Hyperosmolar hyperglycemic state natural history, complications and prognosis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:
Overview
The symptoms of hyperosmolar hyperglycemic state (HHS) develop slowly over a period of days to weeks as compared to diabetic ketoacidosis which presents within hours of inciting event. The symptoms range from fatigue, weakness, leg cramps, polyuria, dehydration and eventually seizures and coma. If left untreated, patients may develop multiorgan failure and eventually death. Common complications are renal failure, thrombotic events, and cardiovascular complications. The complications due to treatment can be cerebral edema, pulmonary edema, hypoglycemia, and electrolyte imbalance. The mortality rate ranges from 5-20% which is ten times higher than diabetic ketoacidosis. The prognosis of the hyperosmolar hyperglycemic state (HHS) depends on the hemodynamic status, comorbidities, and age at the time of presentation.
Natural History, Complications, and Prognosis
Natural History
- The symptoms of hyperosmolar hyperglycemic state (HHS) usually develop over several days to weeks as compared to diabetic ketoacidosis which presents within hours of inciting event.
- Early in the course of disease HHS usually presents with symptoms of hyperglycemia such as polyuria, polydipsia, leg cramps, weakness, nausea, and dehydration.
- As HHS progresses, it leads to increase in serum osmolality which can present with neurological manifestations such as altered sensorium, focal signs, confused state or even coma. Neurological symptoms rarely present with an osmolality of less than 320 mOsm/kg.
- The severity of dehydration in HHS is due to insidious onset and longer duration of metabolic decompensation and also due to the reduced fluid intake.
- The increase in plasma osmolality leads to water shifts out of the cells and causes intracellular dehydration and with insulin deficiency, it further exacerbates potassium movement out of the cell.
- The dehydration leads to decrease glomerular filtration rate (GFR) and renal clearance of glucose, which further exacerbates hyperglycemia and ultimately renal failure.
- Hypotension or shock during DKA is nearly always the result of dehydration and hypovolemia.
- Heart failure, myocardial infarction, and arrhythmias are seen commonly in an untreated hyperosmolar hyperglycemic state.
- If left untreated, HHS may progress to multi-organ failure, seizures, coma and eventually death.
Complications
People with hyperosmolar hyperglycemic state (HHS) need close and frequent monitoring for complications. Surprisingly, the most common complications of HHS are related to the treatment:[1][2][3][4] Complications of hyperosmolar hyperglycemic state (HHS) include:
- Cardiovascular complications
- Acute renal failure
- Thrombotic events
- Infectious complications
Complications due to the treatment of hyperosmolar hyperglycemic state (HHS) include:
- Cerebral edema due to aggressive hydration
- Pulmonary edema
- Hypoglycemia
- Hypokalemia
Prognosis
The mortality of hyperosmolar hyperglycemic state ranges from 5% to 20%, which is ten times higher than diabetic ketoacidosis. The signs of poor prognosis in hyperosmolar hyperglycemic state (HHS) at the time of diagnosis include:[5][6][7]
- Advance age
- Severe dehydration
- Hypothermia
- Coma
- Hemodynamic instability
- Comorbidities such as chronic kidney disease or heart failure
References
- ↑ Muir AB, Quisling RG, Yang MC, Rosenbloom AL (2004). "Cerebral edema in childhood diabetic ketoacidosis: natural history, radiographic findings, and early identification". Diabetes Care. 27 (7): 1541–6. PMID 15220225.
- ↑ "Diabetic ketoacidosis". Diabetic ketoacidosis. Mayo Foundation for Medical Education and Research. 2006. Retrieved 2007-06-15. Text " By Mayo Clinic Staff " ignored (help)
- ↑ "Diabetic Coma > Diabetic ketoacidosis". Diabetic ketoacidosis. Armenian Medical Network. 2006. Retrieved 2007-06-15. Text " Umesh Masharani, MB, BS, MRCP " ignored (help)
- ↑ "Diabetic ketoacidosis complications". Diabetic ketoacidosis. The Diabetes Monitor. 2007. Retrieved 2007-06-15.
- ↑ Liu WY, Lin SG, Wang LR, Fang CC, Lin YQ, Braddock M, Zhu GQ, Zhang Z, Zheng MH, Shen FX (2016). "Platelet-to-Lymphocyte Ratio: A Novel Prognostic Factor for Prediction of 90-day Outcomes in Critically Ill Patients With Diabetic Ketoacidosis". Medicine (Baltimore). 95 (4): e2596. doi:10.1097/MD.0000000000002596. PMC 5291578. PMID 26825908.
- ↑ Gale EA, Tattersall RB (1978). "Hypothermia: a complication of diabetic ketoacidosis". Br Med J. 2 (6149): 1387–9. PMC 1608617. PMID 102402.
- ↑ Al-Matrafi J, Vethamuthu J, Feber J (2009). "Severe acute renal failure in a patient with diabetic ketoacidosis". Saudi J Kidney Dis Transpl. 20 (5): 831–4. PMID 19736483.