Increased <scp>DKA</scp> at presentation among newly diagnosed type 1 diabetes patients with or without <scp>COVID</scp>‐19: <scp>Data</scp> from a multi‐site surveillance registry
Kara Beliard, Osagie Ebekozien, Carla Demeterco‐Berggren, G. Todd Alonso, Mary Gallagher, Mark A. Clements, Robert Rapaport
Abstract
Highlights To the Editor The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) global pandemic has marked 2020. There have been initial reports on coronavirus disease 2019 (COVID-19) association with diabetes mellitus and diabetic ketoacidosis (DKA).1 Early diabetogenic effect of COVID-19 and glucose homeostasis is postulated to be due to the angiotensin-converting enzyme 2–mediated damage of the pancreatic islet cells, leading to hyperglycemia associated with underproduction of insulin.2 There might also be increased demand for insulin and increased insulin resistance related to cytokine release following COVID-19. An international registry has been established to further understand the different mechanisms and types of diabetes that might co-occur during or after COVID-19. This report focuses on patients with newly diagnosed type 1 diabetes (T1D) simultaneously presenting with COVID-19 in comparison with a cohort of newly diagnosed patients that tested negative for COVID-19 during the same period. The T1D Exchange Quality Improvement Collaborative (T1Dx-QI) is a national cohort of 27 endocrinology sites. The T1Dx-QI initiated the T1D COVID-19 multi-site surveillance registry and invited other sites from the previously described T1D Exchange Clinic Registry (81 sites) to contribute data on T1D patients that tested positive for COVID-19 or patients not tested with suspected COVID-19. Diabetes care providers completed a retrospective chart review of patients in contact with their clinical team during the study period (April 2020-August 2020). Details on the T1D COVID-19 registry have been earlier described.3 This project was reviewed and approved by the Western Institutional Review Board; local participating centers obtained necessary institutional review board approvals. This report describes demographic and DKA status (Yes or No) at presentation for newly diagnosed T1D with or without simultaneous COVID-19. The sites reported the data for the period (April 2020 by August 2020). A total of 17 sites contributed data for newly diagnosed patients with T1D and positive COVID-19 through the registry. The comparison data of newly diagnosed patients with negative COVID-19 were collected from an ad hoc registry for this manuscript from three sites, which also contributed to the newly diagnosed T1D and positive COVID-19 data We report the T1D COVID-19 registry data of 24 patients newly diagnosed with T1D with confirmed COVID-19 (positive test). A total of 124 patients (comparison cohort) with newly diagnosed T1D and negative COVID-19 testing were also reported, and the two groups were compared. The demographics and clinical characteristics are described in Table 1. A total of 97% of our total population were <19 years of age. A total of 71% of the patients with newly diagnosed T1D with positive COVID-19 testing were Hispanic and non-Hispanic Blacks, while 60% of the patients with newly diagnosed T1D and negative COVID-19 testing were White. A total of 75% of the patients with newly diagnosed T1D and positive COVID-19 testing had public insurance coverage, while 57% of the COVID-19 negative group had private insurance. At presentation, more than 60% of patients in both cohorts had DKA. There are limited data on the clinical presentation for patients with newly diagnosed T1D and confirmed COVID-19. The significant finding from our study is a high incidence of DKA at initial presentation (Table 1), which was significantly higher as compared with previous years in the United States.4 DKA is a late finding, indicating a delay in diagnosis. Similarly, high rates of DKA have recently been reported in Germany.5 Our data suggest that the high incidence of DKA is independent of the viral infection and maybe only associated with the reduction in health care visits observed early on during the pandemic. A recent study by Duca et al found that 28% of the patients with newly diagnosed T1D presented in DKA.6 Limitations of this study include the use of a small patient cohort. However, we believe that it will be challenging to collect data on a large cohort of T1D patients with newly diagnosed diagnosis and COVID-19 in a timely fashion. Another limitation is that the comparison cohort does not include all the patients from the sites contributing data to the primary group. The differences in the demographic data might reflect the background, contributing site patient demographics. Furthermore, given the nature of medical chart extraction, we could not collect data on other confounding indicators, which may have explained the observed higher proportion of patients presenting with DKA. This report adds significant new knowledge about DKA's increased risk to the sparse literature on newly diagnosed T1D patients with or without confirmed COVID-19 at diagnosis. Our study has implications for patients diagnosed with T1D during the current COVID-19 pandemic. More research needs to be done to describe the incidence of DKA at diagnosis of T1D in 2020 and to what extent social and physiological factors play a role. No funding was received for this manuscript. The T1Dx-QI is funded by The Leona M. and Harry B. Helmsley Charitable Trust. The T1D Exchange received financial support for COVID-19 response from Abbott Diabetes, Dexcom, Medtronic, Insulet Corporation, JDRF, Eli Lilly, and Tandem Diabetes Care. The authors thank all the principal investigators contributing to this T1D COVID-19 surveillance project. We also appreciate Saketh Rompicherla for data analysis support. R.R. is an associate editor for the Journal of Diabetes. O.E. and R.R. developed the concept for this manuscript. O.E. analyzed the data. O.E. and K.B. wrote the manuscript, contributed equally, and should be regarded as co-first authors. All authors edited and approved the final version. 席卷全球的新型冠状病毒肺炎(COVID-19)给2020年留下了深刻的印记。而在2019年就有COVID-19与糖尿病和糖尿病酮症酸中毒(DKA)相关的初步报告。COVID-19和葡萄糖稳态的早期致糖尿病作用被认为是由于血管紧张素转换酶2介导的胰岛细胞损伤, 导致与胰岛素分泌不足相关的高血糖。患COVID-19后, 对胰岛素的需求也可能增加, 胰岛素抵抗也可能增加, 这与细胞因子的释放有关。我们建立了一个由27个内分泌学站点组成的国家队列(T1Dx-QI)。T1Dx-QI启动了1型糖尿病(T1D) COVID-19多地点监测登记, 并邀请T1D交流诊所登记中心(81个地点)的其他地点, 提供COVID-19检测呈阳性的T1D患者或未检测的疑似COVID-19患者的数据, 以进一步了解在COVID-19期间或之后可能并存的不同机制和类型的糖尿病。 我们报告了24例新近诊断为COVID-19的T1D患者登记数据。同时报告了新诊断为T1D且COVID-19检测阴性的124例患者(对照队列), 并对两组进行了比较。 样本中97%的人年龄在19岁以下。COVID-19检测呈阳性的新诊断T1D患者中, 共有71%的西班牙裔和非西班牙裔黑种人, 而在COVID-19检测呈阴性的新诊断T1D患者中, 有60%是白种人。在新诊断的T1D和COVID-19检测阳性的患者中, 75%的患者有公共保险, 而在阴性组中, 57%的患者有私人保险。在临床表现上, 两个队列中都有超过60%的患者存在DKA。 我们研究的重要发现是DKA在最初出现时的发病率很高, 与美国前几年相比显著增加。DKA一般较晚发病, 表明糖尿病诊断被延迟。我们的数据表明, DKA的高发病率与病毒感染无关, 可能只与COVID-19大流行时早期观察到的医疗就诊减少有关。我们的研究对在当前COVID-19大流行期间被诊断为T1D的患者有意义。还需要做更多的研究来描述2020年诊断为T1D时DKA的发病率, 以及社会和生理因素在多大程度上起作用。