Glycemic control before admission is an important determinant of prognosis in patients with coronavirus disease 2019

Glycated albumin in the detection of diabetes during COVID-19 hospitalization

BACKGROUND

Diabetes has emerged as an important risk factor for COVID-19 adverse outcomes during hospitalization. We investigated whether the measurement of glycated albumin (GA) may be useful in detecting newly diagnosed diabetes during COVID-19 hospitalization.

METHODS

In this cross-sectional test accuracy study we evaluated HCPA Biobank data and samples from consecutive in-patients, from 30 March 2020 to 20 December 2020. ROC curves were used to analyse the performance of GA to detect newly diagnosed diabetes (patients without a previous diagnosis of diabetes and admission HbA1c ≥6.5%).

RESULTS

A total of 184 adults (age 58.6 ± 16.6years) were enrolled, including 31 with newly diagnosed diabetes. GA presented AUCs of 0.739 (95% CI 0.642-0.948) to detect newly diagnosed diabetes. The GA cut-offs of 19.0% was adequate to identify newly diagnosed diabetes with high specificity (85.0%) but low sensitivity (48.4%).

CONCLUSIONS

GA showed good performance to identify newly diagnosed diabetes and may be useful for identifying adults with the condition in COVID-19-related hospitalization.

Lower Glycosylated Hemoglobin Is Associated With Lower In-Hospital Mortality in Patients With COVID-19: A Systematic Review of the Literature and Meta-Analysis

OBJECTIVE

Poor glycemic control during COVID-19 hospitalization is associated with higher mortality. However, the association between long-term glycemic control, as reflected by the glycosylated hemoglobin (HbA1c) and outcomes has yet to be clarified, with some studies reporting no association. The aim of this study is to determine the association between HbA1c and in-hospital mortality in patients with COVID-19.

METHODS

Pubmed, Embase, and Web of Science databases were searched for studies examining the association between HbA1c level and in-hospital COVID-19 mortality. Random-effects meta-analysis was performed. Heterogeneity was assessed using the I2 statistic. Publication bias was assessed using funnel plots.

RESULTS

Among 4142 results, 22 studies were included in the final analysis with a total of 11 220 patients. Lower Hba1c was associated with lower in-hospital mortality [odds ratio (OR), 0.53; 95% CI, 0.37-0.76; I2 81%], in using HbA1c as a dichotomous variable. When only patients with diabetes were included in the analysis, the association remained statistically significant (OR, 0.67; 95% CI, 0.47-0.96). In the subgroup analysis, the association remained statistically significant in studies using as cutoff the HbA1c value of 6.5% (OR, 0.34; 95% CI, 0.15-0.77) and 7% (OR, 0.54; 95% CI 0.32-0.90), but not with greater HbA1c cutoff values; 7.5% and ≥8%. In studies using HbA1C as a continuous variable, HbA1c level did not have a statistically significant association with in-hospital mortality, either in univariate or multivariate analyses.

CONCLUSION

A better glycemic control prior to hospitalization, as reflected by lower HbA1c, is associated with lower in-hospital mortality in patients with COVID-19.

Association between inpatient glycemic variability and COVID-19 mortality: a prospective study

BACKGROUND

This study aimed to determine the association between glycemic variability (GV) and mortality in hospitalized patients with coronavirus disease 2019 (COVID-19).

METHODS

We prospectively analyzed data from inpatients (> 18 years old) with RT-PCR confirmed COVID-19 admitted between March 2020 and July 2021. All patients were hospitalized for more than 48 h and had at least six point-of-care capillary glucose tests obtained three times daily in the pre-prandial period during hospitalization. GV was measured using the glucose standard deviation (SD) and coefficient of variation (CV). ROC curve was adjusted to determine the SD and CV cutoff values associated with mortality (44.7 mg/dL and 27.5%, respectively); values above these were considered indicative of high GV. Logistic regression models were fitted to explore the association between GV and mortality in patients with and without diabetes.

RESULTS

A total of 628 patients were stratified into SD < 44.7 mg/dL (n = 357) versus ≥ 44.7 mg/dL (n = 271) and CV < 27.5% (n = 318) versus ≥ 27.5% (n = 310) groups. After controlling for age, sex, presence of diabetes mellitus (DM) and cardiovascular disease, we found a significant association between high GV and mortality (odds ratio 2.99 [1.88-4.77] for SD and 2.43 [1.54-3.85] for CV; p values < 0.001). The mortality rate was higher with SD ≥ 44.7 mg/dL and CV ≥ 27.5% compared to that with SD < 44.7 mg/dL and CV < 27.5%, regardless of DM (p < 0.001 for all).

