) mmol/L vs 82 (63-144) mmol/L; P < 0.001], C-reactive protein [median (IQR) of 27 (9-83) mg/L vs 14 (5-33) mg/L; P < 0.001] and anion gap [median (IQR) of 24.0 (19.2-29.0) mEq/L vs 22 (17-27) mEq/L; P < 0.001]; while a lower venous pH [mean (SD) of 7.10 ± 0.15 vs 7.20 ± 0.13; P < 0.001] and bicarbonate level [mean (SD) of 9.2 ± 4.1 mmol/L vs 11.6 ± 4.3 mmol/L; P < 0.001] at admission than those not requiring ICU management of DKA (P < 0.001). Patients in the ICU group had a longer LOS [median (IQR) of 4.2 (2.7-7.1) d vs 2.0 (1.0-3.9) d; P < 0.001] and DKA duration [median (IQR) of 24 (13-37) h vs 15 (19-24) h, P < 0.001] than those not requiring ICU admission. In the multivariate logistic regression analysis model, age, Asian ethnicity, concurrent coronavirus disease 2019 (COVID-19) infection, DKA severity, DKA trigger, and NSTEMI were the main predicting factors for ICU admission.

CONCLUSION

In the largest tertiary center in Qatar, 25% of all DKA patients required ICU admission. Older age, T2DM, newly onset DM, an infectious trigger of DKA, moderate-severe DKA, concurrent NSTEMI, and COVID-19 infection are some factors that predict ICU requirement in a DKA patient.

Systemic Infection Predictive Value of Procalcitonin to Lactic Acid Ratio in Diabetes Ketoacidosis Patients

INTRODUCTION

Early detection of bacterial infections associated with adequate antibiotic treatment is key to improving diabetic ketoacidosis (DKA) outcomes. Our study aimed to investigate the different sepsis markers (including procalcitonin to lactic acid ratio, PLR) to diagnose bacterial infection in patients with DKA within one hour after admission.

METHODS

A total of 165 patients diagnosed with DKA were enrolled between July 2014 and July 2018 and divided into an infection group (N =62) and a non-infection group (N=103) based on the positive aetiological tests such as blood culture, sputum culture, urine culture, or definite focus of pulmonary, soft tissue, kidney, etc.

RESULTS

Our findings suggest the following: 1) leucocytes (threshold above 10×10⁹ /L) and PLR (threshold above 0.438) within one hour after admission can help to identify patients with infection in the context of DKA. 2) A subgroup analysis demonstrated that PLR also has a high diagnostic efficacy for infection in patients with DKA, regardless of the type of diabetes.

CONCLUSION

This study concludes that leucocyte count (threshold > 10×10⁹/L) and PLR (threshold above 0.438) show a diagnostic value to help distinguish DKA patients with infection. By combining these two markers, the reduction of antibiotic misuse may be possible.

Clinical, psychological and demographic factors in a contemporary adult cohort with diabetic ketoacidosis and type 1 diabetes

BACKGROUND

Diabetic ketoacidosis (DKA) is a potentially life-threatening but often preventable acute complication of type 1 diabetes (T1D). Understanding clinical and psychosocial characteristics of people with DKA, particularly those with multiple presentations, may aid the development of prevention strategies.

AIMS

To describe clinical, psychological and demographic factors in adults with DKA and particularly those factors associated with recurrent admissions.

METHODS

A retrospective analysis was performed of all admissions with DKA in people with T1D over a 4-year period from 1 November 2013 to 31 October 2017 at a metropolitan tertiary hospital in Australia. Potential cases were identified by International Classification of Diseases-10th Revision coding data. Data were then manually extracted by clinicians from the electronic medical record.

RESULTS

There were 154 clinician-adjudicated admissions for DKA among 128 people with T1D. Of these, 16 (13%) had multiple DKA admissions. Forty-one (32%) had a history of depression. The most common factors contributing to presentation included insulin omission (54%), infection (31%), alcohol excess (26%) and new diabetes diagnosis (16%). Compared to people with single admissions, those with recurrent DKA were more likely to smoke (69% vs 27%, P = 0.003), be unemployed (31% vs 11%, P = 0.04) and use illicit substances (44% vs 17%, P = 0.02).

