USA: Study on Diabetic Ketoacidosis (DKA) and COVID-19

A recent study reported that in hospitalized patients, the prevalence of diabetic ketoacidosis (DKA) quadrupled during the pandemic period versus the pre-pandemic period. Also, mortality of DKA almost doubled in COVID-19 patients and COVID-19 was associated with higher rates of renal failure in DKA patients.

The researchers suggest DKA screening for all COVID-19+ patients and prioritizing ICU DKA/COVID-19+ with low blood pressures, oxygen saturation, or renal insufficiency. The study appears in the journal Diabetes & Metabolic Syndrome: Clinical Research & Reviews.

It is known that diabetes mellitus (DM) is not a risk for developing COVID-19; however, diabetics infected with COVID-19 have worse outcomes. Recently, diabetic ketoacidosis (DKA), a potentially lethal complication of diabetes, was described in 110 COVID-19 patients with a 45% mortality rate in a systematic review by Pal et al. of 19 case series. However, case series cannot describe an association, much less a cause-and-effect relationship between COVID-19 and DKA.

Against the above background, Faraz Khan, Kings County Hospital – New York City Health and Hospitals, Department of Emergency Medicine, USA, and colleagues aimed to describe the prevalence/outcomes of diabetic ketoacidosis patients comparing pre- (March–April 2019) and pandemic (March–April 2020) periods.

The study included admitted pandemic DKA/COVID-19+ patients comparing prevalence/outcomes to pre-pandemic DKA patients that took place in eleven hospitals of New York City Health & Hospitals. The included participants during the pandemic period were admitted COVID-19+ patients (>18 years) and were admissions (>18 years) selected through the medical record during the pre-pandemic period.

COVID-19+ by PCR testing was the intervention. Mortality during the index hospitalization was the main outcome. Secondary outcomes were demographics, medical histories and triage vital signs, and laboratory tests.

DKA was defined as beta-hydroxybutyrate (BHBA) (>0.4 mmol/L) and bicarbonate (<15 mmol/L) or pH (<7.3).

Study's Salient Findings

• Demographics and past medical histories were similar during the pre-pandemic (n = 6938) vs. pandemic (n = 7962) periods.
• DKA prevalence was greater during the pandemic (3.14%) vs. the pre-pandemic period (0.72%).
• DKA/COVID-19+ mortality rates were greater (46.3% vs. pre-pandemic period (18%)).
• Surviving vs. non-surviving DKA/COVID-19+ patients had more severe DKA with lower bicarbonates by 2.7 mmol/L and higher both Anion Gaps by 3.0 mmol/L and BHBA by 2.1 mmol/L.

To conclude, the study showed that it is not necessary that the patients with worse DKA died but patients with worse COVID-19. This was seen as higher SOFA scores, respiratory rates, and worst renal failure were associated with higher mortality rates.

"This data helps characterize the prevalence and mortality associated with DKA and COVID-19 and helps guide future management strategies in these patients," the authors concluded.

Reference

Faraz Khan, Lorenzo Paladino, Richard Sinert, The impact of COVID-19 on Diabetic Ketoacidosis patients, Diabetes & Metabolic Syndrome: Clinical Research & Reviews, Volume 16, Issue 1, 2022, 102389, ISSN 1871-4021, https://doi.org/10.1016/j.dsx.2022.102389.