CONCLUSION

High glycemic variability was independently associated with mortality in patients with and without DM, who were hospitalized with COVID-19.

Association between glycemic control and the outcome in hospitalized patients with COVID-19

PURPOSE

Coronavirus disease 2019 (COVID-19) clinical outcome and disease severity affected by several factors; deterioration of glycemic control is one of them. Therefore, achieving optimum blood glucose parameters is hypothesized for better consequences of COVID-19. However, varying data supporting this hypothesis is available in literature. The intention of this study was to investigate the role of glycemic management on the prognosis of hospitalized COVID-19 patients with varying degrees of severity.

METHODS

From April 2020 to January 2021, we carried this retrospective cohort in a clinical care facility in Pakistan.

RESULTS

Mortality was lowest in patients with HbA1c of less than 7% (53 mmol/mol) (p < 0.001). Similarly, mortality was found lowest in patients with fasting blood glucose less than 126 mg/dl and random blood glucose less than 160 mg/dl (p < 0.001 in each). In contrast, need for admission in critical care was found highest in patients with HbA1c between 7 and 10% (53-86 mmol/mol) (p 0.002). However, participants with blood glucose levels during fasting greater than 200 mg/dl and random blood glucose levels greater than 250 mg/dl were found to have a greater need for invasive mechanical ventilation. Cox regression hazard showed no difference in risk of death and invasive mechanical ventilation based on previous glycemic control.

CONCLUSION

Effective diabetic management is correlated with a considerably lower risk of mortality and invasive mechanical ventilation in COVID-19 cases.

At-admission HbA1c levels in Hospitalized COVID-19 Participants With and Without Known Diabetes

Background

To examine glycaemic status, and the impact of at-admission HbA1c levels on outcome, in a large group of participants hospitalized for COVID-19.

Methods

We inclued 515 participants with confirmed COVID-19 infection, with or without known diabetes, who met the following additional criteria: 1) age > 18 years, 2) HbA_1c was determined at admission; 3) fasting plasma glucose was determined in the week of admission, and 4) discharge or death was reached before the end of the study. We examined attributes of participants at admission and 3–6 months post-discharge. To assess the associations of pre-admission attributes with in-hospital mortality, logistic regression analyses were performed.

Results

Mean age was 70 years, 98.8% were of white race, 49% were female, 31% had known diabetes (KD), an additional 7% met the HbA1c criterion for diabetes, and 13.6% died. In participants with KD, FPG and HbA1c levels were not associated with mortality in adjusted analyses; however, in participants without KD, whereas FPG showed direct association with mortality, HbA1c showed slight inverse association.

Conclusions

There was a very high prevalence of people without KD with HbA1c levels above normal at-admission. This alteration does not seem to have been related to blood glucose levels.

One year into the clash of pandemics of diabetes and COVID-19: Lessons learnt and future perspectives

There is a bidirectional relationship between coronavirus disease 2019 (COVID-19) and diabetes. Furthermore, the COVID-19 pandemic has catalyzed the use of technology in diabetes care. Future research is required to assess the impact of COVID-19 on new-onset diabetes and the influence of diabetes on responses to COVID-19 vaccines.

Elevated HbA1c levels in pre-Covid-19 infection increases the risk of mortality: A sistematic review and meta-analysis

AIMS

Diabetes is emerging as a risk factor for coronavirus disease (COVID)-19 prognosis. However, contradictory findings have been reported regarding the impact of glycaemic control on COVID-19 outcome. The aim of this meta-analysis was to explore the impact of hospital pre-admission or at-admission values of HbA1c on COVID-19 mortality or worsening in patients with diabetes.

MATERIALS AND METHODS

We searched PubMed, Embase and Scopus up to 30th December 2020. Eligibility criteria for study selection were the following: (1)enrolling patients with any form of diabetes mellitus and hospitalized for COVID-19 and (2) reporting data regarding HbA1c values before infection or at hospital admission in relation to COVID-19 mortality or worsening. Descriptive statistics, HbA1c values, odds ratios (ORs) and hazard ratios were extracted from seven observational studies and generic inverse variance (random effects) of OR was used to estimate the effect of HbA1c on COVID-19 outcome.

