ORIGINAL ARTICLE

THE RELATIONSHIP BETWEEN ADMISSION BLOOD GLUCOSE LEVELS AND

HOSPITAL MORTALITY
Madhumathi R1, Rajiv, E2, Amogh Dudhwewala3, Kavya S. T4, Srinivasa V5.

HOW TO CITE THIS ARTICLE:

Madhumathi R, Rajiv, E, Amogh Dudhwewala, Kavya S. T, Srinivasa V . “The Relationship between Admission
Blood Glucose Levels and Hospital Mortality”. Journal of Evolution of Medical and Dental Sciences 2013; Vol2,
Issue 27, July 8; Page: 4872-4876.

ABSTRACT: AIMS/HYPOTHESIS: The purpose of this study was to examine the relationship among
the blood glucose levels and mortality rates between the patients admitted to Intensive care unit.
METHODS: In a Retrospective Observational study, Blood glucose levels were measured on patients
admitted to the Intensive care unit. These measurements were matched against demographic data
and hospital mortality rates. RESULTS: Overall in-hospital mortality was 33%. Blood glucose levels
during admission were an independent predictor of mortality. There was a significant interaction
among baseline blood glucose status and mortality (p<0.001). Higher Blood glucose levels were
associated with greater mortality evens between non-diabetes patients also. Between non-diabetes
the lowest mortality rate (3.0%) was observed in a group of people with BGL between 100-
140mg/dl. Compared with this group patients with a BGL of >140mg/dl had increased mortality rate
(p<0.001, after adjustment for age and sex). The risk increased farther at higher glucose levels.
KEYWORDS: Blood glucose levels (BGL), Hyperglycemia, Impaired glucose tolerance, Mortality,
Myocardial infraction.

INTRODUCTION: Hyperglycemia in critical illness is associated with increased mortality. This has
been demonstrated in a number of clinical situations most notably myocardial infarction [1] stroke
[2] and intensive care. [3] There are data available from a general hospital indicating that patients
with newly diagnosed hyperglycemia have an increased risk of mortality. [4] It is however, unclear
at what threshold of blood glucose leads to increase risk of mortality in hospitalized patients. Most
studies have analyzed hyperglycemia as a dichotomized variable. [1, 2]But the cut-off levels used do
not necessarily best reflect a threshold for increased in-hospital mortality rates. There is also paucity
of data regarding the nature of relationship between the blood glucose levels (BGLs) and hospital
mortality. A dose response relationship between BGLs and mortality has been demonstrated in
myocardial infarction. [5] There are no such known data for hospitalized patients in general. To
answer these questions we analyzed the relationship between BGL on hospital admission and
inpatient mortality rates.

METHODS: This was a Retrospective observational study, all patients irrespective of their diagnosis
and diabetes status, who were admitted to the Medical Intensive care unit were included in the
study. Patient’s age, sex, random blood sugar at admission, diagnosis and disease outcome were
thoroughly studied and analysed. Details regarding diabetes status and other co-morbid conditions
were enquired.

RESULTS: A total of 156 patients were included, out of which 78 were males and 56 were females.
Mean random blood glucose level in these patients was 146mg/dl, with a standard deviation of 20.

Journal of Evolution of Medical and Dental Sciences/ Volume 2/ Issue 27/ July 8, 2013 Page 4872
 ORIGINAL ARTICLE
There was an overall mortality of 53 patients (i.e., 33%). Among these, 32 patients (i.e. 66%) had
random blood glucose level >140mg/dl. Among the 32, 11 patients had pre-existing co-morbidity in
the form of diabetes. A statistically significant correlation was found between blood glucose level
more than 140 mg/dl at admission and the mortality rate (p<0.001).

