Lactate levels as a predictor of mortality in patients with diabetic ketoacidosis in the emergency department

Öz

Aim: Diabetic ketoacidosis (DKA) is a life-threatening metabolic disorder commonly seen in patients with diabetes, particularly in emergency departments. Early identification of high-risk patients is crucial for reducing mortality. Lactate, a marker of tissue hypoxia, may have prognostic value in predicting outcomes in DKA patients. Material and Methods: This retrospective study included patients diagnosed with DKA in the emergency department of a tertiary healthcare center between January 1, 2019, and January 1, 2024. Patients were identified using the hospital's electronic medical records system. Data collected included demographic characteristics, clinical parameters, laboratory results, and patient outcomes. The diagnosis of DKA was based on established clinical and laboratory criteria, including hyperglycemia, metabolic acidosis, and ketonemia or ketonuria. The primary outcome was in-hospital mortality. Results: A total of 85 patients were included in the study, with a mean age of 54 years (IQR: 35–70). Of the study population, 44.7% were female. The overall mortality rate was 15.3%, with 72 patients surviving (84.7%) and 13 patients not surviving (15.3%). The median age of non-survivors was significantly higher than that of survivors (66 years vs. 51 years, p = 0.049). Additionally, lactate levels were significantly higher in non-survivors than in survivors, indicating a potential prognostic role of lactate in predicting outcomes in DKA patients. Conclusion: Elevated lactate levels at admission are strongly associated with increased mortality in patients with diabetic ketoacidosis. Monitoring lactate levels in the emergency department could be a useful prognostic tool for identifying high-risk patients and guiding early interventions.

Anahtar Kelimeler

• Diabetic ketoacidosis
• lactate
• mortality

Acil serviste diyabetik ketoasidozda mortalite prediktörü olarak laktat düzeyleri

Öz

Amaç: Diyabetik ketoasidoz (DKA), özellikle acil servislerde diyabet hastalarında yaygın olarak görülen, hayatı tehdit eden metabolik bir bozukluktur. Yüksek riskli hastaların erken tespiti, mortalitenin azaltılması açısından kritik öneme sahiptir. Doku hipoksisinin bir belirteci olan laktat, DKA hastalarında sonuçları öngörmede prognostik değere sahip olabilir. Gereç ve Yöntemler: Bu retrospektif çalışmaya, 1 Ocak 2019 - 1 Ocak 2024 tarihleri arasında üçüncü basamak bir sağlık merkezinin acil servisinde DKA tanısı alan hastalar dahil edilmiştir. Hastalar, hastanenin elektronik tıbbi kayıt sistemi kullanılarak belirlenmiştir. Toplanan veriler arasında demografik özellikler, klinik parametreler, laboratuvar sonuçları ve hasta sonuçları yer almıştır. DKA tanısı, hiperglisemi, metabolik asidoz ve ketonemi veya ketonüriyi içeren yerleşik klinik ve laboratuvar kriterlere dayanarak konulmuştur. Birincil sonuç ölçütü hastane içi mortalite olarak belirlenmiştir. Bulgular: Çalışmaya toplam 85 hasta dahil edilmiştir ve hastaların ortalama yaşı 54 yıl (IQR: 35–70) olarak bulunmuştur. Çalışma popülasyonunun %44,7’si kadındı. Genel mortalite oranı %15,3 olup, 72 hasta (%84,7) sağ kalırken, 13 hasta (%15,3) hayatını kaybetmiştir. Hayatta kalamayan hastaların medyan yaşı, sağ kalanlara kıyasla anlamlı derecede daha yüksekti (66 yıl vs. 51 yıl, p = 0,049). Ayrıca, laktat seviyeleri hayatta kalamayan hastalarda sağ kalanlara kıyasla anlamlı derecede daha yüksekti ve bu durum, laktatın DKA hastalarındaki sonuçları öngörmede potansiyel bir prognostik role sahip olabileceğini göstermektedir. Sonuç: Başvuru anındaki yüksek laktat seviyeleri, diyabetik ketoasidoz hastalarında artmış mortalite ile güçlü bir şekilde ilişkilidir. Acil serviste laktat seviyelerinin izlenmesi, yüksek riskli hastaların belirlenmesi ve erken müdahalelerin yönlendirilmesi için faydalı bir prognostik araç olabilir.

