A nationwide study of adults admitted to hospital with diabetic ketoacidosis or hyperosmolar hyperglycaemic state and COVID‐19

AimsTo investigate characteristics of people hospitalized with coronavirus-disease-2019 (COVID-19) and diabetic ketoacidosis (DKA) or hyperosmolar hyperglycaemic state (HHS), and to identify risk factors for mortality and intensive care admission.Materials and methodsRetrospective cohort study with anonymized data from the Association of British Clinical Diabetologists nationwide audit of hospital admissions with COVID-19 and diabetes, from start of pandemic to November 2021. The primary outcome was inpatient mortality. DKA and HHS were adjudicated against national criteria. Age-adjusted odds ratios were calculated using logistic regression.ResultsIn total, 85 confirmed DKA cases, and 20 HHS, occurred among 4073 people (211 type 1 diabetes, 3748 type 2 diabetes, 114 unknown type) hospitalized with COVID-19. Mean (SD) age was 60 (18.2) years in DKA and 74 (11.8) years in HHS (p < .001). A higher proportion of patients with HHS than with DKA were of non-White ethnicity (71.4% vs 39.0% p = .038). Mortality in DKA was 36.8% (n = 57) and 3.8% (n = 26) in type 2 and type 1 diabetes respectively. Among people with type 2 diabetes and DKA, mortality was lower in insulin users compared with non-users [21.4% vs. 52.2%; age-adjusted odds ratio 0.13 (95% CI 0.03-0.60)]. Crude mortality was lower in DKA than HHS (25.9% vs. 65.0%, p = .001) and in statin users versus non-users (36.4% vs. 100%; p = .035) but these were not statistically significant after age adjustment.ConclusionsHospitalization with COVID-19 and adjudicated DKA is four times more common than HHS but both associate with substantial mortality. There is a strong association of previous insulin therapy with survival in type 2 diabetes-associated DKA

How reliable is estimation of glomerular filtration rate at diagnosis of type 2 diabetes?

OBJECTIVE—The Cockcroft-Gault (CG) and Modification of Diet in Renal Disease (MDRD) equations previously have been recommended to estimate glomerular filtration rate (GFR). We compared both estimates with true GFR, measured by the isotopic 51Cr-EDTA method, in newly diagnosed, treatment-naïve subjects with type 2 diabetes. RESEARCH DESIGN AND METHODS—A total of 292 mainly normoalbuminuric (241 of 292) subjects were recruited. Subjects were classified as having mild renal impairment (group 1, GFR <90 ml/min per 1.73 m2) or normal renal function (group 2, GFR ≥90 ml/min per 1.73 m2). Estimated GFR (eGFR) was calculated by the CG and MDRD equations. Blood samples drawn at 44, 120, 180, and 240 min after administration of 1 MBq of 51Cr-EDTA were used to measure isotopic GFR (iGFR). RESULTS—For subjects in group 1, mean (±SD) iGFR was 83.8 ± 4.3 ml/min per 1.73 m2. eGFR was 78.0 ± 16.5 or 73.7 ± 12.0 ml/min per 1.73 m2 using CG and MDRD equations, respectively. Ninety-five percent CIs for method bias were –11.1 to –0.6 using CG and –14.4 to –7.0 using MDRD. Ninety-five percent limits of agreement (mean bias ± 2 SD) were –37.2 to 25.6 and –33.1 to 11.7, respectively. In group 2, iGFR was 119.4 ± 20.3 ml/min per 1.73 m2. eGFR was 104.4 ± 26.3 or 92.3 ± 18.7 ml/min per 1.73 m2 using CG and MDRD equations, respectively. Ninety-five percent CIs for method bias were –17.4 to –12.5 using CG and –29.1 to –25.1 using MDRD. Ninety-five percent limits of agreement were –54.4 to 24.4 and –59.5 to 5.3, respectively. CONCLUSIONS—In newly diagnosed type 2 diabetic patients, particularly those with a GFR ≥90 ml/min per 1.73 m2, both CG and MDRD equations significantly underestimate iGFR. This highlights a limitation in the use of eGFR in the majority of diabetic subjects outside the setting of chronic kidney disease

Influence of body weight on the performance of glomerular filtration rate estimators in subjects with type 2 diabetes

The American Diabetes Association recommends estimation of glomerular filtration rate (GFR) (1) by either the Cockcroft-Gault (2) or the Modification of Diet in Renal Disease (MDRD) (3) equation in all patients with diabetes. The implication is that these equations provide similar results. Body weight is a numerator in the Cockcroft- Gault equation; however, it is absent from the MDRD equation. This may explain some of the difference in the ability of these equations to estimate GFR in patients with type 2 diabetes, over 80% of whom are obese (4), and may lead to discrepancies in reporting of chronic kidney disease stage (5). Our study was designed to identify whether body weight may explain variability in performance between the Cockcroft-Gault and MDRD equations in patients newly diagnosed with type 2 diabetes

Association Between SGLT2 Inhibitor Treatment and Diabetic Ketoacidosis and Mortality in People With Type 2 Diabetes Admitted to Hospital With COVID-19

OBJECTIVE To determine the association between prescription of SGLT2 inhibitors (SGLT2is) and diabetic ketoacidosis (DKA) incidence or mortality in people with type 2 diabetes (T2D) hospitalized with COVID-19. RESEARCH DESIGN AND METHODS This was a retrospective cohort study based on secondary analysis of data from a large nationwide audit from a network of 40 centers in the U.K. with data collection up to December 2020. The study was originally designed to describe risk factors associated with adverse outcomes among people with diabetes who were admitted to hospital with COVID-19. The primary outcome for this analysis was DKA on or during hospital admission. The secondary outcome was mortality. Crude, age-sex adjusted, and multivariable logistic regression models were used to generate odds ratios (ORs) and 95% CIs for people prescribed SGLT2i compared with those not prescribed SGLT2i. RESULTS The original national audit included 3,067 people with T2D who were admitted to hospital with COVID-19, of whom 230 (7.5%) were prescribed SGLT2is prior to hospital admission. The mean age of the overall cohort was 72 years, 62.3% were men, and 34.9% were prescribed insulin. Overall, 2.8% of the total population had DKA and 35.6% of people in the study died. The adjusted odds of DKA were not significantly different between those prescribed SGLT2is and those not (OR 0.56; 95% CI 0.16–1.97). The adjusted odds of mortality associated with SGLT2is were similar in the total study population (OR 1.13; 95% CI 0.78–1.63), in the subgroup prescribed insulin (OR 1.02; 95% CI 0.59–1.77), and in the subgroup that developed DKA (OR 0.21; 95% CI 0.01–8.76). CONCLUSIONS We demonstrate a low risk of DKA and high mortality rate in people with T2D admitted to hospital with COVID-19 and limited power, but no evidence, of increased risk of DKA or in-hospital mortality associated with prescription of SGLT2is