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      Predictors of adverse in-hospital outcome and recovery in patients with diabetes mellitus and COVID-19 pneumonia in Iraq

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          Abstract

          Background and aims

          There is limited data about the prognosis and impact of COVID-19 pneumonia on patients with diabetes mellitus (DM). We aimed to assess blood indices, ECG markers of sudden death and malignant arrhythmias on admission, and diabetes lowering drugs as possible predictors of adverse in-hospital outcome and COVID-19 pneumonia recovery status.

          Methods

          A retrospective study included patients with newly diagnosed COVID-19 pneumonia from August 20, to October 5, 2020.

          Results

          A total of 192 patients with COVID-19 pneumonia were included in the present study, of whom 67 patients had DM. Low lymphocytes % [0.4(0.1–0.9), P = .011] and QTc interval prolongation [0.4(0.1–0.8), P = .022] were associated with increased length of ICU stay. On the other hand, metformin use [0.3(0.2–4), P = .032] and DPP-4 inhibitors use [0.3(0.2–3), P = .040] were associated with decreased length of ICU stay. QTc interval prolongation [0.4(0.1–0.9), P = .017] was associated with increased length of hospital stay, while using metformin [0.4(0.2–3), P = .022] was associated with decreased length of hospital stay. Low lymphocytes % [0.5(0.4–1.6), P = .001], insulin use [0.4(0.3–5), P = .003], and old age [0.5(0.1–2.3), P = .025] were associated with extensive lung injury. The risk for in-hospital death was associated with high neutrophil% [1(1–1.4), P = .045], while metformin use was associated with decreased risk for in-hospital death [0.1(0.1–0.6), P = .025]. Insulin use [0.3(0.2–4), P = .013] was associated with partial recovery following acute COVID pneumonia.

          Conclusions

          Metformin and DPP-4 inhibitors use were associated with favorable in-hospital outcomes, while insulin use was associated with extensive lung injury and post-acute COVID-19 pneumonia partial recovery.

          Highlights

          • Metformin and DPP-4 inhibitors use were associated with favorable in-hospital outcomes.

          • Insulin use was associated with extensive lung injury and partial recovery following acute COVID-19 pneumonia.

          • Low lymphocyte %, high neutrophil %, old age, and ↑ QTc were predictors of adverse outcome in patients with DM and COVID-19.

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          Most cited references 25

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          A new coronavirus associated with human respiratory disease in China

           Fan Wu,  Su Zhao,  Bin Yu (2020)
          Emerging infectious diseases, such as severe acute respiratory syndrome (SARS) and Zika virus disease, present a major threat to public health 1–3 . Despite intense research efforts, how, when and where new diseases appear are still a source of considerable uncertainty. A severe respiratory disease was recently reported in Wuhan, Hubei province, China. As of 25 January 2020, at least 1,975 cases had been reported since the first patient was hospitalized on 12 December 2019. Epidemiological investigations have suggested that the outbreak was associated with a seafood market in Wuhan. Here we study a single patient who was a worker at the market and who was admitted to the Central Hospital of Wuhan on 26 December 2019 while experiencing a severe respiratory syndrome that included fever, dizziness and a cough. Metagenomic RNA sequencing 4 of a sample of bronchoalveolar lavage fluid from the patient identified a new RNA virus strain from the family Coronaviridae, which is designated here ‘WH-Human 1’ coronavirus (and has also been referred to as ‘2019-nCoV’). Phylogenetic analysis of the complete viral genome (29,903 nucleotides) revealed that the virus was most closely related (89.1% nucleotide similarity) to a group of SARS-like coronaviruses (genus Betacoronavirus, subgenus Sarbecovirus) that had previously been found in bats in China 5 . This outbreak highlights the ongoing ability of viral spill-over from animals to cause severe disease in humans.
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            Angiotensin-Converting Enzyme 2: SARS-CoV-2 Receptor and Regulator of the Renin-Angiotensin System