Anahtar Kelimeler

• Diyabetik ketoasidoz
• laktat
• mortalite

Kaynakça

1. Calimag APP, Chlebek S, Lerma EV, Chaiban JT. Diabetic ketoacidosis. Dis Mon. 2023;69(3):101418.
2. Long B, Lentz S, Koyfman A, Gottlieb M. Euglycemic diabetic ketoacidosis: Etiologies, evaluation, and management. Am J Emerg Med. 2021;44:157-160.
3. Dhatariya KK, Glaser NS, Codner E, Umpierrez GE. Diabetic ketoacidosis. Nat Rev Dis Primers. 2020;6(1):40.
4. Barski L, Golbets E, Jotkowitz A, Schwarzfuchs D. Management of diabetic ketoacidosis. Eur J Intern Med. 2023;117:38-44.
5. Umpierrez G, Korytkowski M. Diabetic emergencies - ketoacidosis, hyperglycaemic hyperosmolar state and hypoglycaemia. Nat Rev Endocrinol. 2016;12(4):222-232.
6. Liu Y, Mo W, Wang H, Shao Z, Zeng Y, Bi J. Feature selection and risk prediction for diabetic patients with ketoacidosis based on MIMIC-IV. Front Endocrinol (Lausanne). 2024;15:1344277.
7. Xie W, Li Y, Meng X, Zhao M. Machine learning prediction models and nomogram to predict the risk of in-hospital death for severe DKA: A clinical study based on MIMIC-IV, eICU databases, and a college hospital ICU. Int J Med Inform. 2023;174:105049.
8. Ibrahim A, Bayramoglu B, Hokenek NM, Tekyol D. Lactate clearance during the first 2 hours after hospital admission: A useful biomarker for predicting 30-day mortality in patients with diabetic ketoacidosis. Int J Clin Pract. 2021;75(7):e14204.

9. Siregar NN, Soewondo P, Subekti I, Muhadi M. Seventy-Two Hour Mortality Prediction Model in Patients with Diabetic Ketoacidosis: A Retrospective Cohort Study. J ASEAN Fed Endocr Soc. 2018;33(2):124-129.
10. Modi A, Agrawal A, Morgan F. Euglycemic Diabetic Ketoacidosis: A Review. Curr Diabetes Rev. 2017;13(3):315-321.
11. Lai CY, Tian L, Schisterman EF. Exact confidence interval estimation for the Youden index and its corresponding optimal cut-point. Comput Stat Data Anal. 2012;56(5):1103-1114.
12. Hamud AA, Mudawi K, Shamekh A, Kadri A, Powell C, Abdelgadir I. Diabetic ketoacidosis fluid management in children: systematic review and meta-analyses. Arch Dis Child. 2022;107(11):1023-1028.
13. Karges B, Tittel SR, Bey A, et al. Continuous glucose monitoring versus blood glucose monitoring for risk of severe hypoglycaemia and diabetic ketoacidosis in children, adolescents, and young adults with type 1 diabetes: a population-based study. Lancet Diabetes Endocrinol. 2023;11(5):314-323.
14. Shi J, Chen F, Zheng K, et al. Clinical nomogram prediction model to assess the risk of prolonged ICU length of stay in patients with diabetic ketoacidosis: a retrospective analysis based on the MIMIC-IV database. BMC Anesthesiol. 2024;24(1):86.
15. Song C, Dhaliwal S, Bapat P, et al. Point-of-Care Capillary Blood Ketone Measurements and the Prediction of Future Ketoacidosis Risk in Type 1 Diabetes. Diabetes Care. 2023;46(11):1973-1977.
16. Nyenwe EA, Kitabchi AE. The evolution of diabetic ketoacidosis: An update of its etiology, pathogenesis and management. Metabolism. 2016;65(4):507-521.
17. Suwarto S, Sutrisna B, Waspadji S, Pohan HT. Predictors of five days mortality in diabetic ketoacidosis patients: a prospective cohort study. Acta Med Indones. 2014;46(1):18-23.
18. Cully M, Thompson AD, DePiero AD. Is lactic acidosis predictive of outcomes in pediatric diabetic ketoacidosis?. Am J Emerg Med. 2020;38(2):329-332.
19. Blanchard F, Charbit J, Van der Meersch G, et al. Early sepsis markers in patients admitted to intensive care unit with moderate-to-severe diabetic ketoacidosis. Ann Intensive Care. 2020;2;10(1):72.