Incidence, predictors, and short-term outcomes of acute kidney injury in children with diabetic ketoacidosis: a systematic review

Risk factors of acute kidney injury in children with diabetic ketoacidosis

BACKGROUND

Acute kidney injury (AKI) in pediatric patients has been linked to unfavorable short-term and long-term health outcomes. Despite the significance of AKI awareness in children with diabetes mellitus type 1 (T1D), the incidence of AKI in children admitted with diabetic ketoacidosis (DKA) has been under looked.

OBJECTIVES

The primary objective of this study was to investigate the incidence of acute kidney injury (AKI) in pediatric patients hospitalized for diabetic ketoacidosis (DKA), and to identify the clinical and biochemical markers associated with the development of AKI.

METHODS

A retrospective medical record review was conducted at King Abdulaziz University Hospital, a tertiary hospital in Jeddah, Saudi Arabia. The study included 373 children aged 18 years or younger from 2012 to 2022 with complete medical records available for analysis. We collected baseline and diabetes characteristics, in addition to clinical variables at presentation. Acute kidney injury (AKI) was diagnosed using the serum creatinine criteria established by the kidney disease: Improving Global Outcomes (KDIGO) organization. Descriptive comparisons were performed. Uni- and multivariable logistic regression analyses were employed to identify potential risk factors associated with the development of AKI.

RESULTS

299 patients (80.2%) developed AKI including 98 (26.3%) stage 1, and 118 (31.6%) stage 2 and 83 (22.3%) stage 3. The frequency of AKI was higher in patients with severe DKA (26.9% vs. 19.7%, p=0.01) while in mild DKA the percentage of AKI was less than non-AKI (31.9% vs. 45.1%, p<0.01The median last HbA1C prior to DKA presentation was 12%, and majority (88.2%) had DKA episodes in past. children who developed AKI had a significantly higher median heart rate (120 bpm, IQR 104-138) compared to those without AKI (108 bpm, IQR 98-124, p<0.01). A high percentage of children with AKI had low Glasgow coma scale (<15) compared to non-AKI (5.7% vs. 1.7%) but the difference was not statistically significant (p=0.22). Half of the children presented with DKA had poor outpatient follow up visits. The proven infections were observed in 53 (14.2%) children in DKA. It was higher in non-AKI group compared to AKI group (15.1% vs. 10.8%, p=0.46). At the time of discharge 131 (44%) patients with AKI showed persistent acute kidney disease. We did not observe mortality. Children with AKI had longer hospital stay compared to non-AKI (4 days vs. 3 days, p=0.02). None of the study participant have died during the studied hospital encounters.

CONCLUSION

Our findings indicate that AKI is common in children admitted with DKA. Longer duration and poor controlled T1D; previous episodes of DKA, severe DKA, infection and higher heart rate are risk factors to develop AKI. At the time of discharge, 131 (44%) patients AKI showed persistent acute kidney disease (AKD). The longer hospital stay in children with AKI highlights the significant morbidity of AKI.

CLINICAL TRIAL NUMBER

Not applicable.

Acute kidney injury and long-term renal outcomes in pediatric diabetic ketoacidosis

BACKGROUND

The cumulative evidence suggests that children with type 1 diabetes mellitus (T1DM) and diabetic ketoacidosis (DKA) have increased risk of acute kidney injury (AKI). However, there is insufficient data among Thai patients, and the available information of long-term renal outcomes is limited.

OBJECTIVES

To investigate the proportion and risk factors associated with AKI in children with T1DM and DKA, and to differentiate long-term renal outcomes between those experiencing AKI and those who are unaffected.

METHODS

Conducting a retrospective study, we enrolled children aged 1-18 years with T1DM and DKA at university hospital from January 2010 to August 2023. Participants were categorized into two groups based on the presence of AKI according to the 2012 KDIGO guidelines. The clinical parameters associated with these risk factors and long-term renal outcomes were evaluated.

RESULTS

This study included 85 children with T1DM admitted for 122 episodes of DKA, with 46 episodes (37.7 %) experiencing AKI. Identified AKI risk factors during DKA encompassed hypertension (adjusted odds ratio, aOR, 4.36; p = 0.05), serum glucose >500 mg/dL (aOR, 13.7; p < 0.001), WBC counts >15,000 cells/mm3 (aOR, 16.13; p < 0.001), and neutrophil-lymphocyte ratio >5.5 (aOR, 5.29; p = 0.04). For long-term renal outcomes, individuals with AKI during DKA demonstrated higher prevalence of hypertension, microalbuminuria, and abnormal glomerular filtration rates.

