1型糖尿病儿童因糖尿病酮症酸中毒住院的急性肾损伤

JAMA Pediatr. 2017 May 1;171(5):e170020.

Hursh BE, Ronsley R, Islam N, Mammen C, Panagiotopoulos C.

加拿大不列颠哥伦比亚儿童医院

儿童急性肾损伤（AKI）与较差的短期、长期疾病预后有关。但目前尚无因糖尿病酮症酸中毒（DKA）住院的糖尿病患儿AKI发生情况的研究。本研究旨在确定DKA住院患儿发生AKI的比例，并确定与AKI相关的临床和生化标志物。

患者为2008年9月1日至2013年12月31日间因DKA入住加拿大不列颠哥伦比亚省儿童医院。共入组165例，年龄均在18岁以下，均有完整的医疗记录用于数据分析。所有数据收集时间在2014年9月8日和2015年6月26日之间。数据分析为2015年8月25日至2016年6月8日。急性肾损伤指肾脏疾病/改善全球成果（Kidney Disease/Improving Global Outcomes）项目的血清肌酐标准。采用多重Logistic回归分析与AKI相关的潜在因素。

结果显示，在165例DKA住院儿童中，106例（64.2％）发展为AKI，其中AKI 1期37例，34.9％；AKI 2期48例，45.3％；AKI 3期，21例为19.8％。两名患者需要血液透析治疗。在调整后的多重Logistic回归模型中，与血清碳酸氢盐水平≥10mEq/L相比，低于10 mEq/L发生严重AKI（2级或3级）比率高5倍，调整比值比[aOR]为5.22，95％CI：1.35-20.22。初始心率每增加5次/min，发生严重AKI的几率增加22％，aOR为1.22，95％CI：1.07-1.39。与初始校正钠水平为135-144 mEq/L相比，≥145 mEq/L发生轻度（1级）AKI的比率高3倍，aOR为3.29，95％CI：1.25％8.66）。无论是否发生AKI，无死亡病例。

本研究是迄今为止首个记录了DKA住院患儿较高的AKI发生率。AKI与血容量不足和严重酸中毒的标志物相关。AKI因其增加发病率和死亡率以及慢性肾脏疾病的风险而倍受关注，这一发现与已经患糖尿病肾病风险的儿童尤其相关。需要有策略来改善1型糖尿病患儿的AKI诊断、治疗和随访。

JAMA Pediatr. 2017 May 1;171(5):e170020.

Acute Kidney Injury in Children With Type 1 Diabetes Hospitalized for Diabetic Ketoacidosis

Hursh BE, Ronsley R, Islam N, Mammen C, Panagiotopoulos C.

British Columbia Children's Hospital, British Columbia, Canada.

IMPORTANCE:Acute kidney injury (AKI) in children is associated with poor short-term and long-term health outcomes; however, the frequency of AKI in children hospitalized for diabetic ketoacidosis (DKA) has not been previously examined.

OBJECTIVES:To determine the proportion of children hospitalized for DKA who develop AKI and to identify the associated clinical and biochemical markers of AKI.

DESIGN, SETTING, AND PARTICIPANTS:This medical record review of all DKA admissions from September 1, 2008, through December 31, 2013, was conducted at British Columbia Children's Hospital, the tertiary pediatric hospital in British Columbia, Canada. Children aged 18 years or younger with type 1 diabetes and DKA and with complete medical records available for data analysis were included (n = 165). All data collection occurred between September 8, 2014, and June 26, 2015. Data analysis took place from August 25, 2015, to June 8, 2016.

MAIN OUTCOMES AND MEASURES:Acute kidney injury was defined using Kidney Disease/Improving Global Outcomes serum creatinine criteria. Multinomial logistic regression was used to identify potential factors associated with AKI.

RESULTS:Of the 165 children hospitalized for DKA, 106 (64.2%) developed AKI (AKI stage 1, 37 [34.9%]; AKI stage 2, 48 [45.3%]; and AKI stage 3, 21 [19.8%]). Two children required hemodialysis. In the adjusted multinomial logistic regression model, a serum bicarbonate level less than 10 mEq/L (compared with ≥10 mEq/L) was associated with a 5-fold increase in the odds of severe (stage 2 or 3) AKI (adjusted odds ratio [aOR], 5.22; 95% CI, 1.35-20.22). Each increase of 5 beats/min in initial heart rate was associated with a 22% increase in the odds of severe AKI (aOR, 1.22; 95% CI, 1.07-1.39). Initial corrected sodium level of 145 mEq/L or greater (compared with 135-144 mEq/L) was associated with a 3-fold increase in the odds of mild (stage 1) AKI (aOR, 3.29; 95% CI, 1.25-8.66). There were no cases of mortality in patients with or without AKI.

CONCLUSIONS AND RELEVANCE:This study is the first to date to document that a high proportion of children hospitalized for DKA develop AKI. Acute kidney injury was associated with markers of volume depletion and severe acidosis. Acute kidney injury is concerning because it is associated with increased morbidity and mortality as well as increased risk of chronic renal disease, a finding that is especially relevant among children who are already at risk for diabetic nephropathy. Strategies are needed to improve the diagnosis, management, and follow-up of AKI in children with type 1 diabetes.

PMID:28288246

DOI:10.1001/jamapediatrics.2017.0020