Indian Journal of Critical Care Medicine

Register      Login

SEARCH WITHIN CONTENT

FIND ARTICLE

Volume / Issue

Online First

Archive
Related articles

VOLUME 25 , ISSUE 12 ( December, 2021 ) > List of Articles

Pediatric Critical Care

Risk Factors for Cerebral Edema and Acute Kidney Injury in Children with Diabetic Ketoacidosis

Veena Raghunathan, Ganesh Jevalikar, Maninder Dhaliwal, Dhirendra Singh, Sidharth K Sethi, Parjeet Kaur, Sunit C Singhi

Keywords : Acute kidney injury (AKI), Cerebral edema (CE), Diabetic ketoacidosis (DKA), Pediatric

Citation Information : Raghunathan V, Jevalikar G, Dhaliwal M, Singh D, Sethi SK, Kaur P, Singhi SC. Risk Factors for Cerebral Edema and Acute Kidney Injury in Children with Diabetic Ketoacidosis. Indian J Crit Care Med 2021; 25 (12):1446-1451.

DOI: 10.5005/jp-journals-10071-24038

License: CC BY-NC 4.0

Published Online: 17-12-2021

Copyright Statement:  Copyright © 2021; The Author(s).


Abstract

Objectives: To study the clinical profile and risk factors of cerebral edema and acute kidney injury in children with diabetic ketoacidosis. Design: Retrospective review of medical records. Patients: Fifty consecutive patients (age <18 years) admitted to our pediatric intensive care unit with a diagnosis of diabetic ketoacidosis over 5 years. Materials and methods: Retrospective analysis of medical records was done, and data including patients’ age, sex, presenting features, biochemical profile including blood glucose, osmolality, urea, creatinine, and venous blood gas, electrolytes were recorded at admission, at 12 and 24 hours. Treatment details including fluid administration, rate of fall of glucose, time to resolution of diabetic ketoacidosis were noted. Complications such as cerebral edema and acute kidney injury were recorded. Patients with and without cerebral edema and acute kidney injury were compared. Variables that were significant on univariate analysis were entered in a multiple logistic regression analysis to determine the independent predictors for cerebral edema and acute kidney injury. Odds ratio and 95% confidence interval were calculated using SPSS version 22. Measurements and main results: Between November 2015 and 2020, 48 patients were admitted for a total of 50 episodes of diabetic ketoacidosis. Two patients had recurrent diabetic ketoacidosis. Median age was 9.5 years (range 1–17). Thirty-one patients (62%) had new-onset type I diabetes mellitus. Twenty-two patients (44%) presented with severe diabetic ketoacidosis. Cerebral edema and acute kidney injury were seen in 11 (22%) and 15 (30%) patients, respectively. On multiple logistic regression analysis, higher blood urea level, lower serum bicarbonate level, and higher corrected sodium levels at admission were identified to be variables independently associated with risk of cerebral edema. Conclusions: Higher corrected sodium, higher urea level, and lower serum bicarbonate levels at admission are predictive of cerebral edema in patients presenting with diabetic ketoacidosis. The severity of dehydration and acidosis in DKA appears to be a common factor responsible for the development of dysfunction of both brain and kidney.


