COVID-19 patients with diabetes at higher risk of complications, death

Diabetes is independently associated with the prognosis of the novel coronavirus disease (COVID-19), according to a study in Wuhan, China, the ground zero of the pandemic.

“More attention should be paid to the prevention and treatment for diabetic patients, especially those who require insulin therapy,” the researchers said.

This retrospective cohort study extracted and compared demographic, clinical, laboratory, radiologic, treatments, complications, and clinical outcomes data from electronic medical records of 84 diabetic and 500 nondiabetic patients. The risk factors for the prognosis of COVID-19 were determined by applying Kaplan-Meier method and multivariate Cox analysis.

The diabetes group showed higher levels of neutrophils (p=0.014), C-reactive protein (p=0.008), procalcitonin (p<0.01), and D-dimer (p=0.033), as well as lower levels of lymphocytes (p=0.032) and albumin (p=0.035) than the nondiabetes cohort. In addition, the incidence of bilateral pneumonia was higher in diabetic patients (86.9 percent; p=0.020). [Am J Med 2021;134:E6-E14]

For complications and clinical outcomes, a significantly higher incidence of respiratory failure (36.9 percent vs 24.2 percent; p=0.022), acute cardiac injury (47.4 percent vs 21.2 percent; p<0.01), and death (20.2 percent vs 8.0 percent; p=0.001) was found in the diabetes vs the nondiabetes group.

Kaplan-Meier survival curve showed a shorter overall survival time among COVID-19 patients with diabetes. In multivariate Cox analysis, diabetes (hazard ratio, 2.180; p=0.031) was an independent risk factor for the prognosis of COVID-19.

In subgroup analysis, diabetic patients were divided into insulin- and noninsulin-required groups. Those who required insulin appeared to have an increased risk of disease progression and worse prognosis after the infection of SARS-CoV-2, the causative agent of COVID-19.

“It is well known that diabetes is an ageing disease, and previous studies have shown that ageing is one of the important risk factors affecting the prognosis of COVID-19,” the researchers said. “Therefore, a high proportion of elderly patients in the diabetes group might suggest a poor clinical outcome.” [Lancet 2020;395:1054-1062]

Additionally, previous studies reported the association of diabetes with increased risks for morbidity and mortality of multiple viral infections, including the 2009 influenza A (H1N1), MERS-CoV, and SARS-CoV. [BMC Infect Dis 2019;19:964; Diabet Med 2006;23:623-628; Virol Sin 2016;31:81-84]

“Both SARS-CoV and SARS-CoV-2 share the same receptor angiotensin-converting enzyme 2,” the researchers said. [Nature 2003;426:450-454; Nat Microbiol 2020;5:562-569]

“It is reported that angiotensin-converting enzyme 2 is widely expressed in multiple organs, including the heart, respiratory tract, liver, kidney, pancreas, and intestine, which might provide an explanation for why some COVID-19 patients have multiple organ dysfunctions,” they added. [Viruses 2019;11:59]

A chronic inflammatory disease, diabetes mellitus is characterized by multiple macro- and microvascular abnormalities that can affect the body’s response to pathogens. [Gerontology 2013;59:99-104]

“The relationship between diabetes and infection has always been an important concern of clinicians,” the researchers said. “Infectious diseases, especially influenza and pneumonia, are very common among elderly diabetic patients.”