Background: Patients with diabetes who are hospitalized with COVID-19 have been found to have increased lengths of stay and greater intensive care unit utilization compared to those without diabetes. Diabetic ketoacidosis (DKA) is an acute diabetes emergency that accounts for a high number of hospitalizations, hospital readmissions, and healthcare utilization. Our study aims to evaluate the characteristics and outcomes of patients with DKA and concurrent COVID-19 infection.

Methods: This retrospective study looked at electronic medical records between March 1, 2020 to September 21, 2021, and included patients aged ≥ 18 years with DKA. Clinical characteristics, hospital course, and complications were compared between patients admitted with DKA and confirmed COVID-19 infection (COVID+) to those with DKA without COVID-19 infection (COVID-).

Results: Among 1940 patients admitted with DKA, 11.6% (n: 226) had confirmed COVID-19 and 88.4% (n: 1714) did not have COVID-19. Baseline characteristics (age, sex, race) were similar between both groups. Patients with COVID-19 presented with a lower admission blood glucose (386.2 ± 183.4 vs 419.0 ± 220.3 mg/dL, p< 0.05) and lactic acid (2.2 ± 1.9 vs 3.0 ± 3.1 mmol/L, p< 0.001), and higher bicarbonate (17.5 ± 5.2 vs 16.4 ± 6.6 mmol/L, p< 0.05). Patients with COVID-19 required longer times to normalization of hyperglycemia to BG < 250 mg/dL (median (IQR) 8.1 (4.7 – 12.3) vs 6.9 (3.4 - 10.1) hours, p< 0.001) compared to those without COVID-19. Those with COVID-19 had an increased mortality (15.9% vs 2.8%, p< 0.001), longer hospital LOS (6.0 (4.0 – 15.0) vs 4.0 (3.0 – 7.0) days, p< 0.001), and longer ICU LOS (median (IQR) 22.0 (0.0 – 130.4) vs 16.5 (0.0 – 47.7) hours, p< 0.001). Those with COVID-19 also had higher rates of complications including acute respiratory failure, mechanical ventilation, sepsis, and acute thrombotic events. They also experienced higher rates of hypoglycemia during their hospitalization (BG < 70 mg/dL). Of 226 patients with COVID-19 infection, 33 (14.6%) had hypoglycemia < 40 mg/dL. Of 1714 patients without COVID-19 infection, 181 (10.6%) had hypoglycemia < 40 mg/dL. In evaluating the four different COVID-19 waves, there were no significant differences in mortality rates between waves: first wave 30.8%, second wave 15.8%, third wave 14.5%, fourth wave 7.3% and in between the waves, 20.5%. Though mortality trended lower as time progressed, it was not statistically significant with a p-value of 0.265.

Conclusions: Our data shows that COVID-19 infection is associated with increased mortality, worse clinical outcomes, and longer LOS among patients hospitalized with DKA while also presenting with less severe hyperglycemia and acidosis compared to those without COVID-19 infection. Our data did not show a significant difference in initial laboratory studies or outcomes between the four different waves, which indicates that DKA with concurrent COVID-19 infection continued to result in high mortality. Further studies into how evolving treatments for COVID-19 change outcomes for patients with DKA is warranted.

IMAGE 1: COVID and DKA: Complications, Mortality and LOS