Frequency and Risk Factors of Acute Kidney Injury During Diabetic Ketoacidosis in Children and Association With Neurocognitive Outcomes.
Frequency and Risk Factors of Acute Kidney Injury During Diabetic Ketoacidosis in Children and Association With Neurocognitive Outcomes.
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儿童糖尿病酮症酸中毒期间急性肾损伤的频率和危险因素及其与神经认知结局的关系
DOI：
10.1001/jamanetworkopen.2020.25481
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发表时间：
2020-12-01
影响因子：
13.8
通讯作者：
Pediatric Emergency Care Applied Research Network (PECARN) DKA FLUID Study Group
中科院分区：
文献类型：
--
作者：
Myers SR;Glaser NS;Trainor JL;Nigrovic LE;Garro A;Tzimenatos L;Quayle KS;Kwok MY;Rewers A;Stoner MJ;Schunk JE;McManemy JK;Brown KM;DePiero AD;Olsen CS;Casper TC;Ghetti S;Kuppermann N;Pediatric Emergency Care Applied Research Network (PECARN) DKA FLUID Study Group
儿童糖尿病酮症酸中毒（DKA）期间急性肾损伤（AKI）的相关机制、风险因素和结局是什么？在这项队列研究中，使用了DKA期间液体治疗的大型、多中心、前瞻性研究中1359次DKA发作的数据，43%的发作发生了AKI，并与更严重的酸中毒和更严重的循环容量耗竭相关。患有AKI的儿童在DKA期间更有可能出现轻微的认知障碍，并且在长期随访时智商较低。这些结果表明，AKI在儿童DKA中很常见，儿童DKA期间存在多器官功能障碍模式，可能存在共同的病理生理机制。本队列研究探讨了儿童糖尿病酮症酸中毒急性肾损伤的机制、危险因素和结局。急性肾损伤（AKI）常发生在儿童糖尿病酮症酸中毒（DKA）期间，但其潜在机制和相关性尚不清楚。研究AKI的风险因素及其与儿科DKA神经认知结局的相关性。本队列研究是对DKA研究中正在调查的儿科急诊应用研究网络液体疗法数据的二次分析，该研究是一项前瞻性、多中心、随机临床试验，比较了13家美国医院的儿科DKA液体方案。纳入的DKA发作发生在血糖≥ 300 mg/dL且静脉pH值低于7.25或血清碳酸氢盐水平低于15 mEq/L的18岁以下儿童中。需要静脉注射胰岛素治疗的DKA。使用肾脏疾病：改善全球结局标准，使用血清肌酐测量评估AKI发生率和分期。使用单变量和多变量方法比较了有和无AKI的DKA发作，探索相关因素。在1359例DKA发作中（平均[SD]患者年龄：11.6 [4.1]岁; 727例[53.5%]女孩; 651例[47.9%]新发糖尿病患者），584例发作发生AKI（43%; 95% CI，40%-46%）。共有252起AKI事件（43%; 95% CI，39%-47%）为2期或3期。多变量分析确定年龄较大（每1年调整的比值比[AOR]，1.05; 95% CI，1.00 - 1.09; P = 0.03），初始血清尿素氮较高（AOR每增加1 mg/dL，1.14; 95% CI，1.11 - 1.18; P <.001），心率升高（z评分增加1-SD的AOR，1.20; 95% CI，1.09 - 1.32; P <.001），葡萄糖校正钠水平较高（每增加1 mEq/L的AOR，1.03; 95% CI，1.00 - 1.06; P =.001）和葡萄糖浓度（每100 mg/dL增加的AOR，1.19; 95% CI，1.07 - 1.32; P =.001）和较低的pH值（每0.1增加的AOR，0.63; 95% CI，0.51 - 0.78; P <.001）作为与AKI相关的变量。与未患AKI的儿童相比，患有AKI的儿童在DKA期间的短期记忆测试中得分较低（平均[SD]数字广度回忆：6.8 [2.4] vs 7.6 [2.2]; P = 0.02），并且在DKA恢复后3至6个月的平均（SD）智商得分较低（100.0 [12.2] vs 103.5 [13.2]; P = 0.005）。在调整DKA严重程度和人口统计学因素（包括社会经济状况）后，差异仍然存在。这些结果表明，在DKA期间，AKI可能更频繁地发生在具有更大酸中毒和循环容量耗竭的儿童中，并且可能是涉及肾脏和大脑的多器官损伤模式的一部分。
What are the mechanisms, risk factors, and outcomes associated with acute kidney injury (AKI) during pediatric diabetic ketoacidosis (DKA)? In this cohort study using data from 1359 DKA episodes in a large, multicenter, prospective study of fluid treatment during DKA, AKI occurred in 43% of episodes and was associated with greater acidosis and greater circulatory volume depletion. Children who had AKI were more likely to have subtle cognitive impairment during DKA and lower IQ at longer-term follow-up. These findings suggest that AKI is frequent in pediatric DKA and there is a pattern of multiorgan dysfunction during childhood DKA with the possibility of common pathophysiologic mechanisms. This cohort study examines the mechanisms, risk factors, and outcomes associated with acute kidney injury during pediatric diabetic ketoacidosis. Acute kidney injury (AKI) occurs commonly during diabetic ketoacidosis (DKA) in children, but the underlying mechanisms