CONCLUSIONS

There is a high prevalence of psychiatric illness, illicit substance use and social disadvantage among people admitted with DKA, particularly those with recurrent presentations. Insulin omission, often due to inappropriate sick day management, was the most common reason for DKA occurrence. Innovative multidisciplinary models of care are required to address these challenges.

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.

Factors Associated with Acute Complications among Individuals with Type 1 Diabetes in China: The 3C Study

Background: To identify the sociodemographic and clinical characteristics related to the occurrence of diabetic ketoacidosis (DKA) and frequent hypoglycemia in children, adolescents and adults with type 1 diabetes in China.Methods: The 3C Study was an epidemiological study that recruited 849 type 1 diabetes patients aged 0-78 years in Beijing and Shantou, China. Separate logistic regression models were used to evaluate the association of sociodemographic and clinical factors with the occurrence of DKA in the past 12 months or frequent hypoglycemia (≥5 episodes) in the past 7 days.Results: Children and adolescents were significantly more likely to have DKA in the past 12 months compared to adults: odds ratio (OR) and (95% confidence interval [CI]), 4.67 (1.90, 11.52) for <13 years and 4.00 (1.59, 10.10) for 13 to <19 years. Underweight participants were also more likely to have DKA relative to normal weight participants: OR (95% CI), 6.87 (2.64, 17.87). Children and participants who did not receive diabetes education in the past 12 months were more likely to have frequent hypoglycemia: OR (95% CI), 2.95 (1.23, 7.06) and 7.67 (1.77, 13.2), respectively. Participants who reported self-monitoring of blood glucose ≤2 times/week (ref: 7 times/week) and participants who had higher HbA1c levels were less likely to have frequent hypoglycemia: OR (95% CI), 0.14 (0.03, 0.64) and 0.78 (0.63, 0.96), respectively. Gender, family income, parent education, health insurance coverage, diabetes duration, and insulin administration method were not significantly associated with DKA or frequent hypoglycemia in this sample.Conclusions: Children, adolescents and underweight individuals with type 1 diabetes in China were more likely to report DKA, and children, individuals without adequate diabetes education, and those with lower HbA1c levels were more likely to have frequent hypoglycemia. These patients should be targeted for preventive interventions.

Intractable hiccups as a rare gastrointestinal manifestation in severe endocrine and metabolic crisis: case report and review of the literature

Diabetic ketoacidosis (DKA) and thyroid storm (TS) are severe metabolic and endocrine disorders. Both usually manifest with multiple systemic clinical signs and symptoms, and digestive symptoms, such as nausea and vomiting, are most common in these patients. Moreover, the presence of a concurrent severe or rare complication may worsen the condition or even cause death due to misdiagnosis, delayed diagnosis, or inappropriate treatment. The identification of these symptoms is usually closely related to the severity and prognosis of the disease. Although clinical prognosis might be improved by prompt diagnosis and aggressive treatment, some rare and insidious metabolic complications are difficult to identify early. Moreover, life-threatening gastrointestinal symptoms are very rare in patients with DKA and TS. Here, we report an inpatient diagnosed with DKA and Graves' disease who developed life-threatening intractable hiccups resulting in TS and respiratory failure during the treatment of DKA. In addition, we review the literature to discuss the possible underlying mechanism of intractable hiccups in the development of TS.

Clinical characteristics and outcomes of care in adult patients with diabetic ketoacidosis: A retrospective study from a tertiary diabetes center in Thailand

Background

Diabetic ketoacidosis (DKA) is a metabolic catastrophe which could occur in any type of diabetes. Even when fundamental key points of DKA treatment had been followed, some differences exist in treatment protocols in each physician, highlighting the need to assess adherence to DKA guideline.

Aim

This study aimed to examine trend of hospitalized DKA patients and outcomes of treatment over a decade at Theptarin Hospital, a multi-discipline based diabetes center in Thailand.

Method

A retrospective study of DKA episodes admitted over a 14-year period (2005–2018) was done. Clinical characteristics, laboratory data, type of diabetes, severity of DKA were collected and analyzed.

