From a total of 613 HE admissions, 321 patients were eligible and included in this study.
Sociodemographic and morbidity features
The participants were comprised of 129 (40.2%) males and 192 (59.8%) females, with a sex ratio of 1:1.5. The mean age of the patients was 43.3 ± 18.4 years. Their age ranged from 15 - 85 years. There were 153 (47.7%) DKA and 168 (52.3%) HHS cases. HHS patients were significantly older than DKA patients (57.3 ± 12.7 vs. 28.0 ± 9.2 years, P < 0.001). Patients with T1DM and T2DM were 143 (44.5%) and 178 (55.5%). At admission, 117 (36.4%) patients had no prior DM history and the rest 204 (63.6%) were known DM patients on treatment for a 4-year median duration. Hundred-four (32.4%) patients had comorbidities, of whom 46 (44.2%) had hypertension.
Table 1: Sociodemographic and morbidity features of hyperglycemic emergency patients
Variables
|
DKA (n = 153)
|
HHS (n = 168)
|
P-value
|
Age (years), mean ± SD
|
28.0 ± 9.2
|
57.3 ± 12.7
|
<0.001
|
Sex, male (%)
|
59 (38.6)
|
70 (41.7)
|
0.571
|
Residence, urban (%)
|
62 (40.5)
|
101 (60.1)
|
<0.001
|
Type 1 diabetes
|
143 (93.5)
|
0
|
|
Type 2 diabetes
|
10 (6.5)
|
168 (100)
|
|
known diabetes
|
88 (57.5)
|
125 (74.4)
|
|
Hypertension
|
7 (4.6)
|
39 (23.2)
|
<0.001
|
Congestive heart failure
|
0
|
12 (7.1)
|
|
Ischemic heart disease
|
2 (1.3)
|
5 (3.0)
|
|
Chronic kidney disease
|
2 (1.3)
|
8 (4.8)
|
|
Chronic liver disease
|
4 (2.6)
|
6 (3.6)
|
|
Stroke
|
0
|
12 (7.1)
|
|
Asthma
|
1 (0.7)
|
1 (0.6)
|
|
COPD
|
0
|
2 (1.2)
|
|
Epilepsy
|
4 (2.6)
|
0
|
|
COPD: Chronic Obstructive Pulmonary Disease; SD: Standard Deviation
Clinical admission features
Compared with DKA, both admission systolic and diastolic blood pressure records stood significantly higher while admission Glasgow Coma Scale (GCS) score remained significantly lower among DM patients hospitalized with HHS. The clinical admission features of the study participants as DKA compared to HHS are displayed in Table 2.
Table 2: Clinical admission features of hyperglycemic emergency patients
Variables
|
DKA (Mean ± SD)
|
HHS (Mean ± SD)
|
P-value
|
SBP (mmHg)
|
107.4 ± 12.0
|
110.0 ± 20.6
|
<0.001
|
DBP (mmHg)
|
69.7 ± 5.6
|
70.2 ± 10.1
|
<0.001
|
Pulse rate (bpm)
|
97.2 ± 12.4
|
93.4 ± 11.4
|
0.317
|
Respiratory rate (bpm)
|
25.9 ± 3.3
|
20.5 ± 3.7
|
0.615
|
Temperature (0C)
|
36.7 ± 0.9
|
36.6 ± 0.9
|
0.705
|
GCS score
|
12.4 ± 2.0
|
10.5 ± 2.9
|
<0.001
|
DBP: Diastolic Blood Pressure; DKA: Diabetic Ketoacidosis; GCS: Glasgow Coma Scale; HHS: Hyperosmolar Hyperglycemic State; SBP: Systolic Blood Pressure; SD: Standard Deviation
Biochemical admission features
The mean admission blood glucose level (BGL) of the study participants was 544.5 ± 123.1 mg/dL. Admission BGL, serum creatinine (SCr.) and blood urea nitrogen (BUN) were significantly higher in patients admitted with HHS than DKA. The biochemical admission features of the study participants as DKA compared to HHS are displayed in Table 3.
Table 3: Biochemical admission features of hyperglycemic emergency patients
Variable
|
DKA (Mean ± SD)
|
HHS (Mean ± SD)
|
P-value
|
BGL (mg/dL)
|
421.2 ± 34.5
|
656.8 ± 36.3
|
<0.001
|
Serum potassium (mEq/L)
|
3.7 ± 0.6
|
4.2 ± 0.5
|
0.075
|
Serum sodium (mEq/L)
|
135.8 ± 3.5
|
137.2 ± 3.9
|
0.052
|
Serum chloride (mEq/L)
|
106.4 ± 5.6
|
105.9 ± 6.2
|
0.324
|
Serum creatinine (mg/dL)
|
1.1 ± 0.5
|
1.4 ± 0.8
|
<0.001
|
BUN (mg/dL)
|
18.6 ± 8.5
|
22.8 ± 10.6
|
<0.001
|
BGL: Blood Glucose Level; BUN: Blood Urea Nitrogen; DKA: Diabetic Ketoacidosis; HHS: Hyperosmolar Hyperglycemic State; SD: Standard Deviation
Hyperglycemic emergency precipitating conditions
Infection was documented in 154 (48.0%) of the study participants. Fifty-eight (37.7%) of the infection cases were pneumonia. Treatment noncompliance was recorded in 124 (38.6%) of the patients. The noncompliance type in 83 (66.9%) of the patients was medication discontinuation.
