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The effect of dehydration, hyperchloremia and volume of fluid resuscitation on acute kidney injury in children admitted to hospital with diabetic ketoacidosis

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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.

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Data Availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

AKI:

Acute kidney injury

DKA:

Diabetic ketoacidosis

IVF:

Intravenous fluid

PICU:

Pediatric intensive care unit

KDIGO:

Kidney Disease Improving Global Outcomes

Cr:

Creatinine

GCS:

Glasgow coma scale

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Acknowledgements

We would like to thank Dejana Nikitovic, our PICU research coordinator, for her support and mentorship through the creation of this project. We would also like to thank Dr. Alberto Nettel-Aguirre, biostatistician at Alberta Children’s Hospital for his assistance in formulating our methodology. We thank our colleagues from Alberta Children’s Hospital who provided insight and expertise that greatly assisted this research. This research would not have been possible without the expertise and mentorship of Drs. Simon Parsons and Andrew Wade, who supervised through this project.

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Authors and Affiliations

  1. Department of Pediatrics, Faculty of Medicine, University of Calgary, Calgary, Canada

    Rebecca E. Hay, Simon J. Parsons & Andrew W. Wade

  2. Division of Critical Care, Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children’s Hospital of Eastern Ontario, Ottawa, Canada

    Rebecca E. Hay

  3. Section of Critical Care, Department of Pediatrics, Faculty of Medicine, University of Calgary, Alberta Children’s Hospital, Calgary, Canada

    Simon J. Parsons

  4. Section of Nephrology, Department of Pediatrics, Faculty of Medicine, University of Calgary, Alberta Children’s Hospital, Calgary, Canada

    Andrew W. Wade

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Correspondence to Rebecca E. Hay.

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Hay, R.E., Parsons, S.J. & Wade, A.W. The effect of dehydration, hyperchloremia and volume of fluid resuscitation on acute kidney injury in children admitted to hospital with diabetic ketoacidosis. Pediatr Nephrol 39, 889–896 (2024). https://doi.org/10.1007/s00467-023-06152-0

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