Hyperglycaemic crisis in the Eastern Cape province of South Africa: High mortality and association of hyperosmolar ketoacidosis

December 2010, Vol. 100, No. 12 SAMJ Diabetic hyperglycaemic crisis is a major reason for high-care unit admissions,1 with mortality rates of up to 30%.2-9 It is characteristically classified as ketoacidotic or hyperosmolar.10 Presentations with the combination of ketoacidosis and hyperosmolality are recognised,6,7,11-16 and have variably been described as ketoacidosis with hyperosmolality or hyperosmolar state with ketoacidosis, depending on whether ketoacidosis or hyperosmolality was considered dominant.15 Therapy and outcome of treatment for hyperglycaemic crisis is related to the presence of hyperosmolality and ketoacidosis.1 Hyperosmolality is associated with the use of hypotonic fluids, anticoagulation and the more frequent occurrence of vascular thrombosis,17 while ketoacidosis may necessitate the use of sodium bicarbonate.18 Hyperglycaemic hyperosmolar non-ketoacidosis is associated with a higher morbidity and mortality than diabetic ketoacidosis,6,7,19 which is mainly attributed to hyperosmolality, older age6,7 and the more frequent association of hyperosmolar non-ketoacidosis with type 2 diabetes.19 Few studies6,7,11,13 have described the clinical and laboratory features and outcomes of treatment for hyperosmolar diabetic ketoacidosis. A single report from Africa11 included only 8 cases. This study investigated the frequencies, presenting characteristics and outcomes of admissions for various types of hyperglycaemic crisis at Nelson Mandela Academic Hospital, Walter Sisulu University (WSU), Mthatha. The hospital is the referral centre for primary and secondary health care facilities in the O R Tambo district of the Eastern Cape province of South Africa, which has a population of about 1.7 million people.20 Like the rest of the province the O R Tambo district has poorly developed health infrastructure and a disproportionately high burden of communicable diseases, particularly HIV/AIDS, tuberculosis and neurocysticercosis.