Hyperglycemia and outcomes in patients with sepsis

A Study on the Incidence and Impact of Dysglycemia in Non-diabetic Sepsis Patients

Context Dysglycemia is common in severe sepsis and is associated with a poor prognosis. There is a limited amount of research on stress-induced dysglycemia in non-diabetic sepsis patients. Aim This study aims to estimate the incidence of dysglycemia among non-diabetic patients presenting with sepsis at the Emergency Department and to determine its correlation with gender, age, APACHE II (Acute Physiology and Chronic Health Evaluation) scores, diagnosis, and duration of hospital stay. Materials and methods The study was conducted at a medical college hospital in Kochi from January 1, 2023, to December 31, 2023. A minimum sample size of 77 was derived after a pilot study, with a 95% confidence interval and 10% allowable error. A total of 100 non-diabetic sepsis patients meeting the inclusion and exclusion criteria were analyzed with regard to gender, age, diagnosis, glycemic status (hypo/hyper/normoglycemic), APACHE II scores, and hospital stay duration. Statistical analysis was performed using IBM SPSS Statistics for Windows, Version 20 (Released 2011; IBM Corp., Armonk, New York) software. Categorical variables were expressed as frequency and percentage. Continuous variables were presented as mean ± SD (standard deviation) and median (Q1-Q3). To test the statistical significance of the association between the presence of various factors (gender, age, diagnosis) and dysglycemia, the chi-square test was used. To test the statistical significance of the difference in the mean age and APACHE II score values with dysglycemia, an independent sample t-test was used. To test the statistical significance of the difference in the median hospital stay with dysglycemia, the Whitney U test was used. Data were represented as mean ± SD, and a p-value of <0.05 was considered to be statistically significant. Results The incidence of dysglycemia in the inclusion group was 49% (hypoglycemia in 16% and hyperglycemia in 33% of cases), and it increased with age (p=0.002). The majority of the dysglycemic patients fell into the age group >40 years. Dysglycemia was 54.8% in pneumonia and 66.7% in gastrointestinal sepsis ( p=0.138). Dysglycemia increased with an increase in APACHE II scores (p=0.017). The median hospital stay was almost the same in both normoglycemics and dysglycemics. Conclusion Dysglycemia is a frequent complication in non-diabetic patients with sepsis. It increased with age and APACHE II score, but it does not prolong the duration of hospital stay, nor is it associated with the diagnosis.

Impact of Metabolic Syndrome on Post-Operative Infection in Patients Undergoing Flexible Ureteroscopy Lithotripsy

Background: To investigate retrospectively whether metabolic syndrome (MetS) of flexible ureteroscopy (fURS) lithotripsy can be used to predict post-operative infection. Patients and Methods: After screening, 1,110 patients who received fURS lithotripsy for upper urinary tract stones in our center between January 2015 and December 2022 were analyzed retrospectively. Patients were divided into MetS-positive group and MetS-negative group. Post-operative infection was divided into fever, urosepsis, and septic shock. Relevant data during the peri-operative period were collected. Univariable and multivariable logistic regression analyses were adopted to estimate the impact of metabolic syndrome on post-operative infection in patients undergoing fURS lithotripsy. Results: Among the 1,110 patients, 427 tested positive for MetS, whereas 683 tested negative. Eighty-eight patients suffered from fever (67 patients in the MetS-positive group and 21 in the MetS-negative group). Forty-nine patients had urosepsis (29 patients in the MetS-positive group and 20 in the MetS-negative group), of whom seven patients developed septic shock. No patient developed multiple organ failure or died because of infection. The prevalence of post-operative infections in the MetS-positive group was higher than that in the MetS-negative group (p < 0.001). Multivariable logistic regression analyses showed that diabetes mellitus, MetS-positive, positive urine culture, and longer operation time were positively correlated with post-operative fever. Positive MetS, positive urine culture, and longer operation time were strongly correlated with post-operative urosepsis. Conclusions: Metabolic syndrome was found to be associated with post-operative infection in patients undergoing fURS lithotripsy, suggesting it can serve as a predictive factor.