RESULTS

HbA1c was linearly associated with an increased COVID-19 mortality or worsening when considered as a continuous variable (OR 1.01 [1.01, 1.01]; p < 0.00001). Similarly, when analysing studies providing the number of events according to the degree of glycaemic control among various strata, a significantly increased risk was observed with poor glycaemic control (OR 1.15 [1.11, 1.19]; p < 0.00001), a result corroborated by sensitivity analysis.

CONCLUSIONS

Notwithstanding the large heterogeneity in study design and patients' characteristics in the few available studies, data suggest that patients with diabetes and poor glycaemic control before infection might have an increased risk of COVID-19 related mortality.

Predictive value of HbA1c for in-hospital adverse prognosis in COVID-19: A systematic review and meta-analysis

BACKGROUND AND AIMS

Clinical and laboratory predictors of adverse clinical course and death in COVID-19 patients urgently need to be identified. So far, the association between HbA1c and in-hospital mortality of COVID-19 remains a controversial issue. The aim of this study is to analyze predictive value of HbA1c for adverse prognosis in COVID-19.

METHODS

Both Chinese and English databases were systematically searched using specific keywords associated with the aims until November 21th, 2020. The Newcastle-Ottawa Scale (NOS) was used for quality assessment. A Statistical analysis was carried out using Review Manager 5.3 and STATA 15.1.

RESULTS

Nine clinical trials were included in this study involving 2577 subjects. The results indicate that the association between elevated HbA1c referred as a continuous variable and adverse prognosis of COVID-19 was not significant (OR, 1.02; 95%CI, 0.95-1.09). However, higher HbA1c levels regarded as a dichotomous variable contributed to an increase mortality of COVID-19 (OR, 2.300; 95%CI, 1.679-3.150). Results were stable in a sensitivity analysis. More studies are needed to demonstrate the effect of HbA1c on hospital mortality.

CONCLUSION

Prolonged uncontrolled hyperglycemia increases the risk of adverse prognosis in COVID-19. Patients with higher HbA1c should be monitored strictly to minimize the risk of adverse prognosis in COVID-19.

Fasting plasma glucose and glucose fluctuation are associated with COVID-19 prognosis regardless of pre-existing diabetes

AIMS

We aimed to investigate the role of Fasting Plasma Glucose (FPG) and glucose fluctuation in the prognosis of COVID-19 patients stratified by pre-existing diabetes.

METHODS

The associations of FPG and glucose fluctuation indexes with prognosis of COVID-19 in 2,642 patients were investigated by multivariate Cox regression analysis. The primary outcome was in-hospital mortality; the secondary outcome was disease progression. The longitudinal changes of FPG over time were analyzed by the latent growth curve model in COVID-19 patients stratified by diabetes and severity of COVID-19.

RESULTS

We found FPG as an independent prognostic factor of overall survival after adjustment for age, sex, diabetes and severity of COVID-19 at admission (HR: 1.15, 95% CI: 1.06-1.25, P = 1.02 × 10^-3). Multivariate logistic regression analysis indicated that the standard deviation of blood glucose (SDBG) and largest amplitude of glycemic excursions (LAGE) were also independent risk factors of COVID-19 progression (P = 0.03 and 0.04, respectively). The growth trajectory of FPG over the first 3 days of hospitalization was steeper in patients with critical COVID-19 in comparison to moderate patients.

CONCLUSIONS

Hyperglycemia and glucose fluctuation were adverse prognostic factors of COVID-19 regardless of pre-existing diabetes. This stresses the importance of glycemic control in addition to other therapeutic management.

A meta-analysis on the risk factors adjusted association between cardiovascular disease and COVID-19 severity

BACKGROUND

Cardiovascular disease (CVD), one of the most common comorbidities of coronavirus disease 2019 (COVID-19), has been suspected to be associated with adverse outcomes in COVID-19 patients, but their correlation remains controversial.

METHOD

This is a quantitative meta-analysis on the basis of adjusted effect estimates. PubMed, Web of Science, MedRxiv, Scopus, Elsevier ScienceDirect, Cochrane Library and EMBASE were searched comprehensively to obtain a complete data source up to January 7, 2021. Pooled effects (hazard ratio (HR), odds ratio (OR)) and the 95% confidence intervals (CIs) were estimated to evaluate the risk of the adverse outcomes in COVID-19 patients with CVD. Heterogeneity was assessed by Cochran's Q-statistic, I2test, and meta-regression. In addition, we also provided the prediction interval, which was helpful for assessing whether the variation across studies was clinically significant. The robustness of the results was evaluated by sensitivity analysis. Publication bias was assessed by Begg's test, Egger's test, and trim-and-fill method.

