Impact of diabetes mellitus on outcomes of patients with sepsis: an updated systematic review and meta-analysis

Abstract

Background The effect of concurrent diabetes on the outcome of sepsis is not conclusively known. A meta-analysis published in 2017 indicated that diabetes did not influence the mortality of patients with sepsis but increased the risk of acute renal injury. In view of publication of several new studies in recent years, there is a need for updated evidence. Methods A systematic search was conducted using the PubMed, Scopus, Embase, and Google Scholar databases. Studies that were done in patients with sepsis, were observational in design- either cohort or case–control or analysed retrospective data were considered for inclusion. Statistical analysis was performed using STATA software. Results A total of 21 studies were included. The risk of in-hospital mortality (RR 0.98, 95% CI 0.93, 1.04) and mortality at latest follow up i.e., within 90 days of discharge (RR 0.94, 95% CI 0.86, 1.04) among diabetic and non-diabetic subjects was statistically similar. There was an increased risk of in-hospital mortality among those with high blood glucose level at admission (RR 1.45, 95% CI 1.01, 2.09). Among those who were diabetic, the risk of acute renal failure (RR 1.54, 95% CI 1.34, 1.78) was higher than non-diabetics. The risk of respiratory failure, adverse cardiac events, need for additional hospitalization post-discharge and length of hospital stay was similar among diabetics and non-diabetics. Conclusions Diabetes is not associated with poor survival outcomes in patients with sepsis but is associated with increased risk of acute renal failure. High blood glucose levels, irrespective of the diabetes status, are associated with increased risk of in-hospital mortality. Findings underscore the need for better evaluation of renal function in diabetic patients with concurrent sepsis.

Association between glucose-to-lymphocyte ratio and in-hospital mortality in intensive care patients with sepsis: A retrospective observational study based on Medical Information Mart for Intensive Care IV

“…The mechanisms that lead to glucose dysregulation are complex. Elevated blood glucose levels tend to reduce membrane fluidity, which impedes polymorphonuclear leukocyte (PMN) function, leading to reduced phagocytosis, intracellular killing, suboptimal migration, and chemotaxis ( 20 , 36 , 37 ). In addition, the neuroendocrine stress response can increase adrenal cortex secretion by 10 times, including excessive glycogenolysis, gluconeogenesis, and insulin resistance ( 38 ).…”

“…In addition, numerous studies have demonstrated an association between failure to control hyperglycemia and adverse outcomes in patients in the intensive care unit (ICU), including death, nosocomial infection, wound complications, prolonged ICU stay, and an increased incidence of critical illness neuropathy ( 19 ). Acute hyperglycemia is an independent risk factor for in-hospital mortality in critically ill patients with sepsis ( 20 ).…”

Is compromised intestinal barrier integrity responsible for the poor prognosis in critically ill patients with pre-existing hyperglycemia?

“…Taken together, Although the severities of infection, circulatory dysfunction, and IECs damage were milder, neither a slighter compromised intestinal barrier integrity nor a better outcome was achieved in HbA1c ≥ 6.5% Group. Since gut dysbiosis and compromised intestinal barrier integrity have been induced by hyperglycemia before the onset of critical illness [ 10 , 12 ], for those patients with pre-existing hyperglycemia, the co-effect of hyperglycemia and critical illness will result in more severe compromised intestinal barrier integrity, bacterial translocation, and finally worse outcome [ 4 , 5 ]. Therefore, we suggested that the compromised intestinal barrier integrity might be responsible for the poor prognosis in critically ill patients with pre-existing hyperglycemia.…”

“…Interestingly, some anti-diabetic agents with the capability of improving intestinal barrier integrity can bring advantages in the management of critical illness [30]. Given that hyperglycemia, irrespective of the diabetes status, is associated with poor prognosis in critically ill patients [4,5], the role of compromised intestinal barrier integrity in critically ill patients with pre-existing hyperglycemia theoretically answers the question why it is important to control hyperglycemia. This study had some limitations.…”

“…As one of the most common comorbidities, diabetes is strongly associated with poor prognosis in critical illness [ 2 , 3 ]. As is known to all, hyperglycemia is the most specific symptom of diabetes, and recent studies have updated our knowledge that hyperglycemia, irrespective of the diabetes status, is associated with increased risk of in-hospital mortality in critically ill patients [ 4 , 5 ]. However, the underlying mechanism by which hyperglycemia results in poor prognosis remains debated.…”