Impact of diabetes mellitus on outcomes of patients with sepsis: an updated systematic review and meta-analysis

BACKGROUND

The effect of concurrent diabetes on the outcome of sepsis is not conclusively known. A meta-analysis published in 2017 indicated that diabetes did not influence the mortality of patients with sepsis but increased the risk of acute renal injury. In view of publication of several new studies in recent years, there is a need for updated evidence.

METHODS

A systematic search was conducted using the PubMed, Scopus, Embase, and Google Scholar databases. Studies that were done in patients with sepsis, were observational in design- either cohort or case-control or analysed retrospective data were considered for inclusion. Statistical analysis was performed using STATA software.

RESULTS

A total of 21 studies were included. The risk of in-hospital mortality (RR 0.98, 95% CI 0.93, 1.04) and mortality at latest follow up i.e., within 90 days of discharge (RR 0.94, 95% CI 0.86, 1.04) among diabetic and non-diabetic subjects was statistically similar. There was an increased risk of in-hospital mortality among those with high blood glucose level at admission (RR 1.45, 95% CI 1.01, 2.09). Among those who were diabetic, the risk of acute renal failure (RR 1.54, 95% CI 1.34, 1.78) was higher than non-diabetics. The risk of respiratory failure, adverse cardiac events, need for additional hospitalization post-discharge and length of hospital stay was similar among diabetics and non-diabetics.

CONCLUSIONS

Diabetes is not associated with poor survival outcomes in patients with sepsis but is associated with increased risk of acute renal failure. High blood glucose levels, irrespective of the diabetes status, are associated with increased risk of in-hospital mortality. Findings underscore the need for better evaluation of renal function in diabetic patients with concurrent sepsis.

Divergent Sepsis Pathophysiology in Older Adults

Significance: Both incidence and mortality rates of sepsis significantly increase with advanced age, and the majority of sepsis patients are late middle-aged or older. With the proportion of older adults rapidly increasing in developed countries, age-dependent sepsis vulnerability is an urgent medical issue. Due to an increasing life expectancy, postsepsis complications and health care costs are expected to increase as well. Recent Advances: Older patients suffer from higher sepsis incidence and mortality rates, likely resulting from frequent comorbidities, increased coagulation, dysgylcemia, and altered immune responses. Critical Issues: Despite a large number of ongoing clinical and basic research studies, there is currently no effective therapeutic strategy targeting older patients with severe sepsis. The disparity between clinical and basic studies is a problem, and this is largely due to the use of animal models lacking clinical relevance. Although the majority of sepsis cases occur in older adults, most laboratory animals used for sepsis research are very young. Further, despite the wide use of combination fluid and antibiotic treatment in intensive care unit (ICU) patients, most animal research does not include such treatment. Future Directions: Because sepsis is a systemic disease with multiple organ dysfunction, combined therapy approaches, not those targeting single pathways or single organs, are essential. As for preclinical research, it is critical to confirm new findings using aged animal models with clinically relevant ICU-like medical treatments. Antioxid. Redox Signal. 35, 1358-1375.

Analysis of Glucose Levels in Patients Hospitalized With COVID-19 During the First Phase of This Pandemic in West Texas

Background:

Patients with hyperglycemia during hospitalization, especially during ICU hospitalizations, often have worse outcomes, even if they do not have a premorbid diagnosis of diabetes. High glucose levels can provide insight into the underlying pathogenesis of a disease and can contribute to tissue injury. Some patients with COVID-19 have hyperglycemia during hospitalizations.

Methods:

The Infectious Disease and Control office at University Medical Center in Lubbock, Texas, provided a list of patients with a COVID-19 infection hospitalized between March 1 and May 15, 2020. The medical records were reviewed to collect information on age, gender, history of diabetes, and glucose levels on admission and through the first 7 days of hospitalization.