Table 4: Hyperglycemic emergency precipitating conditions
Precipitating conditions
|
Frequency (%)
|
Infection
|
154 (48.0)
|
Pneumonia
|
58 (37.7)
|
Urinary tract infection
|
39 (25.3)
|
Sepsis
|
29 (18.8)
|
Diabetic foot ulcer
|
11 (7.2)
|
Others
|
17 (11.0)
|
Noncompliance
|
124 (38.6)
|
Medication discontinuation
|
83 (66.9)
|
Missed insulin doses
|
41 (33.1)
|
Newly diagnosed diabetes
|
63 (19.6)
|
Cardiovascular events
|
18 (5.6)
|
Physical traumatic injury
|
3 (0.9)
|
Treatment outcome of HE
The median duration of hospital stay of the study participants was 7-day. The total number of the study participants registered dead was 53 (16.5%); 36 (21.4%) of the patients admitted with HHS and 17 (11.1%) of the patients hospitalized with DKA.
Predictors of mortality among DM patients admitted with HE
As per the multivariable binary logistic regression analysis of the variables significantly associated (P ≤ 0.2) with the mortality on the bivariable analysis, infection (AOR = 3.74, 95% CI: 1.85-7.57, P <0.001), comorbidity (AOR = 2.95, 95% CI: 1.34-6.48, P = 0.007), and lower admission GCS ≤ 8 (AOR = 2.58, 95% CI: 1.17-5.71, P = 0.019) were the independent predictors of mortality among DM patients hospitalized with HE. Table 5 illustrates the predictors of mortality among DM patients hospitalized with HE.
Table 5: Predictors of mortality among hospitalized hyperglycemic emergency patients
Variable
|
Died
|
COR (95% CI)
|
P-value
|
AOR (95% CI)
|
P-value
|
Yes (%)
|
No (%)
|
|
Age
|
|
|
|
|
|
|
15-24
|
5 (8.8)
|
52 (91.2)
|
1.00
|
|
1.00
|
|
25-34
|
8 (11.3)
|
63 (88.7)
|
1.32 (0.41-4.28)
|
0.643
|
1.22 (0.36-4.14)
|
0.751
|
35-44
|
9 (20.0)
|
36 (80.0)
|
2.60 (0.81-8.40)
|
0.110
|
1.42 (0.40-5.07)
|
0.592
|
45-54
|
6 (11.1)
|
48 (88.9)
|
1.30 (0.37-4.54)
|
0.681
|
0.47 (0.12-1.88)
|
0.287
|
55-64
|
9 (18.8)
|
39 (81.2)
|
2.40 (0.75-7.73)
|
0.142
|
0.98 (0.26-3.70)
|
0.971
|
≥65
|
16 (34.8)
|
30 (65.2)
|
5.55 (1.85-16.67)
|
0.002
|
1.45 (0.37-5.70)
|
0.595
|
GCS
|
|
|
|
|
|
|
3 – 8
|
24 (29.6)
|
57 (70.4)
|
3.06 (1.66 – 5.67)
|
<0.001
|
2.58 (1.17 – 5.71)
|
0.019
|
9 – 15
|
29 (12.1)
|
211 (87.9)
|
1.00
|
|
1.00
|
|
SCr. (mg/dL)
|
|
|
|
|
|
|
≤ 1.2
|
33 (13.6)
|
209 (86.4)
|
1.00
|
|
1.00
|
|
> 1.2
|
20 (25.3)
|
59 (74.7)
|
2.15 (1.15 – 4.02)
|
0.017
|
1.48 (0.69 – 3.18)
|
0.316
|
Comorbidity
|
|
|
|
|
|
|
Yes
|
30 (28.8)
|
74 (71.2)
|
3.42 (1.87 – 6.27)
|
<0.001
|
2.95 (1.34 – 6.48)
|
0.007
|
No
|
23 (10.6)
|
194 (89.4)
|
1.00
|
|
1.00
|
|
Infection
|
|
|
|
|
|
|
Yes
|
37 (24.0)
|
117 (76.0)
|
2.99 (1.58 – 5.63)
|
0.001
|
3.74 (1.85 – 7.57)
|
<0.001
|
No
|
16 (9.6)
|
151 (90.4)
|
1.00
|
|
1.00
|
|
AOR: Adjusted Odds Ratio; COR: Crude Odds Ratio; GCS: Glasgow Coma Scale; SCr.: Serum Creatinine