Analysis Of Clinical Characteristics Of Adult Diabetic Patients With Combined DKA And Their Typing

Diabetes mellitus is a disease that causes disorders of glucose metabolism in the body due to various reasons,and is a public health problem urgently needed to be solved all over the world.Diabetic ketoacidosis(DKA)is one of the most serious acute complications of diabetes mellitus,which greatly increases the length of hospitalization and hospital costs of diabetic patients.Previous studies have concluded that diabetic ketoacidosis occurs mostly in patients with type 1 diabetes mellitus(T1DM)and is an important feature to distinguish it from type 2 diabetes mellitus(T2DM).A growing number of studies have shown that DKA occurs in an increasing proportion of patients with T2DM,in some cases more than half.Latent autoimmune diabetes in adults(LADA)is a subtype of type 1 diabetes.It has similar pathogenesis in immunity with classical type 1 diabetes,but its initial clinical manifestations overlap with type 2 diabetes.It is a special type of diabetes between type 1 diabetes and type 2 diabetes.Several studies have found that the clinical presentation and outcome of different types of diabetes mellitus with diabetic ketoacidosis vary.In clinical work,diabetic patients seen for ketoacidosis often suffer from unclear typing.Therefore,it is necessary to summarize the clinical characteristics of patients with different types of diabetes mellitus DKA and discuss the diagnostic staging.Objective:By summarizing the clinical characteristics of adult diabetic patients with different types of combined DKA,and evaluating the diagnostic value of relevant laboratory indicators in each diagnosis,we can provide a theoretical basis for the diagnostic typing of adult diabetic patients with combined DKA.Methods:Patients hospitalized for diabetic ketoacidosis in Cangzhou People’s Hospital from June 2015 to February 2022 were retrospectively collected and selected for this study,excluding patients with incomplete clinical data,and patients with repeated hospitalization were counted according to the first admission only.A total of 31 cases met the classical T1MD diagnostic criteria(2021 version of the Chinese guidelines for the diagnosis and treatment of type 1 diabetes),36 cases met the LADA diagnostic criteria(2021 version of the expert consensus for the diagnosis and treatment of occult autoimmune diabetes in adults),and 34 cases met the T2DM diagnostic criteria(2020version of the Chinese guidelines for the prevention and treatment of type 2diabetes).Clinical data,including general information and biochemical parameters,were collected retrospectively.General clinical data include gender,inducement,main symptoms at the time of treatment,personal history(smoking history,drinking history),family history of diabetes,and related complications and complications.The laboratory test results include admission blood glucose,glycosylated hemoglobin(HbA1c),C-peptide(fasting and 2h after meal),islet autoantibodies(GADA,IAA,ICA),admission arterial blood PH,anion gap,triglyceride,blood potassium,white blood cells,total cholesterol,low density lipoprotein,three items(FT3,FT4,TSH),blood creatinine,high density lipoprotein,myocardial injury markers,etc.The general data and biochemical indexes of classical type 1 T1DM patients,LADA patients and T2DM patients were analyzed to summarize the clinical characteristics of different types of diabetic patients with combined DKA.The sensitivity and specificity of each clinical index for the diagnosis of diabetes mellitus staging with combined DKA were divided by subject operating characteristic(ROC)curves,and the index value at the maximum of Jorden index(sensitivity-1+ specificity)was used as the best cut-off point(all two-sided test,P<0.05 as a statistically significant difference).Results:1.101 inpatients with adult diabetes mellitus combined with DKA: there were 31 cases of classical T1DM,15 females and 16 males;34 cases of T2DM,17 females and 17 males;and 36 cases of LADA,13 females and 23 males.There was no statistical significance in the three groups in terms of gender and the number of newly diagnosed patients(P>0.05).The three groups had statistical significance in personal history,family history and age of onset of diabetes(P<0.05).In terms of family history and personal history of diabetes(smoking history and drinking history),the proportion of type 2 diabetes patients with DKA is the highest,followed by type 1 diabetes patients,and LADA patients with DKA are the lowest.In terms of age of onset,the patients with classic type 1 diabetes combined with DKA are the lowest,and the patients with type 2 diabetes combined with DKA are the highest,while the age of onset of patients with LADA combined with DKA is in the middle of the two levels.2.The percentage of LADA combined with DKA group without causative factors > T1DM combined with DKA group > T2DM combined with DKA group.In patients with causative factors for DKA,infection was the main factor triggering DKA,with the highest percentage of patients in the T2DM combined DKA group having infection.The remaining causative factors also included poor glycemic control,self-isolation of glucose-lowering drugs or insulin.In terms of clinical symptoms,digestive system symptoms,such as abdominal pain,diarrhea,nausea,vomiting,weakness,and poor appetite,were the main clinical manifestations of patients with different types of DKA at the time