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

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

J Korean Diabetes 2017;18(3):193-204.

Published online: 10 January 2017

DOI: https://doi.org/10.4093/jkd.2017.18.3.193

Clinical and Laboratory Characteristics of Pediatric Diabetic Ketoacidosis: A Single-Center Study

Iee Ho Choi1, Min Sun Kim1, 2, Pyoung Han Hwang1, 2, Dae-Yeol Lee1, 2

1Department of Pediatrics, Chonbuk National University Medical School, Jeonju, Korea

2Research Institute of Clinical Medicine of Chonbuk National University–Biomedical Institute of Chonbuk National University Hospital, Jeonju, Korea

Corresponding author: Min Sun Kim Department of Pediatrics, Chonbuk National University Hospital, 20 Geonji-ro, Deokjin-gu, Jeonju 54907, Korea, E-mail: children@jbnu.ac.kr

Received 20 February 2017       Revised 5 June 2017       Accepted 18 July 2017

Copyright © 2017 Korean Diabetes Association

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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.

Keywords: Child, Diabetic ketoacidosis, Diabetes mellitus, Type 1

References

1. Lee JI, Sohn TS, Chang SA, Lee JM, Cha BY, Son HY, Son HS. Clinical characteristics and outcomes of diabetic ketoacidosis at a single institution. Korean Diabetes J. 2008; 32:165–70.
crossref
2. Rewers A, Klingensmith G, Davis C, Petitti DB, Pihoker C, Rodriguez B, Schwartz ID, Imperatore G, Williams D, Dolan LM, Dabelea D. Presence of diabetic ketoacidosis at diagnosis of diabetes mellitus in youth: the Search for Diabetes in Youth Study. Pediatrics. 2008; 121:e1258–66.
crossref
3. Rosenbloom AL. Hyperglycemic crises and their complications in children. J Pediatr Endocrinol Metab. 2007; 20:5–18.
crossref
4. Kim MK, Lee SH, Kim JH, Lee JI, Kim JH, Jang EH, Yoon KH, Lee KW, Song KH. Clinical characteristics of Korean patients with new-onset diabetes presenting with diabetic ketoacidosis. Diabetes Res Clin Pract. 2009; 85:e8–11.
crossref
5. Solá E, Garzón S, García-Torres S, Cubells P, Morillas C, HernándezMijares A. Management of diabetic ketoacidosis in a teaching hospital. Acta Diabetol. 2006; 43:127–30.
crossref
6. Delaney MF, Zisman A, Kettyle WM. Diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic syndrome. Endocrinol Metab Clin North Am. 2000; 29:683–705. V.
crossref
7. Barski L, Nevzorov R, Rabaev E, Jotkowitz A, Harman-Boehm I, Zektser M, Zeller L, Shleyfer E, Almog Y. Diabetic ketoacidosis: clinical characteristics, precipitating factors and outcomes of care. Isr Med Assoc J. 2012; 14:299–303.
8. Efstathiou SP, Tsiakou AG, Tsioulos DI, Zacharos ID, Mitromaras AG, Mastorantonakis SE, Panagiotou TN, Mountokalakis TD. A mortality prediction model in diabetic ketoacidosis. Clin Endocrinol (Oxf). 2002; 57:595–601.
crossref
9. Freire AX, Umpierrez GE, Afessa B, Latif KA, Bridges L, Kitabchi AE. Predictors of intensive care unit and hospital length of stay in diabetic ketoacidosis. J Crit Care. 2002; 17:207–11.
crossref
10. Wolfsdorf JI, Allgrove J, Craig ME, Edge J, Glaser N, Jain V, Lee WW, Mungai LN, Rosenbloom AL, Sperling MA, Hanas R. International Society for Pediatric and Adolescent Diabetes. ISPAD Clinical Practice Consensus Guidelines 2014. Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes. 2014; 15(Suppl 20):154–79.
