Acute kidney injury common in pediatric diabetic ketoacidosis
medwireNews: Almost two-thirds of children hospitalized with diabetic ketoacidosis (DKA) develop acute kidney injury (AKI) within 24 hours of hospitalization, study findings indicate.
The most severe cases of AKI (stage 2 or 3) were significantly associated with increased volume depletion and more severe acidosis, the researchers report.
“Overall, these data suggest that clinicians should consider AKI as a frequent complication that accompanies pediatric DKA and should be especially alert to its presence in severe presentations of DKA,” Constadina Panagiotopoulos (University of British Columbia, Vancouver, Canada) and co-authors write in JAMA Pediatrics.
They reviewed the medical records of 165 children (median age 10.6 years) with type 1 diabetes who were hospitalized for diabetic ketoacidosis between 2008 and 2013, 75.8% of whom were newly diagnosed with type 1 diabetes during their stay.
Of these, 106 (64.2%) met the Kidney Disease/Improving Global Outcomes serum creatinine criteria for AKI, of which 34.9% was stage 1, 45.3% stage 2, and 19.8% stage 3. In 99.1% of cases, AKI occurred within 24 hours of hospitalization, and it resolved with conservative fluid management by 72 hours in just over half (50.9%) of the patients.
Forty patients were admitted to pediatric intensive care overall, and 85.0% of these developed AKI, compared with 57.6% of the 125 treated on a general pediatric ward. Two children required hemodialysis but none died.
Panagiotopoulos and team suggest that the high rate of AKI among the children admitted to intensive care “is associated with the severe intravascular depletion inherent in more severe cases of DKA.”
They add: “This theory is supported by our study findings that clinical markers of volume depletion, specifically, elevated heart rate and corrected sodium level at presentation to the hospital, were both associated with more severe AKI.”
Indeed, each 5 beats/minute increase in initial heart rate was associated with a 22% increased likelihood of severe AKI, whereas an initial corrected sodium level of 145 mEq/L or greater was associated with a 3.29-fold increased likelihood of mild (stage 1) AKI compared with a level of 135–144 mEq/L.
In addition, patients with more severe acidosis at baseline, indicated by a serum bicarbonate level below 10 mEq/L, were 5.22 times more likely to develop severe (stage 2 or 3) AKI than those with less severe acidosis.
Panagiotopoulos et al conclude: “Prospective longitudinal studies are urgently needed to better understand both the risk factors for and long-term implications of AKI in this population, especially because these children are already at risk for chronic kidney disease secondary to diabetic nephropathy over the long term.”
In an accompanying editorial, Benjamin Laskin (The Children’s Hospital of Philadelphia, Pennsylvania, USA) and Jens Goebel (Children’s Hospital Colorado, Aurora, USA) “commend the authors for exploring AKI in a novel pediatric population.”
They say the findings help to pinpoint patients in whom kidney function “should be more diligently examined”, as well as “providing insights on relevant fluid strategies, and increasing awareness for a group of patients who may benefit from closer long-term nephrology follow-up.”
By Laura Cowen
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