            ACE2 (angiotensin-converting enzyme 2) has a multiplicity of physiological roles that revolve around its trivalent function: a negative regulator of the renin-angiotensin system, facilitator of amino acid transport, and the severe acute respiratory syndrome-coronavirus (SARS-CoV) and SARS-CoV-2 receptor. ACE2 is widely expressed, including, in the lungs, cardiovascular system, gut, kidneys, central nervous system, and adipose tissue. ACE2 has recently been identified as the SARS-CoV-2 receptor, the infective agent responsible for coronavirus disease 2019, providing a critical link between immunity, inflammation, ACE2, and cardiovascular disease. Although sharing a close evolutionary relationship with SARS-CoV, the receptor-binding domain of SARS-CoV-2 differs in several key amino acid residues, allowing for stronger binding affinity with the human ACE2 receptor, which may account for the greater pathogenicity of SARS-CoV-2. The loss of ACE2 function following binding by SARS-CoV-2 is driven by endocytosis and activation of proteolytic cleavage and processing. The ACE2 system is a critical protective pathway against heart failure with reduced and preserved ejection fraction including, myocardial infarction and hypertension, and against lung disease and diabetes mellitus. The control of gut dysbiosis and vascular permeability by ACE2 has emerged as an essential mechanism of pulmonary hypertension and diabetic cardiovascular complications. Recombinant ACE2, gene-delivery of Ace2, Ang 1–7 analogs, and Mas receptor agonists enhance ACE2 action and serve as potential therapies for disease conditions associated with an activated renin-angiotensin system. rhACE2 (recombinant human ACE2) has completed clinical trials and efficiently lowered or increased plasma angiotensin II and angiotensin 1-7 levels, respectively. Our review summarizes the progress over the past 20 years, highlighting the critical role of ACE2 as the novel SARS-CoV-2 receptor and as the negative regulator of the renin-angiotensin system, together with implications for the coronavirus disease 2019 pandemic and associated cardiovascular diseases.
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              Association of Blood Glucose Control and Outcomes in Patients with COVID-19 and Pre-existing Type 2 Diabetes

              Summary Type 2 diabetes (T2D) is a major comorbidity of COVID-19. However, the impact of blood glucose (BG) control on the degree of required medical interventions and on mortality in patients with COVID-19 and T2D remains uncertain. Thus, we performed a retrospective, multi-centered study of 7,337 cases of COVID-19 in Hubei Province, China, among which 952 had pre-existing T2D. We found that subjects with T2D required more medical interventions and had a significantly higher mortality (7.8% versus 2.7%; adjusted hazard ratio [HR], 1.49) and multiple organ injury than the non-diabetic individuals. Further, we found that well-controlled BG (glycemic variability within 3.9 to 10.0 mmol/L) was associated with markedly lower mortality compared to individuals with poorly controlled BG (upper limit of glycemic variability exceeding 10.0 mmol/L) (adjusted HR, 0.14) during hospitalization. These findings provide clinical evidence correlating improved glycemic control with better outcomes in patients with COVID-19 and pre-existing T2D.
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                Author and article information

                Journal
                Diabetes Metab Syndr
                Diabetes Metab Syndr
                Diabetes & Metabolic Syndrome
                Diabetes India. Published by Elsevier Ltd.
                1871-4021
                1878-0334
                5 December 2020
                January-February 2021
                5 December 2020
                : 15
                : 1
                : 33-38
                Affiliations
                [a ]Internal Medicine Department, Medicine College, University of Kufa, Najaf, Iraq
                [b ]Internal Medicine Department, Jabir Ibn Hayyan Medical University Faculty of Medicine, Kufa, Iraq
                [c ]Research Unit, Najaf Health Bureau, Ministry of Health, Iraq
                Author notes
                []Corresponding author. Internal medicine department, Medicine College, university of Kufa, P.O. 21, Kufa, Najaf, Iraq.
                Article
                S1871-4021(20)30508-7
                10.1016/j.dsx.2020.12.014
                7832757
                33296788
                © 2020 Diabetes India. Published by Elsevier Ltd. All rights reserved.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

                Categories
                Article

                covid-19, diabetes mellitus, pneumonia, predictor, outcome

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