of consultation.In the T1DM combined with DKA group,"three more" symptoms were the main manifestations,while in the T2DM combined with DKA group and LADA combined with DKA group,nausea and vomiting were the main symptoms when patients visited the clinic.3.The incidence of hyperlipidemia and hypokalemia in the T2DM combined with DKA group was significantly higher than that in the other two groups,while the incidence of both diseases in the classical T1DM combined with DKA group was the lowest.The incidence of diabetic peripheral neuropathy was significantly higher than that of other diabetic complications,while diabetic peripheral vascular disease had the lowest incidence among the complications.4.The positive rates of GADA,ICA and IAA in all three groups of patients showed that the LADA combined with DKA group > classical T1DM combined with DKA group > T2DM combined with DKA group,and a few T2DM patients combined with DKA also showed positive islet autoantibodies.In the islet autoantibodies,the positive rate of GADA was significantly higher than that of ICA and IAA in the three groups.Among them,patients in the LADA combined with DKA group mostly showed two or more positive antibodies.Glycosylated hemoglobin in the three groups: T2DM combined with DKA group > LADA combined with DKA group > T1DM combined with DKA group.5.In the classical T1DM combined DKA group and the LADA combined DKA group,fasting C peptide,2h postprandial C peptide,and ALT had better diagnostic values for distinguishing patients with classical type 1 diabetes from those with LADA;in the T2DM combined DKA group and the LADA combined DKA group,fasting C peptide,2h postprandial C peptide,and cholesterol had better diagnostic values for distinguishing patients with type 2from those with LADA The diagnostic value of glycosylated hemoglobin,fasting C-peptide and 2h postprandial C-peptide was good for differentiating classical type 1 diabetes from type 2 diabetes in both the classical type 1 combined DKA and T2DM combined DKA groups.The combination of glycosylated hemoglobin,fasting C-peptide and postprandial 2hC-peptide had good diagnostic value to distinguish the classical T1DM combined with DKA group,LADA combined with DKA group and T2DM combined with DKA group.The combination of glycosylated hemoglobin,fasting C-peptide and postprandial 2hC-peptide has good diagnostic value to distinguish the classical T1DM combined with DKA group,LADA combined with DKA group and T2DM combined with DKA group.Conclusions:1.General clinical characteristics of classical type 1 diabetic patients with combined DKA in this study: diabetic ketoacidosis occurs mostly without obvious triggers,with a low age of onset,and they mostly present to the clinic with worsening symptoms of polyphagia,polydipsia and polyuria,and may also present with critical manifestations such as respiratory distress and impaired consciousness,with disorders of water-electrolyte metabolism,such as hyperkalemia,and almost never with a family history of diabetes There is hardly any family history of diabetes mellitus,as well as a history of smoking and alcohol consumption.2.General clinical characteristics of type 2 diabetic patients with combined DKA in this study: most of them had diabetic ketoacidosis caused by infection,with an older age of onset,most of them presented with gastrointestinal symptoms such as nausea and vomiting,most of them had a family history of diabetes or a history of smoking and alcohol consumption,and they often presented with multiple diabetic complications,most of them were accompanied by hyperlipidemia and hypokalemia at the time of consultation.3.General clinical characteristics of LADA patients with combined DKA in this study: diabetic ketoacidosis often occurs without obvious causes,the age of onset is between classical type 1 diabetes and type 2 diabetes,most of them are male,they often present with symptoms of nausea and vomiting,and may present with critical manifestations such as respiratory distress and impaired consciousness,most of them have no family history of diabetes and history of smoking and drinking alcohol Most of the patients had no family history of diabetes mellitus or history of smoking and drinking,with or without hyperlipidemia.4.Aspects of pancreatic islet function:2h postprandial C-peptide lower than 1.075ng/m and fasting C-peptide lower than 0.540ng/mL were considered as classical type 1 diabetes mellitus with DKA;2h postprandial C-peptide higher than 3.26ng/mL and fasting C-peptide higher than 0.605ng/mL were considered as type 2 diabetes mellitus with DKA;islet function of LADA patients was in the middle of classical type 1 diabetes mellitus and type 2diabetes mellitus patients.The islet function of LADA patients was in the middle of classical type 1 diabetes and type 2 diabetes.The postprandial 2hC-peptide ranged from 1.075ng/m to 3.26ng/Ml,and fasting C-peptide ranged from 0.540ng/mL to 0.605ng/mL,which were considered as LADA with combined DKA.5.Fasting C-peptide and postprandial 2-hC-peptide have high diagnostic value in distinguishing three types of diabetes with DKA.Among them,postprandial 2-hC-peptide has the highest diagnostic value,and its sensitivity and specificity are higher than other indicators.The combined diagnosis of glycosylated hemoglobin,fasting and postprandial 2hC peptide has a higher diagnostic value in distinguishing three different types of diabetes with DKA than that of each indicator alone.