Volume 32, Issue 1 (3-2025)
RJMS 2025, 32(1): 1-9 |
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Ethics code: IR.IUMS.REC 1396.8923496025
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Maghsoomi Z, Shahbeigy S. Preexisting Diabetes and Severity and Outcomes of Acute Pancreatitis: A Cross-Sectional Study. RJMS 2025; 32 (1) :1-9
URL: http://rjms.iums.ac.ir/article-1-9172-en.html
URL: http://rjms.iums.ac.ir/article-1-9172-en.html
Research Center for Prevention of Cardiovascular Disease, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran, & Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran , zmaghsoomi@gmail.com
Abstract: (214 Views)
Background & Aims: Acute pancreatitis (AP) is a common gastrointestinal emergency with a wide clinical spectrum, ranging from mild, self-limiting forms to severe cases involving organ failure, which can lead to significant morbidity and mortality (1, 2). The prediction of severity within the first 48 hours of hospitalization is essential for optimal management and better outcomes. To achieve this, several prognostic scoring systems are commonly used, including Ranson (4), APACHE-II (5), BISAP, and especially organ failure-based scores such as SOFA (6) and Marshall (7, 8). Type 2 (T2) diabetes mellitus (DM) as a chronic metabolic disorder that may be associated with immune dysfunction (9). This condition can alter the body’s response to acute inflammatory processes such as AP and potentially increase disease severity (10, 11). Moreover, not only does DM itself increase the risk of AP, but uncontrolled blood glucose levels may also enhance its severity (12, 13). Although several studies have investigated the relationship between DM and AP (14–16), the impact of DM on the severity and prognosis of AP remains unclear, with conflicting findings. Some studies have reported that patients with DM with AP experience more severe disease, higher mortality rates, and more complications (17, 18), while others have found no significant association (19). Therefore, this study aims to compare the causes of AP, disease severity (based on various prognostic scores), and mortality in AP patients with T2DM (T2DM-AP patients) and other patients with AP (OAP) in an Iranian population.
Methods: This cross-sectional study reviewed medical records of 150 patients with AP admitted to Firouzabadi Hospital from February 2015 to February 2017. AP was diagnosed based on the revised Atlanta criteria (2012) (20). Patients with a history of end-stage renal disease (eGFR < 15 mL/min/1.73 m²), heart failure (NYHA class III or IV), cirrhosis, or severe pulmonary disease were excluded. Data were extracted, including demographic information, etiology of AP (alcohol, drugs, and triglycerides >500 mg/dL in the absence of other causes (19)), and laboratory results. Prognostic scores (Ranson, BISAP, APACHE-II, SOFA, Marshall, and Glasgow) were retrospectively calculated using data from the first 72 hours of hospitalization. Local complications and necrotizing pancreatitis were recorded based on clinical files and CT scan findings (21). Data were analyzed using SPSS v20. Continuous variables with a parametric distribution were reported as mean ± SD, while categorical variables were presented as frequency and percentage. A chi-square test was used to analyze the difference between T2DM-AP and OAP. Statistical significance was set at p < 0.05.
Results: Of the 150 patients, 30 (20%) had T2DM and 120 (80%) were OAP. The mean age of T2DM-AP patients was 56.3±9.9 years, compared to 53.2±9.9 years in OAP. 63.3% of T2DM-AP patients and 46.7% of OAP were female. All T2DM-AP patients were on oral medications, with no history of receiving SGLT2 inhibitors, GLP-1 receptor agonists, or DPP-4 inhibitors. The most common cause of AP in both groups was biliary disease (53.3% in T2DM-AP patients vs. 59.2% in OAP). Hypertriglyceridemia was more frequent in T2DM-AP patients, though the difference was not statistically significant. SOFA Score at 48 and MARSHALL scores showed statistically significant differences, particularly at 48 hours and beyond, indicating more severe organ dysfunction in T2DM-AP patients. RANSON scores trended toward significance, suggesting T2DM-AP patients may present with more severe disease, though not statistically confirmed. Other scores (APACHE-II, BISAP, GLASGOW) do not show significant differences between groups. Five T2DM-AP and five OAPs died during hospitalization. Mortality was significantly higher in T2DM-AP patients (16.7% vs. 4.2%, p = 0.018). Although some complications, such as acute necrotic collection (ANC), appeared more frequently in T2DM-AP patients (13.3% vs. 7.5%), and peripancreatic fluid collection was also lower (6.7% vs. 14.2%), the differences were not statistically significant.