Results:

This study included 63 patients with a mean age of 62.1 ± 14.1 years. Thirty-five patients (55.6%) were males. The in-hospital mortality rate was 30.2%. The mean admission glucose level was 129.4 ± 57.1 mg/dL in patients who survived (N = 47) and 189.6 ± 112.2 mg/dL in patients who died during hospitalization (N = 16, P = .007). An admission glucose greater than 180 mg/dL predicted mortality in a model adjusted for a diabetes, age, and male gender. The mean differences between the maximum and minimum glucose levels calculated over the first 7 days of hospitalization were 112.93 ± 115.4 (N = 47) in patients who survived and were 240.5 ± 97.7 (N = 15) in patients who died during hospitalization (P = .0003). A difference between the maximum and minimum glucose level greater than 105 mg/dL was associated with increased mortality.

Conclusions:

Patients who died during hospitalization for COVID-19 had higher admission glucose levels than patients who survived. Larger differences between maximum and minimum glucose levels during the first 7 days of hospitalization were associated with increased mortality. These results suggest that high glucose levels identify patients at increased risk for mortality and warrant more study.

Association between acute respiratory failure requiring mechanical ventilation and the production of advanced glycation end products

Patients with acute respiratory failure often have hyperglycemia. Elevated glucose levels could cause acute lung injury through the production of advanced glycation end products. We measured glucose, advanced glycation end products, glycated albumin, circulating glycated hemoglobin, and soluble receptor for advanced glycation end product (sRAGE) levels on admission, at 24 hours, and at 72 hours in 40 patients with acute respiratory failure requiring mechanical ventilation. We compared these values with healthy control subjects. The mean age was 63.3±11.2 years. Fifty percent of the patients were women. Thirteen patients (32.5%) died during this hospitalization. The mean maximum glucose level on the day of admission was 215.7±171.1 mg/dL. Compared with control subjects, there was a significant reduction in advanced glycation end product levels (p=0.0001) in the patients at all 3 time points. Circulating glycated hemoglobin levels were significantly higher in patients compared with control subjects. We also observed a moderate increase in glycated albumin levels on admission and at 24 hours when compared with the control samples. Overall sRAGE levels were similar to controls, but patients with dense infiltrates on chest X-ray had increased levels compared with patients who did not have these dense infiltrates on the day of admission. Patients with acute respiratory failure requiring mechanical ventilation have decreased levels of advanced glycation end products and increased levels of circulating glycated hemoglobin. The results from this pilot study suggest that the acute stress associated with respiratory failure might create glycated proteins which could contribute to disease pathogenesis.

Glucose and Lactate Levels at Admission as Predictors of In-hospital Mortality

Objective

Glucose and lactate levels in patients at the time of admission have been studied in diverse patient groups. Some studies suggest that elevated glucose levels at admission predict worse outcomes. Elevated Lactate levels have also been reported to be directly associated with increased mortality. We wanted to determine if the combination of admission glucose and lactate levels improves the predictability of inpatient mortality and length of stay (LOS).

Methods

This is a retrospective study. We included all adult patients admitted at an academic medical center from October 1, 2015 to September 30, 2016. We collected basic clinical information, including age, gender, admission glucose and lactate levels, LOS, and mortality. We separated outcomes based on glucose and lactate levels by dividing them into quartiles. We also stratified patients based on normal lactate (<2.0 mmol/L), high lactate (2.0-4.0 mmol/L), and very high lactate (>4 mmol/L) levels; and on normal glucose (60-140 mg/dl), high glucose (140-200 mg/dl), and very high glucose (>200 mg/dl) levels.

