Journal List > J Korean Diabetes > v.18(3) > 1055068

Choi, Kim, Hwang, and Lee: Clinical and Laboratory Characteristics of Pediatric Diabetic Ketoacidosis: A Single-Center Study

Abstract

Background

Diabetic ketoacidosis (DKA) is an acute complication of pediatric type 1 diabetes mellitus (T1DM). We aimed to determine the risk factors and clinical characteristics of children and adolescents with DKA.

Methods

We retrospectively evaluated 59 episodes of DKA in 43 patients who were hospitalized for DKA between January 2006 and December 2015. DKA was classified as mild, moderate, or severe, according to patient history of DKA. The clinical and laboratory characteristics of these subgroups were compared.

Results

The average patient age was 11.98 ± 4.40 years (range, 1.3∼17.9 years). Moderate episodes were the most common, with 21 episodes (35.6%), followed by 19 severe (32.2%) and 19 mild episodes (32.2%). Significant differences were observed between the subgroups regarding their characteristics of aggravated. Severe DKA episodes were more often observed during the winter season. Recurrent DKA cases were determined in 31 episodes (52.5%) who were significantly older, had higher body mass index, and lower serum C-peptide levels than the newly diagnosed DKA group. Female patients experienced severe and moderate cases more frequently (P = 0.041), which included two deaths. Only blood glucose levels were significantly higher in these fatal cases (P = 0.022).

Conclusion

Even among the patients who had previously experienced DKA and older children with low serum C-peptide levels, there was no reduction in the severity of DKA. We recommend that patients with DKA be carefully treated and continuously informed regarding the importance of maintaining proper blood glucose levels, regardless of their previous history of DKA, age, or regularity of insulin therapy.

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Fig. 1.
Seasonal distribution of diabetic ketoacidosis severity (A) and prior diabetic ketoacidosis history (B) on the day of admission. Months are numbered from 1∼12 for January∼December, respectively. DKA, diabetic ketoacidosis.
jkd-18-193f1.tif
Table 1.
Comparison of the clinical and laboratory characteristics of patients with diabetic ketoacidosis
Characteristic Total (n = 59, 100.0%) Mild DKA (n = 19, 32.2%) Moderate DKA (n = 21, 35.6%) Severe DKA (n = 19, 32.2%) P-value
Age (y) 11.98 ± 4.40 11.19 ± 5.09 11.85 ± 4.60 12.91 ± 3.36 0.484
  (1.3∼17.9) (1.3∼17.9) (2.8∼17.1) (6.7∼17.9)  
Sex 0.041*
Male 20 10 6 4  
Female 39 (66.1) 9 (47.4) 15 (71.4) 15 (78.9)  
BMI (kg/m2) 17.37 ± 3.66 17.51 ± 4.66 17.12 ± 3.02 17.50 ± 3.34 0.929
In-hospital mortality 2 (3.4) 0 (0.0) 1 (4.8) 1 (5.3) 0.374
Newly diagnosed DKA cases 28 (47.5) 8 (42.1) 11 (52.4) 9 (47.4) 0.747
Recurrent episodes 31 (52.5) 11 (57.9) 10 (47.6) 10 (52.6)  
Duration of T1DM in 3.83 ± 3.15 4.08 ± 3.20 4.00 ± 3.49 3.38 ± 3.17 0.924
recurrent episodes (y) (0.5∼9.5) (1.5∼9.4) (0.6∼9.5) (0.5∼8.9)  
Arterial pH 7.13 ± 0.12 7.26 ± 0.04a 7.15 ± 0.03b 6.99 ± 0.08c 0.000**
Plasma glucose level (mg/dL) 563.74 ± 147.01 492.00 ± 149.84a 593.80 ± 141.02a,b 603.84 ± 130.16b 0.031*
Fasting serum C-peptide (ng/mL) 0.36 ± 0.40 0.38 ± 0.53 0.37 ± 0.36 0.31 ± 0.30 0.858
GADA level (normal range ≤ 0.9 U/mL) 26.93 ± 38.41 23.47 ± 29.98 24.92 ± 30.14 32.77 ± 54.51 0.836
GADA positivity 45 (76.3) 12 (63.2) 18 (85.7) 15 (78.9) 0.233
HbA1c (%) 12.88 ± 2.38 12.17 ± 2.78 12.79 ± 1.87 13.68 ± 2.33 0.144
Serum creatinine (mg/dL) 0.98 ± 0.34 0.91 ± 0.25 1.01 ± 0.26 1.03 ± 0.48 0.511
Anion gap 28.86 ± 9.54 25.23 ± 10.42 30.28 ± 7.41 30.91 ± 10.53 0.203
Corrected serum Na level (mg/dL) 141.84 ± 5.90 141.11 ± 4.50a,b 139.20 ± 5.10b 145.55 ± 6.40a 0.002**
Effective serum osmolality (mOsm/kg) 300.17 ± 12.78 297.02 ± 10.77a,b 295.59 ± 10.56a 308.58 ± 13.43b 0.002**

Values were obtained at the time of diagnosis and are presented as mean ± SD (range), number only, number (%), or mean ± SD only. DKA, diabetic ketoacidosis; BMI, body mass index; T1DM, type 1 diabetes mellitus; GADA, anti-glutamic acid decarboxylase antibody; HbA1c, glycated hemoglobin; SD, standard deviation. The superscript letters indicate significant differences between groups identified by Tukey's multiple comparison test.

