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Diabetic Ketoacidosis Mortality Prediction Model (DKA MPM) Score

Calculators  Multiple body systems
The Diabetic Ketoacidosis Mortality Prediction Model (DKA MPM) Score is calculated and utilized to predict inpatient mortality in diabetic ketoacidosis using criteria such as a serum glucose ≥ 250 mg/dL (14.1 mmol/L), positive urine ketones, and metabolic acidosis (arterial blood pH < 7.30 and HCO3 < 15 mEq/L (15 mmol/L).
Acute comorbidities
COPD, Immunosuppression, cirrhosis, CHF, previous MI, and/or previous stroke
No 0
Yes 6
pH <7.0
No 0
Yes 4
>50 units regular insulin required over 12 hr
No 0
Yes 4
Serum glucose >300 mg/dL (16.7 mmol/L) after 12 hr
No 0
Yes 4
Depressed mental state
As determined by the examiner
No 0
Yes 4
Fever
Axillary temperature ≥38°C (100.4ºF)
No 0
Yes 3
Result:

Background

Measured Factor
DKA MPM Score
Measured Factor Disease
  • Low risk of inpatient mortality
  • Very high risk of inpatient mortality
Measured Factor Detail
The DKA MPM Score is a tool utilized to predict inpatient mortality in patients presenting with diabetic ketoacidosis. Patients are checked at presentation for severe comorbidities and pH level, 12 hours after presentation for the amount of insulin they have used and their serum glucose, and 24 hours after presentation for depressed mental state and fever.                                                                                                                                                                                                                                                                                                                                                                                                                     DKA MPM Score of 0 - 14 indicates a low risk of inpatient mortality.                                                                                                                                                                                                                                                                                                                                                                                       DKA MPM Score of 15 - 18 indicates a high risk of inpatient mortality.                                                                                                                                                                                                                                                                                                                                                                              A DKA MPM Score of 19 - 25 indicates a very high risk of inpatient mortality.
Speciality
Multi-Speciality
Body System
Multiple body systems
Measured Factor Low Impact
  • DKA MPM score of 0 - 14 indicates a low risk of inpatient mortality.
Measured Factor High Impact
  • DKA MPM score of 19 - 25 indicates a very high risk of inpatient mortality.

Result Interpretation

Ranges Ranges
  • Critical High: 1500%
  • Normal: 0 - 14
  • Normal Adult Male: 0 - 14
  • Normal Adult Female: 0 - 14
  • Normal Pediatric: 0 - 14
  • Normal Neonate Female: 0 - 14
  • Normal Geriatric Male: 0 - 14
  • Normal Geriatric Female: 0 - 14
Result Low Conditions
  • Low risk of inpatient mortality
Result High Conditions
  • Very high risk of inpatient mortality

