Predictive model of glycemic evolution in hospitalized patients in general medicine with new hyperglycemia (ambiglycemia)
DOI:
https://doi.org/10.47196/diab.v60i1.1314Keywords:
hyperglycemia, hospital, predictive modelAbstract
Introduction: hyperglycemia in hospitalized patients is associated with poor outcomes, although there is controversy about the magnitude of this effect in those with or without diabetes mellitus (DM).
Objectives: to differentiate between two populations among hospitalized patients with new-onset hyperglycemia: A) previously unknown or newly diagnosed diabetes mellitus (DM) and B) unexpected hyperglycemia, and to find the associations between baseline metabolic variables and glycemic evolution. The term ambiglycemia (AmbiG) is proposed for this ambiguous glycemia (severity versus stress), which has equal value but different meanings.
Materials and methods: prospective cohort study of 2 years follow up, to observe evolution of 100 adult inpatients with new hyperglycemia >140mg/dl, comparing admission HbA1c (A) ≥6.5% or (B) <6.5%, and reclassifying with new HbA1c at ≥3 month from discharge. Statistics: SPSS v20.
Results: 45 cases in group A and 55 cases in group B. Reclassifying the cases, we found: 47 undiagnosed DM (DMnoc) with HbA1c ≥6.5%, 31 prediabetes (preDM) with HbA1c ≥5.7% and 22 stress hyperglycemia (HGdeS) with HbA1c <5.7%. Using the chi-square test, the relative risk of progression to HbA1c >6.5% was as follows: HbA1c >6.5% at admission: RR 2.88 (95% CI 1.77-4.68), peak glucose >250 mg/dL: RR 2.54 (95% CI 1.61-4.01), and time out of TOR range >50%: RR 2.63 (95% CI 1.79-3.86), all with p<0.001. The model, through multiple linear and logistic regression, successfully predicted the percentage risk of having an HbA1c >6.5% at 3 months. Internal validation: sensitivity = 0.76, specificity = 0.74, PPV = 0.72, NPV = 0.78, and Pearson's r = 0.52.
Conclusions: with this simple three variables, it´s possible to calculate the probability of having a HbA1c >6.5% at 3 months, and also the probable value of HbA1c in the later evolution. Finally, we could reveal the meaning of ambiglycemia (AmbiG) in the hospital.
References
I. Umpierrez GE, Isaacs SD, Bazargan N, You X, et al. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002;87:978-982.
II. McDonnell ME, Umpierrez GE. Insulin therapy for the management of hyperglycemia in hospitalized patients. Endocrinol Metab Clin. 2012;(41)175:201.
III. Draznin B, Aroda VR, Bakris G, et al. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes 2022. Diabetes Care. 2022;45(Supp-1):S244-S253.
IV. Egi M, Bellomo R, Stachowski E, French C, et al. Hypoglycemia and outcome in critically Ill patients. Mayo Clin Proc. 2010;85(3):217-224.
V. Deane AM, Horowitz M. Dysglycaemia in the critically ill significance and management. Diabetes, Obesity and Metabolism. 2013;15:792-801.
VI. Greci L, Kailasam M, Malkani S, Katz D, et al. Utility of HbA1c levels for diabetes case finding in hospitalized patients with hyperglycemia. Diabetes Care. 2003;26:1064-1068.
VII. Umpierrez GE, Reyes D, Smiley D, Hermayer K, et al. Hospital discharge algorithm based on admission HbA1c for the management of patients with type 2 diabetes. Diabetes Care. 2014;37:2934-2939.
VIII. Malmberg K, Rydén L, Efecdic S, Herlitz J, et al. DIGAMI study group. Randomized trial of insulin glucose infusion followed by subcutaneus insulin treatment in diabetic patient with acute myocardial infarction (DIGAMI Study): effects on mortality at 1 year. JACC. 1995;26(1):57-65.
IX. Van den Berghe G, Wouters P, Weekers R, Verwaest H, et al. Intensive insulin therapy in critically Ill patients. N Engl J Med. 2001;345:1359-67.
X. Malmberg K, Rydén L, Wedel H, Birkeland K, Bootsma A, et al.; for the DIGAMI 2 Investigators. Intense metabolic control by means of insulin in patients with diabetes mellitus and acute myocardial infarction (DIGAMI 2): effects on mortality and morbidity. European Heart Journal. 2005;26:650-661.
XI. Finfer S, Chittock DR, Yu-Su S, Cook VD, et al. The NICE-SUGAR Study Investigators. Intensive versus conventional glucose control in critically Ill patients. N Engl J Med. 2009;360:1283-97.
XII. Marik PE, Preiser JC. Toward understanding tight glycemic control in the ICU. A systematic review andm. Chest. 2010;137(3):544-551.
