Risk Factors and Outcomes of Acute Kidney Injury in Children with Diabetic Ketoacidosis

Risk Factors and Outcomes of Acute Kidney Injury in Children with Diabetic Ketoacidosis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Risk Factors and Outcomes of Acute Kidney Injury in Children with Diabetic Ketoacidosis Naseem Alyahyawi, Dalal Alghamdi, Ahlam Almahmoudi, Ibrahim Sandokji, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4938618/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 22 May, 2025 Read the published version in BMC Nephrology → Version 1 posted 7 You are reading this latest preprint version Abstract Background: Acute kidney injury (AKI) in pediatric patients has been linked to unfavorable short-term and long-term health outcomes. Despite the significance of AKI awareness in children with diabetes mellitus type 1 (T1D) , the incidence of AKI in children admitted with diabetic ketoacidosis (DKA) has been under looked. Objectives: The primary objective of this study was to investigate the incidence of acute kidney injury (AKI) in pediatric patients hospitalized for diabetic ketoacidosis (DKA), and to identify the clinical and biochemical markers associated with the development of AKI. Methods: A retrospective medical record review was conducted at King Abdulaziz University Hospital, a tertiary hospital in Jeddah, Saudi Arabia. The study included a total of 373 children aged 18 years or younger from 2012 to 2022 with complete medical records available for analysis. We collected baseline and diabetes characteristics, in addition to clinical variables at presentation. Acute kidney injury (AKI) was diagnosed using the serum creatinine criteria established by the kidney disease: Improving Global Outcomes (KDIGO) organization. Descriptive comparisons were performed. Uni- and multivariable logistic regression analyses were employed to identify potential risk factors associated with the development of AKI. Results: A total of 299 patients (80.2%) developed AKI including 98 (26.3%) stage 1, and 118 (31.6%) stage 2 and 83 (22.3%) stage 3. The frequency of AKI was higher in patients with severe DKA (26.9% vs. 19.7%, p=0.01) while in mild DKA the percentage of AKI was less than non-AKI (31.9% vs. 45.1%, p<0.01) Children with AKI had longer hospital stay compared to non-AKI (4 days vs 3 days , p =0.02). The median last HbA1C prior to DKA presentation was 12%, and majority (88.2%) had DKA episodes in past. children who developed AKI had a significantly higher median heart rate (120 bpm, IQR 104-138) compared to those without AKI (108 bpm, IQR 98-124, p<0.01) . A high percentage of children with AKI had low Glasgow coma scale (<15) compared to non-AKI (5.7% vs. 1.7%) but the difference was not statistically significant( p =0.22). Half of the children presented with DKA had poor outpatient follow up visits. The proven infections were observed in 53 (14.2 %) children in DKA. It was higher in non-AKI group compared to AKI group(15.1% vs 10.8%,p=0.46). Outcome of AKI showed persistent acute kidney disease (AKD) at discharge in 131 (44%) in patients who developed AKI. We did not observe mortality. None of the study participant have died during the studied hospital encounters. Conclusion: Our findings indicate that AKI is common in children admitted with DKA. Longer duration and poor controlled T1D , previous episodes of DKA , Severe DKA , infection and higher heart rate are risk factors to develop AKI The hospital stay was higher in children with AKI highlighting its significant morbidity in Children with AKI Type 1 diabetes Diabetes ketoacidosis Pediatric Acute kidney injury Incidence rate Background Diabetic ketoacidosis (DKA) is a critical and potentially life-threatening complication of diabetes, particularly in children with type 1 diabetes (T1D). DKA is characterized by hyperglycaemia > 250 mg/dl, metabolic acidosis with pH < 7.3 and serum bicarbonate < 15 mEq/l, and positive urinary ketone bodies ( 1 ) DKA may present as an initial manifestation of T1D or occur in children with established T1D at any time during follow up particularly during episodes of intercurrent illness or insulin non-compliance ( 2 ). The severity of DKA often necessitates hospitalization, as it poses significant risks of high morbidity and mortality due to cerebral edema ( 3 ). To mitigate or prevent these complications an evidence-based protocol of timely assessment of fluid, electrolytes and hyperglycaemia management strategies has been recommended ( 4 ). Acute Kidney Injury (AKI) is an important and common complication in children admitted with DKA and the incidence ranges from 14 to 47% ( 5 , 6 ) The most prevalent form of AKI in this demographic is functional AKI, primarily due to hypovolemia and impaired renal perfusion ( 7 ). If severe or prolonged, this functional insult can lead to structural damage of the renal parenchyma and manifest as acute tubular necrosis (ATN). The incidence of severe AKI in children with DKA ranges from 21 to 35%. However, only 4% of patients who developed AKI received renal replacement therapy ( 6 ). Despite the known risk of significant intravascular volume depletion in DKA and the implementation of cautious fluid management strategies, systematic studies on the incidence and impact of AKI in paediatric DKA patients remain limited. The multiple studies have highlighted the incidence of AKI in children with DKA ranging from 14 to 78%, emphasizing the potential for serious renal complications ( 6 , 7 , 8 , 9 , 10 ). Currently, there is a strong evidence linking paediatric AKI to increased morbidity, mortality, and long-term risks of chronic kidney disease (CKD), therefore, understanding its prevalence and predictors of AKI in the context of DKA is crucial ( 11 ). The primary objective of this study investigation was to quantify the incidence of AKI among children with T1D hospitalized for DKA. Secondary objective was to determine the association between clinical and laboratory markers particularly duration of DM, diabetic control ,severity of DKA, and infection with the risk of AKI in this population. Methods Study Design and Setting This retrospective study was conducted at King Abdulaziz University Hospital (KAUH) in Jeddah, Saudi Arabia on children admitted with DKA from January 2012 to December 2022. Participants : Inclusion criteria: we include all patient who were 18 years of age or younger and had laboratory-confirmed DKA, defined by a blood glucose level ≥ 200 mg/dL, pH ≤ 7.3 or bicarbonate level ≤ 15 mEq/L, and elevated serum or urine ketones. Exclusion criteria: any patient who were older than 18 years or patients with incomplete medical documents. Ethic al approval was taken from the KAUH Clinical Research Ethics Board. The patients’ consent was not required due to the retrospective nature of the study. Data Collection: Data collection included comprehensive information on clinical history, physical findings, laboratory parameters including biochemical markers for estimated volume depletion and fluid resuscitation, presence of infection, severity of DKA and AKI , outcome as recovered, acute kidney disease/CKD were documented. Study definitions Acute kidney injury (AKI) was defined according to the Kidney Disease/Improving Global Outcomes (KDIGO) serum creatinine ( Cr ) criteria. KDIGO urine output criteria was not utilized due to inconsistent recording and osmotic diuretic effects on urine output. Due to the lack of pre-admission serum Cr values, we estimated the baseline Cr level (EBC) using an expected glomerular filtration rate (GFR) of 120 mL/min/1.73 m², based on the Schwartz estimating equation. A GFR of 120 ml/min/1.73 m² was chosen based on established standards in pediatric AKI studies. Additionally, a GFR of 90 mL/min/1.73 m² was used in a sensitivity analysis for conservative estimates of AKI. AKI Stages: AKI was classified according to KDIGO criteria: Stage 1: Creatinine values ≥1.5 but <2 times the estimated basal creatinine. Stage 2: Creatinine values ≥2 but <3 times the EBC. Stage 3: Creatinine values ≥3 times the EBC Patients who experienced AKI and are discharged without their serum creatinine returning to baseline are classified as having acute kidney disease (AKD) according to KDIGO guidelines. ADK refers to persistent kidney dysfunction lasting more than 7 days but less than 3 months. Severity of metabolic acidosis: The severity of DKA was documented at presentation as the following: mild: venous pH >7.2 and <7.3, bicarbonate 7.1 and <7.2, bicarbonate <10 mmol/l and severe: venous pH <7.1, bicarbonate <5 mmol/l. Infections/sepsis : Infection episodes were documented the relation to AKI were analyzed Data Analysis: Descriptive statistics were used to summarize baseline demographics, diabetes mellitus characteristics, DKA and AKI parameters. Continuous variables were assessed for normality using the Shapiro–Wilk test. Normally distributed variables were presented as means with standard deviations and compared using Student’s t-test, while non-normally distributed variables were presented as medians with interquartile ranges and compared using the Mann–Whitney U test. Categorical variables were presented as percentages and compared using chi-squared or Fisher's exact tests, as appropriate. Univariate logistic regression analyses were performed to identify factors associated with AKI development, using AKI as the dependent variable and demographic, baseline diabetes, and DKA characteristics as independent variables. Significant predictors from univariate analyses were included in a multivariate logistic regression model. The results were expressed as odds ratios with 95% confidence intervals, and the area under the receiver operating characteristic curve (AUC) was calculated for the combined model predicting AKI. Statistical significance was set at p < 0.05. Data were collected using Microsoft Excel® and analyzed with Stata version 18 (StataCorp, TX, USA). Results We included 373 children who presented with diabetic ketoacidosis (DKA) at King Abdulaziz University Hospital, with a median age of 132 months (IQR 96-156) (Table1). AKI was observed in 299 children (80.2%), categorized as Stage 1 in 98 (26.3%), Stage 2 in 118 (31.6%), and Stage 3 in 83 (22.3%) (Table 3). Table 2 shows the DM characteristics of pediatric patients presented with DKA. Diabetes mellitus (DM) was diagnosed at a