Blood Urea Nitrogen to Serum Albumin Ratio as A New Prognostic Indicator in Critically Ill Patients with Diabetic Ketoacidosis: A Retrospective Cohort Study

Abstract

Objective To investigate the predictive value of the blood urea nitrogen to serum albumin ratio for in-hospital and out-of-hospital mortality in critically ill patients with diabetic ketoacidosis.

Methods Data were obtained from the Medical Information Mart for Intensive Care III (MIMIC III) database, and all eligible participants were categorized into two groups based on the BAR cutoff value. Multiple logistic regression analysis was conducted to determine the association between BAR and in-hospital mortality. The Kaplan–Meier (K–M) analysis was performed to evaluate the predictive performance of BAR. Propensity score matching (PSM) was applied to control confounding factors between the low and high BAR groups.

Results A total of 589 critically ill patients with diabetic ketoacidosis were enrolled. Patients with diabetic ketoacidosis with a higher BAR level were associated with higher in- and out-hospital mortality (all p<0.001). A significant 4-year survival difference was observed between the low and high BAR groups (p<0.0001). After PSM analysis, two PSM groups (202 pairs, n=404) were generated, and similar results were observed in the K–M curve (p<0.0001).

Discussion Elevated BAR levels were associated with an increased risk of in-hospital mortality in critically ill patients with diabetic ketoacidosis, and BAR could serve as an independent prognostic factor in in-hospital and out-of-hospital mortality for patients diagnosed with diabetic ketoacidosis.

Keywords

diabetic ketoacidosis - blood urea nitrogen - albumin - all-cause mortality - MIMIC-III database

^‡ These authors contributed equally to this work: Tingting Hang, Jing Huang.

