key: cord-295393-aln51r9y
authors: Chamorro-Pareja, Natalia; Parthasarathy, Sahana; Annam, Jayabhargav; Hoffman, Julie; Coyle, Christine; Kishore, Preeti
title: Unexpected high mortality in COVID-19 and diabetic ketoacidosis()()
date: 2020-06-24
journal: Metabolism
DOI: 10.1016/j.metabol.2020.154301
sha: 
doc_id: 295393
cord_uid: aln51r9y

nan

J o u r n a l P r e -p r o o f TO THE EDITOR: Patients with diabetes mellitus (DM) appear to be at a greater risk for severe symptoms and complications, including death from COVID-19. 1,2 DM is a common comorbidity in patients affected with COVID-19 and may cause ketosis, ketoacidosis, and diabetic ketoacidosis (DKA) 3 . In patients with DM, acute hyperglycemic crises such as DKA and hyperosmolar hyperglycemic state can be precipitated by an acute illness such as COVID-19 and it can result in catastrophic outcomes. At Jacobi Medical Center, an epicenter of the COVID-19 pandemic crisis, we noted that a significant proportion of patients with COVID-19 also presented with DKA. We identified 50 such patients admitted with COVID-19 from March 10 th to April 30 th of 2020 who concomitantly had DKA upon admission or developed DKA during their hospital course. DKA was defined as blood glucose >250 mg/dL, an elevated anion gap, and positive ketones in blood or urine. COVID-19 was confirmed by real-time reversetranscription polymerase chain reaction (PCR) assay (BioReference Laboratories, Elmwood Park, NJ).

Among the evaluated patients, 32 (64%) were male, the median age was 59 years (IQR 42.3-70), 16 (31%) were Hispanic, 15 (30%) were African American, and the median body mass index (BMI) was 27.15 kg/m2 (see Table 1 ). Six of the 50 patients (12%) had a previous diagnosis of Type 1 DM with a median hemoglobin A1C (HbA1C) before the admission of 11%. Forty-four (88%) patients had previously diagnosed type 2 DM and their median HbA1c before the admission was 8.05%. Eight patients (16%) had previously undiagnosed DM. Twenty (40%) patients were on oral hypoglycemic agents with only 2 on SGLT2 inhibitors (which are known to J o u r n a l P r e -p r o o f increase the risk of ketoacidosis), 24 (48%) were on a home insulin regimen, and 4 (8%) patients were receiving treatment with GLP-1 agonists.

The median value of the initial glucose on presentation in our sample population was 506.5 mg/dL (252.0-1485.0 mg/dL). Forty-three (86%) patients were treated with intravenous insulin infusion protocol and 7 (14%) were treated with subcutaneous insulin protocol. The mean insulin and the intravenous fluids requirements in the first 24 hours were 115. 5 units and 3000 mL respectively. Thirty-eight (76%) patients developed acute kidney injury (AKI) during admission, 11 (22%) patients required renal replacement therapy, 26 (52%) required intensive care unit (ICU) admission, 21 (42%) were intubated, and 25 (50%) patients died. The median length of stay was 9 days (range 1-31); one patient was still admitted at the time of data evaluation.

In general, patients who died (50%) were older than those who survived (mean age 65.2 vs. 49 years), had higher ferritin (mean 8229.6 vs. 3373.4 ng/mL), and higher C-reactive protein levels (mean 355.3 vs. 167.2 mg/L). Mortality was higher in males than females (65.6% vs. 22.2%), and in patients who developed AKI (60.5%), who required dialysis (90.9%), and intubation (80.9%) (See Table 2 ).

In conclusion, mortality in patients with COVID-19 and DKA at our institution was higher than expected when compared with patients admitted historically with DKA in the United States 4 and the mortality for hospitalized COVID-19 patients in our area. 5, 6 Many of these patients developed AKI which likely contributed to the increased risk of adverse outcomes. As has been Journal Pre-proof J o u r n a l P r e -p r o o f previously described, in our analysis, age and male sex were associated with higher mortality in patients with COVID-19 and DKA. 7, 8 Moreover, majority of our patients were Hispanic or African American, and it has been proposed that these patients have a higher risk of mortality from COVID-19. 9,10 Interestingly, majority of these patients with DKA had type 2 diabetes and contrary to expectation many did not have poorly controlled diabetes mellitus before admission. 11, 12 (8) 

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