659 - Factors associated with sustained kidney injury in children and adolescents with diabetic ketoacidosis

Publication Number: 4645.659

Kelly R.. Bergmann, Children's Minnesota, Minneapolis, MN, United States; Amanda J. Nickel, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, United States; Paige Reimche, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, United States; Caitlin Valentino, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; David Guernsey, NYU Langone Health, New York, NY, United States; Emily Hogikyan, Medical College of Wisconsin, Milwaukee, WI, United States; Kersten Bond, Children's Hospital of Michigan, Detroit, MI, United States; Saamia Masoom, Baylor College of Medicine, Houston, TX, United States; Natalie J. Tedford, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States; Adam Isacoff, University of Louisville School of Medicine, Louisville, KY, United States; Deborah R. Liu, Keck USC School of Medicine, Los Angeles, CA, United States; Catherine Coughlin, Boston Children's Hospital, Boston, MA, United States; Jaya CW. Ruffin, University of South Carolina School of Medicine Columbia, Columbia, SC, United States; Michelle Pickett, Medical College of Wisconsin, Milwaukee, WI, United States; Christopher M.. Pruitt, Medical University of South Carolina College of Medicine, Charleston, SC, United States; Andrea T. Cruz, Baylor College of Medicine, Houston, TX, United States; Mohsen Saidinejad, University of California, Los Angeles David Geffen School of Medicine, Torrance, CA, United States; Elizabeth Collins-Dippel, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, United States; M. Jennifer Abuzzahab, Children's Hospitals and Clinics of Minnesota - St. Paul, St Paul, MN, United States; Anupam Kharbanda, Children’s Minnesota, Minneapolis, MN, United States; Petter Bjornstad, University of Washington School of Medicine, Seattle, WA, United States

Background: An estimated 40% of children with diabetic ketoacidosis (DKA) present with acute kidney injury (AKI). Most children present to the emergency department (ED) with AKI already present, yet approximately 5% experience sustained AKI despite treatment. It is currently unclear which children are at risk for developing sustained DKA-related AKI.

Objective: To determine factors contributing to sustained AKI in children with DKA.

Design/Methods: We performed a multicenter, retrospective, cross-sectional study of children aged 2-18 years with DKA presenting to 9 pediatric EDs between January 1, 2020 and December 31, 2023. Children with nonketotic hyperglycemic-hyperosmolar state or those transferred from an outside facility were excluded. The primary outcome was presence of sustained AKI. AKI was defined by Kidney Disease Improving Global Outcomes criteria, using an estimated baseline creatinine (Cr). Sustained AKI was defined as having any of the following: 1) AKI ≥48h after the first Cr value obtained in the ED, 2) unresolved AKI (i.e., using the last Cr measurement in the hospital), or 3) need for dialysis or renal replacement therapy. Logistic regression estimated the association between sustained AKI and demographic, clinical, and treatment factors, with robust cluster standard errors to account for patients with multiple DKA encounters. The adjusted model included a main effect for hospital. Results are presented as adjusted odds ratios (OR) and 95% confidence intervals (CI).

Results: Of 1168 encounters with AKI [median age 13 (IQR 11-15), 52.7% male] (Table 1), 165 (14.1%) exhibited sustained AKI; 137 (83%) had unresolved at discharge and 3 (1.8%) required dialysis. AKI commonly resolved within 24 hours, whereas sustained AKI often persisted up to 120 hours after ED arrival (Figure 1). In multivariable analysis, hospital was a significant predictor of sustained AKI (aOR 8.25, 95% CI 4.94, 13.70), with one hospital discharging children with AKI more often compared to other hospitals (Table 2). Sustained AKI was associated with T2D with DKA (aOR 3.56, 95% CI 1.59, 7.99), mild DKA severity (aOR 1.98, 95% CI 1.21, 3.22), and time to insulin (aOR 1.02, 95% CI 1.00, 1.04). For every 15-minute increase in time to insulin, the odds of sustained AKI.

Conclusion(s): Sustained AKI in pediatric DKA was associated with diabetes type, DKA severity, and time-to-insulin, and with hospital-level variation. Earlier insulin administration may mitigate risk for sustained AKI.

Demographics, clinical characteristics, treatments, and outcomes for children with DKA-related AKI and sustained AKI.


Spaghetti plots for encounters with AKI at any point during the encounter and with sustained AKI.
Plots model the creatinine ratio (observed creatinine divided by expected baseline creatinine) over time and include a locally weighted scatterplot smoothing (LOWESS) smoothing line.

Association between sustained AKI and demographic characteristics, clinical history, and select outcomes.