Effect of Chronic Kidney Disease on Outcomes of Adult Patients Admitted With Hyperosmolar Hyperglycemic State: Analysis of National Inpatient Sample

Background: Treatment guidelines have been well established in patients with HHS and a normal renal function. The mainstay of treatment for patients with HHS includes intravenous volume replacement, potassium replacement, and blood glucose correction by administering insulin. However, this treatment protocol cannot be directly applied to a patient with decreased GFR as it increases the risk of hypoglycemic episodes due to decreased insulin clearance along with increasing the risk of hyperkalemia and volume overload. Hence titrating insulin, maintaining euvolemia and normokalemia becomes further challenging in a patient with HHS in the setting of CKD. Although the above-mentioned complications are well described in multiple studies, there is not enough evidence demonstrating the association between the inpatient mortality and secondary outcomes in patients with HHS with and without CKD. Objective: To compare the inpatient mortality and secondary outcomes in patients admitted with HHS with CKD vs without CKD. Methods: A retrospective cohort study was conducted using the Nationwide Inpatient Sample from 2016 and 2017. About 42 740 hospitalizations who had HHS as primary diagnosis were enrolled and further stratified based on the presence or absence of CKD as a secondary diagnosis using ICD-10 codes. The primary outcome was inpatient mortality and secondary outcomes included length of hospital stay, total Hospital charges, Sepsis, Septic Shock, Acute Kidney Injury (AKI), and Acute Respiratory Failure (ARF). Multivariate regression analysis was done to adjust for confounders. Results: Out of the 42 740 hospitalizations with HHS, about 9 545 had CKD. The in-hospital mortality for patients with HHS was 305 overall, out of which 105 patients had Atrial Fibrillation as a secondary diagnosis. Compared with patients without CKD, patients with CKD had similar in-hospital mortality (aOR 0.93, 95% CI 0.48–1.8, p=0.83) when adjusted for patient and hospital characteristics. Patients with HHS and CKD had similar length of hospital stay, total hospital charges, rate of Sepsis, Septic Shock, and ARF in comparison to patients without CKD; however, patients with CKD had higher odds of developing AKI thorough out hospitalization. Conclusion: This study found that patients admitted with HHS and CKD have similar in-hospital mortality when compared to patients without CKD. However, the study group with CKD has higher odds of developing AKI when compared to the group without CKD. Although AKI is common and correctable in HHS, the above-mentioned association is possible due to the judicious IV fluid replacement in an HHS patient with CKD as a concern for volume overload. Further studies are needed to identify contributing risk factors and establishing fluid replacement guidelines in a patient with HHS and CKD.