Acute glycemic variability and mortality of patients with acute stroke: a meta-analysis

Association between glycemic variability and short-term mortality in patients with acute kidney injury: a retrospective cohort study of the MIMIC-IV database

Acute kidney injury (AKI) represents a significant challenge to global public health problem and is associated with poor outcomes. There is still considerable debate about the effect of mean blood glucose (MBG) and coefficient of variation (CV) of blood glucose on the short-term mortality of AKI patients. This retrospective cohort study aimed to explore the association between glycemic variability and short-term mortality in patients with AKI. Data from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database were analyzed, including 6,777 adult AKI patients. MBG and CV on the first day of ICU admission were calculated to represent the overall glycemic status and variability during the ICU stay in AKI patients. The primary outcome indicator was ICU 30-day mortality of AKI patients. Multivariate Cox regression analysis and smoothed curve fitting were used to assess the relationship between blood glucose levels and mortality. Eventually, the ICU 30-day mortality rate of AKI patients was 23.5%. The increased MBG and CV were significantly correlated with ICU 30-day mortality (hazards ratio (HR) = 1.20, 95% confidence interval (CI) 1.14-1.27; HR = 1.08, 95% CI 1.03-1.13). The smoothed curve fitting showed a U-shaped relationship between MBG on the first day of ICU admission and ICU 30-day mortality (inflection point = 111.3 mg/dl), while CV had a linear relationship with 30-day ICU mortality. Thus, we conclude that MBG and CV were significantly associated with short-term mortality in intensive care patients with AKI. Tighter glycemic control may be an effective measure to improve the prognosis of patients with AKI.

Postoperative Insulin Dose for Cardiac Artery Bypass Graft and Other Cardiac Surgeries in Patients with Type 2 Diabetes: A Retrospective Study

Purpose

Recommendations on perioperative glycemic control in cardiac surgery are based on coronary artery bypass graft surgery (CABG), though coronary artery disease and valvular disease are pathologically distinct. We aimed to compare the postoperative insulin requirement between CABG and other cardiac surgeries in type 2 diabetic patients and identify predictive factors for the maximum postoperative insulin dose.

Patients and Methods

We retrospectively included 60 Japanese patients with diabetes/glucose intolerance (HbA1c > 37 mmol/mol [5.6%]) who were hospitalized for cardiovascular surgery between April 2017 and March 2019. We categorized the subjects into the CABG and non-CABG groups, and performed subgroup analysis on patients who received postoperative insulin therapy.

Results

The CABG group required a significantly higher insulin dose on postoperative days 2, 5, 6, and 7, and a significantly higher maximum postoperative insulin dose (24.6 U vs 9.7 U, P < 0.001) than the non-CABG group. Multivariate linear regression analyses showed that the independent determinants of the maximum postoperative insulin dose were HbA1c and duration of diabetes in the non-CABG group, and HbA1c in the CABG group.

Conclusion

CABG had a higher postoperative insulin requirement than other cardiovascular surgeries; early aggressive insulin therapy is indicated, especially for patients with higher HbA1c levels/longer duration of diabetes.

Acute Glycemic Variability and Early Outcomes After Cardiac Surgery: A Meta-Analysis

The influence of acute glycemic variability (GV) on early outcomes of patients after cardiac surgery remains not fully determined. We performed a systematic review and meta-analysis to evaluate the association between acute GV and in-hospital outcomes of patients after cardiac surgery. Relevant observational studies were obtained by search of electronic databases including Medline, Embase, Cochrane Library, and Web of Science. A randomized-effects model was selected to pool the data by incorporating the influence of potential heterogeneity. Nine cohort studies involving 16 411 patients after cardiac surgery were included in this meta-analysis. Pooled results showed that a high acute GV was associated with an increased risk of major adverse events (MAE) during hospitalization for patients after cardiac surgery [odds ratio [OR]: 1.29, 95% CI: 1.15 to 1.45, p<0.001, I22=38%]. Sensitivity analysis limited to studies of on-pump surgery and GV evaluated by coefficient of variation of blood glucose showed similar results. Subgroup analysis suggested that a high acute GV was related to an increased incidence of MAE in patients after coronary artery bypass graft, but not for those after isolated valvular surgery (p=0.04), and the association was weakened after adjustment of glycosylated hemoglobin (p=0.01). Moreover, a high acute GV was also related to an increased risk of in-hospital mortality (OR: 1.55, 95% CI: 1.15 to 2.09, p=0.004; I22=0%). A high acute GV may be associated with poor in-hospital outcomes in patients after cardiac surgery.