* P < 0.05,

** P < 0.01.

Table 2.
Characteristics of the diabetic ketoacidosis patients according to status of recurrence
Characteristic Newly diagnosed DKA Recurrent DKA P-value
Number of episodes 28 31  
Recurrence of DKA (number of episodes/patients)   5/2, 4/1, 2/5, 1/7  
Patients (male/female) 28 (11/17) 15 (5/10) 0.752
Duration of T1DM (y)   3.83 ± 0.72 (0.5∼9.5)  
Age (y) 10.39 ± 4.60 (1.3∼17.8) 13.56 ± 3.59 (6.2∼17.9) 0.004**
BMI (kg/m2) 16.39 ± 3.49 (12.00∼24.42) 18.45 ± 3.65 (12.70∼27.23) 0.030*
Plasma glucose (mg/dL) 587.72 ± 110.22 535.93 ± 173.46 0.178
HbA1c (%) 12.69 ± 2.48 13.08 ± 2.27 0.530
Arterial pH 7.14 ± 0.12 7.12 ± 0.13 0.616
Fasting serum C-peptide (ng/mL) 0.55 ± 0.45 0.18 ± 0.28 0.001

Values are presented as number only, mean ± SD (range), or mean ± SD only. DKA, diabetic ketoacidosis; T1DM, type 1 diabetes mellitus; BMI, body mass index; HbA1c, glycated hemoglobin; SD, standard deviation. Statistical significance was determined using the independent t-test.

* P < 0.05,

** P < 0.01.

Table 3.
Characteristics of the patients with fatal diabetic ketoacidosis
Characteristic Patient no. 1 Patient no. 2
Sex Female Female
Age (y) 13.4 11.2
BMI (kg/m2) 25.3 12.0
Duration of symptoms (d) 2 7
Month of DKA occurrence November October
Associated disease/symptom (–)/Flu-like symptom(+) (–)/Flu-like symptom(+)
Duration of T1DM (y) 4.7 0
Prior history of DKA No No
Arterial pH 6.80 7.13
Anion gap 16.5 13.5
Plasma glucose (mg/dL) 991 595
HbA1c (%) 15.5 13.5
GADA No Yes
Fasting serum    
C-peptide (ng/mL) 0.01 0.2
Amylase/lipase (IU/L) 20/16 86/53
Brain CT findings Severe hydrocephalus, cerebral edema(+) Cerebral edema(+)
Respected cause Irregular insulin injection

BMI, body mass index; DKA, diabetic ketoacidosis; T1DM, type 1 diabetes mellitus; HbA1c, glycated hemoglobin; GADA, anti-glutamic acid decarboxylase antibodies; CT, computed tomography.

Table 4.
Characteristics of the diabetic ketoacidosis patients according to survival status
Characteristic Surviving Deceased P-value
Number of episodes/patients 57/41 2/2  
Age (y) 12.02 ± 4.45 12.30 ± 1.56 0.930
BMI (kg/m2) 17.42 ± 3.54 18.65 ± 9.40 0.883
Plasma glucose (mg/dL) 553.26 ± 137.76 793.00 ± 280.01 0.022*
HbA1c (%) 12.84 ± 2.38 14.50 ± 1.41 0.332
Serum creatinine (mg/dL) 0.96 ± 0.34 1.39 ± 0.29 0.089
HCO3 (mmol/L) 7.65 ± 5.09 6.00 ± 4.53 0.653
Anion gap 29.47 ± 9.28 15.00 ± 2.12 0.034*
Arterial pH 7.14 ± 0.12 6.97 ± 0.23 0.050
AST (IU/L) 24.11 ± 12.51 19.00 ± 1.41 0.569
ALT (IU/L) 21.44 ± 11.29 18.00 ± 4.24 0.671
Amylase (IU/L) 84.60 ± 148.62 53.00 ± 46.67 0.768
Lipase (IU/L) 59.49 ± 120.50 34.50 ± 26.16 0.774
Fasting serum C-peptide (ng/mL) 0.38 ± 0.42 0.11 ± 0.13 0.358
GADA (U/mL) 25.95 ± 38.55 30.19 ± 42.44 0.881

Values are presented as number only or the mean ± standard deviation. BMI, body mass index; HbA1c, glycated hemoglobin; HCO3 aminotransferase; GADA, anti-glutamic acid decarboxylase antibodies. Statistical significance was determined using the Mann-Whitney U-test.

* P < 0.05.

, bicarbonate; AST, aspartate aminotransferase; ALT, alanine

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