XIII. Umpierrez GE, Smiley D, Zisman A, Prieto L, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 Trial). Diabetes Care. 2007;30:2181-2186.
XIV. Umpierrez GE, Smiley D, Jacobs D, Peng L, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes undergoing general surgery (RABBIT 2 Surgery). Diabetes Care. 2011;34:256-261.
XV. Murad MH, Coburn JA, Coto-Yglesias F, Dzyubak S, et al. Glycemic control in non-critically Ill hospitalized patients. A systematic review and meta-analysis. J Clin Endocrinol Metab. 2012;97:49-58.
XVI. Lwanga SK, Lemeshow S. Sample size determination in health studies. Practical manual. World Health Organization. Geneva; 1991.
XVII. Grimes DA; Schulz KF. Cohort studies: marching towards outcomes. Lancet. 2002; 359:341-45.
XVIII. Katz MH. Multivariable analysis: a primer for readers of medical research. Ann Intern Med 2003;138:644-650.
XIX. Altman DG, Royston P. What do we mean by validating a prognostic model? Stat Med. 2000;19:453-473.
XX. Krinsley JS, Preiser JC. Time in blood glucose range 70 to 140 mg/dl >80% is strongly associated with increased survival in non-diabetic critically ill adults. Critical Care. 2015;19:179-190.
XXI. Moghissi ES, Korytkowski MT, Dinardo M, Einhorn D; Hellman R, et al. American Association of Clinical Endocrinologists and American Diabetes Association. Consensus statement on inpatient glycemic control. Diabetes Care. 2009;32 6):1119-1131.
XXII. Umpierrez GE, Hellman R, Korytkowski MT, Kosiborod M, Maynard GA, et al. Management of hyperglycemia in hospitalized patients in non-critical care setting. An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2012;97:16-38.
XXIII. Pasquel FJ, Lansang MC, Dhatariya K, Umpierrez GE. Management of diabetes and hyperglycaemia in the hospital. Lancet Diabetes Endocrinol. 2021;9:174-88.
XXIV. Korytkowski MT, Muniyappa R, Antinori-Lent K, Donihi AC, Drincic AT, et al. Management of hyperglycemia in hospitalized adult patients in non-critical care settings. An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2022;107:2101-2128.
XXV. Ye J, Deng J, Liang W, Luo H, et al. Time in range assessed by capillary blood glucose in relation to insulin sensitivity and b-cell function in patients with type 2 diabetes mellitus: A cross-sectional study in China. J Diabetes Investig. 2022;13:1825-1833.
XXVI. Wexler DJ, Nathan DM, Grant RW, Regan S, et al. Prevalence of elevated hemoglobin A1c among patients admitted to the hospital without a diagnosis of diabetes. J Clin Endocrinol Metab. 2008;93:4238- 4244.
XXVII. Losser MR, Damoisel C, Payen D. Bench-to-bedside review. Glucose and stress conditions in the intensive care unit. Critical Care. 2010;14:231-243.
XXVIII. Tiruvoipati R, Chiezey B, Lewis D, Ong K, Villanueva E, Haji K, Botha J. Stress hyperglycemia may not be harmful in critically ill patients with sepsis. Journal of Critical Care. 2012;27:153-158.
XXIX. Marik PE, Bellomo R. Stress hyperglycemia: an essential survival response! Critical Care. 2013;17:305-312.
XXX. Roberts G, Quinn S, Valentine N, Alhawassi T, et al. Relative hyperglycemia, a marker of critical illness. Introducing the stress hyperglycemia ratio. J Clin Endocrinol Metab. 2015;100:4490-4497.
XXXI. Marenzi G, Cosentino N, Milazzo V, et al. Prognostic value of the acute-to- chronic glycemic ratio at admission in acute myocardial infarction. A prospective study. Diabetes Care. 2018;41:847-853.
XXXII. Lee TF, Drake SM, Roberts GW, Bersten A, et al. Relative hyperglycemia is an independent determinant of in-hospital mortality in patients with critical illness. Crit Care Med. 2020;48:e115-e122.
Downloads
Published
Issue
Section
License
Copyright (c) 2026 On behalf of the authors. Reproduction rights: Argentine Diabetes Society
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
Dirección Nacional de Derecho de Autor, Exp. N° 5.333.129. Instituto Nacional de la Propiedad Industrial, Marca «Revista de la Sociedad Argentina de Diabetes - Asociación Civil» N° de concesión 2.605.405 y N° de disposición 1.404/13.
La Revista de la SAD está licenciada bajo Licencia Creative Commons Atribución – No Comercial – Sin Obra Derivada 4.0 Internacional.
Por otra parte, la Revista SAD permite que los autores mantengan los derechos de autor sin restricciones.