CONCLUSION

AKI was common in children with T1DM experiencing DKA. Of note, it was linked to severe hyperglycemia, leukocytosis, and an elevated neutrophil-lymphocyte ratio, contributing to the deterioration in long-term renal prognosis.

Research Priorities for Diabetic Ketoacidosis: An Evidence and Gap Mapping Review

BACKGROUND/OBJECTIVES

Diabetic ketoacidosis (DKA) is a common acute complication of diabetes with treatment consisting of reversal of cause, insulin administration, fluid resuscitation and electrolyte repletion. Yet, many aspects of DKA management are currently based on low-quality evidence or physiological rationale. This evidence and gap map review presents an overview of the current body of literature and identifies evidence gaps in relation to therapeutic interventions for DKA.

METHODS

Interventions and outcomes relevant to DKA were identified and iteratively developed to produce a coding model for the proposed evidence and gap map. PubMed was searched with Me SH terms relevant to the identified interventions and outcomes. Studies identified were screened and assigned interventions and outcomes. Interventional research was uploaded to EPPI-Reviewer and EPPI-Mapper to produce the evidence and gap map.

RESULTS

The search identified 1131 studies, of which 18 were non-human and 345 were duplicates. A total of 768 unique studies were screened, and 118 were identified as interventions (52 pediatric and 66 adult studies). A total of 26 high-quality studies, 88 medium-quality studies and 4 low-quality studies were identified. These 118 studies were coded into the proposed DKA evidence and gap map. The intervention domains were fluid therapy, insulin therapy, electrolyte replacement, adjunct therapies and admission type. The outcome domains were DKA resolution, insulin duration, length of stay, morbidity and mortality, complications, and biochemical parameters.

CONCLUSIONS

Fluid type and insulin infusion administration were prominent in the current literature. These studies frequently used DKA resolution and complications associated with DKA such as electrolyte disturbances and cerebral edema as the primary outcomes. Substantial gaps were identified with scant evidence to guide prophylactic electrolyte administration, enteral intake and adjunctive therapy (thiamine, bicarbonate). Even for well-investigated interventions such as fluids and insulin, substantial gaps existed, particularly for patient-centered and healthcare service outcomes.

Diagnosis (by p-RIFLE and KDIGO) and Risk Factors of Acute Kidney Injury in Pediatric Diabetic Ketoacidosis: A Retrospective Study

Background

There are two criteria to diagnose and stage acute kidney injury (AKI) in children: pediatric-Risk, Injury, Failure, Loss (p-RIFLE) and Kidney Disease Improving Global Outcomes (KDIGO). This study aims to find out the extent of agreement in diagnosis (by p-RIFLE and KDIGO) and risk factors of AKI in pediatric diabetic ketoacidosis (DKA).

Materials and Methods

A retrospective cohort study involving children aged ≤15 years with DKA was conducted between January 2014 and December 2022. Those with inborn errors of metabolism, septic shock, and urinary tract disease were excluded. The primary outcome was the extent of agreement in diagnosis of AKI by p-RIFLE and KDIGO. The secondary outcomes were staging agreement, risk factors, complications (hypoglycemia, hypokalemia, and cerebral edema), time to resolution of DKA, and hospital and pediatric intensive care units (PICU) stay.

Results

Data from 161 patients were collected. Mean (SD) age was 8.6 (3.7) years. Good agreement between p-RIFLE and KDIGO criteria for diagnosis of AKI was noted at admission (Kappa = 0.71, p ≤ 0.001), at 24 hours (Kappa = 0.73, p ≤ 0.001) and discharge (Kappa = 0.60, p ≤ 0.001), and for the staging of AKI at admission (Kappa = 0.81, p ≤ 0.001) at 24 hours (Kappa = 0.75, p ≤ 0.001) and discharge (Kappa = 0.48, p ≤ 0.001). On multivariate analysis, age (≤5 years: aOR = 3.03, 95% CI 1.04-8.79) is an independent risk factor for AKI at discharge by KDIGO. Cerebral edema (n = 6, 3.7%), hypoglycemia (n = 66, 41%), and hypokalemia (n = 59, 36.6%) were noted. Resolution and stay in PICU and hospitals were longer for patients with AKI.