RESULT

Our results revealed that COVID-19 patients with pre-existing CVD tended more to adverse outcomes on the basis of 203 eligible studies with 24,032,712 cases (pooled ORs = 1.41, 95% CIs: 1.32-1.51, prediction interval: 0.84-2.39; pooled HRs = 1.34, 95% CIs: 1.23-1.46, prediction interval: 0.82-2.21). Further subgroup analyses stratified by age, the proportion of males, study design, disease types, sample size, region and disease outcomes also showed that pre-existing CVD was significantly associated with adverse outcomes among COVID-19 patients.

CONCLUSION

Our findings demonstrated that pre-existing CVD was an independent risk factor associated with adverse outcomes among COVID-19 patients.

Correlation of Hemoglobin A1C and Outcomes in Patients Hospitalized With COVID-19

Objective

Diabetes is a known risk factor for severe coronavirus disease 2019 (COVID-19). We conducted this study to determine if there is a correlation between hemoglobin A1C (HbA1C) level and poor outcomes in hospitalized patients with diabetes and COVID-19.

Methods

This is a retrospective, single-center, observational study of patients with diabetes (defined by an HbA1C level of ≥6.5% or known medical history of diabetes) who had a confirmed case of COVID-19 and required hospitalization. All patients were admitted to our institution between March 3, 2020, and May 5, 2020. HbA1C results for each patient were divided into quartiles: 5.1% to 6.7% (32-50 mmol/mol), 6.8% to 7.5% (51-58 mmol/mol), 7.6% to 8.9% (60-74 mmol/mol), and >9% (>75 mmol/mol). The primary outcome was in-hospital mortality. Secondary outcomes included admission to an intensive care unit, invasive mechanical ventilation, acute kidney injury, acute thrombosis, and length of hospital stay.

Results

A total of 506 patients were included. The number of deaths within quartiles 1 through 4 were 30 (25%), 37 (27%), 34 (27%), and 24 (19%), respectively. There was no statistical difference in the primary or secondary outcomes among the quartiles, except that acute kidney injury was less frequent in quartile 4.

Conclusion

There was no significant association between HbA1C level and adverse clinical outcomes in patients with diabetes who are hospitalized with COVID-19. HbA1C levels should not be used for risk stratification in these patients.

Lack of association between either outpatient or inpatient glycemic control and COVID-19 illness severity or mortality in patients with diabetes

INTRODUCTION

To evaluate whether outpatient insulin treatment, hemoglobin A1c (HbA1c), glucose on admission, or glycemic control during hospitalization is associated with SARS-CoV-2 (COVID-19) illness severity or mortality in hospitalized patients with diabetes mellitus (DM) in a geographical region with low COVID-19 prevalence.

RESEARCH DESIGN AND METHODS

A single-center retrospective study of patients hospitalized with COVID-19 from January 1 through August 31, 2020 to evaluate whether outpatient insulin use, HbA1c, glucose on admission, or average glucose during admission was associated with intensive care unit (ICU) admission, mechanical ventilation (ventilator) requirement, or mortality.

RESULTS

Among 111 patients with DM, 48 (43.2%) were on outpatient insulin and the average HbA1c was 8.1% (65 mmol/mol). The average glucose on admission was 187.0±102.94 mg/dL and the average glucose during hospitalization was 173.4±39.8 mg/dL. Use of outpatient insulin, level of HbA1c, glucose on admission, or average glucose during hospitalization was not associated with ICU admission, ventilator requirement, or mortality among patients with COVID-19 and DM.

CONCLUSIONS

Our findings in a region with relatively low COVID-19 prevalence suggest that neither outpatient glycemic control, glucose on admission, or inpatient glycemic control is predictive of illness severity or mortality in patients with DM hospitalized with COVID-19.

Impact of undiagnosed type 2 diabetes and pre-diabetes on severity and mortality for SARS-CoV-2 infection

INTRODUCTION

Diabetes and hyperglycemia are risk factors for critical COVID-19 outcomes; however, the impact of pre-diabetes and previously unidentified cases of diabetes remains undefined. Here, we profiled hospitalized patients with undiagnosed type 2 diabetes and pre-diabetes to evaluate its impact on adverse COVID-19 outcomes. We also explored the role of de novo and intrahospital hyperglycemia in mediating critical COVID-19 outcomes.

