In the Journals

Mortality risk heightened with diabetic ketoacidosis plus hyperosmolar hyperglycemic state

Mortality risk is higher for adults admitted to the hospital with both diabetic ketoacidosis and hyperosmolar hyperglycemic state, than for those presenting with either condition alone, and this risk can be exacerbated if severe hypokalemia or hypoglycemia occur, according to findings published in Diabetes Care.

Francisco J. Pasquel

Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are severe acute complications of diabetes. When patients present with DKA and HHS simultaneously, they have worse outcomes compared to patients presenting with isolated crises,” Francisco J. Pasquel, MD, MPH, assistant professor of medicine in the department of endocrinology at Emory University, told Endocrine Today. “[This research] is important because it included a large number of patients with complete data at the individual level, and it included a large number of patients with HHS, a poorly studied condition.”

Pasquel and colleagues identified 1,211 patients who were admitted to Emory University Hospital or Emory University Hospital Midtown with hyperosmolar hyperglycemic state, diabetic ketoacidosis or both from June 2005 to June 2015, with data obtained through the Clinical Data Warehouse program. The researchers also assessed hypoglycemia and hypokalemia occurrences in the month after the hospital visit as well as mortality.

The researchers identified DKA in 465 individuals (mean age, 43 years; 53% women), hyperosmolar hyperglycemic state in 421 individuals (mean age, 57 years; 50% women) and both presenting together in 325 individuals (mean age, 49 years; 52% women). The mortality rate of those with both conditions was 8% compared with rates of 5% for those with hyperosmolar hyperglycemic state and 3% for those with DKA (P = .003). Compared with those with hyperosmolar hyperglycemic state, those with both conditions were at higher mortality risk (HR = 2.7; 95% CI, 1.4-5.3). In addition, when compared with those with DKA, those with hyperosmolar hyperglycemic state and DKA were at higher mortality risk (HR = 1.8; 95% CI, 0.9-3.6).

“We do not know whether patients with combined features of DKA and hyperosmolar hyperglycemic state need to be treated differently compared with patients with isolated DKA or hyperosmolar hyperglycemic state,” the researchers wrote. “We recommend that providers taking care of patients with hyperglycemic crises use insulin infusion algorithms with a low risk of hypoglycemia and monitor and replete potassium levels closely, particularly among patients with DKA-hyperosmolar hyperglycemic state.”

When assessing hypoglycemia and hypokalemia, the researchers defined severe hypoglycemia as blood glucose of less than 40 mg/dL and severe hypokalemia as potassium of less than 2.5 mEq/L. During the first 2 days of hospital treatment, individuals in all three groups had higher odds of mortality if severe hypoglycemia (OR = 3.17; 95% CI, 1.49-6.76) or severe hypokalemia (adjusted OR = 4.81; 95% CI, 1.38-16.83) occurred. 

“We found that low potassium levels during the first 48 hours of admission are very common during all hyperglycemic crises and that severely low levels are associated with higher mortality,” Pasquel said. “Severe hypoglycemia during the first 48 hours was also associated with higher mortality.” – by Phil Neuffer

Disclosures: The authors report no relevant financial disclosures.

Mortality risk is higher for adults admitted to the hospital with both diabetic ketoacidosis and hyperosmolar hyperglycemic state, than for those presenting with either condition alone, and this risk can be exacerbated if severe hypokalemia or hypoglycemia occur, according to findings published in Diabetes Care.

Francisco J. Pasquel

Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are severe acute complications of diabetes. When patients present with DKA and HHS simultaneously, they have worse outcomes compared to patients presenting with isolated crises,” Francisco J. Pasquel, MD, MPH, assistant professor of medicine in the department of endocrinology at Emory University, told Endocrine Today. “[This research] is important because it included a large number of patients with complete data at the individual level, and it included a large number of patients with HHS, a poorly studied condition.”

Pasquel and colleagues identified 1,211 patients who were admitted to Emory University Hospital or Emory University Hospital Midtown with hyperosmolar hyperglycemic state, diabetic ketoacidosis or both from June 2005 to June 2015, with data obtained through the Clinical Data Warehouse program. The researchers also assessed hypoglycemia and hypokalemia occurrences in the month after the hospital visit as well as mortality.

The researchers identified DKA in 465 individuals (mean age, 43 years; 53% women), hyperosmolar hyperglycemic state in 421 individuals (mean age, 57 years; 50% women) and both presenting together in 325 individuals (mean age, 49 years; 52% women). The mortality rate of those with both conditions was 8% compared with rates of 5% for those with hyperosmolar hyperglycemic state and 3% for those with DKA (P = .003). Compared with those with hyperosmolar hyperglycemic state, those with both conditions were at higher mortality risk (HR = 2.7; 95% CI, 1.4-5.3). In addition, when compared with those with DKA, those with hyperosmolar hyperglycemic state and DKA were at higher mortality risk (HR = 1.8; 95% CI, 0.9-3.6).

“We do not know whether patients with combined features of DKA and hyperosmolar hyperglycemic state need to be treated differently compared with patients with isolated DKA or hyperosmolar hyperglycemic state,” the researchers wrote. “We recommend that providers taking care of patients with hyperglycemic crises use insulin infusion algorithms with a low risk of hypoglycemia and monitor and replete potassium levels closely, particularly among patients with DKA-hyperosmolar hyperglycemic state.”

When assessing hypoglycemia and hypokalemia, the researchers defined severe hypoglycemia as blood glucose of less than 40 mg/dL and severe hypokalemia as potassium of less than 2.5 mEq/L. During the first 2 days of hospital treatment, individuals in all three groups had higher odds of mortality if severe hypoglycemia (OR = 3.17; 95% CI, 1.49-6.76) or severe hypokalemia (adjusted OR = 4.81; 95% CI, 1.38-16.83) occurred. 

“We found that low potassium levels during the first 48 hours of admission are very common during all hyperglycemic crises and that severely low levels are associated with higher mortality,” Pasquel said. “Severe hypoglycemia during the first 48 hours was also associated with higher mortality.” – by Phil Neuffer

Disclosures: The authors report no relevant financial disclosures.