Conclusion

p-RIFLE and KDIGO criteria showed good agreement in diagnosis and staging of AKI in pediatric DKA.

Clinical Profile of Acute Kidney Injury in Type 2 Diabetes Mellitus Adult Patients Presenting With Diabetic Ketoacidosis: A Cross-Sectional Study

OBJECTIVE

 The purpose of this cross-sectional study was to identify the characteristics of acute kidney injury (AKI) in adult patients with type 2 diabetes mellitus (T2DM) who were admitted with diabetic ketoacidosis (DKA).

METHODOLOGY

 One hundred patients were selected based on the inclusion and exclusion criteria. Kidney function was assessed using kidney estimated glomerular filtration rate (KeGFR) calculations based on the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Data collection included clinical, biological, and demographic information. Univariate and multivariate logistic regression analyses were performed, with a p-value of less than 0.05 considered statistically significant. The study also examined risk factors, intensive care unit (ICU) treatments, and clinical outcomes.

RESULTS

AKI was significantly associated with ICU length of stay (p = 0.002), and all patients with prolonged ICU admission developed this condition. A higher incidence of AKI was observed in patients requiring mechanical ventilation, renal replacement therapy, or inotropic support. Among the 100 patients included in the study, 94 achieved clinical recovery, including 76 who had AKI, while six patients did not survive.

CONCLUSION

AKI is a common complication of DKA in adults with T2DM, particularly in hot climate regions. Most cases were detected within the first 24 hours, classified as stage 1 severity, and were pre-renal. Early detection plays a crucial role in preventing complications and improving patient recovery. KeGFR calculations proved an effective tool for monitoring kidney function changes in these patients.

Diabetic Ketoacidosis in Pediatric Emergency Medicine: Risk Factors, Myths, and Evidence-Based Management of Complications

Purpose

Diabetic ketoacidosis (DKA) is a common condition among type 1 diabetics, commonly affecting those below the age of 20.

Methods

A comprehensive literature search was conducted in databases like PubMed to identify primary studies conducted in children with DKA. Finally, 79 studies were included for qualitative synthesis.

Results

The disease is characterized by acute-onset metabolic and pathological derangements, necessitating immediate intervention. With the rising incidence, concerns have been emerging regarding the disparities in the presentation and treatment of DKA among different countries with inequitable resources. Within its management lies the common misconceptions, both among patients and primary physicians, prohibiting an optimistic approach to the disease. Pediatric children in particular need specialized treatment and care during an episode of DKA due to its long-term cognitive and neurological sequelae. Hence, efforts have been undertaken to ensure minimization of neurological damage when treating DKA. While guidelines are in place for treatment of DKA, there are considerable differences in their protocols across different regions.

Conclusion

It is imperative to analyze recent evidence and continually update treatment guidelines for DKA. Additionally, maximal efforts need to be taken to bridge the gap between different nations, allowing accessibility to equitable resources to all.

The effect of serum biochemical parameters on clinical prognosis in children presenting with diabetic ketoacidosis

OBJECTIVE

The aim of this study was to determine whether diabetes mellitus has a high risk of diabetic ketoacidosis-related complications. Biochemical parameters affect the resolution time of diabetic ketoacidosis.

METHODS

The present study is based on a retrospective evaluation of the records of patients who presented to the Pediatrics Clinic of Adiyaman University Hospital between January 1, 2017, and October 1, 2022, with a diagnosis ofdiabetic ketoacidosis. The demographic characteristics, serum biochemical parameters, blood gas results, and time to transition to subcutaneous insulin therapy were all recorded.

RESULTS

This study included 49 (49%) female and 51 (51%) male patients aged 1-17 years (mean age: 9.05±4.33 years). The average time to clinical improvement of the sample, that is, transition to subcutaneous insulin therapy, was 21.04±7.8 h. An evaluation of the presence of acute kidney injury based on serum urea and creatinine levels and eGFR values revealed no significant effect on the rate of clinical recovery (respective p-values: p=0.076, p=0.494, and p=0.884). A univariate analysis identified blood glucose (p=0.025), blood gas pH (p<0.001), and blood bicarbonate (p=0.004) values as prognostic factors, while a multivariate analysis revealed pH values had an independent and significant effect on the resolution time of diabetic ketoacidosis.