11. Dunger DB, Sperling MA, Acerini CL, Bohn DJ, Daneman D, Danne TP, Glaser NS, Hanas R, Hintz RL, Levitsky LL, Savage MO, Tasker RC, Wolfsdorf JI; ESPE. LWPES. ESPE/LWPES consensus statement on diabetic ketoacidosis in children and adolescents. Arch Dis Child. 2004; 89:188–94.
crossref
12. DIAMOND Project Group. Incidence and trends of childhood Type 1 diabetes worldwide 1990–1999. Diabet Med. 2006; 23:857–66.
13. EURODIAB ACE Study Group. Variation and trends in incidence of childhood diabetes in Europe. Lancet. 2000; 355:873–6.
14. Usher-Smith JA, Thompson MJ, Sharp SJ, Walter FM. Factors associated with the presence of diabetic ketoacidosis at diagnosis of diabetes in children and young adults: a systematic review. BMJ. 2011; 343:d4092.
crossref
15. Kim MS, Yu KY, Na JI, Kim JD, Lee OK, Lee DY. The changes of incidence of childhood diabetes in Jeollabuk-do for 26 years. J Korean Soc Pediatr Endocrinol. 2008; 13:29–35.
16. Dunger DB, Sperling MA, Acerini CL, Bohn DJ, Daneman D, Danne TP, Glaser NS, Hanas R, Hintz RL, Levitsky LL, Savage MO, Tasker RC, Wolfsdorf JI. European Society for Paediatric Endocrinology; Lawson Wilkins Pediatric Endocrine Society. European Society for Paediatric Endocrinology/Lawson Wilkins Pediatric Endocrine Society consensus statement on diabetic ketoacidosis in children and adolescents. Pediatrics. 2004; 113:e133–40.
crossref
17. Fernandez Castañer M, Montaña E, Camps I, Biarnes J, Merino JF, Escriba JM, Nacher V, Rosel P, Soler J. Ketoacidosis at diagnosis is predictive of lower residual beta-cell function and poor metabolic control in type 1 diabetes. Diabetes Metab. 1996; 22:349–55.
18. Lee HJ, Yu HW, Jung HW, Lee YA, Kim JH, Chung HR, Yoo J, Kim E, Yu J, Shin CH, Yang SW, Lee SY. Factors associated with the presence and severity of diabetic ketoacidosis at diagnosis of type 1 diabetes in Korean children and adolescents. J Korean Med Sci. 2017; 32:303–9.
crossref
19. Barski L, Harman-Boehm I, Nevzorov R, Rabaev E, Zektser M, Jotkowitz AB, Zeller L, Shleyfer E, Almog Y. Gender-related differences in clinical characteristics and outcomes in patients with diabetic ketoacidosis. Gend Med. 2011; 8:372–7.
crossref
20. Oyarzabal Irigoyen M, García Cuartero B, Barrio Castellanos R, Torres Lacruz M, Gómez Gila AL, González Casado I, Hermoso López F, Luzuriaga Tomás C, Rica Etxebarrial I, López García MJ, Rodríguez Rigual M. Ketoacidosis at onset of type 1 diabetes mellitus in pediatric age in Spain and review of the literature. Pediatr Endocrinol Rev. 2012; 9:669–71.
21. Kalliora MI, Vazeou A, Delis D, Bozas E, Thymelli I, Bartsocas CS. Seasonal variation of type 1 diabetes mellitus diagnosis in Greek children. Hormones (Athens). 2011; 10:67–71.
crossref
22. Demirbilek H, Özbek MN, Baran RT. Incidence of type 1 diabetes mellitus in Turkish children from the southeastern region of the country: a regional report. J Clin Res Pediatr Endocrinol. 2013; 5:98–103.
23. Krikovszky D, Luczay A, Körner A, Madácsy L. Diabetic ketoacidosis in childhood. Orv Hetil. 2000; 141:173–7.
24. Son KR, Kim JS, Lee HY, Noh HY, Back HJ, Woo YJ. Multifocal brain infarction and intraventricular hemorrhage in an infant during treatment of diabetic ketoacidosis. J Korean Soc Pediatr Endocrinol. 2002; 7:225–9.

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

TOOLS
Similar articles