This rare but life-threatening emergency can occur in patients with type 1 or type 2 diabetes.

Lack of clinician familiarity and nonspecific symptoms can hinder prompt recognition of hyperosmolar hyperglycemic state (HHS). In this study, researchers used data from a nationwide registry in Denmark to report renal function and acid/base status among 634 patients (median age, 69) who were hospitalized with HHS from 2016 to 2018 and to estimate population incidence rates of HHS among patients with known diabetes. HHS was defined as an admission blood glucose of >600 mg/dL with plasma osmolarity of >320 mOsm/kg H2O. Patients with concomitant HHS and diabetic ketoacidosis (DKA) were identified using administrative data. Clinical information (e.g., presence of hypovolemia or encephalopathy) was not captured in the registry.

Key findings were as follows:

• 62% of patients had pure HHS; the remaining 38% had HHS-DKA overlap.


• Among all patients, 33% of HHS cases represented new diagnoses of diabetes.


• Among patients with pure HHS, 39% had acidosis (pH <7.35), 65% had acute kidney injury, and inpatient mortality was 17%.


• Among patients with previously identified type 1 and type 2 diabetes, incidence rates of HHS were 16.5 and 3.9 cases per 10,000 person-years, respectively.

COMMENT
Although HHS once was thought to occur primarily in people with type 2 diabetes, these results suggest that the incidence is roughly four times greater among patients with type 1 diabetes. In addition, in one third of cases, HHS was the first presentation of diabetes. Given these findings, the absence of a diabetes diagnosis should not preclude checking plasma osmolarity in a patient with marked hyperglycemia and clinical presentation compatible with HHS. — Rahul B. Ganatra, MD, MPH

Dr. Ganatra is Instructor in Medicine at Harvard Medical School and Director of Continuing Medical Education for the Medical Service, VA Boston Healthcare System, Boston.

Rosager EV et al. Incidence and characteristics of the hyperosmolar hyperglycemic state: A Danish cohort study. Diabetes Care 2024 Feb 1; 47:272. (https://doi.org/10.2337/dc23-0988)

GKB-NON-2024-00109