Hiperglikemijske krize u bolesnika sa šećernom bolesti u Republici Hrvatskoj

Kruljac, Ivan (2016) Hiperglikemijske krize u bolesnika sa šećernom bolesti u Republici Hrvatskoj. PhD thesis, Sveučilište u Zagrebu.

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Abstract

Aim. The main aim of this study was to estimate the incidence of diabetic ketosis (DK) and ketoacidosis (DKA) in a well defiend population in Croatia. Secondary aims were: to detect antropomenthric and laboratory parameters which could serve as predictors of DK and DKA; to estimate the incidence of diabetic hyperosmolar syndrome (DHS) in type 2 diabetes mellitus (ŠBT2); to analyze the differences in antropomethric and laboratory parameters between the NKH, DK and DKA groups; to analyze the differences in antropomethric and laboratory parameters between ŠBT1 and ŠBT2; to analyze mortality rates after each hyperglycemic crisis and to search for prognostic factors. Methods. Studied population comprised of 261,749 adults with a residency in City of Zagreb and Zagreb county. Patients admitted to emergency departement in the period between January 1st 2010 and December 31st 2014 with plasma glucose > 13.9 mmol/L were enrolled. Based on their acid-base analysis, urinary ketones and plasma osmolarity, they were classified into one of the following groups: non-ketotic hyperglycemia (NKH), DK, DKA or DHS. Incidence was expressed as the number of episodes per 100,000 person-years. Analysis of mortality was performed in all patients with ŠBT2 with DHS, DKA and DK, and in NKH patients who were age- and gender-matched with DK group in 1:1 fashion. Results. We observed 630 episodes of DK in 520 patients, 215 episodes of DKA in 165 patients and 68 episodes of DHS in 66 patients. Only 8.6% of DK episodes and 34.4% of DKA were attributed to ŠBT1, while all patients with DHS had ŠBT2. Stadardized incidence ratios were as follows: 48.1 (95% CI 44.5 - 52.1) for DK, 17.0 (95% CI 14.9 - 19.4) for DKA and 6.2 (95% CI 5.1 – 7.2) for DHS. Patients with ŠBT1 were younger, leaner, majority had newly diagnosed disease and hyperglycemia was the main cause of admission. During a median follow-up of 33.4 months, mortality rate in NKH patients was 40.9%, 30.2% in DK patients, 44.5% in DKA patients and 46.4% in DHS patients. Patients with DK had lower moratlity when compared with NKH patients (HR 0.63, 95% CI, 0.48 - 0.82; P = 0.0005). Patients with DKA had higher mortality than DK patients (HR 1.92, 95% CI 1.41 - 2.61, P<0.001). When compared with DK and DKA group, patients with NKH were older, had higher prevalence of heart, renal and liver failure, had impaired renal function and used less metformin and alcohol. Heart and renal failure were main negative prognostic factors, while the use of metformin and alcohol were main positive prognostic factors. Conclusion. The majority of patiets with DK and DKA have ŠBT2. DK and DKA are more common complications in patients with ŠBT2, when compared with DHS. Use of metformin and alcohol was associated with DK, which was assosciated with decreased all-cause mortality when compared with NKH and DKA. Lower prevalence of heart and renal failure in patients with DK may explain lower mortality rates. Prognostic factors associated with increased mortality in patients with DKA remain unknown.

Abstract in Croatian

Cilj. Glavni cilj istraživanja je odrediti incidenciju dijabetičke ketoze (DK) i ketoacidoze (DKA) u odraslih osoba na dobro definiranoj populaciji u Republici Hrvatskoj. Ostali ciljevi istraživanja su: otkriti antropometrijske i laboratorijske parametre koji su rizični čimbenici razvoja ketoze i DKA u ispitanika s ŠBT2; odrediti incidenciju dijabetičkog hiperosmolarnog sindroma (DHS) u ispitanika s ŠBT2; odrediti razlike u antropometrijskim i laboratorijskim parametrima između ispitanika s NKH, DK i DKA u ŠBT2; odrediti razlike u antropometrijskim i laboratorijskim parametrima između ispitanika s DKA u ŠBT2 i ŠBT1; odrediti smrtnost nakon pojedine hiperglikemijske krize i tragati za prognostičkim faktorima. Metode. Ispitivana populacija obuhvaćala je ukupno 261,749 odraslih osoba s područja Grada Zagreba i Zagrebačke županije. U studiju su uključeni svi bolesnici koji su u razdoblju od 1.1.2010. do 31.12.2014. pregledani u hitnoj internističkoj ambulanti uz vrijednost glukoze u plazmi > 13.9 mmol/L. Ovisno o nalazu acidobaznog statusa, ketonurije i osmolarnosti plazme su uvršteni u jednu od 4 skupine: neketotična hiperglikemija (NKH), DK, DKA ili DHS. Incidencija je izražena kao broj epizoda DK, DKA i DHS na 100,000 osoba-godina. Analiza smrtnosti je učinjena na svim bolesnicima s ŠBT2 u DHS, DKA i DK skupini, te u jednakog broja bolesnika u NKH skupini, identičnih prema dobi i spolu naspram DK skupine. Rezultati. Zabilježeno je 630 epizoda DK u 520 bolesnika, 215 epizoda DKA u 165 bolesnika i 68 epizoda DHS u 66 bolesnika. Samo 8.6% epizoda DK i 34.4% epizoda DKA zabilježeno je u bolesnika s ŠBT1, dok su preostali bolesnici imali ŠBT2. Standardizirani omjer incidencije je iznosio 48.1 (95% CI 44.5 - 52.1) za DK, 17.0 (95% CI 14.9 - 19.4) za DKA te 6.2 (95% CI 5.1 – 7.2) na DHS. Bolesnici s ŠBT1 i epizodom DK ili DKA su bili značajno mlađi i mršaviji, češće su imali novootkrivenu šećernu bolest, češće su pregledani u hitnoj službi zbog hiperglikemije i češće su bili hospitalizirani. Tijekom medijana praćenja od 33.4 mjeseca, smrtnost u NKH skupini iznosila je 40.9%, u DK skupini 30.2%, u DKA skupini 44.5% i 46.4% u DHS skupini. Smrtnost u DK skupini bila je značajno manja u odnosu na NKH skupinu (HR 0.63, 95% CI, 0.48 - 0.82; P = 0.0005). Smrtnost bolesnika s DKA je bila značajno veća naspram bolesnika s DK (HR 1.92, 95% CI 1.41 - 2.61, P<0.001). Naspram DK i DKA skupine, bolesnici u NKH skupini su bili stariji, češće su pregledani zbog srčanog, bubrežnog i jetrenog zatajenja, imali su 105 lošiju bubrežnu funkciju te su rjeđe koristili metformin i alkohol. Srčano i bubrežno zatajenje su bili glavni negativni prognostički čimbenici, dok su korištenje metformina i alkohola bili glavni pozitivni prognostički čimbenici. Zaključak. Većina bolesnika s DK i DKA imaju ŠBT2. DK i DKA su češće komplikacije ŠBT2, nego što je to DHS. Uzimanje alkohola i metformina doprinosi razvoju DK koja je povezana sa smanjenom smrtnošću naspram bolesnika s NKH i DKA. Manja prevalencija srčanog i bubrežnog zatajenja u bolesnika s DK objašnjava poveznicu sa smanjenom smrtnošću. Nisu otkriveni prognostički čimbenici, koji bi mogli objasniti visoku smrtnost bolesnika s DKA.

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