median age of 108 months (IQR 60-132) (table 2). The interval between diabetes diagnosis and DKA presentation was significantly longer in children who developed AKI (median 72 months, IQR 48-108) compared to those without AKI (median 60 months, IQR 24-96, p=0.01) (table 2). The median HbA1c level before DKA presentation was 12% (IQR 9.9-13.8), and most children (88.2%) had previously experienced DKA episodes (table 2). Notably, half of the children did not have documented outpatient follow-up visits. Conventional insulin therapies were used in 77.8% of cases (table 2). Children with AKI had a lower rate of controlled diabetes (HbA1c ≤8%) compared to those without AKI (7.7% vs. 20.3%, p=0.01) (table 2). Conversely, uncontrolled diabetes (HbA1c >8%) was more prevalent in the AKI group (92.3% vs. 79.7%,P=0,01). Table 3 shows the clinical characteristics of pediatric patients who presented with DKA upon admission. The severity of DKA was classified as mild in 127 (34%), moderate in 126 (33.7%), and severe in 94 (25.2%) patients, respectively. Among the DKA characteristics, the incidence of AKI was higher in children with severe DKA (26.9% vs. 19.7%, p=0.01) and lower in those with mild DKA (31.9% vs. 45.1%, p<0.01) (table 3). The hospital length of stay was longer for children with AKI, with a median of 4 days (IQR 2-6) compared to 3 days (IQR 2-5) for those without AKI (p=0.07) (table 3). At presentation, children who developed AKI had a significantly higher median heart rate (120 bpm, IQR 104-138) compared to those without AKI (108 bpm, IQR 98-124, p<0.01) (table 3). Although a higher proportion of AKI patients had a Glasgow Coma Scale (GCS) score of less than 15 (5.7% vs. 1.7%), this difference was not statistically significant (p=0.22) (table 3). There was a total of 53 (14.2%) children with proven infections; 8(10.8%) in non-AKI group and 45 (15.1%) in AKI group (p = 0.46). For patients with AKI we found 131 children (44%) had AKD according to serum creatine at the time of discharge . None of the study participant have died during the studied hospital encounters. Univariable logistic regression analyses showed significant associations between AKI and the duration of DM prior to DKA, diabetes control (HbA1c ≤8 vs. >8), DKA severity, and heart rate at presentation (Table 4). In the adjusted multivariable logistic regression model for age , gender and infections, heart rate, diabetes duration, and glycemic control remained significantly associated with AKI, with an area under the receiver operating characteristic curve (AUC) of 0.68 (95% CI: 0.61-0.75, p<0.01) (table 4). Discussion Our study revealed that a substantial proportion (80.2%) of children with DKA developed AKI. Huang et al.'s study comprised of 223 participants with 301 episodes of DKA. 56.5% of children and adolescents with DKA developed AKI at the time of admission, according to the findings. Notably, one-third of children with AKI were classified as having severe AKI, indicating not only volume-responsive injury yet also intrinsic renal tubular injury (12). Hursh et al. evaluated 165 children hospitalized for DKA and found a 64.3% prevalence of AKI; the AKI definition used in this study was based on the KDIGO criteria (7).However, this incidence is notably higher compared to the 40% reported in a study by Bergmann , highlighting variability in AKI prevalence across different studies. (13). The magnitude of AKI in our study 80.2%is higher than all three above quoted studies(7,12,13).This discrepancy may be attributed to differences in definitions and diagnostic criteria for AKI, emphasizing the need for standardized criteria in paediatric populations . The prevalent stages of AKI severity (stage II + III) was 41.77 % reported by Al-Khalifa et al. (14). In comparison, the prevalence in our cohort of combined severity of AKI (stage II+III)was 53.9% The high incidence of severe AKI observed in our cohort suggests that a significant number of children with DKA experience intrinsic renal damage rather than just functional AKI or volume-responsive AKI. This finding underscores the severity of renal complications in DKA and indicates that a substantial portion of DKA cases can lead to significant renal impairment. A recent systemic review shows pooled prevalence of severe AKI in 28% among patients with overall prevalence of AKI was 47% (6) Our study identified several clinical and biochemical factors associated with AKI development including duration of T1D, glycemic control. This study showed that prolonged duration of uncontrolled T1D more than 8 years linked to the development of AKI. We showed that elevated HbA1C linked to AKI in children with DKA This aligns with findings from a large New Zealand study, which showed higher HbA1C in children with AKI compared to non -AKI (p-value 0.04) (15). These results highlight the critical role of effective diabetes management by regular follow up and maintaining good control of HbA1C to decrease AKI episodes in these vulnerable population. Interestingly, while some studies have identified high sodium levels (≥145 mEq/L), at admission as predictors of more severe AKI (16), we did not find a significant difference in serum sodium levels between patients with and without AKI (P = 0.88). This discrepancy may be due to variations in patient populations, measurement techniques, or other confounding factors. Our study did demonstrate that a higher heart rate at admission was associated with an increased likelihood of developing AKI. This finding supports the hypothesis that severe volume depletion, as reflected by elevated heart rates, plays a crucial role in AKI development in children with DKA (12,17). However, it is important to note that overzealous fluid resuscitation can lead to hyperchloremia, which has been associated with prolonged recovery time from AKI (18). Thus, balanced fluid management remains essential to avoid exacerbating renal injury while treating DKA. Our findings suggest that the severity of the DKA episode correlates with the likelihood of AKI development (table 4), consistent with other studies indicating that severe metabolic derangements. Huang showed that patients with AKI tends to have more severe acidosis with pH 7.15 compared to pH of 7.20 in non-AKI patients (p-value 0.01) (12) While some studies have shown that initial high-volume intravenous boluses do not significantly differ in AKI resolution compared to low-volume boluses (18), it is important to keep careful fluid management tailored to individual patient needs. Infection is a trigger factor for developing DKA (19) and a major contributing cause for AKI. In our study the incidence of infection rate was higher among patients with AKI although the difference was not statistically significant. However early diagnosis management of infection in DKA patients remains crucial and may help improve the outcomes of DKA and AKI. Furthermore, the observation that a low Glasgow Coma Scale (GCS) score (less than 15) was prevalent among children with AKI is notable. Previous research has suggested that a GCS score of less than 14 is a risk factor for moderate to severe AKI, highlighting the importance of monitoring neurological status in these patients (19). Our study showed that number of patients with renal impairment at time of discharge was significantly high in patients who developed AKI indicating that a significant intrinsic renal damage can occur in patients with DKA and AKI. More studies are needed to assess long- term outcome for renal function. Study Limitations and Future Directions: The primary limitation of this study is its retrospective design, which inherently relies on the accuracy and completeness of medical records. The retrospective nature may affect the precision of the data and limit the ability to establish causality. Future prospective studies with well-defined comparator populations and standardized diagnostic criteria are needed to validate these findings and further elucidate the risk factors for AKI in paediatric DKA patients. Conclusion This study provides substantial evidence of the high incidence of AKI among patients hospitalized with DKA at a local setting. Our findings indicate a strong association between incidence of AKI and severity of DKA. Patients with longer duration of T1D and poor glycaemic control were associated with higher incidence of AKI. A high percentage of patients who of DKA patients developed AKI had persistent AKD indicating significant intrinsic renal damage. While in our study there was no mortality and none of our patients need dialysis, AKI still pose significant morbidity and mortality with AKI highlight the urgent need for effective strategies to prevent, diagnose, and manage AKI in children with T1D and DKA. Abbreviations AKI: Acute Kidney Injury AKD: Acute Kidney disease DKA: Diabetic Ketoacidosis T1D: Type 1 Diabetes KAUH: King Abdulaziz University Hospital KDIGO: Kidney Disease Improving Global Outcomes AUC: Area Under Curve GCS: Glasgow Coma Scale Declarations Ethics approval and consent to participate This study was conducted in accordance with the ethical principles of the Declaration of Helsinki and with the Ethical Guidelines for King Abdulaziz University . The study was approved by the Ethics Review Committee of King Abdulaziz University Hospital . Letter no 14567 issued on January 2024 As the data were collected retrospectively from patient charts, informed consent was deemed unnecessary following the above guidelines. Consent for publication All authors agree to consent for publication Availability of Data and Materials The dataset used and /or analyzed during the current study are valuable upon the request from the corresponding author Competing interests The authors declare no competing interests. Funding Authors declare no funding resource Clinical trial number: not applicable Authors Contributions DA , AA, RA collected the data. IS performed statistical analysis. MS , MA ,SB reviewed the results NY,OS ,JK a senior authors who revised the manuscript. All authors Wrote the manuscript and discussed the results Acknowledgments We would like to thank patients and their families for participating in this study We would like to thanks Naia Fahd Alzahrani and Shahad Nader Alsulaiman for their efforts in collecting data References von Oettingen JE, Rhodes ET, Wolfsdorf JI. Resolution of ketoacidosis in children with new onset diabetes: Evaluation of various definitions. 