DISCUSSION: In this retrospective study, we found that even between the people without known
diabetes, there is a strong association among blood glucose during admission and in-patient
mortality, within the entirety of a heterogeneous population admitted. On analysis of BGL as a
categorical variable, increased risk occurred above a BGL of 140mg/dl. Stress hyperglycemia in
patients who are not known to have diabetes has been associated with greater mortality risk as
compared to the patients with diabetes as such. [1, 2]Our data concur that the relationship among
blood glucose levels and mortality rate is considerably stronger even in individuals without
diabetes. For a given level of hyperglycemia, no diabetes patients probably have greater severity of
illness, which contributed to increased mortality. However, it is possible that hyperglycemia itself
also predisposes to increased mortality. In order to support this, it has been found that
hyperglycemia is associated with increased release of C-reactive protein and other inflammatory
cytokines, increased coagulability, oxidative stress, impairment of leucocyte function and increased
rates of infection.[6]From the Meta-analysis studies, hyperglycemia was defined as an blood glucose
levels above the 6.1–8.0 mmol/ levels to have relative risk of mortality among hyperglycemic
patients who did not have diabetes was 3.9times for myocardial infarction [1] and 3.07 times for
stroke.[2] Many of these studies examined mortality rates with glucose as a dichotomized variable
which is often based on arbitrary cut-off levels or concentrations relating to the diagnosis of
diabetes / impaired glucose tolerance. These cut-off levels do not necessarily best reflect a glucose
threshold above which patients are at increased risk. We suggest that blood glucose levels of
140mg/dl may be an appropriate threshold for defining a minimum glucose level above which
increased risk occurs and intervention might be considered. The Only limitation of the current study
is that some of the hyperglycemic individuals classified as non- diabetes, may well have had
undiagnosed diabetes. Additionally, we did not have a record of glycemic control during the hospital
stay. However, patients admitted with hyperglycemia have been shown to have higher blood glucose
levels on subsequent days. [7]
The Diabetes Mellitus Insulin–Glucose Infusion in Acute Myocardial Infarction (DIGAMI)
study has also demonstrated that peri-infarct administration of insulin to maintain the blood glucose
levels below 10 mmol/l reduces mortality. [9]
In one of the study, insulin infusion therapy did not improve the survival rate between
hyperglycemic patients with myocardial infarction. [10]However the mortality rate after 6 months
was only 2% among patients who maintained a mean blood glucose levels ≤148 mg/dl in the first 24
h, when compared to 11% among patients with a mean BGL >148.0 mg/dl.
The above studies clearly indicate that tight glucose control is likely to be beneficial in
critically ill patients. It is as yet unknown whether this would also be applicable for general hospital
patients without diabetes. Nonetheless, given the strong relationship between blood glucose levels
during admission and mortality, we suggest that control of hyperglycemia in hospitalised patients
may be of therapeutic value. In order to strengthen this we need to have randomised clinical trials
should be performed to establish its beneficial role.

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 ORIGINAL ARTICLE
CONCLUSION: In-patient hyperglycemia is a common finding and important marker of poor clinical
outcome and increase mortality, particularly in patients without a history of diabetes mellitus. All
hospitalized patients should be screened for hyperglycemia. Aggressive glycemic control may reduce
mortality in this population.

REFERENCES:
1. Capes SE, Hunt D, Malmberg K, et al. Stress hyperglycemia and increased risk of death after
myocardial infarction in patients with and without diabetes: a systematic overview. Lancet
355:773–778.
2. Capes SE, Hunt D, Malmberg K, et al. Stress hyperglycemia and prognosis of stroke in non-
diabetes and diabetes patients: a systematic overview. Stroke2001; 32:2426–32.
3. Finney SJ, Zekveld C, Elia A, et al., Glucose control and mortality in critically ill patients. JAMA,
2003; 290:2041–47.
4. Umpierrez GE, Isaacs SD, Bazargan N et al., Hyperglycemia: independent marker ofin-
hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab, 2002;
87:978–982.
5. Wong V, Ross DL, Park K, Boyages S, Cheung NW. Hyperglycemia following acute myocardial
infarction is a predictor of poor cardiac outcomes in the reperfusion era. Diab Res Clin
Pract2001; 64:85–91.
6. Clement S, Braithwaite SS, Magee MF et al. Management of diabetes and hyperglycemia in
hospitals. Diabetes Care2004; 27:553–590.
7. Cely CM, Arora P, Quartin AA, et al. Relationship of baseline glucose homeostasis to
hyperglycemia during medical critical illness. Chest2004; 126:879–887.
8. Van den Berghe G, Wouters P, Weekers F et al. Intensive insulin therapy in critically ill
patients. N Engl J Med 2001; 345:1359–67.
9. Malmberg K, Ryden L, Efendic S et al. Randomised trial of insulin-glucose infusion followed
by subcutaneous insulin treatment in diabetes patients with acute myocardial infarction
(DIGAMI Study): effects on mortality at 1 year. J Am Coll Cardiol2005; 26:57–65.
10. Cheung NW, Wong VW, McLean M. The Hyperglycemia: intensive insulin infusion in infarct
(HI-5) study—a randomised controlled trial of insulin infusion therapy for myocardial
infarction. Diabetes Care 2006; 29:765–70.