Studies

Study Validation 1
A prospective, observational study was done in the ED of a teaching hospital over 14 months. All patients aged >18 years and who met the criteria of hyperglycemic crisis were enrolled. Thirty-day mortality of six independent predictors was the primary end point. Using PHD, risk scores were calculated and patients were disposed as per physician's clinical judgement. Finally, the treating physician's decision and PHD score disposition were compared and the efficiency of PHD in predicting 30-day mortality was analyzed. Multiple logistic regression models were used for analysis. Receiver operating characteristic curve was drawn, and area under the curve along with sensitivity, specificity, positive predictive value, and negative predictive value was analyzed. P < 0.05 was considered statistically significant. A total of 133 patients were included. On applying PHD score, 69, 39, and 25 patients were in the low-, intermediate-, and high-risk groups, respectively, with a mortality rate of 5.8%, 20.5%, and 56%, respectively. On comparing physician disposition with PHD score, an increasing mortality was noticed in ICU, and PHD showed equal weight in risk stratification and appropriate disposition of patients. In adult patients with hyperglycemic crisis, PHD score is validated as a straightforward, prompt tool for predicting 30-day mortality and aids in disposition. The mortality rate in the PHD score Model II was similar to the physician's clinical decision.
References: 2
Study Additional 1
This study was conducted in a tertiary care hospital, Mysuru on 110 patients from November 2007 to October 2009. Clinical presentation and precipitating factors of DKA were monitored. Univariate analysis was done to identify statistically significant risk factors contributing to DKA mortality and was used for multiple logistic regressions to identify independent mortality predictors. A scoring methodology was used to identify the risk of having multiple risk factors in an individual. In this study, the mean age was 42.33 years, with a male to female ratio of 1.2:1. The most common complaints were vomiting and generalized weakness seen in 55 (50%) and 49 (44.5%) cases respectively. The most common precipitating factors were infections and poor compliance to antidiabetic treatment seen in 57 (52%) and 23 (21%) cases respectively. The predictors of mortality included age equal to or more than 65 years, Depressed Mental State (DMS) in the first 24 hour, insulin requirement equal to or more than 50 units in the 12 hours to bring blood glucose to less than 300 mg%, fever in the first 24 hours, shock in the first 24 hours, RBS persistently equal to or more than 300 mg% even after 12 hours with standard treatment protocol, fluid requirement equal to or more than 6 L in the first 24 hours, pH less than 7.2 and bicarbonate less than 15 mmol/l at presentation were statistically significant predictors of mortality. Multivariate analysis failed to identify an independent mortality factor; but, adverse parameters of more than 5 was significantly associated with death. Risk stratification of patients with DKA is possible from simple clinical and laboratory variables available during the first day of hospitalization and further channeling the patients to ICU at the correct time to prevent mortalities.
References: 3
Study Additional 2
A retrospective analysis of 312 admissions to an Australian tertiary referral hospital between 1986 and 1999. Of the patients surveyed, DKA was the diagnosis for 171 presentations (55%), HHS was the diagnosis for 47 presentations (15%) and combined DKA and HHS (DKA-HHS) was diagnosed for 94 presentations (30%). Age at presentation for DKA patients (33+/-1.2 years) was significantly less (P<0.01) than DKA-HHS patients (44+/-2.4 years). This, in turn, was significantly less (P < 0.01) than HHS patients (69+/-1.7 years). There were 15 deaths for the 312 presentations, resulting in an overall mortality rate of 4.8%. Combined mortality rates according to age at presentation were: (i) 0/134 for patients aged <35 years, (II) 5/94 (5.3%) for DKA-HHS and (iii) 8/47 (17%) for HHS. For all presentations associated with ketoacidosis - regardless of the degree of hyperosmolarity - the mortality rate was 7/264 (2.7%), however for all presentations with hyperosmolarity regardless of the degree of acidosis - the mortality rate was 13/141 (9.2%). When the associations between age, category of diabetic emergency, serum osmolarity and various other biochemical parameters with mortality were assessed by logistic regression analysis, age and the degree of hyperosmolarity were found to be the most powerful predictors of a fatal outcome. In particular, patients aged >65 years presenting with a serum osmolarity >375 mOsmol/L were at greatest risk. However, in a multivariate analysis only age emerged as a significant independent predictor of mortality (P < 0.01). The mixed state of ketoacidosis and hyperosmolarity was observed in 30% of presentations for diabetic hyperglycaemic emergencies. Although age and degree of hyperosmolarity both influenced mortality rates, only age was found to be an independent predictor of mortality. The mortality rate for diabetic emergencies associated with ketoacidosis remained low, in keeping with other studies. By contrast, the mortality rate for diabetic emergencies associated with a hyperosmolar state remained considerably higher. This higher mortality will most likely persist because deaths associated with a hyperosmolar state were in elderly patients with significant comorbidity.
References: 4
Study Additional 3
The present study aimed to investigate the utility of platelet to lymphocyte (PLR) in predicting 90-day clinical outcomes in patients with DKA. Patient data exacted from the Multiparameter Intelligent Monitoring in Intensive Care II (MIMIC II) database was analyzed. A total of 278 ICU admissions were analysed and stratified by cutoff value of PLR. The incidence of readmission and mortality was 17.8% in the high PLR group, significantly higher than 7.4% in the low PLR group. The study reports that enhanced PLR presents a higher risk for 90-day incidence of readmission and mortality in patients with DKA and hence may be a novel independent predictor of 90-day outcomes in critically ill DKA patients in ICU units.
References: 5

Authors

Stamatis P. Efstathiou
PhD, 2006
Senior Consultant, Center for the Prevention of Cardiovascular Diseases of Hygeias Melathron, in Athens
Research Interests: Internal medicine physician in private practice
Opinion leader for several pharmaceutical companies including Novartis, Pfizer, Merck Sharp & Dohme, Bristol Myers Squibb, Astra Zeneca, and Sanofi-Aventis

References

  1. Efstathiou SP, Tsiakou AG, Tsioulos DI, Zacharos ID, Mitromaras AG, Mastorantonakis SE, et al. A mortality prediction model in diabetic ketoacidosis. Clin Endocrinol (Oxf). 2002 Nov;57(5):595-601.
  2. Elangovan A, Cattamanchi S, Farook AR, Trichur RV. Validation of Predicting Hyperglycemic Crisis Death Score: A Risk Stratification Tool for Appropriate Disposition of Hyperglycemic Crisis Patients from the Emergency Department. J Emerg Trauma Shock. 2018 Apr-Jun;11(2):104-110. doi: 10.4103/JETS.JETS_2_17.
  3. Mahesh MG, Shivaswamy RP, Chandra BS, Syed S. The Study of Different Clinical Pattern of Diabetic Ketoacidosis and Common Precipitating Events and Independent Mortality Factors. J Clin Diagn Res. 2017 Apr;11(4):OC42-OC46. doi:10.7860/JCDR/2017/25347.9760.
  4. MacIsaac RJ, Lee LY, McNeil KJ, Tsalamandris C, Jerums G. Influence of age on the presentation and outcome of acidotic and hyperosmolar diabetic emergencies. Intern Med J. 2002 Aug;32(8):379-85.
  5. Liu WY, Lin SG, Wang LR, Fang CC, Lin YQ, Braddock M, Zhu GQ, Zhang Z, Zheng MH, Shen FX. Platelet-to-Lymphocyte Ratio: A Novel Prognostic Factor for Prediction of 90-day Outcomes in Critically Ill Patients With Diabetic Ketoacidosis. Medicine (Baltimore). 2016 Jan;95(4):e2596. doi: 10.1097/MD.0000000000002596.