Abstract
IntroductionPrevalence of diabetic ketoacidosis (DKA) complicated by severe hyperglycaemia and hyperosmolality and its outcomes in youth with type 2 diabetes (T2DM) are not well‐described. Our aim is to determine the frequency and clinical outcomes of isolated DKA, DKA with severe hyperglycaemia (DKA + SHG) and DKA with hyperglycaemia and hyperosmolality (DKA + HH) in youth with T2DM admitted for acute hyperglycaemic crisis.MethodsThrough retrospective medical record review, patients with T2DM were identified and categorized into isolated DKA, DKA + SHG (DKA + glucose ≥33.3 mmol/L) and DKA + HH (DKA + glucose ≥33.3 mmol/L + osmolality ≥320 mmol/kg).ResultsForty‐eight admissions in 43 patients ages 9‐18 were included: 28 (58%) had isolated DKA, six (13%) had DKA + SHG and 14 (29%) had DKA + HH. Subgroups’ demographics and medical history were similar. Seventeen patients (35%) had acute kidney injury (AKI). Odds of AKI were higher in DKA + SHG and DKA + HH relative to isolated DKA (P = .015 and .002 respectively). Frequency of altered mental status (AMS) was similar among groups. Three patients (6%) had concurrent soft‐tissue infections at presentation with no differences among subgroup. Three patients (6%) had other medical complications. These occurred only in patients with AKI and DKA + SHG or AKI and DKA + HH.ConclusionsIn youth with T2DM, severe hyperglycaemia ± hyperosmolality frequently complicates DKA. Youth with DKA and features of hyperglycaemic hyperosmolar syndrome, including isolated severe hyperglycaemia, have increased odds of AKI.
Highlights
Prevalence of diabetic ketoacidosis (DKA) complicated by severe hyperglycaemia and hyperosmolality and its outcomes in youth with type 2 diabetes (T2DM) are not well-described
Unadjusted odds of acute kidney injury (AKI) were 10.8 times higher in those with DKA + HH compared to isolated DKA with a 95% CI of 2.4-49.5
Taught as two distinct entities, DKA and hyperglycaemic hyperosmolar syndrome (HHS) represent two ends of a continuous spectrum. In this retrospective review of a large number of youth with T2DM, we report a high rate of severe range hyperglycaemia and hyperosmolality in patients admitted for ‘DKA’
Summary
As prevalence of type 2 diabetes (T2DM) rises among America's youth,[1] paediatric providers will be increasingly responsible for treating acute hyperglycaemic complications of T2DM, including diabetic ketoacidosis (DKA) and hyperglycaemic hyperosmolar syndrome (HHS). In DKA, insulin deficiency is severe enough that in addition to hyperglycaemia, lipolysis begins and ketosis develops.[2]. A mixed presentation of DKA complicated by severe hyperglycaemia and hyperosmolality is common in patients hospitalized with acute hyperglycaemic crisis, occurring in up to 14% of children[8] and 27% of adults.[6]. Retrospective cohort studies and case reports report high rates of mortality, altered mental status (AMS), acute kidney injury (AKI), thrombosis, rhabdomyolysis and other medical complications in those with mixed DKA/HHS and isolated HHS when compared to isolated DKA.[5,6,8,9]. We aimed to determine how frequently DKA is complicated by severe hyperglycaemia and/or hyperosmolality in paediatric patients admitted for acute hyperglycaemic complications of T2DM. We aimed to identify any risk factors associated with hyperosmolality
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