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Prevalence and associated factors of diabetic ketoacidosis among patients with diabetes mellitus at the University of Gondar Comprehensive and Specialized Referral Hospital Northwest, Ethiopia. PLoS One. 2025 Feb 10;20(2):e0318775. doi: 10.1371/journal.pone.0318775. PMID: 39928633; PMCID: PMC11809922 Rane RP, Soundranayagam S, Shade DA, Nauer K, DuMont T, Nashar K, et al. Renal Involvement in Sepsis: Acute Kidney Injury. Crit Care Nurs Q. 2025 Apr-Jun 01;48(2):100-108. doi: 10.1097/CNQ.0000000000000553. Epub 2025 Feb 27. PMID: 40009857. Ahmed HM, Elnaby HRH, El Kareem RMA, Hodeib M. The relationship between hyperchloremia and acute kidney injury in pediatric diabetic ketoacidosis and its impact on clinical outcomes. Pediatr Nephrol. 2022 Jun;37(6):1407-1413. doi: 10.1007/s00467-021-05279-2. Epub 2021 Nov 5. PMID: 34738144. Tables Table 1: Baseline characteristics of pediatric patients with diabetic ketoacidosis (DKA). Children with DKA p -value Total No AKI AKI Number (%) 373 74 (19.8%) 299 (80.2%) Demographics at presentation Age, months (median [IQR]) 132 (96-162) 132 (84-156) 132 (108-168) 0.32 Sex, male (n [%]) 140 (37.5%) 25 (33.8%) 115 (38.5%) 0.50 Weight, kg (median [IQR]) 30 (20-43.4) 30 (20-40) 30 (20-45) 0.58 Height, cm (median [IQR]) 139 (117-150) 137 (120-150) 140 (116.5-150) 0.70 Body mass index, kg/m 2 (median [IQR]) 17.4 (14-21.1) 17.6 (14-20.8) 17.2 (13.9-21.3) 0.91 Nationality, Saudi (n [%]) 178 (47.9%) 40 (54.1%) 138 (46.3%) 0.24 Table 2: DM characteristics of pediatric patients with diabetic ketoacidosis (DKA). Children with DKA p-value Total No AKI AKI Number (%) 373 74 (19.8%) 299 (80.2%) Baseline diabetes characteristics Age of onset, months (median [IQR]) 108 (60-132) 108 (72-132) 108 (60-132) 0.41 Duration of DM, months (median [IQR]) 72 (48-108) 60 (24-96) 72 (48-108) 0.01 Last HbA1C, % (median [IQR]) 12.1 (9.9-13.8) 11.6 (9-13.8) 12.2 (10-13.8) 0.16 History of previous DKA, (n [%]) 329 (88.2%) 67 (90.5%) 262 (87.9%) 0.69 Number of outpatient visits No visits, (n [%]) 190 (50.9%) 40 (54.1%) 150 (50.2%) 0.78 1-2 visits, (n [%]) 86 (23.1%) 17 (23.0%) 69 (23.1%) ≥3 visits, (n [%]) 97 (26%) 17 (23.0%) 80 (26.8%) Insulin regimen type Conventional therapy, (n [%]) 287 (77.8%) 58 (79.5%) 229 (77.4%) 0.76 MDI therapy, (n [%]) 82 (22.2%) 15 (20.6%) 67 (22.6%) Diabetes control Controlled (HbA1C <= 8), (n [%]) 38 (10.2%) 15 (20.3%) 23 (7.7%) 8) , (n [%]) 335 (89.8%) 59 (79.7%) 276 (92.3%) Table 3: Clinical characteristics at admission of pediatric patients with diabetic ketoacidosis (DKA). Children with DKA p-value Total No AKI AKI Number (%) 373 74 (19.8%) 299 (80.2%) Hospital location Emergency, (n [%]) 5 (1.4%) 1 (1.4%) 4 (1.3%) 1.00 Ward, (n [%]) 293 (79.0%) 57 (79.2%) 236 (78.9%) ICU, (n [%]) 73 (19.7%) 14 (19.4%) 59 (19.7%) ICU length of stay, days (median [IQR]) 2 (1-3) 2 (1-2) 2 (1-3) 0.45 Vital signs at admission Systolic BP, mmHg (median [IQR]) 112 (105-122) 112 (105-120) 112 (105-123) 0.55 Diastolic BP, mmHg (median [IQR]) 69.5 (62-77) 68 (61-74) 70 (62-77) 0.12 Heart rate, bpm (median [IQR]) 117 (102-134) 108 (98-124) 120 (104-137) <0.01 Temperature, °C (median [IQR]) 36.9 (36.6-37.1) 36.9 (36.5-37.1) 36.9 (36.6-37.1) 0.67 Presence of infection , (n [%]) 53 (14.2%) 8 (10.8%) 45 (15.1%) 0.46 Glasgow Coma Scale 15, (n [%]) 355 (95.2%) 73 (98.7%) 282 (94.3%) 0.22 <15, (n [%]) 18 (4.8%) 1 (1.4%) 17 (5.7%) Severity of DKA Unknown, (n [%]) 25(6.0%) 11 (3 %) 14 (3.7%) 0.01 Mild, (n [%]) 127 (34%) 32 (45.1%) 95 (31.9%) Moderate, (n [%]) 126 (33.7%) 17 (23.9%) 109 (36.6%) Severe, (n [%]) 94 (25.2 %) 14 (19.7%) 80 (26.9%) Baseline laboratories HbA1C, % (median [IQR]) 12.9 (10.9-14.1) 12.3 (10.5-14.2) 13 (10.9-14.1) 0.51 Bicarbonate, mEq/L (median [IQR]) 10 (6-12) 10.5 (5.5-13) 9 (6-12) 0.24 Na correction, mEq/L (median [IQR]) 140 (136-145) 140 (137-144) 140 (136-145) 0.63 Hospital length of stay, days (median [IQR]) 4 (2-6) 3 (2-5) 4 (2-6) 0.07 AKI stage Stage 1, (n [%]) - - 98 (26.3%) - Stage 2, (n [%]) 118 (31.6%) Stage 3, (n [%]) 83 (22.3%) Renal impairment at discharge , (n [%]) 131 (35.1%) 0 131 (44.0%) <0.01 Mortality 0 (0) 0 (0) 0 (0) - Table 4: Multivariable logistic regression analysis for predictor variables associated with AKI development in children with DKA. Multivariable logistic regression Adjusted multivariable logistic regression* Variable OR 95% CI p-value OR 95% CI p-value Duration of DM 1.01 1.00 1.01 0.049 1.01 1.00 1.01 0.056 Uncontrolled DM (>8) € 3.81 1.69 8.57 0.001 3.59 1.56 8.26 0.003 Heart rate 1.01 1.00 1.02 0.017 1.01 1.00 1.03 0.015 Severity of DKA^ Mild 1.48 0.53 4.18 0.454 1.63 0.57 4.67 0.366 Moderate 3.69 1.27 10.70 0.016 4.09 1.38 12.11 0.011 Severe 2.79 0.94 8.29 0.065 3.16 1.03 9.65 0.043 * Adjusted for age of presentation, sex, and the presence of infection € Reference: controlled DM (HbA1C <= 8) ^ Reference: unknown DKA severity Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 22 May, 2025 Read the published version in BMC Nephrology → Version 1 posted Editorial decision: Revision requested 11 Apr, 2025 Editor assigned by journal 11 Apr, 2025 Reviews received at journal 07 Apr, 2025 Reviewers agreed at journal 25 Mar, 2025 Reviewers invited by journal 24 Mar, 2025 Submission checks completed at journal 24 Mar, 2025 First submitted to journal 19 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4938618","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":433567514,"identity":"f2031ebe-934a-4cf6-8c3b-24bda45ed31f","order_by":0,"name":"Naseem Alyahyawi","email":"","orcid":"","institution":"King Abdulaziz University","correspondingAuthor":false,"prefix":"","firstName":"Naseem","middleName":"","lastName":"Alyahyawi","suffix":""},{"id":433567515,"identity":"b9f14988-4f34-4004-8894-34c9f62b3c9e","order_by":1,"name":"Dalal Alghamdi","email":"","orcid":"","institution":"King Abdulaziz University","correspondingAuthor":false,"prefix":"","firstName":"Dalal","middleName":"","lastName":"Alghamdi","suffix":""},{"id":433567516,"identity":"88e484dc-9613-4828-abe5-4a234c113cfb","order_by":2,"name":"Ahlam Almahmoudi","email":"","orcid":"","institution":"King Abdulaziz University","correspondingAuthor":false,"prefix":"","firstName":"Ahlam","middleName":"","lastName":"Almahmoudi","suffix":""},{"id":433567517,"identity":"e3b36093-5bec-4583-a38c-90ad81876c6f","order_by":3,"name":"Ibrahim Sandokji","email":"","orcid":"","institution":"Taibah University","correspondingAuthor":false,"prefix":"","firstName":"Ibrahim","middleName":"","lastName":"Sandokji","suffix":""},{"id":433567518,"identity":"07d70e0b-3259-4026-bcc1-613d3796d0e3","order_by":4,"name":"Shatha Bokhari","email":"","orcid":"","institution":"King Abdulaziz University","correspondingAuthor":false,"prefix":"","firstName":"Shatha","middleName":"","lastName":"Bokhari","suffix":""},{"id":433567519,"identity":"b82d0aa5-40e0-474e-8f00-9ef86ec7ba76","order_by":5,"name":"Osama Y Safdar","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1UlEQVRIiWNgGAWjYJCCDzwMDHISYCYbcToYZwC1GJOuJXEG0Vrk+w8/bHhTcy99ZvsZA4YPZYcZ5NsP4NdicCPNsHHOseLc2Tw5Bowzzh1mMDiTQECLBIP5Yx62hNx5DDkGzLxtQC0MBLTI9x//2MzzLyFdjv+NAfNfoBb5/gcEPHMgx7CZty0hQVoCaAsjUAvDDUIOu5FT2Di3L8Fw5oxnBQd7zqXzGNwgYAvQYRsb3nxLkJc4n7zxwY8yazn5fgK2oDoSiHlIUD8KRsEoGAWjABcAAL8ARI85F/bNAAAAAElFTkSuQmCC","orcid":"","institution":"King Abdulaziz University","correspondingAuthor":true,"prefix":"","firstName":"Osama","middleName":"Y","lastName":"Safdar","suffix":""},{"id":433567520,"identity":"e190d779-c22b-46be-a7c7-fa047370f51e","order_by":6,"name":"mohammad Shalaby","email":"","orcid":"","institution":"King Abdulaziz University","correspondingAuthor":false,"prefix":"","firstName":"mohammad","middleName":"","lastName":"Shalaby","suffix":""},{"id":433567522,"identity":"39c2fccd-f393-4b17-90e8-fc4ae45d24cb","order_by":7,"name":"Mohamed Shazly","email":"","orcid":"","institution":"King Abdulaziz University","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"","lastName":"Shazly","suffix":""},{"id":433567524,"identity":"a46e617f-f730-4c73-ab86-646b7da25673","order_by":8,"name":"Jameela A Kari","email":"","orcid":"","institution":"King Abdulaziz University","correspondingAuthor":false,"prefix":"","firstName":"Jameela","middleName":"A","lastName":"Kari","suffix":""}],"badges":[],"createdAt":"2024-08-19 12:23:42","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4938618/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4938618/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12882-025-04178-0","type":"published","date":"2025-05-22T15:58:08+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":83460085,"identity":"f98cdcd9-73c9-4ac1-b567-0025ef6c27c6","added_by":"auto","created_at":"2025-05-26 16:10:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1310613,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4938618/v1/79368aad-8fc6-41ab-8b45-e5090baa7ad5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eRisk Factors and Outcomes of Acute Kidney Injury in Children with Diabetic Ketoacidosis\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eDiabetic ketoacidosis (DKA) is a critical and potentially life-threatening complication of diabetes, particularly in children with type 1 diabetes (T1D). DKA is characterized by hyperglycaemia\u0026thinsp;\u0026gt;\u0026thinsp;250 mg/dl, metabolic acidosis with pH\u0026thinsp;\u0026lt;\u0026thinsp;7.3 and serum bicarbonate\u0026thinsp;\u0026lt;\u0026thinsp;15 mEq/l, and positive urinary ketone bodies (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eDKA may present as an initial manifestation of T1D or occur in children with established T1D at any time during follow up particularly during episodes of intercurrent illness or insulin non-compliance (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe severity of DKA often necessitates hospitalization, as it poses significant risks of high morbidity and mortality due to cerebral edema (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). To mitigate or prevent these complications an evidence-based protocol of timely assessment of fluid, electrolytes and hyperglycaemia management strategies has been recommended (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAcute Kidney Injury (AKI) is an important and common complication in children admitted with DKA and the