CONCLUSION

Serum glucose, pH, and bicarbonate levels are the most important determinants of clinical prognosis in patients with diabetic ketoacidosis. These findings can serve as a guide for clinicians in the follow-up and treatment of such patients.

The Effects of Subcutaneous Rapid-Acting Insulin Aspart in the Treatment of Mild and Moderate Diabetic Ketoacidosis in Children: A Prospective Study

Background and objectives The traditional treatment approach to diabetic ketoacidosis (DKA) involves the replacement of fluid and electrolyte deficits and a continuous intravenous infusion of regular insulin. Several clinical trials supported the administration of subcutaneous rapid-acting insulin analogs in the management of uncomplicated DKA. This study aimed to determine the effects/safety of subcutaneous rapid-acting insulin aspart injections in treating uncomplicated mild and moderate DKA in children. Methods In this prospective study in 2022, 25 children with mild/or moderate DKA were enrolled. The main outcome measure was median time (hours) for the resolution of ketoacidosis. Data recorded were as follows: clinical characteristics, severity of ketoacidosis and dehydration, blood glucose, sodium, potassium, creatinine, urine ketones, hospitalization's duration, and complications. Based on the degree of dehydration, fluid deficit was replaced by sodium chloride 0.45%. Insulin aspart 0.15 units/kg subcutaneous injections were given every 2 hours in the hospital outside ICU. Blood glucose was measured hourly and blood gases every 2 hours. Ketoacidosis was considered resolved when the patient did not have nausea/vomiting, was conscious, and could eat, and blood glucose was <250 mg/dL, pH was >7.30, and/or HCO3 was >15 mmol/L. Results Of 25 DKA patients (mean age 11.06±3.89, range 4-17 years, 60% girls), 16 cases (64%) had established type 1 diabetes. Overall, 13 (52%) cases had mild ketoacidosis (average pH=7.25), and 12 (48%) cases had moderate ketoacidosis (average pH=7.15). The mean time to resolution of ketoacidosis was 11.24 hours. All but one patient met DKA recovery criteria without complications. Mild cases compared to moderate cases of DKA had a shorter duration to resolution of DKA (p = 0.04). Mean duration of hospitalization was 2.3 days. No electrolyte disturbances, hypoglycemia events, readmission or mortality, or other adverse effects were observed. Conclusion In children with mild and moderate DKA, subcutaneous rapid-acting insulin aspart administration was an effective, safe, and convenient treatment.

Association between blood urea nitrogen to serum albumin ratio and in-hospital mortality in critical patients with diabetic ketoacidosis: a retrospective analysis of the eICU database

Background

This study aimed to investigate the association between blood urea nitrogen to serum albumin ratio (BAR) and the risk of in-hospital mortality in patients with diabetic ketoacidosis.

Methods

A total of 3,962 diabetic ketoacidosis patients from the eICU Collaborative Research Database were included in this analysis. The primary outcome was in-hospital death.

Results

Over a median length of hospital stay of 3.1 days, 86 in-hospital deaths were identified. One unit increase in LnBAR was positively associated with the risk of in-hospital death (hazard ratio [HR], 1.82 [95% CI, 1.42-2.34]). Furthermore, a nonlinear, consistently increasing correlation between elevated BAR and in-hospital mortality was observed (P for trend =0.005 after multiple-adjusted). When BAR was categorized into quartiles, the higher risk of in-hospital death (multiple-adjusted HR, 1.99 [95% CI, (1.1-3.6)]) was found in participants in quartiles 3 to 4 (BAR≥6.28) compared with those in quartiles 1 to 2 (BAR<6.28). In the subgroup analysis, the LnBAR-hospital death association was significantly stronger in participants without kidney insufficiency (yes versus no, P-interaction=0.023).

Conclusion

There was a significant and positive association between BAR and the risk of in-hospital death in patients with diabetic ketoacidosis. Notably, the strength of this association was intensified among those without kidney insufficiency.

