Diabetes Mellitus and Hypertension as Major Risk Factors of Mortality From Covid-19 Pneumonia

Dear Editor,

Coronavirus disease 2019 (COVID-19) caused by the new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the new pandemic [1] [2]. The most vulnerable populations are patients with comorbidities, notably diabetes mellitus (DM), cardiovascular disease (CVD), hypertension, chronic kidney disease and immunosuppression [3]. DM and its complications such as CVD, chronic kidney disease, neuropathy and diabetic foot ulcers increase susceptibility to infectious diseases and morbidity [3] [4].

Medical records of 172 patients hospitalised with COVID-19 pneumonia in the Department of Infectious Diseases, University Hospital of Alexandroupolis, Greece were retrospectively analysed. The diagnosis of SARS-CoV-2 infection was confirmed with real time-polymerase chain reaction (RT-PCR) in nasopharyngeal specimens. Comorbidities including DM, hypertension, dyslipidaemia, coronary artery disease, heart failure and chronic kidney disease were identified, as based on patient’s history and medical records. The study was approved by the institutional ethics committee and all patients gave their informed consent.

The majority of patients were men (57%). Mean age was 61.1±15.8 years. Of these, 81.4% exhibited radiological and clinical findings of pneumonia, 20.9% were intubated and 18.2% died. Overall, among patients with pneumonia, the commonest comorbidities were hypertension (38.4%), DM (20.9%) and dyslipidaemia (20.9%) ([Table 1]). Specifically, among those who died from pneumonia, all comorbidities were more frequent. DM was significantly (p<0.001, odds ratio [OR]: 26.28, 95% confidence interval [CI]: 9.91–69.69) more frequent among those who died (71%) vs. those who survived (8.5%). Similarly, hypertension was significantly (p<0.001, OR: 8.66, 95% CI: 3.46–21.68) more frequent among those who died (77.4%) vs. those who survived (28.4%). The total age-standardised prevalence of diabetes in Greece was 9.1%, according to data of WHO in 2016[5]. All patients had type 2 DM. Regrettably, HbA_1cwas not available to assess glycaemic control. All patients had been treated with oral hypoglycaemic agents. The majority of patients used metformin combined with dipeptidylpeptidase-4 (DPP-4) inhibitors or sodium glucose cotransporter 2 (SGLT2) inhibitors. There was no difference in treatment regimens among those who survived and those who died.

Table 1 Comorbidities of patients with COVID-19 pneumonia.

	Hospitalised patients with confirmed COVID-19 pneumonia (n=172)	Patients who died due to COVID-19 pneumonia (n=31)
Age, years (mean, SD)	61.1±15.8	69.2±13.8
Gender
Male (n,%)	98 (57%)	18 (58%)
Comorbidities (n,%)
Hypertension	66 (38.4%)	24 (77.4%)
Diabetes mellitus	36 (20.9%)	22 (71%)
Coronary artery disease	18 (10.5%)	11 (35.5%)
Dyslipidaemia	36 (20.9%)	16 (51.6%)
Heart failure	21 (12.2%)	5 (16.1%)
Chronic kidney disease	11 (6.4%)	3 (9.7%)

Several studies have identified DM and CVD as major risk factors for the clinical outcome of COVID-19 pneumonia, in addition to advanced age [6]. In a Chinese study (N=1099), among 173 patients with severe disease 23.7% had hypertension and 16.2% DM [7]. Similarly, in Italy, among 1591 patients admitted to the intensive care unit, 49% had hypertension, 21% CVD and 17% DM [8]. In USA, hypertension was also the most common comorbidity (49.7%), followed by obesity (48.3%), DM (28.3%) and CVD (27.8%) [9]. DM is considered as a low-grade inflammation state, which may aggravate the inflammatory process caused by SARS-CoV-2 leading to poor prognosis [10]. In this context, antidiabetic agents with the potential to reduce inflammation, hypoxia, liver injury and excess cytokine release are being discussed [11] [12].

In conclusion, in our department the commonest comorbidities were hypertension, DM and dyslipidaemia. Among those who died from severe pneumonia, more than 70% had DM or hypertension. These results add to the growing concern about the vulnerability of subjects with DM [6] [7] and the need to protect them by reducing infection in the community.

Publication History

Article published online:
09 December 2020

• References

• 1 Coronaviridae Study Group of the International Committee on Taxonomy of Viruses The species Severe acute respiratory syndrome-related coronavirus: classifying 2019-nCoV and naming it SARS-CoV-2. Nat Microbiol 2020; 5: 536-544
• 2 World Health Organization WHO Director-General’s opening remarks at the media briefing on COVID-19 - 11 March 2020, 2020. Available https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19-11-march-2020. Last accessed: 10th October 2020
• 3 Li H, Liu SM, Yu XH. et al. Coronavirus disease 2019 (COVID-19): Current status and future perspectives. Int J Antimicrob Agents 2020; 55: 105951
• 4 Deshpande AD, Harris-Hayes M, Schootman M. Epidemiology of diabetes and diabetes-related complications. Phys Ther 2008; 88: 1254-1264
• 5 World Health Organization (WHO) Diabetes country profiles. 2016; https://www.who.int/diabetes/country-profiles/grc_en.pdf?ua=1, Last accessed 12th November 2020;
• 6 Pititto BA, Ferreira SRG. Diabetes and Covid-19: More than the sum of two morbidities. Rev Saude Publica 2020; 54: 54
• 7 Guan W, Ni Z, Hu Y. et al. Clinical characteristics of coronavirus disease 2019 in China. N Eng J Med 2020; 382: 1708-1720
• 8 Grasselli G, Zangrillo A, Zanella A. et al. Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy Region, Italy. JAMA 2020; 323: 1574-1581
• 9 Garg S, Kim L, Whitaker M. et al. Hospitalized rates and characteristics of patients with laboratory-confirmed Coronavirus Disease 2019 – COVID-NET, 14 States, March 1-30, 2020. MMWR Morb Mortal Wkly Rep 2020; 69: 458-464
• 10 Zhou F, Yu T, Du R. et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Lancet 2020; 395: 1054-1062
• 11 Papachristou S, Penlioglou T, Stoian AP. et al. COVID-19 and sodium-glucose cotransporter 2 inhibitors: No fear to attempt? Exp Clin Endocrinol Diabetes. 2020; Sep 10. Online ahead of print
• 12 Penlioglou T, Papachristou S, Papanas N. COVID-19 and diabetes mellitus: may old anti-diabetic agents become the new philosopher’s stone?. Diabetes Ther 2020; 11: 1-3