Results

A total of 94 DKA episodes occurred in 81 diabetic patients (females 61.5%, mean age 47.4 ± 20.4 years, T1DM 41.5%, T2DM 50.0%, Ketosis-prone diabetes 8.5%, baseline A1C 10.8 ± 3.0%). While infection was the common precipitating factor in T2DM, omission of insulin was the usual precipitating factor in T1DM. During ongoing management, 26.6% of patients developed hypokalemia and supplementation was not prescribed as per protocol in this group of patients. Almost 13% of patients experienced hypoglycemia in the first 24 h. Median time to resolution of DKA was 8.5 h. Four T2DM patients expired from the precipitating cause of DKA which accounted for mortality rate at 4.3% in our study.

Conclusions

Inadequate metabolic monitoring and iatrogenic hypoglycemia remain areas of concern for DKA management. Occurrence of hypokalemia was related to poor adherence to protocol guidance on potassium supplementation. A strengthened educational program for nursing and medical staffs should be emphasized.

Characteristics of hyperglycemic crises in an adult population in a teaching hospital in Colombia

Background

Hyperglycemic crisis are the most serious forms of acute decompensation of diabetes mellitus and require urgent medical attention. The epidemiological data of these conditions in Latin America are scarce and in Colombia unknown, that is why we decided to describe the clinical characteristics and factors associated with the mortality of adults who presented with hyperglycemic crises in a teaching hospital in Colombia.

Materials and methods

Retrospective cohort study of all episodes of hyperglycemic crisis treated in Pablo Tobón Uribe Hospital in a three-year period.

Results

The records of 2233 hospitalization episodes related to diabetes mellitus were review, the prevalence of hyperglycemic crises was 2%, half of the events were diabetic ketoacidosis and 57% of the events occurred in people with type 2 diabetes mellitus, 32% of the events were precipitated by an infection and 27% by and inadequate therapy. The average hospital length of stay was 14 ± 3 days and the mortality rate 2.27%.

Conclusions

In a teaching hospital in Latin America hyperglycemic crises are common, with diabetic ketoacidosis being the most frequent, and in a significant number of cases may be preventable. The hospital length of stay in our population is longer than reported in the literature.

Early Occurrence Cases of Diabetes Mellitus: Clinical Picture in Two Major Tertiary Care Hospitals in India

INTRODUCTION

Type 1 diabetes mellitus (T1D) is one of the most common endocrine diseases in childhood. However, very limited information is available on this disease.

OBJECTIVES

This study was done to assess risk factors, clinical features and management practices in T1D patients.

METHODS

A review of records of 39 T1D cases admitted over the past five years in two hospitals was done.

RESULTS

The mean age at diagnosis among males (n=21) was 19.9±10.3 years and among females (n=18) was 12.3±7.5 years (t=2.614, p=0.013). Mean age at diagnosis of patients who were underweight (n=7) was 9.9±4.4 years, compared to 17.8±10.1 years among patients (n=32) with normal or overweight status (t=2.028, p=0.05). The family history of T1D was present among 7(18.0%) cases. The most common symptoms among the cases were fatigue 22(56.4%), polyuria 19(48.7%) and polydipsia 18(46.1%). The most common sign was weight loss 27(69.2%). The most common complications were diabetic nephropathy and skin infections seen each among 10(25.6%) cases. Mean duration of T1D was significantly more among patients with diabetic nephropathy (p<0.001), compared to those without. Mean HbA1c value among patients was 12.9±2.7. It was significantly more among patients with Diabetic Ketoacidosis (DKA) (p=0.012). A short-acting insulin was used in the management of T1D among 59.5% cases. The outcome of the management showed a loss of one patient who developed DKA.

CONCLUSION

Routine growth monitoring and blood glucose analysis is required among T1D cases. The present study provides a database of risk factors, clinical features, and management practices among patients with T1D in this region and addresses several issues important to both patients and their care providers.

Plasma glucose to glycated hemoglobin ratio: Method of differentiating fulminant type 1 diabetes from diabetic ketoacidosis

OBJECTIVES

In fulminant type 1 diabetes mellitus (fT1DM), plasma glucose (PG) levels are strongly increased, unlike glycated hemoglobin (HbA_1C) levels, resulting in a sharply increased PG/HbA_1C ratio. We investigated the PG/HbA_1C ratio in fT1DM and tested the accuracy of cutoff points to easily and efficiently differentiate fT1DM from diabetic ketoacidosis (DKA).