Results

A total of 5,436 adult patients were included in our study. The median age was 58 years, and 57% of the patients were male. The median LOS was 6 days, and the overall in-hospital mortality rate was 11%. When the patients were separated in quartiles based on admission glucose values, mortality was higher in the 4th quartile (≥173 mg/dL): 14.87%, probability value (p): <0.001. When the patients were separated in quartiles based on lactate levels, the mortality was higher in the 4th quartile (≥2.23 mmol/L): 21.95%, p: 0.001. When the patients were paired according to normal, high, or very high lactate and glucose levels, the groups that had higher mortality were as follows: normal glucose/very high lactate: 32.43%; high glucose/very high lactate: 34.04%; and very high glucose and very high lactate: 39.15%. The groups with very high glucose and very high lactate had increased odds of mortality when compared with the other groups (p: <0.001).

Conclusions

Admission glucose and lactate levels provide useful information in the estimation of inpatient mortality. The LOS was shortened in the groups with higher glucose, lactate, or both. The combination of glucose and lactate levels predicted mortality better than either value alone. 

The association between admission glucose levels and outcomes in adults admitted to a tertiary care hospital

Background: Hyperglycemia at the time of hospital admission has been associated with poor outcomes in several patient groups, but there is little information about this association in hospitalized patients with diverse diagnoses.

Methods: We identified all adult patients admitted between 10/1/2015 and 9/30/2016 who had glucose levels measured during the first 24 h after admission to the hospital. Clinical information included age, gender, glucose levels, diagnoses based on ICD 10 discharge coding, length of stay (LOS), and mortality. Patients were classified into quartiles based on glucose levels and into clinically relevant glucose categories.

Results: This study included 18,478 adult patients admitted to a tertiary care hospital. The median age was 53 years, the median LOS was 4 days, and the overall in-hospital mortality was 3.8%. The median admission glucose level was 117 mg/dL. Mortality increased in each glucose quartile; it was also highest in patients admitted with a glucose <55 mg/dL or with a glucose >200 mg/dL. The LOS was significantly shorter in patients in glucose quartiles 1 and 2.

Conclusions: Admission glucose levels were associated with in-hospital mortality and LOS in this cohort of hospitalized patients. Attention to glucose levels can help identify patients at risk for poor outcomes.

The effects of SIRT1/FoxO1 on LPS induced INS-1 cells dysfunction

Oxidative stress is one of the key mechanisms of sepsis related organ dysfunction including stress hyperglycemia. Silent mating type information regulation 2 homolog 1 (SIRT1) could regulate glucose metabolism through its deacetylase activity. In this study, we aimed to investigate the role of SIRT1/forkhead box protein 1 (FoxO1) pathway on lipopolysaccharide (LPS) induced INS-1 cells dysfunction from aspects of oxidative stress and apoptosis. After being treated with 1 mg/L LPS together with or without SIRT1 activator resveratrol (RSV) or SIRT1 inhibitor EX527, cell viability, ROS generation, malondialdehyde (MDA), superoxide, insulin secretion, and activity of superoxide dismutase (SOD) in INS-1 cells were measured by specific assays. Protein expression of SIRT1, FoxO1, toll-like receptor 4 (TLR4), and acetylated FoxO1 (ac-FoxO1) were detected by western blot analysis. Nuclear and cytoplasmic protein was extracted respectively to analyze SIRT1 and FoxO1 redistribution. Mitochondrial potentials and apoptosis were detected by flow cytometry or observed under fluorescence microscope. Results showed that LPS decreased cell viability and insulin secretion, increased ROS, MDA, and superoxide generation, whereas inhibited SOD activity and FoxO1 nuclear transportation. Activation of SIRT1 by RSV down-regulated TLR4 expression, SIRT1 and FoxO1 nuclear protein expression increased after RSV pretreatment. Additionally, LPS induced decreased mitochondrial membrane potentials and structural abnormalities, which could be partially reversed by RSV. SIRT1/FoxO1 may be one of potential targets which could resist against LPS-induced INS-1 cells from oxidative stress damage and mitochondrial dysfunction.