and associations are unclear. To investigate risk factors for AKI and its association with neurocognitive outcomes in pediatric DKA. This cohort study was a secondary analysis of data from the Pediatric Emergency Care Applied Research Network Fluid Therapies Under Investigation in DKA Study, a prospective, multicenter, randomized clinical trial comparing fluid protocols for pediatric DKA in 13 US hospitals. Included DKA episodes occurred among children age younger than 18 years with blood glucose 300 mg/dL or greater and venous pH less than 7.25 or serum bicarbonate level less than 15 mEq/L. DKA requiring intravenous insulin therapy. AKI occurrence and stage were assessed using serum creatinine measurements using Kidney Disease: Improving Global Outcomes criteria. DKA episodes with and without AKI were compared using univariable and multivariable methods, exploring associated factors. Among 1359 DKA episodes (mean [SD] patient age, 11.6 [4.1] years; 727 [53.5%] girls; 651 patients [47.9%] with new-onset diabetes), AKI occurred in 584 episodes (43%; 95% CI, 40%-46%). A total of 252 AKI events (43%; 95% CI, 39%-47%) were stage 2 or 3. Multivariable analyses identified older age (adjusted odds ratio [AOR] per 1 year, 1.05; 95% CI, 1.00-1.09; P = .03), higher initial serum urea nitrogen (AOR per 1 mg/dL increase, 1.14; 95% CI, 1.11-1.18; P < .001), higher heart rate (AOR for 1-SD increase in z-score, 1.20; 95% CI, 1.09-1.32; P < .001), higher glucose-corrected sodium (AOR per 1 mEq/L increase, 1.03; 95% CI, 1.00-1.06; P = .001) and glucose concentrations (AOR per 100 mg/dL increase, 1.19; 95% CI, 1.07-1.32; P = .001), and lower pH (AOR per 0.1 increase, 0.63; 95% CI, 0.51-0.78; P < .001) as variables associated with AKI. Children with AKI, compared with those without, had lower scores on tests of short-term memory during DKA (mean [SD] digit span recall: 6.8 [2.4] vs 7.6 [2.2]; P = .02) and lower mean (SD) IQ scores 3 to 6 months after recovery from DKA (100.0 [12.2] vs 103.5 [13.2]; P = .005). Differences persisted after adjusting for DKA severity and demographic factors, including socioeconomic status. These findings suggest that AKI may occur more frequently in children with greater acidosis and circulatory volume depletion during DKA and may be part of a pattern of multiple organ injury involving the kidneys and brain.
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DOI：
10.1056/nejmoa1716816
发表时间：
2018-06-14
期刊：
The New England journal of medicine
影响因子：
--
作者：
Kuppermann N;Ghetti S;Schunk JE;Stoner MJ;Rewers A;McManemy JK;Myers SR;Nigrovic LE;Garro A;Brown KM;Quayle KS;Trainor JL;Tzimenatos L;Bennett JE;DePiero AD;Kwok MY;Perry CS 3rd;Olsen CS;Casper TC;Dean JM;Glaser NS;PECARN DKA FLUID Study Group
通讯作者：
PECARN DKA FLUID Study Group
影响因子：
0.7
作者：
Ferenbach DA;Bonventre JV
通讯作者：
Bonventre JV
影响因子：
2.3
作者：
Basu, Rajit K.;Kaddourah, Ahmad;Goldstein, Stuart L.
通讯作者：
Goldstein, Stuart L.
影响因子：
3.4
作者：
Glaser, NS;Wootton-Gorges, SL;Kuppermann, N
通讯作者：
Kuppermann, N
DOI：
10.1152/ajprenal.00533.2012
发表时间：
2013-03-01
影响因子：
4.2
作者：
Gao, Guofeng;Zhang, Binzhi;Reeves, W. Brian
通讯作者：
Reeves, W. Brian