incidence ranges from 14 to 47% (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe most prevalent form of AKI in this demographic is functional AKI, primarily due to hypovolemia and impaired renal perfusion (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). If severe or prolonged, this functional insult can lead to structural damage of the renal parenchyma and manifest as acute tubular necrosis (ATN). The incidence of severe AKI in children with DKA ranges from 21 to 35%. However, only 4% of patients who developed AKI received renal replacement therapy (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite the known risk of significant intravascular volume depletion in DKA and the implementation of cautious fluid management strategies, systematic studies on the incidence and impact of AKI in paediatric DKA patients remain limited. The multiple studies have highlighted the incidence of AKI in children with DKA ranging from 14 to 78%, emphasizing the potential for serious renal complications (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Currently, there is a strong evidence linking paediatric AKI to increased morbidity, mortality, and long-term risks of chronic kidney disease (CKD), therefore, understanding its prevalence and predictors of AKI in the context of DKA is crucial (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe primary objective of this study investigation was to quantify the incidence of AKI among children with T1D hospitalized for DKA. Secondary objective was to determine the association between clinical and laboratory markers particularly duration of DM, diabetic control ,severity of DKA, and infection with the risk of AKI in this population.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e \u003cstrong\u003eStudy Design and Setting\u003c/strong\u003e \u003cp\u003eThis retrospective study was conducted at King Abdulaziz University Hospital (KAUH) in Jeddah, Saudi Arabia on children admitted with DKA from January 2012 to December 2022.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eParticipants\u003c/b\u003e: Inclusion criteria: we include all patient who were 18 years of age or younger and had laboratory-confirmed DKA, defined by a blood glucose level\u0026thinsp;\u0026ge;\u0026thinsp;200 mg/dL, pH\u0026thinsp;\u0026le;\u0026thinsp;7.3 or bicarbonate level\u0026thinsp;\u0026le;\u0026thinsp;15 mEq/L, and elevated serum or urine ketones. Exclusion criteria: any patient who were older than 18 years or patients with incomplete medical documents.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthic\u003c/strong\u003eal approval was taken from the KAUH Clinical Research Ethics Board. The patients\u0026rsquo; consent was not required due to the retrospective nature of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection:\u003c/strong\u003e Data collection included comprehensive information on clinical history, physical findings, laboratory parameters including biochemical markers for \u0026nbsp;estimated volume depletion and fluid resuscitation, \u0026nbsp;presence of infection, severity of DKA and AKI , outcome \u0026nbsp;as recovered, acute kidney disease/CKD were documented.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy definitions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAcute kidney injury (AKI)\u003c/strong\u003e was defined according to the Kidney Disease/Improving Global Outcomes (KDIGO) serum creatinine (\u003cu\u003eCr\u003c/u\u003e) criteria. KDIGO urine output criteria was not utilized due to inconsistent recording and osmotic diuretic effects on urine output. Due to the lack of pre-admission serum Cr values, we estimated the baseline Cr level (EBC) using an expected glomerular filtration rate (GFR) of 120 mL/min/1.73 m\u0026sup2;, based on the Schwartz estimating equation. A GFR of 120 ml/min/1.73 m\u0026sup2; was chosen based on established standards in pediatric AKI studies. Additionally, a GFR of 90 mL/min/1.73 m\u0026sup2; was used in a sensitivity analysis for conservative estimates of AKI.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAKI Stages:\u0026nbsp;\u003c/strong\u003eAKI was classified according to KDIGO criteria:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eStage 1: Creatinine values \u0026ge;1.5 but \u0026lt;2 times the estimated basal creatinine.\u003c/li\u003e\n \u003cli\u003eStage 2: Creatinine values \u0026ge;2 but \u0026lt;3 times the EBC.\u003c/li\u003e\n \u003cli\u003eStage 3: Creatinine values \u0026ge;3 times the EBC\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003ePatients who experienced AKI and are discharged without their serum creatinine returning to baseline are classified as having acute kidney disease (AKD) according to KDIGO guidelines. ADK refers to persistent kidney dysfunction lasting more than 7 days but less than 3 months.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSeverity of metabolic acidosis:\u0026nbsp;\u003c/strong\u003eThe severity of DKA was documented at presentation as the following:\u0026nbsp;\u003c/p\u003e\n\u003cul class=\"decimal_type\"\u003e\n \u003cli\u003emild: venous pH \u0026gt;7.2 and \u0026lt;7.3, bicarbonate \u0026lt;15 mmol/l,\u0026nbsp;\u003c/li\u003e\n \u003cli\u003emoderate: venous pH \u0026gt; 7.1 and \u0026lt;7.2, bicarbonate \u0026lt;10 mmol/l and\u0026nbsp;\u003c/li\u003e\n \u003cli\u003esevere: venous pH \u0026lt;7.1, bicarbonate \u0026lt;5 mmol/l.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eInfections/sepsis\u003c/strong\u003e : Infection episodes were documented the relation to AKI were analyzed \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis:\u003c/strong\u003e Descriptive statistics were used to summarize baseline demographics, diabetes mellitus characteristics, DKA and AKI parameters. Continuous variables were assessed for normality using the Shapiro\u0026ndash;Wilk test. Normally distributed variables were presented as means with standard deviations and compared using Student\u0026rsquo;s t-test, while non-normally distributed variables were presented as medians with interquartile ranges and compared using the Mann\u0026ndash;Whitney U test. Categorical variables were presented as percentages and compared using chi-squared or Fisher\u0026apos;s exact tests, as appropriate. Univariate logistic regression analyses were performed to identify factors associated with AKI development, using AKI as the dependent variable and demographic, baseline diabetes, and DKA characteristics as independent variables. Significant predictors from univariate analyses were included in a multivariate logistic regression model. The results were expressed as odds ratios with 95% confidence intervals, and the area under the receiver operating characteristic curve (AUC) was calculated for the combined model predicting AKI. Statistical significance was set at p \u0026lt; 0.05. Data were collected using Microsoft Excel\u0026reg; and analyzed with Stata version 18 (StataCorp, TX, USA).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eWe included 373 children who presented with diabetic ketoacidosis (DKA) at King Abdulaziz University Hospital, with a median age of 132 months (IQR 96-156) (Table1). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAKI was observed in 299 children (80.2%), categorized as Stage 1 in 98 (26.3%), Stage 2 in 118 (31.6%), and Stage 3 in 83 (22.3%) (Table 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2 shows the DM characteristics of pediatric patients presented with DKA. Diabetes mellitus (DM) was diagnosed at a median age of 108 months (IQR 60-132) (table 2). The interval between diabetes diagnosis and DKA presentation was significantly longer in children who developed AKI (median 72 months, IQR 48-108) compared to those without AKI (median 60 months, IQR 24-96, p=0.01) (table 2). The median HbA1c level before DKA presentation was 12% (IQR 9.9-13.8), and most children (88.2%) had previously experienced DKA episodes (table 2). Notably, half of the children did not have documented outpatient follow-up visits. Conventional insulin therapies were used in 77.8% of cases (table 2). Children with AKI had a lower rate of controlled diabetes (HbA1c \u0026le;8%) compared to those without AKI (7.7% vs. 20.3%, p=0.01) (table 2). Conversely, uncontrolled diabetes (HbA1c \u0026gt;8%) was more prevalent in the AKI group (92.3% vs. 79.7%,P=0,01).\u003c/p\u003e\n\u003cp\u003eTable 3 shows the clinical characteristics of pediatric patients who presented with DKA upon admission. The severity of DKA was classified as mild in 127 (34%), moderate in 126 (33.7%), and severe in 94 (25.2%) patients, respectively. Among the DKA characteristics, the incidence of AKI was higher in children with severe DKA (26.9% vs. 19.7%, p=0.01) and lower in those with mild DKA (31.9% vs. 45.1%, p\u0026lt;0.01) (table 3). The hospital length of stay was longer for children with AKI, with a median of 4 days (IQR 2-6) compared to 3 days (IQR 2-5) for those without AKI (p=0.07) (table 3).\u003c/p\u003e\n\u003cp\u003eAt presentation, children who developed AKI had a significantly higher median heart rate (120 bpm, IQR 104-138) compared to those without AKI (108 bpm, IQR 98-124, p\u0026lt;0.01) (table 3). Although a higher proportion of AKI patients had a Glasgow Coma Scale (GCS) score of less than 15 (5.7% vs. 1.7%), this difference was not statistically significant (p=0.22) (table 3). There was a total of 53 (14.2%) children with proven infections; 8(10.8%) in non-AKI group and 45 (15.1%) in AKI group (p = 0.46).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor patients with AKI we found 131 children (44%) had AKD according to serum creatine at the time of discharge \u0026nbsp;. None of the study participant have died during the studied hospital encounters.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUnivariable logistic regression analyses showed significant associations between AKI and the duration of DM prior to DKA, diabetes control (HbA1c \u0026le;8 vs. \u0026gt;8), DKA severity, and heart rate at presentation (Table 4). In the adjusted multivariable logistic regression model for age , gender and infections, heart rate, diabetes duration, and glycemic control remained significantly associated with AKI, with an area under the receiver operating characteristic curve (AUC) of 0.68 (95% CI: 0.61-0.75, p\u0026lt;0.01) (table 4).