What are the risk factors for outcomes like in-hospital death and complications of COVID-19 in people with diabetes?
As of late July 2020, there have been over 15 million COVID-19 cases worldwide since the first cases were reported back in December of 2019. Deaths related to COVID-19 have reached 600,000. Several epidemiological studies have characterized patient populations that may be particularly vulnerable to the disease. Specifically, older populations and those with underlying diseases are at a much higher risk of infection and may have worse outcomes than the general public. Diabetes mellitus is one of the most common comorbid conditions seen in COVID-19 positive patients. An estimated 425 million people are living with diabetes globally. Because much is still unknown regarding diabetes and COVID-19, analyzing the clinical characteristics and laboratory findings of these patients may help identify important risk factors that can guide healthcare providers in making clinical decisions through the current pandemic. A new study published in Diabetes Research and Clinical Practice explores the risk factors for in-hospital death and complications of COVID-19 in the diabetic population.
The study took place in two hospitals in the Hubei province of China, Wuhan Union Hospital of Tongji Medical College and Jinyintan Hospital. All patients with pre-existing diabetes diagnosed with SARS CoV-2 pneumonia from December 31, 2019, to April 5, 2020, were identified. Electronic medical records were used to review patients‘ admission data along with demographics, exposure history, comorbidities, symptoms, treatments, in-hospital complications, laboratory results, chest CT images, and outcomes. Patients were classified into two groups based on fasting blood glucose (FBG). Group 1 was comprised of patients with FBG ≤ 11mmol/L (≤196mg/dL) and group 2 of patients with FBG > 11mmol/L (>196mg/dL). Chest CT scans were obtained for each patient and used to evaluate the extent of pulmonary involvement. Each of the 5 lung lobes were scored from 0 to 5 as follows: 0 = no involvement; 1 = ≤5% involvement; 2 = 6-25% involvement; 3 = 26-49% involvement; 4 = 50-75% involvement; 5 = >75% involvement. A high-resolution CT (HRCT) score of 0 to 25 was then calculated.
The outcome of interest was either the intensive care unit (ICU) entry or in-hospital death. Secondary outcomes included in-hospital complications, such as SARS-CoV-2-related acute respiratory distress syndrome (ARDS), acute cardiac injury, acute kidney injury, and secondary infection.
There was a total of 132 patients included in the final analysis. Nineteen of them were admitted to the ICU and unfortunately passed while admitted. A vast majority of these patients had a history of type 2 diabetes. Comorbid conditions were prevalent among this population, with over half of the patients presenting with at least one. The most common comorbidity was hypertension (64.4%), followed by cardiovascular or cerebrovascular diseases (9.1%). Almost a fourth of all patients developed at least one complication. ARDS was the most common, followed by cardiac injury.
In comparison to group 1, those in group 2 had more extended hospital stays, experienced more complications, and were more likely to require systemic corticosteroid treatment or intubation. Patients in group 2 were also more likely to require intensive care (21.4% vs. 9.2%), develop acute respiratory distress syndrome (ARDS) (23.2% vs. 9.2%) or experience acute cardiac injuries (12.5% vs. 1.3%) compared to their group 1 counterparts. Also, significantly higher death rates were observed in group 2 versus group 1 (19.6% vs. 5.3%).
Multivariable analysis showed higher risks of death (OR: 7.629, 95%CI: 1.391–37.984) and in-hospital complications (OR: 3.232, 95%CI: 1.393–7.498) in patients with glucose levels >11 mmol/L on admission. Additionally, those with admission d-dimer of 1.5 µg/mL (OR: 6.645, 95%CI: 1.212–36.444) and HRCT score of 10 or more (OR: 7.792, 95%CI: 2.195–28.958) had increased odds of in-hospital death and complications, respectively.
The results of this study showed that patients with poorly controlled blood glucose levels were more likely to experience complications or in-hospital death due to COVID-19. HRCT score, white blood cell count, albumin, LDH, myoglobin, high-sensitivity troponin I, and procalcitonin were also associated with poor outcomes. Of these, glucose levels and d-dimer may be of most importance as prognostic factors. HRCT scoring was a vital inspection tool for this study and may be considered for risk assessment in clinical settings. However, given the many limitations of this small, retrospective study, further research is needed to determine the accuracy and generalizability of these findings.
- Patients with admission blood glucose levels above 196mg/dL are at much higher risk of complications or death related to COVID-19.
- D-dimer and HRCT scores may serve as vital prognostic factors for COVID-19 outcomes.
- Patients with diabetes are more than twice as likely to require ICU care or develop ARDS.
Li Y, Han X, Alwalid O, et al. Baseline characteristics and risk factors for short-term outcomes in 132 COVID-19 patients with diabetes in Wuhan China: A retrospective study [published online ahead of print, 2020 July 3]. Diabetes Res Clin Pract. 2020;166:108299. doi:10.1016/j.diabres.2020.108299
Melinda Rodriguez, PharmD Candidate 2021, Lake Erie College of Osteopathic Medicine – L|E|C|O|M School of Pharmacy