key: cord-1052229-vdpxhdfr authors: Li, Juyi; Wang, Xiufang; Chen, Jian; Zuo, Xiuran; Zhang, Hongmei; Deng, Aiping title: COVID‐19 infection may cause ketosis and ketoacidosis date: 2020-05-18 journal: Diabetes Obes Metab DOI: 10.1111/dom.14057 sha: 82622008a09f2efba2ee6caa2629b3622f3efb8b doc_id: 1052229 cord_uid: vdpxhdfr The present study included 658 hospitalized patients with confirmed COVID‐19. Forty‐two (6.4%) out of 658 patients presented with ketosis on admission with no obvious fever or diarrhoea. They had a median (interquartile range [IQR]) age of 47.0 (38.0–70.3) years, and 16 (38.1%) were men. Patients with ketosis were younger (median age 47.0 vs. 58.0 years; P = 0.003) and had a greater prevalence of fatigue (31.0% vs. 10.6%; P < 0.001), diabetes (35.7% vs. 18.5%; P = 0.007) and digestive disorders (31.0% vs. 12.0%; P < 0.001). They had a longer median (IQR) length of hospital stay (19.0 [12.8–33.3] vs. 16.0 [10.0–24.0] days; P < 0.001) and a higher mortality rate (21.4% vs. 8.9%; P = 0.017). Three (20.0%) out of the 15 patients with diabetic ketosis developed acidosis, five patients (26.7%) with diabetic ketosis died, and one of these (25.0%) presented with acidosis. Two (7.4%) and four (14.3%) of the 27 non‐diabetic ketotic patients developed severe acidosis and died, respectively, and one (25.0%) of these presented with acidosis. This suggests that COVID‐19 infection caused ketosis or ketoacidosis, and induced diabetic ketoacidosis for those with diabetes. Ketosis increased the length of hospital stay and mortality. Meanwhile, diabetes increased the length of hospital stay for patients with ketosis but had no effect on their mortality. In December 2019, unexplained viral pneumonia occurred in Wuhan, Hubei province, in China. 1,2 A novel coronavirus, later named COVID-19 by the World Health Organization, was isolated from patients with this pneumonia. 3 The clinical symptoms of COVID-19 infection vary but mainly involve fever and cough. COVID-19 mostly manifests as mild upper respiratory disease and gastrointestinal disease, severe viral pneumonia with systemic organ failure, or even death. 4, 5 However, little attention has been paid to metabolic diseases caused by COVID-19, especially in patients with diabetes mellitus. *J. L., X.W. and J.C. contributed equally. Patients with COVID-19 who died or were discharged during the period from January 1 to March 3, 2020, were included in this retrospective cohort study. The study protocol was approved by the Ethics Committee of the Central Hospital, and the requirement for informed consent was waived because of the retrospective nature of our research. Epidemiological, demographic and clinical data, as well as computed tomography (CT) images of lungs, laboratory investigations (viral nucleic acids test), treatment options, and management outcomes, were extracted from electronic medical records. Ketosis was defined as positive urine ketone or serum ketone test results, while ketoacidosis was defined with a positive test result of urine ketone or serum ketone, and arterial pH < 7.35 or carbon dioxide combining power < 18 mmol/L. 6,7 Data are expressed as medians (interquartile range [IQR]) or percentages (%). We used the Mann-Whitney U-test, the chi-squared test or Fisher's exact test in order to compare the differences among various groups, including the differences between ketosis and non-ketosis groups or between diabetes and non-diabetes groups. In the present study, we reported that COVID-19 infection caused ketosis or ketoacidosis, and induced diabetic ketoacidosis (DKA) for those patients with diabetes. Ketosis increased the length of hospital stay and mortality. Meanwhile, diabetes increased the length of hospital stay for patients with ketosis but had no effect on their mortality. Ketones are formed in the liver from free fatty acids. 8 When ketone consumption decreases, it results in ketosis, which can be clinically evident by elevated blood concentrations of ketone bodies (β-hydroxybutyrate, acetoacetate and acetone). 9 Ketoacidosis, a T A B L E 2 Characteristics and clinical outcomes of patients with or without diabetes with ketosis who were infected with COVID-19 Diabetic ketoacidosis is a potentially fatal metabolic complication attributable to uncontrolled blood glucose, 12 which is more common in people with type 1 diabetes. However, it can also occur in type 2 diabetes and viral infection. 13 In the present study, three patients with COVID-19 had DKA, one of whom died. We should pay attention to COVID-19 patients with ketoacidosis, therefore, especially those with diabetes, in order to reduce the associated mortality from complications of COVID-19. Notably, the mechanism of COVID-19-induced DKA needs further research. The study was limited because of the small number of patients with COVID-19 progressing from ketosis to ketoacidosis. Future studies should pay considerable attention to ketosis and ketoacidosis in such a population, as well as observe the long-term prognosis of the disease. In conclusion, we reported that COVID-19 infection caused ketosis or ketoacidosis, and induced DKA for those patients with diabetes. Ketosis increased the length of hospital stay and mortality. Meanwhile, diabetes increased the length of hospital stay for patients with ketosis but had no effect on their mortality. The mechanism of COVID-19-induced ketosis, ketoacidosis or DKA needs further research. We thank all healthcare workers involved in the diagnosis and treatment of patients in Wuhan. The authors declare no competing interests. contributed equally. 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