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study revealed that a substantial proportion (80.2%) of children with DKA developed AKI.\u0026nbsp;Huang et al.\u0026apos;s study comprised of 223 participants with 301 episodes of DKA. 56.5% of children and adolescents with DKA developed AKI at the time of admission, according to the findings. Notably, one-third of children with AKI were classified as having severe AKI, indicating not only volume-responsive injury yet also intrinsic renal tubular injury (12). Hursh et al. evaluated 165 children hospitalized for DKA and found a 64.3% prevalence of AKI; the AKI definition used in this study was based on the KDIGO criteria (7).However, this incidence is notably higher compared to the 40% reported in a study by Bergmann , highlighting variability in AKI prevalence across different studies. (13). The magnitude of AKI in our study 80.2%is higher than all three above quoted studies(7,12,13).This discrepancy may be attributed to differences in definitions and diagnostic criteria for AKI, emphasizing the need for standardized criteria in paediatric populations .\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe prevalent stages of AKI severity (stage II + III) was 41.77 % reported by Al-Khalifa et al. (14). In comparison, the prevalence in our cohort of combined severity of AKI (stage II+III)was \u0026nbsp;53.9%\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe high incidence of severe AKI observed in our cohort suggests that a significant number of children with DKA experience intrinsic renal damage rather than just functional AKI or volume-responsive AKI. This finding underscores the severity of renal complications in DKA and indicates that a substantial portion of DKA cases can lead to significant renal impairment. A recent systemic review shows pooled prevalence of severe AKI in 28% among patients with overall prevalence of AKI was 47% (6)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur study identified several clinical and biochemical factors associated with AKI development including duration of T1D, glycemic control. This study showed that prolonged duration of uncontrolled T1D more than 8 years linked to the development of AKI.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe showed that elevated HbA1C linked to AKI in children with DKA This aligns with findings from a large New Zealand study, which showed higher \u0026nbsp; HbA1C in children with AKI compared to non -AKI (p-value 0.04) \u0026nbsp;(15). These results highlight the critical role of effective diabetes management by regular follow up and maintaining good control of HbA1C to decrease AKI episodes in these vulnerable population.\u003c/p\u003e\n\u003cp\u003eInterestingly, while some studies have identified high sodium levels (\u0026ge;145 mEq/L), at admission as predictors of more severe AKI (16), we did not find a significant difference in serum sodium levels between patients with and without AKI (P = 0.88). This discrepancy may be due to variations in patient populations, measurement techniques, or other confounding factors.\u003c/p\u003e\n\u003cp\u003eOur study did demonstrate that a higher heart rate at admission was associated with an increased likelihood of developing AKI. This finding supports the hypothesis that severe volume depletion, as reflected by elevated heart rates, plays a crucial role in AKI development in children with DKA (12,17). However, it is important to note that overzealous fluid resuscitation can lead to hyperchloremia, which has been associated with prolonged recovery time from AKI (18). Thus, balanced fluid management remains essential to avoid exacerbating renal injury while treating DKA.\u003c/p\u003e\n\u003cp\u003eOur findings suggest that the severity of the DKA episode correlates with the likelihood of AKI development (table 4), consistent with other studies indicating that severe metabolic derangements. Huang showed that patients with AKI tends to have more severe acidosis with pH 7.15 compared to pH of 7.20 in non-AKI patients (p-value 0.01) (12)\u003c/p\u003e\n\u003cp\u003eWhile some studies have shown that initial high-volume intravenous boluses do not significantly differ in AKI resolution compared to low-volume boluses (18), it is important to keep careful fluid management tailored to individual patient needs.\u003c/p\u003e\n\u003cp\u003eInfection is a trigger factor for developing DKA (19) and a major contributing cause for AKI. In our study the incidence of infection rate was higher among patients with AKI although the difference was not statistically significant. However early diagnosis management of infection in DKA patients remains crucial and may help improve the outcomes of DKA and AKI.\u003c/p\u003e\n\u003cp\u003eFurthermore, the observation that a low Glasgow Coma Scale (GCS) score (less than 15) was prevalent among children with AKI is notable. Previous research has suggested that a GCS score of less than 14 is a risk factor for moderate to severe AKI, highlighting the importance of monitoring neurological status in these patients (19).\u003c/p\u003e\n\u003cp\u003eOur study showed that number of patients with renal impairment at time of discharge was significantly high in patients who developed AKI indicating \u0026nbsp; that a significant intrinsic renal damage can occur in patients with DKA and AKI.\u003c/p\u003e\n\u003cp\u003eMore studies are needed to assess long- term outcome for renal function.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Limitations and Future Directions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary limitation of this study is its retrospective design, which inherently relies on the accuracy and completeness of medical records. The retrospective nature may affect the precision of the data and limit the ability to establish causality. Future prospective studies with well-defined comparator populations and standardized diagnostic criteria are needed to validate these findings and further elucidate the risk factors for AKI in paediatric DKA patients.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study provides substantial evidence of the high incidence of AKI among patients hospitalized with DKA at a local setting.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur findings indicate a strong association between incidence of AKI and \u0026nbsp; severity of DKA. Patients with longer duration of T1D and poor glycaemic control were associated with higher incidence of AKI. \u0026nbsp;A high percentage of patients who of DKA patients developed AKI had persistent AKD indicating significant intrinsic renal damage. While in our study there was no mortality and none of our patients need dialysis, AKI still pose significant morbidity and mortality with AKI highlight the urgent need for effective strategies to prevent, diagnose, and manage AKI in children with T1D and DKA.\u0026nbsp;\u003c/p\u003e\n"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eAKI:\u0026nbsp;\u003c/strong\u003eAcute Kidney Injury\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAKD:\u0026nbsp;\u003c/strong\u003eAcute Kidney disease\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDKA:\u0026nbsp;\u003c/strong\u003eDiabetic Ketoacidosis\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eT1D:\u0026nbsp;\u003c/strong\u003eType 1 Diabetes\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKAUH:\u003c/strong\u003e King Abdulaziz University Hospital\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKDIGO:\u0026nbsp;\u003c/strong\u003eKidney Disease Improving Global Outcomes\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAUC:\u003c/strong\u003e Area Under Curve\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGCS:\u0026nbsp;\u003c/strong\u003eGlasgow Coma Scale\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the ethical principles of the Declaration of Helsinki and with the Ethical Guidelines for King Abdulaziz University . The study was approved by the Ethics Review Committee of King Abdulaziz University Hospital . Letter no 14567 issued on January 2024 As the data were collected retrospectively from patient charts, informed consent was deemed unnecessary following the above guidelines.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Consent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors agree to consent for publication\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Availability of Data and Materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dataset used and /or analyzed during the current study are valuable upon the request from the corresponding author\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Funding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors declare no funding resource\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Clinical trial number:\u003c/strong\u003e not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDA , AA, RA collected the data. IS performed statistical analysis. MS , MA ,SB reviewed the results NY,OS ,JK a senior authors who revised the manuscript. All authors Wrote the manuscript and discussed the results\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Acknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank patients and their families for participating in this study\u003c/p\u003e\n\u003cp\u003eWe would like to thanks Naia Fahd Alzahrani and Shahad Nader Alsulaiman for their efforts in collecting data\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003evon Oettingen JE, Rhodes ET, Wolfsdorf JI. Resolution of ketoacidosis in children with new onset diabetes: Evaluation of various definitions. Diabetes Res Clin Pract. 2018 Jan;135:76-84. doi: 10.1016/j.diabres.2017.09.011. Epub 2017 Oct 28. PMID: 29111277; PMCID: PMC6013285.\u003c/li\u003e\n\u003cli\u003eRobert AA, Al-Dawish A, Mujammami M, Dawish MAA. Type 1 Diabetes Mellitus in Saudi Arabia: A Soaring Epidemic. Int J Pediatr. 2018 May 8;2018:9408370. doi: 10.1155/2018/9408370. PMID: 29853923; PMCID: PMC5964576.\u003c/li\u003e\n\u003cli\u003eRewers A, Chase HP, Mackenzie T, Walravens P, Roback M, Rewers M, et al. Predictors of acute complications in children with type 1 diabetes. JAMA. 2002 May 15;287(19):2511-8. doi: 10.1001/jama.287.19.2511. PMID: 12020331.\u003c/li\u003e\n\u003cli\u003eMarks BE, Meighan S, Fivekiller EE, Escobar E, Berget C. Ketone Management in Pediatric Diabetes Centers in the USA: Current Practices and a Call for Improved Standardization. Horm Res Paediatr. 