Systemic Inflammatory Response Index (SIRI) as a Predictive Marker for Adverse Outcomes in Children with New-Onset Type 1 Diabetes Mellitus

(1) Background: Although most cases of new-onset type 1 diabetes mellitus (T1DM) are managed without serious events, life-threatening complications do arise in a subset of patients. Our objective was to assess the correlation between elevated SIRI values and adverse events related to the onset of T1DM. (2) Methods: This retrospective study, spanning ten years, included 187 patients with new-onset T1DM divided into three groups based on SIRI tertiles. The primary outcome was the occurrence of acute complications during hospital admission, while the secondary outcome was prolonged Intensive Care Unit (ICU) admission. (3) Results: Patients with high SIRI values were more likely to experience higher disease activity, leading to longer ICU admission times and more frequent complications. Multivariate logistic regression analysis revealed that the SIRI was independently associated with acute complications (p = 0.003) and prolonged ICU length of stay (p = 0.003). Furthermore, receiver operating characteristic analysis demonstrated the SIRI's superior predictive accuracy compared to venous pH (AUC = 0.837 and AUC = 0.811, respectively) and to the individual component cell lineages of the SIRI. (4) Conclusions: These findings emphasize the potential utility of the SIRI as a prognostic marker in identifying patients at increased risk during T1DM hospital admissions.

The effect of dehydration, hyperchloremia and volume of fluid resuscitation on acute kidney injury in children admitted to hospital with diabetic ketoacidosis

BACKGROUND

Acute kidney injury (AKI) is a recognized comorbidity in pediatric diabetic ketoacidosis (DKA), although the exact etiology is unclear. The unique physiology of DKA makes dehydration assessments challenging, and these patients potentially receive excessive amounts of intravenous fluids (IVF). We hypothesized that dehydration is over-estimated in pediatric DKA, leading to over-administration of IVF and hyperchloremia that worsens AKI.

METHODS

Retrospective cohort of all DKA inpatients at a tertiary pediatric hospital from 2014 to 2019. A total of 145 children were included; reasons for exclusion were pre-existing kidney disease or incomplete medical records. AKI was determined by change in creatinine during admission, and comparison to a calculated baseline value. Linear regression multivariable analysis was used to identify factors associated with AKI. True dehydration was calculated from patients' change in weight, as previously validated. Fluid over-resuscitation was defined as total fluids given above the true dehydration.

RESULTS

A total of 19% of patients met KDIGO serum creatinine criteria for AKI on admission. Only 2% had AKI on hospital discharge. True dehydration and high serum urea levels were associated with high serum creatinine levels on admission (p = 0.042; p < 0.001, respectively). Fluid over-resuscitation and hyperchloremia were associated with delayed kidney recovery (p < 0.001). Severity of initial AKI was associated with cerebral edema (p = 0.018).

CONCLUSIONS

Dehydration was associated with initial AKI in children with DKA. Persistent AKI and delay to recovery was associated with hyperchloremia and over-resuscitation with IVF, potentially modifiable clinical variables for earlier AKI recovery and reduction in long-term morbidity. This highlights the need to re-address fluid protocols in pediatric DKA.

Diabetic Ketoacidosis in Children and Adolescents; Diagnostic and Therapeutic Pitfalls

Diabetic ketoacidosis (DKA) represents an acute, severe complication of relative insulin deficiency and a common presentation of Type 1 Diabetes Mellitus (T1DM) primarily and, occasionally, Type 2 Diabetes Mellitus (T2DM) in children and adolescents. It is characterized by the biochemical triad of hyperglycaemia, ketonaemia and/or ketonuria, and acidaemia. Clinical symptoms include dehydration, tachypnoea, gastrointestinal symptoms, and reduced level of consciousness, precipitated by a variably long period of polyuria, polydipsia, and weight loss. The present review aims to summarize potential pitfalls in the diagnosis and management of DKA. A literature review was conducted using the Pubmed/Medline and Scopus databases including articles published from 2000 onwards. Diagnostic challenges include differentiating between T1DM and T2DM, between DKA and hyperosmolar hyperglycaemic state (HHS), and between DKA and alternative diagnoses presenting with overlapping symptoms, such as pneumonia, asthma exacerbation, urinary tract infection, gastroenteritis, acute abdomen, and central nervous system infection. The mainstays of DKA management include careful fluid resuscitation, timely intravenous insulin administration, restoration of shifting electrolyte disorders and addressing underlying precipitating factors. However, evidence suggests that optimal treatment remains a therapeutic challenge. Accurate and rapid diagnosis, prompt intervention, and meticulous monitoring are of major importance to break the vicious cycle of life-threatening events and prevent severe complications during this potentially fatal medical emergency.

Renal Biomarkers and Novel Therapies in Pediatric Nephrology: From Chronic Kidney Disease to Renal Transplantation

Chronic kidney disease (CKD), a growing problem with an estimated prevalence of 74 [...].