RESEARCH DESIGN AND METHODS

Prospective cohort of 317 hospitalized COVID-19 cases from a Mexico City reference center. Type 2 diabetes was defined as previous diagnosis or treatment with diabetes medication, undiagnosed diabetes and pre-diabetes using glycosylated hemoglobin (HbA1c) American Diabetes Association (ADA) criteria and de novo or intrahospital hyperglycemia as fasting plasma glucose (FPG) ≥140 mg/dL. Logistic and Cox proportional regression models were used to model risk for COVID-19 outcomes.

RESULTS

Overall, 159 cases (50.2%) had type 2 diabetes and 125 had pre-diabetes (39.4%), while 31.4% of patients with type 2 diabetes were previously undiagnosed. Among 20.0% of pre-diabetes cases and 6.1% of normal-range HbA1c had de novo hyperglycemia. FPG was the better predictor for critical COVID-19 compared with HbA1c. Undiagnosed type 2 diabetes (OR: 5.76, 95% CI 1.46 to 27.11) and pre-diabetes (OR: 4.15, 95% CI 1.29 to 16.75) conferred increased risk of severe COVID-19. De novo/intrahospital hyperglycemia predicted critical COVID-19 outcomes independent of diabetes status.

CONCLUSIONS

Undiagnosed type 2 diabetes, pre-diabetes and de novo hyperglycemia are risk factors for critical COVID-19. HbA1c must be measured early to adequately assess individual risk considering the large rates of undiagnosed type 2 diabetes in Mexico.

The relationship between obesity, hemoglobin A1c and the severity of COVID-19 at an urban tertiary care center in New York City: a retrospective cohort study

OBJECTIVES

To determine if obesity and diabetes are risk factors for severe outcomes in COVID-19 and to compare patient outcomes in those two conditions.

DESIGN

Retrospective cohort study.

SETTING

Urban tertiary care center in New York City.

PARTICIPANTS

302 patients admitted in an inpatient setting, ≥18 years old, with a laboratory-confirmed diagnosis of COVID-19 via nasal PCR swab were randomly selected. Patients were separated into two cohorts based on their body mass index and hemoglobin A1c. 150 patients were placed in the non-obese, non-diabetic cohort and 152 patients were placed in the corresponding cohort (obesity alone, obesity and diabetes, and diabetes alone).

MEASUREMENTS

Primary outcomes were development of acute kidney injury, commencement of renal replacement therapy, aminotransferase elevation, troponin elevation, lactic acidosis, development of septic shock, use of vasopressors, presence of acute respiratory distress syndrome (ARDS) and intubation. The secondary outcomes were length of stay in days and mortality.

RESULTS

Patients with obesity and/or diabetes were more likely to develop ARDS (79 patients vs 57 patients, p<0.0001) and to be intubated (71 patients vs 45 patients, p=0.0031). Patients with obesity and/or diabetes were more likely to require vasopressors (60 patients vs 41 patients, p=0.0284) and to develop lactic acidosis (median 3.15 mmol/L, IQR 1.8 to 5.2 mmol/L, p=0.0432). When comparing patients with diabetes with and without obesity against patients with obesity alone, they were more likely to develop ARDS (87.5%, p=0.0305). Despite these findings, there was no difference in mortality.

CONCLUSIONS

In patients hospitalised with COVID-19, those with obesity and/or diabetes were more likely to suffer severe complications, but had negligible differences in mortality. This highlights the importance of close monitoring of patients with these conditions and additional areas of research needed to explain the mortality findings.

Immune Response to SARS-CoV-2 Infection in Obesity and T2D: Literature Review

In December 2019, a novel coronavirus known as SARS-CoV-2 was first detected in Wuhan, China, causing outbreaks of the coronavirus disease COVID-19 that has now spread globally. For this reason, The World Health Organization (WHO) declared COVID-19 a public health emergency in March 2020. People living with pre-existing conditions such as obesity, cardiovascular diseases, type 2 diabetes (T2D), and chronic kidney and lung diseases, are prone to develop severe forms of disease with fatal outcomes. Metabolic diseases such as obesity and T2D alter the balance of innate and adaptive responses. Both diseases share common features characterized by augmented adiposity associated with a chronic systemic low-grade inflammation, senescence, immunoglobulin glycation, and abnormalities in the number and function of adaptive immune cells. In obese and T2D patients infected by SARS-CoV-2, where immune cells are already hampered, this response appears to be stronger. In this review, we describe the abnormalities of the immune system, and summarize clinical findings of COVID-19 patients with pre-existing conditions such as obesity and T2D as this group is at greater risk of suffering severe and fatal clinical outcomes.