2024 Oct 15:1-9. doi: 10.1159/000541430. Epub ahead of print. PMID: 39406189.\u003c/li\u003e\n\u003cli\u003eSoltysiak J, Krzysko-Pieczka I, Gertig-Kolasa A, Mularz E, Skowrońska B, Ostalska-Nowicka D et al. Acute kidney injury and diabetic kidney disease in children with acute complications of diabetes. Pediatr Nephrol. 2023 May;38(5):1643-1652. doi: 10.1007/s00467-022-05735-7. Epub 2022 Oct 13. PMID: 36227434; PMCID: PMC10060302.\u003c/li\u003e\n\u003cli\u003eMeena J, Yadav J, Kumar J, Dawman L, Tiewosh K, Mittal A et al. Incidence, predictors, and short-term outcomes of acute kidney injury in children with diabetic ketoacidosis: a systematic review. Pediatr Nephrol. 2023 Jul;38(7):2023-2031. doi: 10.1007/s00467-023-05878-1. Epub 2023 Jan 27. PMID: 36705755.\u003c/li\u003e\n\u003cli\u003eHursh BE, Ronsley R, Islam N, Mammen C, Panagiotopoulos C. Acute Kidney Injury in Children With Type 1 Diabetes Hospitalized for Diabetic Ketoacidosis. JAMA Pediatr. 2017 May 1;171(5). doi: 10.1001/jamapediatrics.2017.0020. Epub 2017 May 1. PMID: 28288246.\u003c/li\u003e\n\u003cli\u003eMarzuillo P, Iafusco D, Zanfardino A, Guarino S, Piscopo A, Casaburo F, et al. Acute Kidney Injury and Renal Tubular Damage in Children With Type 1 Diabetes Mellitus Onset. J Clin Endocrinol Metab. 2021 Jun 16;106(7):e2720-e2737. doi: 10.1210/clinem/dgab090. PMID: 33595665.\u003c/li\u003e\n\u003cli\u003eHegab AM, Khalil FF, Abosedera MM. Incidence and factors associated with acute kidney injury among children with type 1 diabetes hospitalized with diabetic ketoacidosis: A prospective study. Pediatr Diabetes. 2022 Sep;23(6):783-791. doi: 10.1111/pedi.13370. Epub 2022 Jun 10. PMID: 35644034.\u003c/li\u003e\n\u003cli\u003eAl-Matrafi J, Vethamuthu J, Feber J. Severe acute renal failure in a patient with diabetic ketoacidosis. Saudi J Kidney Dis Transpl. 2009 Sep;20(5):831-4. PMID: 19736483.\u003c/li\u003e\n\u003cli\u003eYang EM, Lee HG, Oh KY, Kim CJ. Acute Kidney Injury in Pediatric Diabetic Ketoacidosis. Indian J Pediatr. 2021 Jun;88(6):568-573. doi: 10.1007/s12098-020-03549-9. Epub 2020 Nov 19. PMID: 33210207.\u003c/li\u003e\n\u003cli\u003eHuang SK, Huang CY, Lin CH, Cheng BW, Chiang YT, Lee YC, et al.Acute kidney injury is a common complication in children and adolescents hospitalized for diabetic ketoacidosis. PLoS One. 2020 Oct 7;15(10). doi: 10.1371/journal.pone.0239160. PMID: 33027293; PMCID: PMC7540857.\u003c/li\u003e\n\u003cli\u003eBergmann KR, Bjornstad P, Abuzzahab MJ, Zhong L, Collins-Dippel E, Nickel A, et al. Multicentre, retrospective cohort study protocol to identify racial and ethnic differences in acute kidney injuries in children and adolescents with diabetic ketoacidosis. BMJ Open. 2024 Jun 5;14(6). doi: 10.1136/bmjopen-2024-086261. PMID: 38839382; PMCID: PMC11163677.\u003c/li\u003e\n\u003cli\u003eAl Khalifah R, Al-Eyadhy A, Musibeeh N, Alshalawi A, Alanazi N, Alhboob A, et al. Risk factors, outcomes, and predictors of resolution of acute kidney injury in children with diabetic ketoacidosis. Pediatr Nephrol. 2023 Feb;38(2):573-582. doi: 10.1007/s00467-022-05578-2. Epub 2022 May 18. PMID: 35585363.\u003c/li\u003e\n\u003cli\u003ePittman F, Di Somma H, Wong W, Prestidge C, Reed P, Gunn AJ, et al Determinants of acute kidney injury in children with new onset type 1 diabetes: A cohort study of children aged \u0026lt;15 years: Auckland, New Zealand (2006-2016). Endocrinol Diabetes Metab. 2022 Sep;5(5). doi: 10.1002/edm2.362. Epub 2022 Aug 4. PMID: 35927794; PMCID: PMC9471584.\u003c/li\u003e\n\u003cli\u003eRaghunathan V, Jevalikar G, Dhaliwal M, Singh D, Sethi SK, Kaur P, et al. Risk Factors for Cerebral Edema and Acute Kidney Injury in Children with Diabetic Ketoacidosis. Indian J Crit Care Med. 2021 Dec;25(12):1446-1451. doi: 10.5005/jp-journals-10071-24038. PMID: 35027807; PMCID: PMC8693099.\u003c/li\u003e\n\u003cli\u003eSutherland SM, Kwiatkowski DM. Acute kidney injury in children. Adv Chronic Kidney Dis. 2017;24:380-7.\u003c/li\u003e\n\u003cli\u003eHay RE, Parsons SJ, Wade AW. The effect of dehydration, hyperchloremia and volume of fluid resuscitation on acute kidney injury in children admitted to hospital with diabetic ketoacidosis. Pediatr Nephrol. 2024 Mar;39(3):889-896. doi: 10.1007/s00467-023-06152-0. Epub 2023 Sep 21. PMID: 37733096.\u003c/li\u003e\n\u003cli\u003eBirhanu A, Ambachew S, Baye N, Getnet E, Admas S, Gebrie,et al. Prevalence and associated factors of diabetic ketoacidosis among patients with diabetes mellitus at the University of Gondar Comprehensive and Specialized Referral Hospital Northwest, Ethiopia. PLoS One. 2025 Feb 10;20(2):e0318775. doi: 10.1371/journal.pone.0318775. PMID: 39928633; PMCID: PMC11809922\u003c/li\u003e\n\u003cli\u003eRane RP, Soundranayagam S, Shade DA, Nauer K, DuMont T, Nashar K, et al. Renal Involvement in Sepsis: Acute Kidney Injury. Crit Care Nurs Q. 2025 Apr-Jun 01;48(2):100-108. doi: 10.1097/CNQ.0000000000000553. Epub 2025 Feb 27. PMID: 40009857.\u003c/li\u003e\n\u003cli\u003eAhmed HM, Elnaby HRH, El Kareem RMA, Hodeib M. The relationship between hyperchloremia and acute kidney injury in pediatric diabetic ketoacidosis and its impact on clinical outcomes. Pediatr Nephrol. 2022 Jun;37(6):1407-1413. doi: 10.1007/s00467-021-05279-2. Epub 2021 Nov 5. PMID: 34738144.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1:\u0026nbsp;\u003c/strong\u003eBaseline characteristics of pediatric patients with diabetic ketoacidosis (DKA).\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"779\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 402px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChildren with DKA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo AKI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAKI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e373\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e74 (19.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e299 (80.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDemographics at presentation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 476px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eAge,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003emonths (median [IQR])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e132 (96-162)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e132 (84-156)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e132 (108-168)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eSex,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003emale (n [%])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e140 (37.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e25 (33.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e115 (38.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eWeight,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003ekg (median [IQR])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e30 (20-43.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e30 (20-40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e30 (20-45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.58\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eHeight,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003ecm (median [IQR])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e139 (117-150)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e137 (120-150)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e140 (116.5-150)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eBody mass index,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003ekg/m\u003csup\u003e2\u0026nbsp;\u003c/sup\u003e(median [IQR])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e17.4 (14-21.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e17.6 (14-20.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e17.2 (13.9-21.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eNationality,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003eSaudi (n [%])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e178 (47.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e40 (54.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e138 (46.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2:\u0026nbsp;\u003c/strong\u003eDM characteristics of pediatric patients with diabetic ketoacidosis (DKA).\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"788\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 402px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChildren with DKA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo AKI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAKI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e373\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e74 (19.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e299 (80.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline diabetes characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 476px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eAge of onset,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003emonths (median [IQR])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e108 (60-132)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e108 (72-132)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e108 (60-132)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.41\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eDuration of DM,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003emonths (median [IQR])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e72 (48-108)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e60 (24-96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e72 (48-108)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eLast HbA1C,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e% (median [IQR])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e12.1 (9.9-13.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e11.6 (9-13.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e12.2 (10-13.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eHistory of previous DKA,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e(n [%])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e329 (88.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e67 (90.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e262 (87.