Publikationsverlauf

Eingereicht: 14. Juni 2023
Eingereicht: 10. Februar 2024

Angenommen: 22. Februar 2024

Accepted Manuscript online:
22. Februar 2024

Artikel online veröffentlicht:
10. April 2024

• References

• 1 Umpierrez G, Korytkowski M. Diabetic emergencies – ketoacidosis, hyperglycaemic hyperosmolar state and hypoglycaemia. Nat Rev Endocrinol 2016; 12: 222-232
• 2 Jensen ET, Stafford JM, Saydah S. et al. Increase in prevalence of diabetic ketoacidosis at diagnosis among youth with type 1 diabetes: The SEARCH for Diabetes in Youth Study. Diabetes Care 2021; 44: 1573-1578
• 3 Ramphul K, Joynauth J. An update on the incidence and burden of diabetic ketoacidosis in the U.S. Diabetes Care 2020; 43: e196-e197
• 4 Yuyama Y, Kawamura T, Nishikawa-Nakamura N. et al. Relationship between bedside ketone levels and time to resolution of diabetic ketoacidosis: A retrospective cohort study. Diabetes Ther 2021; 12: 3055-3066
• 5 Takahashi K, Anno T, Takenouchi H. et al. Serious diabetic ketoacidosis induced by insulin allergy and anti-insulin antibody in an individual with type 2 diabetes mellitus. J Diabetes Investig 2022; 13: 1788-1792
• 6 Liu Q, Wang Y, Chen Z. et al. Age- and sex-specific reference intervals for blood urea nitrogen in Chinese general population. Sci Rep 2021; 11: 10058
• 7 Maitland K. Management of severe paediatric malaria in resource-limited settings. BMC Med 2015; 13: 42
• 8 Brar PC, Tell S, Mehta S. et al. Hyperosmolar diabetic ketoacidosis-- review of literature and the shifting paradigm in evaluation and management. Diabetes Metab Syndr 2021; 15: 102313
• 9 Yao Y, Zhang P, Wang J. et al. Dissecting target toxic tissue and tissue specific responses of irinotecan in rats using metabolomics approach. Front Pharmacol 2017; 8: 122
• 10 Eckart A, Struja T, Kutz A. et al. Relationship of nutritional status, inflammation, and serum albumin levels during acute illness: A prospective study. Am J Med 2020; 133: 713.e7-722.e7
• 11 Bae SJ, Kim K, Yun SJ. et al. Predictive performance of blood urea nitrogen to serum albumin ratio in elderly patients with gastrointestinal bleeding. Am J Emerg Med 2021; 41: 152-157
• 12 Huang D, Yang H, Yu H. et al. Blood urea nitrogen to serum albumin ratio (BAR) predicts critical illness in patients with coronavirus disease 2019 (COVID-19). Int J Gen Med 2021; 14: 4711-4721
• 13 Zhao D, Liu Y, Chen S. et al. Predictive value of blood urea nitrogen to albumin ratio in long-term mortality in intensive care unit patients with acute myocardial infarction: A propensity score matching analysis. Int J Gen Med 2022; 15: 2247-2259
• 14 Johnson AE, Pollard TJ, Shen L. et al. MIMIC-III, a freely accessible critical care database. Sci Data 2016; 3: 160035
• 15 Nyenwe EA, Kitabchi AE. The evolution of diabetic ketoacidosis: An update of its etiology, pathogenesis and management. Metabolism 2016; 65: 507-521
• 16 Wang ZH, Kihl-Selstam E, Eriksson JW. Ketoacidosis occurs in both Type 1 and Type 2 diabetes--a population-based study from Northern Sweden. Diabet Med 2008; 25: 867-870
• 17 Miller KM, Foster NC, Beck RW. et al. Current state of type 1 diabetes treatment in the U.S.: Updated data from the T1D Exchange clinic registry. Diabetes Care 2015; 38: 971-978
• 18 Benoit SR, Hora I, Pasquel FJ. et al. Trends in emergency department visits and inpatient admissions for hyperglycemic crises in adults with diabetes in the U.S., 2006-2015. Diabetes Care 2020; 43: 1057-1064
• 19 Gregg EW, Hora I, Benoit SR. Resurgence in diabetes-related complications. JAMA 2019; 321: 1867-1868
• 20 Seth P, Kaur H, Kaur M. Clinical profile of diabetic ketoacidosis: A prospective study in a tertiary care hospital. J Clin Diagn Res 2015; 9: OC01-OC04
• 21 Shaltout AA, Channanath AM, Thanaraj TA. et al. Ketoacidosis at first presentation of type 1 diabetes mellitus among children: A study from Kuwait. Sci Rep 2016; 6: 27519
• 22 Su D, Li J, Guo M. et al. Clinical analysis of electrolyte disorders in patients with diabetic ketoacidosis. Clin Lab 2021; 67
• 23 Al-Matrafi J, Vethamuthu J, Feber J. Severe acute renal failure in a patient with diabetic ketoacidosis. Saudi J Kidney Dis Transpl 2009; 20: 831-834
• 24 Chen PK, Shih CC, Lin FC. et al. Prolonged use of noninvasive positive pressure ventilation after extubation among patients in the intensive care unit following cardiac surgery: The predictors and its impact on patient outcome. Sci Rep 2019; 9: 9539
• 25 Shen R, Gao M, Tao Y. et al. Prognostic nomogram for 30-day mortality of deep vein thrombosis patients in intensive care unit. BMC Cardiovasc Disord 2021; 21: 11
• 26 Lu HY, Ning XY, Chen YQ. et al. Predictive value of serum creatinine, blood urea nitrogen, uric acid, and β(2)-microglobulin in the evaluation of acute kidney injury after orthotopic liver transplantation. Chin Med J 2018; 131: 1059-1066
• 27 Khoury J, Bahouth F, Stabholz Y. et al. Blood urea nitrogen variation upon admission and at discharge in patients with heart failure. ESC Heart Fail 2019; 6: 809-816
• 28 Bendardaf R, Bhamidimarri PM, Al-Abadla Z. et al. Ferritin, blood urea nitrogen, and high chest CT score determines ICU admission in COVID-19 positive UAE patients: A single center retrospective study. PLoS One 2022; 17: e0269185
• 29 Bae JC, Seo SH, Hur KY. et al. Association between serum albumin, insulin resistance, and incident diabetes in nondiabetic subjects. Endocrinol Metab 2013; 28: 26-32
• 30 Cheng PC, Hsu SR, Cheng YC. Association between serum albumin concentration and ketosis risk in hospitalized individuals with type 2 diabetes mellitus. J Diabetes Res 2016; 2016: 1269706
• 31 Ugajin M, Yamaki K, Iwamura N. et al. Blood urea nitrogen to serum albumin ratio independently predicts mortality and severity of community-acquired pneumonia. Int J Gen Med 2012; 5: 583-589
• 32 Fang J, Xu B. Blood urea nitrogen to serum albumin ratio independently predicts mortality in critically Ill patients with acute pulmonary embolism. Clin Appl Thromb Hemost 2021; 27 10760296211010241
• 33 Lin Z, Zhao Y, Xiao L. et al. Blood urea nitrogen to serum albumin ratio as a new prognostic indicator in critical patients with chronic heart failure. ESC Heart Fail 2022; 9: 1360-1369