Diabetic ketoacidosis and mortality in COVID-19 infection

Abstract

Aim: - Patients with diabetes have increased morbidity and mortality from COVID-19. Case reports describe patients with simultaneous COVID-19 and diabetic acidosis (DKA), however there is limited data on the prevalence, predictors and outcomes of DKA in these patients.

Methods: - Patients with COVID-19 were identified from the electronic medical record. DKA was defined by standardized criteria. Proportional hazard regression models were used to determine risk factors for, and mortality from DKA in COVID-19.

Results: - Of 2366 patients admitted for COVID-19, 157 (6.6%) patients developed DKA, 94% of whom had antecedent type 2 diabetes, 0.6% had antecedent type 1 diabetes, and 5.7% patients had no prior diagnosis of diabetes. Patients with DKA had increased hospital length of stay and in-patient mortality. Higher HbA1c predicted increased risk of incident DKA (HR 1.47 per 1% increase, 95% CI 1.40-1.54). Risk factors for mortality included older age (HR 1.07 per 5 years, 95% CI 1.06-1.08) and need for pressors (HR 2.33, 95% CI 1.82-2.98). Glucocorticoid use was protective in patients with and without DKA.

Conclusion: - The combination of DKA and COVID-19 is associated with greater mortality, driven by older age and COVID-19 severity.

Keywords: COVID-19; Coronavirus; Diabetic ketoacidosis, DKA; SARS-CoV-2.

Fig. 1

. Prevalence of diabetes among study patients who did and did not develop DKA. Of the 6.6% of patients in our study who developed DKA, 94% had a known prior diagnosis of DM (overwhelmingly T2D 99.3%). The overall majority of patients did not develop DKA (93.3%) and of these, only 36% had a prior known history of T2D (overwhelmingly T2D 99.5%). DM, diabetes mellitus; T2D, Type 2 diabetes mellitus; DKA, diabetic ketoacidosis.

Fig. 2

. Kaplan-Meier survival analysis of survival stratified by DKA and diabetes status. A) Death was more likely among patients who developed DKA (36.9% vs. 25.6%, P < 0.05) with a mean survival of 40.0 ± 1.9 days compared to patients who did not develop DKA (54.0 ± 1.9 days, P = 0.0008). B) Among patients with diabetes (n = 955), mean survival in patients with DKA was 40.0 ± 1.9 days compared to 40.6 ± 0.7 days in patients without DKA, with one-quarter of deaths occurring within 12 days (95% CI: 7–20) of admission in patients with DKA compared to 22 days (95% CI: 13–42) for patients without DKA (P = 0.03). DKA, diabetic ketoacidosis.