Differences in clinical characteristics and outcomes according to subtypes of hyperglycemic crises Open Access

Pasquel, Francisco (2016)

Permanent URL: https://etd.library.emory.edu/concern/etds/r781wg88q?locale=en


ABSTRACT Differences in Clinical Characteristics and Outcomes According to Subtypes of Hyperglycemic Crises By Francisco Pasquel, M.D. Background: Many patients with hyperglycemic crises present with combined features of diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). Methods: This study aimed to determine the proportional distribution of hyperglycemic crises (isolated HHS, isolated DKA and combined DKA-HHS) in adult patients admitted to two academic centers between 2005 and 2015. Results: Among 1211 patients, 465 (38%) had DKA (ICD-code and bicarbonate <18 mEq/L on presentation), 421 (35%) patients had HHS (ICD-code, effective osmolality >=300, and bicarbonate >18 mEq/L) and 325 (27%) had combined features of DKA-HHS (DKA + osmolality >=300). HHS patients were older, more likely to be African American, and had higher BMI. Cerebral edema and rhabdomyolysis were uncommon. Age was independently associated with increased mortality [adjusted OR (aOR): 1.05, 95% confidence interval (CI): 1.03-1.07]. After adjusting for age, gender, BMI and race, subjects with combined DKA-HHS had higher mortality compared to subjects with isolated hyperglycemic crises (aOR: 2.5, CI: 1.4-4.6). Hypokalemia (<3mEq/L) was common (N:326, 27.37%) but did not differ among groups. Severe hypokalemia (potassium <2.5 mEq/L) occurred in 75 subjects (6.3%) and was associated with increase in mortality (OR 3.17, 95% CI: 1.49, 6.76). This association remained significant after adjusting for hyperglycemic crises categories, demographic variables and metabolic parameters on admission (aOR 4.49, 95% CI: 1.82, 11.0.9). A combination of age (>50 years) and effective osmolality (>=300 mOsm/kg) increases the sensitivity and specificity (c-statistic: 0.70) to discriminate case fatalities. Conclusions: A combination of HHS and DKA increase the risk of mortality among patients presenting with hyperglycemic crises. Predictors of mortality included age, effective osmolality, and severe hypokalemia. Revision of current hyperglycemic crises subtypes classification and diagnostic criteria for hyperosmolality may be considered.

Table of Contents

TABLE OF CONTENTS Introduction 1 Methods 2 Data source 2 Data analysis 3 Results 4 Hyperglycemic crises categories and mortality 5 Diagnostic criteria parameters on admission and hospital mortality 5 Acute complications 6 Discussion 7 Conclusions 10 References 11 Tables 13 Figures 16

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