661 - Racial and ethnic differences in acute kidney injury among children and adolescents with diabetic ketoacidosis

Publication Number: 4647.661

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

Background: Acute kidney injury (AKI) is increasingly recognized as a complication in children with diabetic ketoacidosis (DKA). However, studies examining the association between race and ethnicity, and DKA-related AKI are limited.

Objective: To determine whether race and ethnicity are associated with DKA-related AKI and health outcomes.

Design/Methods: We performed a multicenter, retrospective, cross-sectional study of children aged 2-18 years presenting to 9 participating emergency departments with DKA between January 1, 2020 and December 31, 2023. We excluded encounters with nonketotic hyperglycemic-hyperosmolar state and transfers from an outside facility. Our primary outcome was the presence of AKI, defined by Kidney Disease Improving Global Outcomes creatinine criteria. The predictor was race and ethnicity, as recorded in the patient chart. Logistic regression was used to estimate the association between race and ethnicity and AKI, using robust cluster standard errors. The model included a random intercept for hospital, and adjusted for age, sex, diabetes type, technology use, and DKA severity. We further estimated the predicted probability of AKI by race and ethnicity using marginal analysis.

Results: A total of 3487 encounters were included, of which 1372 (39.3%) identified as non-Hispanic (NH)-White, 1124 (32.2%) as NH-Black, and 619 (17.8%) as Hispanic/Latine (Table 1). AKI occurred in 1168 (33.5%) encounters and was more common in NH-Black (48.4%) children compared to NH-White (24.1%) or Hispanic/Latine (25.4%) children. In univariable analysis, children with AKI were more likely to be of NH-Black race and ethnicity, have known T1D, and more severe DKA compared to children without AKI (all p< 0.0001) (Table 2). In multivariable analysis, NH race and ethnicity were independently associated with AKI (aOR 2.50, 95% CI 1.92, 3.24) (Figure 1). Male sex (aOR 1.78, 95% CI 1.43, 2.21), insulin pump use (aOR 1.50, 95% CI 1.14, 1.98), and severe DKA (aOR 3.20, 95% CI 2.56, 3.99) were also associated with AKI; new-onset diabetes was protective (aOR 0.67, 95% CI 0.51, 0.88). The predicted probability of AKI was 42% (95% CI 39%, 46%) for NH-Black children, compared to 27% (95% CI 24%, 30%) for NH-White and 26% (95% CI 23%, 30%) for Hispanic/Latine children.

Conclusion(s): NH-Black children are at higher risk for DKA-related AKI compared to other racial and ethnic groups. The higher risk of AKI in NH-Black children is likely multifactorial, and further research should explore contributing factors, including diabetes control and social vulnerability.

Demographics, clinical characteristics, treatments, and outcomes for DKA encounters by race and ethnicity.


Demographics, clinical characteristics, and outcomes for DKA encounters by AKI status.


Forest plot showing the adjusted odds of DKA-related AKI by select demographic and clinical characteristics.
The logistic regression model used robust cluster standard errors to account for patients with multiple DKA encounters and included a main effect for hospital.