Diabetic Ketoacidosis and Mortality in COVID-19 Infection

Background: Hyperglycemic patients with or without a history of diabetes have increased morbidity and mortality from COVID-19. Published case reports describe patients with COVID-19 and simultaneous presentation of diabetic acidosis (DKA), however there is limited data on the prevalence, predictors and outcomes of DKA in patients hospitalized with COVID-19. Methods: Patients with COVID-19 were identified from the electronic medical record. DKA was defined by standardized criteria. Proportional hazard regression models were used to determine risk factors for, and mortality from DKA in COVID-19. Findings: Of 2366 patients admitted for COVID-19, 157 (6.6%) patients developed DKA. Ninety-four percent of patients with incident DKA had a history of type 2 diabetes, while 5.7% patients had no prior diagnosis of diabetes. Patients with compared to without DKA had increased hospital length of stay and in-patient mortality. Each unit of higher HbA1c predicted a 47% increased risk of incident DKA (HR 1.47, 95% CI 1.40-1.54). Risk factors for mortality included older age (HR 1.07 per 5 years, 95% CI 1.06 - 1.08) and need for pressors (HR 2.33, 95% CI 1.82-2.98). An interaction between use of glucocorticoids and older age and pressor use indicated a protective effect of glucocorticoid use with both increasing age and for patients on pressors. Interpretation: The combination of DKA and COVID-19 is associated with greater mortality, driven by older age and severity of COVID-19 disease. Improved outpatient treatment of diabetes may prevent the development of DKA in patients with COVID-19. Funding Statement: None. Declaration of Interests: JSS, MBB, DJM, JZ, PK, SM, MTY and UBP have no disclosures. TLN: Amgen Ethics Approval Statement: This study protocol was approved by the Institutional Review Board of Columbia University Irving Medical Center and the requirement for informed consent was waived.