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Clinical Care/Education/Nutrition
Clinical characteristics and outcomes of patients with end-stage renal disease hospitalized with diabetes ketoacidosis
  1. Rodolfo J Galindo1,
  2. Francisco J Pasquel1,
  3. Maya Fayfman1,
  4. Katerina Tsegka1,
  5. Neil Dhruv1,
  6. Saumeth Cardona1,
  7. Heqiong Wang2,
  8. Priyathama Vellanki1,
  9. Guillermo E Umpierrez1
  1. 1Division of Endocrinology, Emory University School of Medicine, Atlanta, Georgia, USA
  2. 2Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
  1. Correspondence to Professor Guillermo E Umpierrez; geumpie{at}emory.edu

Abstract

Introduction There is limited evidence to guide management in patients with end-stage renal disease (ESRD) on chronic hemodialysis admitted with diabetes ketoacidosis. Thus, we investigated the clinical characteristics and outcomes of patients with ESRD admitted with diabetic ketoacidosis (DKA).

Methods In this observational study, we used International Classification of Diseases Ninth/Tenth Revision codes to identify adult (aged 18–80 years) patients admitted to Emory University Hospitals between 1 January 2006 and 31 December 2016. DKA and ESRD diagnoses were confirmed by reviewing medical records and by admission laboratory results.

Results Among 307 patients with DKA meeting the inclusion and exclusion criteria, 22.1% (n: 68) had ESRD on hemodialysis and 77.9% (n: 239) had preserved renal function (estimated glomerular filtration rate >60 mL/min/1.73 m2). Compared with patients with preserved renal function, the admission blood glucose was higher (804.5±362.6 mg/dL vs 472.5±137.7 mg/dL) and the mean hemoglobin A1c was lower (9.6%±2.1 vs 12.0%±2.5) in patients with DKA and ESRD, both p<0.001. The rates of hypoglycemia <70 mg/dL (34% vs 14%, p=0.002) and <54 mg/dL (13% vs 5%, p=0.04) were higher in the ESRD group. During hospitalization, more patients with ESRD develop volume overload (28% vs 3%, p<0.001) and require mechanical ventilation (24% vs 3%, p=<0.001). There were no differences in hospital mortality (3% vs 0%, p=0.21), but length of stay (median 7.0 vs 3.0 days, p<0.001) was longer in the ESRD cohort. After adjusting for multiple covariates, patients with DKA and ESRD have higher odds of hypoglycemia (OR 3.3, 95% CI 1.51 to 7.21, p=0.003) and volume overload (OR 4.22, 95% CI 1.37 to 13.05, p=0.01) compared with patients with DKA with preserved renal function.

Conclusions Patients with DKA and ESRD on chronic hemodialysis had worse clinical outcomes including higher rates of hypoglycemia, volume overload, need for mechanical ventilation and longer length of stay, compared with patients with preserved kidney function.

  • ketoacidosis
  • dialysis
  • ESRD
  • hypoglycemia
https://creativecommons.org/licenses/by/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

https://doi.org/10.1136/bmjdrc-2019-000763

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    Footnotes

    • Presented at Part of this study was presented at the 78th Scientific Sessions of the American Diabetes Association, Orlando, June 2018.

    • Contributors RJG and GEU designed the study and wrote the manuscript. FJP, MF, KT, ND, SC, HW, and PV contributed to the study design, data collection, data analysis and reviewed/edited the manuscript. RJG and GEU are the guarantors of this work and, as such, had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    • Funding Research reported in this publication was supported by a grant to RJG from the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institute of Health Under Award number P30DK11102. RJG received research support to Emory University for investigator-initiated studies from Novo Nordisk, and consulting fees from Abbott Diabetes Care, Sanofi and Novo Nordisk. PV is supported in part by the National Institute of Health grant 3K12HD085850 and has received consulting fees from Merck and Boehringer Ingelheim. FJP is supported in part by the National Institute of Health grant 1K23GM128221-01A1 and received consulting fees from Boehringer Ingelheim, Eli Lilly and AstraZeneca. GEU is partly supported by research grants from the National Center for Advancing Translational Sciences of the National Institutes of Health under Award number UL1TR002378 from the Clinical and Translational Science Award program and a National Institutes of Health (NIH) grant U30, P30DK11102, and has received research grant support to Emory University for investigator-initiated studies from Sanofi, Novo Nordisk, and Dexcom.

    • Patient consent for publication Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement Data are available upon reasonable request. Study protocol and deidentified data that underlie the results of this article will be available upon reasonable request. Data will be available beginning 9 months and ending 12 months following article publication. We will share data with investigators whose proposed use of data has been approved by an independent review committee identified for this purpose.