Published: 2018-03-28

Study of glycemic gap in hyperglycemic emergencies of type 2 diabetes mellitus

Periyasamy Sivakumar, Thiyagarajan Manjuladevi Moonishaa, Neethu George


Background: Type 2 diabetes mellitus (T2DM) is associated with two serious hyperglycemic emergencies namely Diabetic ketoacidosis (DKA) and Hyperosmolar hyperglycemic state (HHS). The aim of the study was to determine the usefulness of glycemic gap in T2DM patients with DKA and HHS.

Methods: T2DM cases above 20 years of age were included in this study. The study population was divided into three broad groups as T2DM without hyperglycemic emergencies, T2DM with DKA, T2DM with HHS, with 50 subjects in each group. Glycemic gap was calculated in the study population and compared between the three groups. The relationship between glycemic gap and the conventional indicators of severity in hyperglycemic emergencies of T2DM were determined.

Results: Of the three study groups, T2DM cases with HHS presented with substantial alterations in the baseline biochemical parameters. The glycemic gap was also highly elevated in the HHS cases than the others. Glycemic gap showed significant correlation only with plasma osmolality of the HHS cases.

Conclusions: Elevated glycemic gap indicating stress induced hyperglycemia (SIH) occur in hyperglycemic emergencies of T2DM, especially HHS. 


Diabetic ketoacidosis, Glycemic gap, Hyperglycemic emergencies, Hyperosmolar hyperglycemic state, Type 2 diabetes mellitus

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International Diabetes Federation. IDF Diabetes Atlas. 7th ed. Brussels, Belgium: International Diabetes Federation; 2015.

Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009; 32:1335-43.

Bhansali A, Sukumar SP. Hyperosmolar hyperglycemic state. World Clin Diabetol. 2016;2(1):1-10.

Liao WI, Wang JC, Chang WC, Hsu CW, Chu CM, Tsai SH. Usefulness of glycemic gap to predict icu mortality in critically ill patients with diabetes. Medicine. 2015;94(36):1-7.

Rau CS, Wu SC, Chen YC, Chien PC, Hsieh HY, Kuo PJ, et al. Stress-Induced Hyperglycemia in Diabetes: A Cross-Sectional Analysis to Explore the Definition Based on the Trauma Registry Data. Int J Environ Res Public Health. 2017;14(1527):1-11.

Liao WI, Sheu WH, Chang WC, Hsu CW, Chen YL, Tsai SH. An elevated gap between admission and a1c-derived average glucose levels is associated with adverse outcomes in diabetic patients with pyogenic liver abscess. Plos One. 2013;8(5):1-8.

Chen PC, Liao WI, Wang YC, Chang WC, Hsu CW, Chen YH, et al. An elevated glycemic gap is associated with adverse outcomes in diabetic patients with community- acquired pneumonia. Medicine. 2015;94(34):1-9.

American Diabetes Association. Standards of medical care in diabetes-2015: summary of revisions. Diabetes Care. 2015;38(1):S8-S16.

Nathan DM, Kuenen J, Borg R, Zheng H, Schoenfeld D, Heine RJ. Translating the A1C assay into estimated average glucose values. Diabetes Care. 2008;31(8):1-6.

Hood JL, Scott MG. Physiology and Disorders of Water, Electrolyte, and Acid-Base Metabolism. In: Burtis CA, Ashwood ER, Bruns DE (eds.) Tietz Textbook of Clinical Chemistry and Molecular Diagnostics. 5th ed. New Delhi: Elsevier; 2012:1628.

Scott MG, LeGrys VA, Hood JL. Electrolytes and Blood Gases. In: Burtis CA, Ashwood ER, Bruns DE (eds.) Tietz Textbook of Clinical Chemistry and Molecular Diagnostics. 5th ed. New Delhi: Elsevier; 2012:815.

National Kidney Foundation. CKD-EPI creatinine equation. 2009. Available at Accessed on 1 December 2017.

Bai F, Jiang FF, Lu JJ, Ma SG, Peng YG, Jin Y, et al. The impact of hyperglycemic emergencies on the kidney and liver. J Diabetes Res. 2013:1-8.

McCowen KC, Malhotra A, Bistrian BR. Stress-Induced Hyperglycemia. Crit Care Clin. 2001;17(1):107-24.

Marik PE, Bellomo R. Stress hyperglycemia: an essential survival response. Critical Care. 2013;17(305):1-7.

Leonidou L, Mouzaki A, Michalaki M, DeLastic AL, Kyriazopoulou V, Bassaris HP, et al. Cytokine production and hospital mortality in patients with sepsis-induced stress hyperglycemia. J Infect. 2007;55(4):340-46.

Brealey D, Singer M. Hyperglycemia in Critical Illness: A Review. J Diabetes Sci Technol. 2009;3(6):1250-6.

Krinsley JS, Egi M, Kiss A, Devendra AN, Schuetz P, Maurer PM, et al. Diabetic status and the relation of the three domains of glycemic control to mortality in critically ill patients: an international multicenter cohort study. Critical Care. 2013;17(37):1-15.

Falciglia M, Freyberg RW, Almenoff PL, D'Alessio DA, Render ML. Hyperglycemia-Related Mortality in Critically Ill Patients Varies with Admission Diagnosis. Crit Care Med. 2009;37(12):3001-8.

McAlister FA, Majumdar SR, Blitz S, Rowe BH, Romney J, Marrie TJ. The relation between hyperglycemia and outcomes in 2,471 patients admitted to the hospital with community-acquired pneumonia. Diabetes Care. 2005;28(4):810-4.

Sung J, Bochicchio GV, Joshi M, Bochicchio K, Tracy K, Scalea TM. Admission hyperglycemia is predictive of outcome in critically ill trauma patients. J Trauma. 2005;59(1):80-3.

Bruno A, Levine SR, Frankel MR, Brott TG, Lin Y, Tilley BC, et al. Admission glucose level and clinical outcomes in the NINDS rt-PA Stroke Trial. Neurology. 2002;59(5):669-74.

Egi M, Bellomo R, Stachowski E, French CJ, Hart GK, Hegarty C, et al. Blood glucose concentration and outcome of critical illness: The impact of diabetes. Crit Care Med. 2008;36(8):2249-55.

Sechterberger MK, Bosman RJ, Straaten HMO, Siegelaar SE, Hermanides J, Hoekstra JBL. The effect of diabetes mellitus on the association between measures of glycaemic control and ICU mortality: a retrospective cohort study. Critical Care. 2013;17(52):1-9.

Jacobi J, Bircher N, Krinsley J, Agus M, Braithwaite SS, Deutschman C, et al. Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. Crit Care Med. 2012;40(12):3251-76.