HTML PDF Share
  1. Olivieri L, Chasm R. Diabetic ketoacidosis in the pediatric emergency department. Emerg Med Clin North Am 2013;31(3):755–773. DOI: 10.1016/j.emc.2013.05.004. PMID: 23915602.
  2. Shastry RM, Bhatia V. Cerebral edema in diabetic ketoacidosis. Indian Pediatr 2006;43(8):701–708. PMID: 16951433.
  3. White PC, Dickson BA. Low morbidity and mortality in children with diabetic ketoacidosis treated with isotonic fluids. J Pediatr 2013;163(3):761–766. DOI: 10.1016/j.jpeds.2013.02.005.
  4. Cameron FJ, Scratch SE, Nadebaum C, Northam EA, Koves I, Jennings J, et al. DKA Brain Injury Study Group. Neurological consequences of diabetic ketoacidosis at initial presentation of type 1 diabetes in a prospective cohort study of children. Diabetes Care 2014;37(6): 1554–1562. DOI: 10.2337/dc13-1904.
  5. Chen J, Zeng H, Ouyang X, Zhu M, Huang Q, Yu W, et al. The incidence, risk factors, and long-term outcomes of acute kidney injury in hospitalized diabetic ketoacidosis patients. BMC Nephrol 2020;12;21(1):48. DOI: 10.1186/s12882-020-1709-z. PMID: 32050921; PMCID: PMC7017527.
  6. Myers SR, Glaser NS, Trainor JL, Nigrovic LE, Garro A, Tzimenatos L, et al. Frequency and risk factors of acute kidney injury during diabetic ketoacidosis in children and association with neurocognitive outcomes. JAMA Netw Open 2020;3(12):e2025481. DOI: 10.1001/jamanetworkopen.2020.25481.
  7. Wolfsdorf JI, Glaser N, Agus M, Fritsch M, Hanas R, Rewers A, et al. ISPAD clinical practise consensus guidelines 2018: Diabetic ketoacidosis and the hyperglycaemic hyperosmolar state. Pediatr Diabetes 2018;19(27):155–177. DOI: 10.1111/pedi.12701.
  8. Muir AB, Quisling RG, Yang MC, Rosenbloom AL. Cerebral edema in childhood diabetic ketoacidosis: natural history, radiographic findings, and early identification. Diabetes Care 2004;27(7):1541–1546. DOI: 10.2337/diacare.27.7.1541. PMID: 15220225.
  9. Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. Kidney Disease: Improving Global Outcomes (KDIGO). Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl 2012;2:1–138. DOI: 10.1038/kisup.2012.6.
  10. Usher-Smith JA, Thompson M, Ercole A, Walter FM. Variation between countries in the frequency of diabetic ketoacidosis at first presentation of type 1 diabetes in children: a systematic review. Diabetologia 2012;55(11):2878–2894. DOI: 10.1007/s00125-012-2690-2. PMID: 22933123; PMCID: PMC3464389.
  11. Newton CA, Raskin P. Diabetic ketoacidosis in type 1 and type 2 diabetes mellitus: clinical and biochemical differences. Arch Intern Med 2004;164(17):1925–1931. DOI: 10.1001/archinte.164.17.1925.
  12. Matz R. Hypothermia in diabetic acidosis. Hormones 1972;3(1):36–41. DOI: 10.1159/000178256.
  13. Moradi S, Kerman SR, Rohani F, Salari F. Association between diabetes complications and leukocyte counts in Iranian patients. J Inflamm Res 2012;5:7–11. DOI: 10.2147/JIR.S26917. PMID: 22334791; PMCID: PMC3278259.
  14. Karavanaki K, Kakleas K, Georga S, Bartzeliotou A, Mavropoulos G, Tsouvalas M, et al. Plasma high sensitivity C-reactive protein and its relationship with cytokine levels in children with newly diagnosed type 1 diabetes and ketoacidosis. Clin Biochem 2012;45(16–17):1383–1388. DOI: 10.1016/j.clinbiochem.2012.05.003. PMID: 22584003.
  15. Karavanaki K, Karanika E, Georga S, et al. Cytokine response to diabetic ketoacidosis (DKA) in children with type 1 diabetes (T1DM). Endocr J 2011;58(12):1045–1053. DOI: 10.1507/endocrj.ej11-0024.
  16. Jahagirdar RR, Khadilkar VV, Khadilkar AV, Lalwani SK. Management of diabetic ketoacidosis in PICU. Indian J Pediatr 2007;74(6):551–554. DOI: 10.1007/s12098-007-0106-y. PMID: 17595497.
  17. Tiwari LK, Jayashree M, Singhi S. Risk factors for cerebral edema in diabetic ketoacidosis in a developing country: role of fluid refractory shock. Pediatr Crit Care Med 2012;13(2):e91–e96. DOI: 10.1097/PCC.0b013e3182196c6d.
  18. Varadarajan P, Suresh S. Role of infections in children with diabetic ketoacidosis–a study from South India. Int J Diabetes Clin Res 2014;1:009. DOI: 10.23937/2377-3634/1410009.
  19. Yadav D, Nair S, Norkus EP, Pitchumoni CS. Nonspecific hyperamylasemia and hyperlipasemia in diabetic ketoacidosis: incidence and correlation with biochemical abnormalities. Am J Gastroenterol 2000;95(11):3123–3128. DOI: 10.1111/j.1572-0241.2000.03279.x. PMID: 11095328.
  20. Glaser N, Barnett P, McCaslin I, Nelson D, Trainor J, Louie J, et al. Risk factors for cerebral edema in children with diabetic ketoacidosis. N Engl J Med 2001;344(4):264–269. DOI: 10.1056/NEJM200101253440404.
  21. Agarwal N, Dave C, Patel R, Shukla R, Kapoor R, Bajpai A. Factors associated with cerebral edema at admission in Indian children with diabetic ketoacidosis. Indian Pediatr 2020;57(4):310–313. PMID: 32038036.
  22. Lawrence SE, Cummings EA, Gaboury I, Daneman D. Population-based study of incidence and risk factors for cerebral edema in pediatric diabetic ketoacidosis. J Pediatr 2005;146(5):688–692. DOI: 10.1016/j.jpeds.2004.12.041.
  23. Kuppermann N, Ghetti S, Schunk JE, Stoner M, Rewers A, McManemy JK, et al. PECARN DKA FLUID Study Group. Clinical trial of fluid infusion rates for pediatric diabetic ketoacidosis. N Engl J Med 2018;378(24):2275–2287. DOI: 10.1056/NEJMoa1716816.
  24. Hursh BE, Ronsley R, Islam N, Mammen C, Panagiotopoulos C. Acute kidney injury in children with type 1 diabetes hospitalized for diabetic ketoacidosis. JAMA Pediatr 2017;171(5):e170020. DOI: 10.1001/jamapediatrics.2017.0020.
  25. Weissbach A, Zur N, Kaplan E, Kadmon G, Gendler Y, Nahum E. Acute kidney injury in critically ill children admitted to the PICU for diabetic ketoacidosis. a retrospective study. Pediatr Crit Care Med 2019;20(1):e10–e14. DOI: 10.1097/PCC.0000000000001758.
  26. Baalaaji M, Jayashree M, Nallasamy K, Singhi S, Bansal A. Predictors and outcome of acute kidney injury in children with diabetic ketoacidosis. Indian Pediatr 2018;55(4):311–314. PMID: 29428918.
  27. Williams V, Jayashree M, Nallasamy K, et al. 0.9% saline versus Plasma-Lyte as initial fluid in children with diabetic ketoacidosis (SPinK trial): a double-blind randomized controlled trial. Crit Care 2020;24(1):1. DOI: 10.1186/s13054-019-2683-3. PMID: 31898531; PMCID: PMC6939333.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.