American Diabetes Association
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Hypoglycemic and Hyperglycemic Crises Among U.S. Adults With Diabetes and End-stage Kidney Disease: Population-Based Study, 2013–2017

posted on 2021-11-05, 18:33 authored by Rodolfo J. Galindo, Mohammed K. Ali, Shealeigh A. Funni, Andrew B. Dodge, Shaheen S. Kurani, Nilay D. Shah, Guillermo E. Umpierrez, Rozalina G. McCoy
Objective: We characterized annual trends of severe hypoglycemic and hyperglycemic crises (diabetic ketoacidosis/hyperglycemic hyperosmolar state) in patients with diabetes and end-stage kidney disease (DM/ESKD).

Design: Nationwide, retrospective study of adults (≥18 years) with DM/ESKD, from the United States Renal Data System registry, 2013 to 2017. Primary outcome was annual rates of emergency department visits or hospitalizations for hypoglycemic and hyperglycemic crises, reported as number of events/1000 person-years. Adjusted event rates and risk factors were adjusted for patient age, sex, race/ethnicity, dialysis modality, comorbidities, treatment regimen and U.S. region.

Results: Among 521,789 adults with DM/ESKD (median age 65 years [IQR 57-73], 56.1% male, and 46% White), overall adjusted rates of hypoglycemic and hyperglycemic crises were 53.64 and 18.24 per 1000 person-years, respectively. For both hypoglycemia and hyperglycemia crises, the risks decreased with age and were lowest in older patients (≥75 vs 18-44 years: IRR 0.35 [95% CI 0.33-0.37] and 0.03 [0.02-0.03], women (IRR 1.09 [1.06-1.12] and 1.44 [1.35-1.54]), and with smoking (IRR 1.36 [1.28-1.43] and 1.71 [1.53-1.91]), substance abuse (IRR 1.27 [1.15-1.42] and 1.53 [1.23-1.9]), retinopathy (IRR 1.10 [1.06-1.15] and 1.36 [1.26-1.47]), and insulin therapy (vs. no therapy; IRR 0.60 [0.59-0.63] and 0.44 [0.39-0.48]), respectively. For hypoglycemia, specifically, additional risk was conferred by Black race (IRR 1.11 [1.08-1.15]) and amputation history (IRR 1.20 [1.13-1.27]).

Conclusions: In this nationwide study of patients with DM/ESKD, hypoglycemic crises were three-fold more common than hyperglycemic crises, greatly exceeding national reports in non-dialysis patients with chronic kidney disease. Young, Black, and female patients were disproportionately affected.


This work was supported by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the National Institutes of Health (NIH) under Award Numbers P30DK111024 (RJG), K23DK123384 (RJG) and K23DK114497 (RGM). GEU is partly supported by NIH/NATS UL1 TR002378 from the Clinical and Translational Science Award program, and both GEU and MKA are partially supported by 1P30DK111024-01 from the NIH/NIDDK. RGM is also supported by NIDDK (R03DK127010). Role of Funding Source: The funders have no role in the design and conduct of the study, collection, management, analysis, and interpretation of the data, nor on the preparation, review or approval of the manuscript. Database for analyses was provided by the United States Renal Data System under a standard data use agreement. Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the US government.