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    HEMANT JC

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    Dharmendra Chaurasiya

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    HEMANT JC

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    HEMANT JC

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    Acute Kidney Injury in

    Pediatric Diabetic
    Kim1 Ketoacidosis
    Eun Mi Yang1 & Hyun Gyung Lee1 & Ka Young Oh2 & Chan Jong

    SPEAKER
    Dr. Hemant Yadav
    Introduction
     Type 1 diabetes mellitus is a common, chronic, metabolic disorder that

    has significant consequences for physical and emotional development .


     The incidence of TIDM is steadily increasing in nearly all parts of the

    world by about 2–5% per year .


     Diabetic ketoacidosis (DKA) is the most serious complication of TIDM

    and results from metabolic abnormalities due to a severe deficiency of


    insulin or insulin effectiveness.
     DKA occurs in 20–40% of children with new-onset diabetes and in

    children with known diabetes who omit insulin doses or who do not
    successfully manage during intercurrent illness
    INTRODUCTION
    • DKA is associated with numerous acid-base, hydration and
    electrolyte derangements , accompanied by both volume depletion
    and subsequent massive fluid-rehydration treatment upon
    presentation .

    • AKI was defined according to the Kidney Disease/Improving


    Global Outcomes guidelines: stage 1 AKI was defined as a
    creatinine level 1.5 to <2 times the expected baseline creatinine ,
    stage 2 AKI defined as the creatinine level 2 to <3 times the EBC,
    stage 3 AKI defined as the creatinine value >3 times the EBC.
    Research Hypothesis
    P( Population ) : children with age < 18 years
    I( Intervention ) :
    C(Comparision):
    O(Outcome): Incidence of AKI in DKA and
    Type 1 DM
    T( Type of study): Retrospective study
    RESEARCH QUESTIONS
    What is the incidence of AKI in DKA and Type
    1 DM patient (age < 18 years)
    Primary Objectives
    To assess the incidence and clinical
    characteristics of acute kidney injury in
    children with type 1 diabetes mellitus and
    diabetic ketoacidosis .
    Secondary Objectives
    To identify the associated risk factors for AKI
    in children with type 1 diabetes mellitus and
    diabetic ketoacidosis .
    Methodology

    STUDY DESIGN
     Type of study: Retrospective study

     Place of study: Department of Pediatrics, Chonnam National

    University Hospital and Medical School, Gwangju, South


    Korea
     Period of study : 15 years in a single Korean center

     Ethical approval : Institutional review board of authors ‘ hospital and

    followed all of the relevant Declaration of Helsinki specifications.


     Data collection : From single center in Korea from Jan 2004 to Dec 2018
    Methodolody
    Inclusion criteria : Children aged < 18-y-old
    and had a diagnosis of DKA (Hyperglycemia,
    blood glucose ≥200 mg/dl, venous pH ≤ 7.3,
    or bicarbonate (HCO3) level ≤ 15 mEq/L, and
    elevation of serum or urine ketones).

    Exclusion criteria : Children with type 2


    diabetes and children whose treatment had
    been initiated before admission were
    excluded.
    Statistical Analysis
     Categorical data were summarized as counts and percentages .
     Continuous data were summarized as median values with interquartile
    ranges.
     Continuous data were analyzed using the Student’s t test or the Mann–
    Whitney U-test, as appropriate, and categorical data were analyzed using
    the chi-square test.
     To identify the predictors of AKI on admission, logistic regression was
    used to identify the risk factors for AKI in DKA with TIDM.
     In the primary analysis, univariate analysis was used to identify the
    association between severe AKI and the following factors: duration of
    TIDM, previously diagnosed TIDM, leukocytosis [white blood cell (WBC) >
    25,000/mm3 ], platelet count, serum Na, and AG. The authors included all
    significant variables in a multivariate model. The results were evaluated
    with 95% confidence intervals .
     A P value of <0.05 was considered statistically significant.
     All statistical analyses were performed using with SPSS software version
    21.0
    RESULT
     The authors studied 90 episodes of DKA in 55 children; 13
    children were responsible for 48 episodes (6 children had 2
    episodes, 3 children had 3 episodes, 2 children had 4 episodes, 1
    patient had 6 episodes and 1 patient had 13 episodes.
    Results
     This shows the process of participant inclusion/exclusion
    and AKI severity classification.
    Results
     AKI occurred in a total of 70 hospitalizations of 44 children.
    According to the KDIGO guidelines of AKI, the highest stage of
    AKI was I in 18 (20.0%), II in 39 (43.3%), and III in 13 (14.4%) of
    AKI cases. The number of AKI decreased to 28 (47.4%) and 13
    (28.3%) after 12 h and 24 h of admission, respectively .
    Result
     AKI occurred more frequently in children with a previous
    diagnosis of TIDM than in those with newly diagnosed TIDM
    (OR = 2.857, P = 0.019)
     Duration of disease was longer than those without (4.3 ± 3.3
    y vs. 2.4 ± 3.1 y in the AKI and no-AKI group, respectively; P
    = 0.006).
     The WBC count (P = 0.001) and AG levels (P = 0.025) were
    significantly elevated in the AKI group
     The HCO3 level (P = 0.004) was significantly lower in
    children with AKI.
     The C-reactive protein, glucose, Na, K, Cl, and hemoglobin
    A1c were not different between groups.
     The severity of DKA was not significantly correlated with the
    severity of AKI (P = 0.413)
    Result
    Variables contributed significantly to the
    prediction of severe AKI are duration of
    TIDM, WBC level, platelet, Na, AG.
     The logistic regression analysis identified
    that longer disease duration and high AG
    were independent predictors of developing
    severe AKI in pediatric DKA with TIDM (odds
    ratio, 1.225, P = 0.013; odds ratio, 1.130, P =
    0.038).
    DISCUSSION
     A major concern in pediatric DKA is the high incidence of AKI.

     AKI is associated with poor outcomes in hospitalized children.

     It increases hospital stay, mortality rate, and development of


    chronic kidney disease .
    DISCUSSION
     The cause of AKI in the hyperglycemic crisis is presumed to be a
    pre-renal factor.

     Hyperglycemia leads to osmotic polyuria that causes hypovolumia


    and results in renal hypoperfusion leading to decreased GFR.

     The serum Na level on admission in patients with DKA is usually


    low because of the osmotic flux of water from the intracellular to
    the extracellular space in the presence of hyperglycemia
    DISCUSSION
     Evidence of kidney damage is absent, and if the underlying cause
    of renal hypoperfusion is reversed promptly, the renal function
    returns to normal.

     If the pre-renal insult is severe or prolonged, intrinsic renal


    parenchymal damage can develop.
    LIMITATION
     This was a single-center and retrospective study with a relatively
    small sample size, the results may be vulnerable to confounding
    errors and bias.
     Urine output data were not included to define AKI because the
    database lacked some of these data.
     Baseline serum creatinine data were not collected in some
    patients, resulting in the need to calculate an estimated baseline
    value
     Long-term clinical outcomes of the enrolled patients were not
    investigated.
    CONCLUSION
     This study revealed the frequency and risk factors of AKI in
    children with DKA.

     A high proportion of children with DKA developed AKI, although,


    most cases of AKI were reversible conditions in the present study.

     Patients with longer disease duration of TIDM and high AG are at


    risk for developing AKI and these patients should be monitored
    carefully.
    Take home message
    REFERENCE

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