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Table 1: Age distribution of patients studied
Age in years MLC-LIVE MLC-DEATH NON-MLC ALIVE NON-MLC DEATH
17-20 12(17.9%) 2(6.9%) 6(35.3%) 2(6.5%)

21-30 34(50.7%) 12(41.4%) 4(23.5%) 5(16.1%)

31-40 11(16.4%) 6(20.7%) 2(11.8%) 11(35.5%)

41-50 6(9%) 2(6.9%) 4(23.5%) 5(16.1%)

51-60 1(1.5%) 2(6.9%) 2(2%) 4(12.9%)

61-70 5(4.5%) 5(10.3%) 6(5.9%) 4(12.9%)

Total 69(100%) 31(100%) 25(100%) 31(100%)

Mean ± SD 30.61±12.02 38.17±17.87 32.00±13.46 41.77±13.82
P = 0.06**

Table 2: Gender distribution of patients studied

Gender MLC-LIVE MLC-DEATH NON-MLC ALIVE NON-MLC DEATH

Male 43(64.2%) 14(48.3%) 13(64.7%) 16(51.6%)

Female 26(35.8%) 17(51.7%) 12(35.3%) 15(48.4%)

Total 69 31 25 31

Table: 3 Co morbid condition

Co morbid condition MLC-LIVE MLC-DEATH NON-MLC ALIVE NON-MLC DEATH

Nil 59(88.1%) 11(37.9%) 17(99.7%) 18(58.1%)

DM 04(0.05%) 8(10.3%) 3(0.14%) 3(6.5%)

HTN 2(3.0%) 4(24.1%) 0(0%) 3(9.7%)

Asthma 1(1.5%) 1(3.4%) 0(0%) 0(0%)

Alcohol 1(1.5%) 2(6.9%) 5(0.2%) 2(6.5%)

Old 0(0%) 2(6.9%) 0(0%) 0(0%)

HIV 0(0%) 0(0%) 0(0%) 4(12.9%)

Smoker 0(0%) 1(3.4%) 0(0%) 2(6.5%)

Post-partum 0(0%) 2(6.9%) 0(0%) 0(0%)

Hanging & epileptic 2(3.0%) 0(0%) 0(0%) 0(0%)

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Table 4: Random Blood Sugar (RBS) of patients studied
NON-MLC NON-MLC
RBS MLC-LIVE MLC-DEATH
ALIVE DEATH
<100 15(21.4%) 5(17.9%) 8(32.0%) 6(.19%)

100-140 54(78.6%) 8(17.9%) 9(36%) 2(0.06%)

>140 0(0%) 18(64.3%) 8(32.0%) 23(74.2%)

Total 69 31 25 31
Mean ± SD 104.85±20.45 129.00±85.50 126.62±45.94 121.61±55.68
P = <0.001

AUTHORS:
1. Madhumathi R, 5. Assistant Professor, Department of Medicine,
2. Rajiv, E, Bangalore Medical College & Research Institute,
3. Amogh Dudhwewala, Karnataka.India.
4. Kavya S. T, 6. Assistant Professor, Department of Medicine,
Bangalore Medical College & Research Institute,
5. Srinivasa V.
Karnataka.India.

PARTICULARS OF CONTRIBUTORS: NAME ADRRESS EMAIL ID OF THE

1. Associate Professor, Department of CORRESPONDING AUTHOR:
Medicine, Bangalore Medical College & Dr. Madhumathi R,
Research Institute, Karnataka. India. Associate Professor,
2. Post Graduate Student, Department of Department of Medicine,
Medicine, Bangalore Medical College & BMCRI, Bangalore.
Research Institute, Karnataka.India. Email- [email protected]
3. Post Graduate Student, Department of
Medicine, Bangalore Medical College &
Research Institute, Karnataka.India.
Date of Submission: 26/05/2013.
4. Post Graduate Student, Department of Date of Peer Review: 27/05/2013.
Medicine, Bangalore Medical College & Date of Acceptance: 09/06/2013.
Research Institute, Karnataka.India. Date of Publishing: 02/07/2013

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