medwireNews: A study of more than a thousand patients suggests that having both diabetic ketoacidosis (DKA) and a hyperosmolar hyperglycemic state (HHS) on arrival at hospital leads to more than twice the likelihood of death there than either condition alone.
Among 1211 patients with a first admission for confirmed hyperglycemic crisis at two US academic hospitals during a 10-year period, one in four (27%) had combined features of DKA and HHS compared with 38% with isolated DKA and 35% with isolated HHS.
Overall, 8% of the DKA–HHS patients died in hospital compared 5% with isolated HHS and 3% with isolated DKA, so that DKA–HHS was associated with a hazard ratio for death of 2.7 compared with isolated HHS and of 1.8 compared with isolated DKA after adjusting for age, sex, body mass index, and comorbidity.
The researchers add: “We also observed that the development of hypoglycemia and hypokalemia, two common complications related to insulin therapy, are associated with increased mortality independently of hyperglycemic crises categories.”
Hypoglycemia while in hospital, defined as plasma glucose below 40 mg/dL (2.22 mmol/L), occurred in just 2% of each of the subtypes of hyperglycemic crises but its development within 48 hours of admission was associated with a 4.8-fold increase in risk for hospital death after adjusting for demographic variables and hyperglycemic crisis categories.
Hypokalemia was much more common, and occurred within 48 hours of hospital admission in 62% of the DKA–HHS group, 54% of the isolated DKA group and 51% of the isolated HHS group.
Patients with combined DKA–HHS had the lowest potassium levels during this period, despite having the highest levels on entry to hospital; severe hypokalemia (potassium <2.5 mEq/L) within 48 hours of admission occurred in 34 patients and was associated with a 4.9-fold increased likelihood of mortality after adjusting for potential confounders.
“Our results provide estimates that highlight the importance of identifying patients with concomitant DKA and HHS, a distinctive high-risk category,” note Francisco Pasquel and colleagues at Emory University in Atlanta, Georgia, USA.
Reporting their findings in Diabetes Care, they add: “Our results highlight the strong association between hypoglycemia and hypokalemia with mortality and raise awareness for the need to implement effective protocols to closely monitor both glucose and potassium levels during insulin therapy.”
By Anita Chakraverty
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