Conclusion: This cross-sectional study examined the severity, mortality, and local complications of AP in patients with T2DM compared to OAP. Our main findings showed that although the distribution of primary causes of AP (mostly biliary) was similar between the two groups, AP due to hypertriglyceridemia (>500 mg/dL) was more frequent among T2DM-AP patients. More importantly, prognostic scores such as SOFA and Marshall—which focus on organ failure assessment—were significantly higher in T2DM-AP patients. Another clinically important finding was a statistically significantly higher mortality rate in the T2DM-AP patients (16.7%) than in OAP (4.2%). No significant differences were observed in the occurrence of local complications.
T2DM is a chronic metabolic condition predominantly associated with insulin resistance. It increases the likelihood of gallstone formation (22) and is associated with other metabolic disorders, such as obesity (a known risk factor for AP) (23) and hypertriglyceridemia (24). Additionally, certain antidiabetic medications, such as GLP-1 receptor agonists and DPP-4 inhibitors, have been linked to AP (25). These factors may contribute to a higher incidence of AP in T2DM patients (13). In our study, hypertriglyceridemia-induced AP was more common in T2DM-AP patients than in OAP. Triglyceride levels in patients with T2DM are typically mild to moderate (150–1000 mg/dL) (26), and even within this range, an increased risk of AP has been documented (27). Our results regarding the superiority of SOFA and Marshall scores in predicting outcomes—compared to other scores like Ranson, APACHE-II, BISAP, and Glasgow (Imrie)—may be due to the limitations of those systems in identifying severe cases, as discussed in a meta-analysis (28). Moreover, SOFA and Marshall scores reflect organ failure, suggesting that systemic damage and organ dysfunction are likely contributors to disease severity in these patients. Previous studies have also reported associations between DM and increased severity of AP (17, 19, 29, 30). In our study, mortality was higher among T2DM-AP patients. Although other studies have similarly reported increased mortality in these cases (29, 31), there remain some discrepancies between the association of T2DM-AP patients and mortality (32). There is no association between mortality in T2DM-AP patients vs OAPs in some studies (10, 33). This discrepancy may partly stem from the retrospective design of such studies, which limits the ability to isolate the effect of DM or control for confounding variables. Regarding local complications, ANCs were more prevalent in T2DM-AP patients than in OAPs, though the difference was not statistically significant and aligns with previous studies (29, 30, 34). Another study demonstrated a relationship between DM-AP patients and local complications (such as cysts and abscesses requiring drainage) (10), although it did not describe other local complications. This study has several limitations. The cross-sectional study with retrospective design restricts the ability to establish causality. The relatively small sample size—particularly in the T2DM-AP group (n=30)—and lack of data on diabetes duration, glycemic control (such as HbA1c levels), and patient weight or BMI limited further analysis. Despite these limitations, these findings present important clinical implications. Physicians should recognize that T2DM-AP patients are a vulnerable population at higher risk for severe disease and death. These patients need earlier intensive monitoring in specialized units, aggressive blood glucose management, and continuous organ function assessment. Using organ failure-based prognostic scores like Marshall and SOFA may be helpful for this group. Given the variability in clinical study results, further research with a large sample size is necessary to understand how DM affects outcomes in patients with AP.
In the studied population, AP in patients with T2DM was associated with a higher prevalence of hypertriglyceridemia, worse prognostic scores (SOFA and Marshall), and significantly higher mortality rates. Future prospective studies with larger sample sizes are recommended to confirm these findings and to investigate the role of glycemic control in the outcomes of AP.
Type of Study: Research |
Subject:
Endocrinology
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