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of outpatient visits\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 476px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eNo visits,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e(n [%])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e190 (50.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e40 (54.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e150 (50.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 74px;\"\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e1-2 visits,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e(n [%])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e86 (23.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e17 (23.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e69 (23.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026ge;3 visits,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e(n [%])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e97 (26%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e17 (23.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e80 (26.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInsulin regimen type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 476px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eConventional\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003cem\u003etherapy,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e(n [%])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e287 (77.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e58 (79.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e229 (77.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 74px;\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eMDI therapy,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e(n [%])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e82 (22.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e15 (20.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e67 (22.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiabetes control\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 476px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eControlled (HbA1C \u0026lt;= 8),\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e(n [%])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e38 (10.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e15 (20.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e23 (7.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eUncontrolled (HbA1C \u0026gt; 8) ,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e(n [%])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e335 (89.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e59 (79.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e276 (92.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3:\u0026nbsp;\u003c/strong\u003eClinical characteristics at admission of pediatric patients with diabetic ketoacidosis (DKA).\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"794\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 416px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChildren with DKA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo AKI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAKI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e373\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e74 (19.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e299 (80.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHospital location\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 482px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eEmergency,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e(n [%])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e5 (1.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e1 (1.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e4 (1.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eWard,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e(n [%])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e293 (79.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e57 (79.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e236 (78.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eICU,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e(n [%])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e73 (19.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e14 (19.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e59 (19.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eICU length of stay,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003edays (median [IQR])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e2 (1-3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e2 (1-2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e2 (1-3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVital signs at admission\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 482px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eSystolic BP,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003emmHg (median [IQR])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e112 (105-122)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e112 (105-120)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e112 (105-123)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eDiastolic BP,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003emmHg (median [IQR])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e69.5 (62-77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e68 (61-74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e70 (62-77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eHeart rate,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003ebpm (median [IQR])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e117 (102-134)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e108 (98-124)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e120 (104-137)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eTemperature,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026deg;C (median [IQR])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e36.9 (36.6-37.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e36.9 (36.5-37.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e36.9 (36.6-37.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePresence of infection\u003cem\u003e,\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;(n [%])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e53 (14.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e8 (10.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e45 (15.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGlasgow Coma Scale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 482px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e15,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e(n [%])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e355 (95.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e73 (98.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e282 (94.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026lt;15,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e(n [%])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e18 (4.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e1 (1.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e17 (5.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeverity of DKA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 482px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eUnknown,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e(n [%])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e25(6.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e11 (3 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e14 (3.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eMild,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e(n [%])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e127 (34%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e32 (45.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e95 (31.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eModerate,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e(n [%])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e126 (33.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e17 (23.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e109 (36.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eSevere,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e(n [%])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e94 (25.2 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e14 (19.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e80 (26.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline laboratories\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 482px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eHbA1C,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e% (median [IQR])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e12.9 (10.9-14.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e12.3 (10.5-14.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e13 (10.9-14.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eBicarbonate,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003emEq/L (median [IQR])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e10 (6-12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e10.5 (5.5-13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e9 (6-12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eNa correction,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003emEq/L (median [IQR])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e140 (136-145)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e140 (137-144)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e140 (136-145)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHospital length of stay,\u0026nbsp;\u003c/strong\u003edays (median [IQR])\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e4 (2-6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e3 (2-5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e4 (2-6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAKI stage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eStage 1,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e(n [%])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 150px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 133px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e98 (26.