Children with Diabetic Ketoacidosis Treated with Restricted Fluid Regime in Intensive Care: Risk of Acute Kidney Injury is not Increased and Resolves
Main Article Content
http://orcid.org/0000-0002-5897-9173
Ella Davidson
Benedict Griffiths, MBBS Bsc (hons)
Jon Lillie, MBBS Bsc
http://orcid.org/0000-0003-1776-5184
Abstract
Background: Children admitted to intensive care with diabetic ketoacidosis are at risk of acute kidney injury. Recent UK guidelines recommends against restricted fluid provision due to a theoretical risk of kidney injury. To date no data has been published that documents this risk in an intensive care cohort.
Aims: To describe the natural history of acute kidney injury in patients admitted with diabetic ketoacidosis in whom a restrictive fluid regime was provided.
Methods: Retrospective analysis, within a UK Pediatric Intensive Care Unit. Between January 2011 and December 2020 219 patients were referred to the South Thames Retrieval Service with Diabetic Ketoacidosis, of whom 52 were admitted to Evelina PIC. 49 of these records were complete and used for analysis of acute kidney injury stage using Kidney Disease: Improving Global Outcomes criteria measured by serial creatinine. Clinical outcome at discharge from Pediatric Intensive Care was also recorded.
Results: 19 out of 49 (38%) patients had acute kidney injury (17 present on admission to pediatric intensive care). Three patients required renal replacement therapy though all of them went on to re-establish their baseline renal function. This compares favourably to published data documenting an acute kidney injury incidence of 43-64% in general paediatric and pediatric intensive care cohorts.
Conclusion: In the context of diabetic ketoacidosis, use of a restrictive fluid regime was not associated with higher levels of acute kidney injury than other studies and renal function recovery was observed in all patients followed up.
Article Details
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
2 British Society of Paediatrics and Endocrinology, Interim Guideline for the Management of Children and Young People under the age of 18 years with Diabetic Ketoacidosis. Available: https://www.bsped.org.uk/media/1798/bsped-dka-guideline-2020.pdf
3 National Institute for Health and Care Excellence. Diabetes (type 1 and type 2) in children and young people: diagnosis and management [NG18]. Published 01 August 2015. Available: https://www.nice.org.uk/Guidance/NG18
4 Lillie, J et al. Management of fluids in paediatric diabetic ketoacidosis: concerns over new guidance. Arch Dis Child 2020 Oct;105(10):1019-1020
5 Kuppermann N, Ghetti S, Schunk JE, et al; PECARN DKA FLUID Study Group. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. N Engl J Med. 2018 Jun 14;378(24):2275-2287. Doi: 10.1056/NEJMoa1716816. PMID: 29897851; PMCID: PMC6051773.
6 Wright N, Thomas R. Response to: Management of fluids in paediatric diabetic ketoacidosis: concerns over new guidance. Arch Dis Child 2020;105:1020–1021.
7 Alkandari, O et al. Acute kidney injury is an independent risk factor for pediatric intensive care unit mortality, longer length of stay and prolonged mechanical ventilation in critically ill children: a two-center retrospective cohort study Crit Care. 2011 Jun 10;15(3):R146. doi: 10.1186/cc10269.
8 Wolfsdorf JI, et al. International Society for Pediatric and Adolescent Diabetes Guidelines 2018, Chapter 11. Published 2018. Accessed 3rd April 2021. http://ispad.org/page/Guidelines2018Chap11
9 Royal College of Physicians of Ireland. National Clinical Guideline for Management of Paediatric Diabetic Ketoacidosis. Published Mar 2019. Accessed 3rd April 2021. Available: https://www.hse.ie/eng/about/who/cspd/ncps/paediatrics-neonatology/resources/management-of-paediatric-diabetic-ketoacidosis1.pdf
10 Hursh BE, Ronsley R, Islam N, et al. Acute Kidney Injury in Children With Type 1 Diabetes Hospitalized for Diabetic Ketoacidosis. JAMA Pediatr. 2017 May 1;171(5):e170020. doi: 10.1001/jamapediatrics.2017.0020. Epub 2017 May 1. PMID: 28288246.
11 Myers SR, Glaser NS, Trainor JL, 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
12 Evelina London South Thames Retrieval Service Guidance. Published Jan 2018. Accessed May 15th 2021. https://www.evelinalondon.nhs.uk/resources/our-services/hospital/south-thames-retrieval-service/diabetic-ketoacidosis-jan-2018.pdf
13 Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics. 2017 Sep;140(3):e20171904. doi: 10.1542/peds.2017-1904. Epub 2017 Aug 21. Erratum in: Pediatrics. 2017 Nov 30;: Erratum in: Pediatrics. 2018 Sep;142(3): PMID: 28827377.
14 Khwaja A. KDIGO clinical practice guidelines for acute kidney injury. Nephron Clin Pract. 2012;120(4):c179-84. doi: 10.1159/000339789. Epub 2012 Aug 7. PMID: 22890468.
15 Paediatric Intensive Care Audit Network. PICANet 2021 Report Supplementary Special Chapters. Published Jan 22. Accessed 3rd April: https://www.picanet.org.uk/wp-content/uploads/sites/25/2022/01/PICANet-2021-Supplementary-Special-Chapters_v1.0-13Jan2022.pdf
16 Marlow RD, Lo D, Walton LJ. Accurate paedatric weight estimation by age: mission impossible? Arch Dis Child. 2011 Apr;96(1):A1-A2.
17 Keukalaere M, Fieuws S, et al. Evolution of body mass index in children with type 1 diabetes mellitus. Eur J Pediatr. 2018 Jul;177:1661-1666 doi: 10.1007/s00431-018-3224-9