Endocrine Abstracts

Introduction: Acute renal failure (ARF) is a rare but life-threatening complication of severe diabetic ketoacidosis (DKA) in children.

Aim: To characterise the presentation, treatment and clinical course of children with DKA complicated by severe ARF requiring renal support.

Method: Retrospective notes review of patients aged <16 years admitted in 2011–2016 to 3 UK regional paediatric intensive care units (St George’s Hospital, London, Leeds Children’s Hospital and Bristol Royal Hospital for Children) with DKA complicated by ARF requiring renal dialysis.

Results: [Median (range)]. Five (male=2, female=3) cases with type 1 diabetes aged 13.5(9.6–15.9) years were identified, including 4 newly diagnosed and 1 known patient with poor compliance. All presented in winter between December and April. Length of PICU stay was 8(2–20) days. Four were ventilated for 3.5(3–11) days, and 3 required inotropic support. At presentation, HbA1C was 148(90–173) mmol/mol and glucose 35(28–47) mmol/l. Blood gas analysis showed an initial pH of <6.8 in all patients, base excess between unrecordable and −28, bicarbonate between unrecordable and 4.6 mmol/l; and took 2(2–3) days to normalise. Level of dehydration was estimated at 8(7–10)%. All required additional fluid boluses on clinical judgement and, received intravenous fluids and insulin 0.05–0.1 U/kg according to national DKA protocol. Intravenous antibiotics were given to all (positive blood cultures (n=0), positive respiratory secretions with staphylococcus aureus (n=2) and streptococcus pneumoniae (n=1)). None had a previous history of renal impairment. Abnormal renal function was evident from admission with presenting urea 16.9(9.2–29) mmol/l, creatinine 144(82–289) umol/l; and peak urea 21.3(17.4–51.3) mmol/l, creatinine 375(279–903) umol/l. All underwent haemodialysis for 8(1–13) days and renal function normalised after 2 months (9 days–14 months). Renal imaging during initial presentation reported increased echogenicity in 2 and bilateral mild hydronephrosis in 1 patient(s). Hypertension was reported in 2 patients who were both treated by amlodipine that was later discontinued when blood pressure normalised.

Conclusions: Severe ARF in DKA was associated with extremely low blood pH<6.8 and evidence of hypovolaemic shock at presentation. Haemodialysis was effective and all made a full recovery of renal function. However, future risk of chronic renal impairment remains unclear and long term renal surveillance is required.