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 66px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eStage 2,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e(n [%])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e118 (31.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eStage 3,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e(n [%])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e83 (22.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRenal impairment at discharge\u003cem\u003e,\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;(n [%])\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e131 (35.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e131 (44.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMortality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eTable 4:\u0026nbsp;\u003c/strong\u003eMultivariable logistic regression analysis for predictor variables associated with AKI development in children with DKA.\u0026nbsp;\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"791\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 212px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMultivariable logistic regression\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjusted multivariable logistic regression*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 212px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 145px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 212px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration of DM\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.00\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.049\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.056\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 212px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUncontrolled DM (\u0026gt;8)\u003csup\u003e\u0026euro;\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.81\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.69\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e8.57\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.59\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.56\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e8.26\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.003\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 212px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHeart rate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.00\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.02\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.017\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.00\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.03\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.015\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 212px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeverity of DKA^\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 212px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eMild\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e1.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e4.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.454\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e1.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e4.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e0.366\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 212px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eModerate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.69\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.27\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e10.70\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.016\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.09\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.38\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e12.11\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.011\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 212px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eSevere\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.79\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.94\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e8.29\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.065\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.16\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.03\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e9.65\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.043\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" style=\"width: 791px;\"\u003e\n \u003cp\u003e* Adjusted for age of presentation, sex, and the presence of infection\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003csup\u003e\u0026euro; \u0026nbsp;\u003c/sup\u003e\u003c/strong\u003eReference: controlled DM (HbA1C \u0026lt;= 8)\u003c/p\u003e\n \u003cp\u003e^ Reference: unknown DKA severity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Type 1 diabetes, Diabetes ketoacidosis, Pediatric, Acute kidney injury, Incidence rate","lastPublishedDoi":"10.21203/rs.3.rs-4938618/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4938618/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cu\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/u\u003e\u003cstrong\u003e \u003c/strong\u003eAcute kidney injury (AKI) in pediatric patients has been linked to unfavorable short-term and long-term health outcomes. Despite the significance of AKI awareness in children with diabetes mellitus type 1 (T1D) , the incidence of AKI in children admitted with diabetic ketoacidosis (DKA) has been under looked.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eObjectives:\u003c/strong\u003e\u003c/u\u003e\u003cstrong\u003e \u003c/strong\u003eThe primary objective of this study was to investigate the incidence of acute kidney injury (AKI) in pediatric patients hospitalized for diabetic ketoacidosis (DKA), and to identify the clinical and biochemical markers associated with the development of AKI.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/u\u003e\u003cstrong\u003e \u003c/strong\u003eA retrospective medical record review was conducted at King Abdulaziz University Hospital, a tertiary hospital in Jeddah, Saudi Arabia. The study included a total of 373 children aged 18 years or younger from 2012 to 2022 with complete medical records available for analysis. We collected baseline and diabetes characteristics, in addition to clinical variables at presentation. Acute kidney injury (AKI) was diagnosed using the serum creatinine criteria established by the kidney disease: Improving Global Outcomes (KDIGO) organization. Descriptive comparisons were performed. Uni- and multivariable logistic regression analyses were employed to identify potential risk factors associated with the development of AKI.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/u\u003e \u0026nbsp;A total of 299 patients (80.2%) developed AKI including 98 (26.3%) stage 1, and 118 (31.6%) stage 2 and 83 (22.3%) stage 3. The frequency of AKI was higher in patients with severe DKA (26.9% vs. 19.7%, p=0.01) while in mild DKA the percentage of AKI was less than non-AKI (31.9% vs. 45.1%, p\u0026lt;0.01) Children with AKI had \u0026nbsp;longer hospital \u0026nbsp;stay compared to non-AKI (4 days vs 3 days , \u003cem\u003ep\u003c/em\u003e=0.02). The median last HbA1C prior to DKA presentation was 12%, and majority (88.2%) had DKA episodes in past. children who developed AKI had a significantly higher median heart rate (120 bpm, IQR 104-138) compared to those without AKI (108 bpm, IQR 98-124, p\u0026lt;0.01) . A high percentage of children with AKI had low Glasgow coma scale (\u0026lt;15) compared to non-AKI (5.7% vs. 1.7%) but the difference was not statistically significant( \u003cem\u003ep\u003c/em\u003e=0.22). Half of the children presented with DKA had poor \u0026nbsp;outpatient follow up visits. The proven infections were observed in 53 (14.2 %) children \u0026nbsp;in DKA. It was higher \u0026nbsp;in non-AKI group compared to AKI group(15.1% vs 10.8%,p=0.46). Outcome of AKI showed persistent acute kidney disease (AKD) at discharge in 131 (44%) \u0026nbsp;in patients who developed AKI. \u0026nbsp;We did not observe mortality. None of the study participant have died during the studied hospital encounters.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/u\u003e Our findings indicate that AKI is common in children admitted with DKA. Longer duration and poor controlled T1D , previous episodes of DKA , Severe DKA , infection and higher heart rate are risk factors to develop AKI\u003c/p\u003e\n\u003cp\u003eThe hospital stay was higher in children with AKI highlighting its significant morbidity in Children with AKI\u003c/p\u003e","manuscriptTitle":"Risk Factors and Outcomes of Acute Kidney Injury in Children with Diabetic Ketoacidosis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-26 12:43:42","doi":"10.21203/rs.3.rs-4938618/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-11T04:40:09+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-11T04:34:57+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-07T07:34:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"300744154849950579953260132684883565870","date":"2025-03-25T06:45:53+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-24T21:36:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-24T06:24:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nephrology","date":"2025-03-19T10:10:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"28d92715-b878-4634-b6a4-4a56e0f4cb82","owner":[],"postedDate":"March 26th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-26T16:03:11+00:00","versionOfRecord":{"articleIdentity":"rs-4938618","link":"https://doi.org/10.1186/s12882-025-04178-0","journal":{"identity":"bmc-nephrology","isVorOnly":false,"title":"BMC Nephrology"},"publishedOn":"2025-05-22 15:58:08","publishedOnDateReadable":"May 22nd, 2025"},"versionCreatedAt":"2025-03-26 12:43:42","video":"","vorDoi":"10.1186/s12882-025-04178-0","vorDoiUrl":"https://doi.org/10.1186/s12882-025-04178-0","workflowStages":[]},"version":"v1","identity":"rs-4938618","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4938618","identity":"rs-4938618","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}