Glycemic Variability and Prognosis of Patients with Intracerebral Hemorrhage: A Meta-Analysis

Glycemic disorder may affect the outcomes of patients with intracerebral hemorrhage (ICH). However, the association between glycemic variability (GV) and prognosis in these patients remains to be determined. We performed a meta-analysis to compressive the influence of GV on functional outcome and mortality in patients with ICH. Observational studies comparing the risks of poor functional outcome (defined as modified Rankin Scale>2) and all-cause mortality between ICH patients with higher versus lower acute GV were retrieved by systematic search of Medline, Web of Science, Embase, CNKI, and Wanfang databases. A random-effect model was used to pool the data after incorporating the between-study heterogeneity. Sensitivity analyses were performed to evaluate the stability of the findings. Eight cohort studies involving 3400 patients with ICH were included in the meta-analysis. The follow-up duration was within 3 months after admission. All of the included studies used standard deviation of blood glucose (SDBG) as the indicator of acute GV. Pooled results showed that ICH patients with higher SDBG were associated with a higher risk of poor functional outcome as compared to those with lower SDBG [risk ratio (RR): 1.84, 95% confidence interval (CI): 1.41 to 2.42, p<0.001, I2=0%]. In addition, patients with higher category of SDBG were also associated with a higher mortality risk (RR: 2.39, 95% CI: 1.79 to 3.19, p<0.001, I2=0%). In conclusion, high acute GV may be a predictor of poor functional outcome and mortality of patients with ICH.

A review of stress-induced hyperglycaemia in the context of acute ischaemic stroke: Definition, underlying mechanisms, and the status of insulin therapy

The transient elevation of blood glucose produced following acute ischaemic stroke (AIS) has been described as stress-induced hyperglycaemia (SIH). SIH is common even in patients with AIS who have no previous diagnosis of diabetes mellitus. Elevated blood glucose levels during admission and hospitalization are strongly associated with enlarged infarct size and adverse prognosis in AIS patients. However, insulin-intensive glucose control therapy defined by admission blood glucose for SIH has not achieved the desired results, and new treatment ideas are urgently required. First, we explore the various definitions of SIH in the context of AIS and their predictive value in adverse outcomes. Then, we briefly discuss the mechanisms by which SIH arises, describing the dual effects of elevated glucose levels on the central nervous system. Finally, although preclinical studies support lowering blood glucose levels using insulin, the clinical outcomes of intensive glucose control are not promising. We discuss the reasons for this phenomenon.

Clinical relevance of glucose metrics during the early brain injury period after aneurysmal subarachnoid hemorrhage: An opportunity for continuous glucose monitoring

Hyperglycaemia, hypoglycaemia and higher glucose variability during the Early Brain Injury (EBI) period of aneurysmal subarachnoid hemorrhage (aSAH) have been associated with poor clinical outcome. However, it is unclear whether these associations are due to direct glucose-driven injury or if hyperglycaemia simply acts as a marker of initial severity. Actually, strict glucose control with intensive insulin therapy has not been demonstrated as an effective strategy for improving clinical outcomes after aSAH. Currently published studies describing an association between hyperglycaemia and prognosis in aSAH patients have been based on isolated glucose measurements and did not incorporate comprehensive dynamic evaluations, such as those derived from subcutaneous continuous glucose monitoring devices (CMG). Arguably, a more accurate knowledge on glycaemic patterns during the acute phase of aSAH could increase our understanding of the relevance of glycaemia as a prognostic factor in this disease as well as to underpin its contribution to secondary focal and diffuse brain injury. Herein, we have summarized the available evidence on the diagnostic and prognostic relevance of glucose metrics during the acute phase of cerebrovascular diseases, focusing in the EBI period after aSAH. Overall, obtaining a more precise scope of acute longitudinal glucose profiles could eventually be useful for improving glucose management protocols in the setting of acute aSAH and to advance toward a more personalized management of aSAH patients during the EBI phase.