Abstract：
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.
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.
摘要：
背景：急性肾损伤（AKI）是公认的小儿糖尿病酮症酸中毒（DKA）的合并症，虽然确切的病因尚不清楚。DKA的独特生理学使脱水评估具有挑战性，这些患者可能会接受过量的静脉输液（IVF）。我们假设小儿DKA的脱水估计过高，导致IVF的过度管理和高氯血症恶化AKI。
方法：回顾性队列研究了2014年至2019年在某三级儿科医院住院的所有DKA患者。共有145名儿童被包括在内；排除的原因是先前存在的肾脏疾病或医疗记录不完整。AKI通过入院时肌酐的变化来确定，并与计算的基线值进行比较。线性回归多变量分析用于确定与AKI相关的因素。真正的脱水是根据患者的体重变化计算的，如先前验证的。液体过度复苏定义为高于真实脱水的总液体。
结果：共有19%的患者在入院时符合KDIGO血清肌酐AKI标准。只有2%的人在出院时出现AKI。真正的脱水和高血清尿素水平与入院时的高血清肌酐水平相关（p=0.042；p<0.001，分别）。液体过度复苏和高氯血症与肾脏延迟恢复有关（p<0.001）。初始AKI的严重程度与脑水肿相关(p=0.018)。
结论：脱水与DKA患儿的初始AKI相关。持续AKI和恢复延迟与高氯血症和IVF过度复苏有关，早期AKI恢复和长期发病率降低的潜在可修改的临床变量。这突出了在儿科DKA中重新处理流体方案的需要。更高分辨率版本的图形摘要可作为补充信息。
方法：回顾性队列研究了2014年至2019年在某三级儿科医院住院的所有DKA患者。共有145名儿童被包括在内；排除的原因是先前存在的肾脏疾病或医疗记录不完整。AKI通过入院时肌酐的变化来确定，并与计算的基线值进行比较。线性回归多变量分析用于确定与AKI相关的因素。真正的脱水是根据患者的体重变化计算的，如先前验证的。液体过度复苏定义为高于真实脱水的总液体。
结果：共有19%的患者在入院时符合KDIGO血清肌酐AKI标准。只有2%的人在出院时出现AKI。真正的脱水和高血清尿素水平与入院时的高血清肌酐水平相关（p=0.042；p<0.001，分别）。液体过度复苏和高氯血症与肾脏延迟恢复有关（p<0.001）。初始AKI的严重程度与脑水肿相关(p=0.018)。
结论：脱水与DKA患儿的初始AKI相关。持续AKI和恢复延迟与高氯血症和IVF过度复苏有关，早期AKI恢复和长期发病率降低的潜在可修改的临床变量。这突出了在儿科DKA中重新处理流体方案的需要。更高分辨率版本的图形摘要可作为补充信息。