METHODS

We report 41 cases of fT1DM in which PG/HbA_1C ratio was studied as a novel clinical parameter to predict fT1DM. Clinical and biochemical characteristics were analyzed in 41 fT1DM and 51 DKA patients in China. Receiver-operating characteristic curve analysis was used to identify PG/HbA_1C ratio cutoff points to differentiate fT1DM from DKA.

RESULTS

PG/HbA_1C ratio was significantly higher in fT1DM patients (7.24±2.49mmol/L/%; i.e., 0.88±0.36L/mol) than in DKA patients (2.60±0.69mmol/L/%; i.e., 0.06±0.01L/mol) (P<0.001). PG/HbA_1C ratio exceeded 4.2mmol/L/% (i.e., 0.6 l/mol) in 39 of the 41 fT1DM patients (95.1%), versus only 1 of the 51 DKA patients (1.9%).

CONCLUSIONS

PG/HbA_1C ratio is a simple tool that may be useful to identify DKA patients at high risk of fT1DM. PG/HbA_1C ratio with a threshold of≥4.2mmol/L/% (i.e., 0.6L/mol) can be adopted as a new clinical parameter in predicting fT1DM.

Clinical study of pregnancy-associated fulminant type 1 diabetes

BACKGROUND

Studies reported that fulminant type 1 diabetes (fT1DM) can occurred during pregnancy or within 2 weeks after delivery, and was defined as pregnancy-associated fulminant type 1 diabetes (PF). In PF patients, plasma glucose (PG) levels have an abrupt rise while glycated hemoglobin (HbA_1C) levels are not markedly elevated, resulting in a sharply increased PG/HbA_1C ratio.

METHODS

We studied 30 PF patients, 21 non-pregnant fulminant type 1 diabetes (NPF) patients, and 26 female patients of child-bearing age (13-49 years) with diabetic ketoacidosis (DKA), all from China. We analyzed the PG/HbA_1C ratio among these groups, with the goal of finding a method for predicting PF. The clinical and biochemical characteristics of the PF and NPF patients were analyzed and compared with the characteristics of the DKA patients. In order to detect PF in DKA patients, receiver-operating characteristic curves analysis was used to identify the cut-off points of the PG/HbA_1C ratio.

RESULTS

When we compared the clinical characteristics of these three groups, we found that the onset of hyperglycemic symptoms, arterial PH value, serum potassium, PG, HbA_1C, fasting and postprandial serum C-peptide concentration, glutamic acid decarboxylase (GAD) antibodies positivity were all significantly different (P < 0.001). The PG/HbA_1C ratio was significantly higher in PF and NPF patients (5.29 ± 1.39 and 6.38 ± 2.62) than in DKA patients (1.93 ± 0.55; P < 0.001). Receiver-operating characteristic (ROC) curves analyses showed that PG/HbA_1C ratio at a cut-off value of 3.3 resulted in the highest Youden index, with corresponding sensitivity of 93 and 100% specificity for identifying PF from DKA.

CONCLUSIONS

PF patients showed a more severe acidosis, with maternal and fetal mortality rates being high. PG/HbA_1C ratio with a threshold of ≥3.3 can be used as a cut-off point in predicting PF from DKA in China. Elevated PG/HbA_1C ratio at the time of diagnosis is predictive for more severe insulin secretion dysfunction and poor prognosis.

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.

Blood Ketones: Measurement, Interpretation, Limitations, and Utility in the Management of Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) remains a common medical emergency. Over the last few years, new national guidelines have changed the focus in managing the condition from being glucose-centered to ketone-centered. With the advent of advancing technology and the increasing use of hand-held, point-of-care ketone meters, greater emphasis is placed on making treatment decisions based on these readings. Furthermore, recent warnings about euglycemic DKA occurring in people with diabetes using sodium-glucose co-transporter 2 (SGLT-2) inhibitors urge clinicians to inform their patients of this condition and possible testing options. This review describes the reasons for a change in treating DKA, and outlines the benefits and limitations of using ketone readings, in particular highlighting the difference between urine and capillary readings.