Letters to the Editor
min/1.73 m2) with all except one having estimated GFR above
90 mL/min/1.73 m2.
Second, Martinez Herrada et al (1) emphasized the chal-
lenges in using serum creatinine measurements as an indicator
of AKI in children with DKA. We agree that as serum creatinine
measurements can be falsely elevated due to elevated levels of
acetoacetate, glucose, and glycosylated hemoglobin, it may be
that the true prevalence of AKI in our population is actually
lower than 30%. In any case, the fact that all of our patients had
normal creatinine levels at follow-up and no effect on outcome
was found, emphasizes the benign nature of KDIGO defined
AKI in our patient population.
Dr. Weissbach has disclosed that he does not have any
­potential conflicts of interest.
Avichai Weissbach, MD, Pediatric Intensive Care Unit,
Schneider Children’s Medical Center of Israel, Petach Tikva,
Israel
REFERENCES
1. Martinez Herrada A, Shein SL, Rotta AT: Methodologic Challenges
in the Diagnosis of Acute Kidney Injury in Children With Diabetic
Ketoacidosis. Pediatr Crit Care Med 2019; 20:589
2. Weissbach A, Zur N, Kaplan E, et al: Acute kidney injury in critically ill
children admitted to the PICU for diabetic ketoacidosis. A retrospec-
tive study. Pediatr Crit Care Med 2019; 20:e10–e14
3. Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney
Injury Work Group: KDIGO clinical practice guideline for acute kidney
injury. Kidney Int Suppl 2012; 2:8–12
4. Zappitelli M, Parikh CR, Akcan-Arikan A, et al: Ascertainment and ep-
idemiology of acute kidney injury varies with definition interpretation.
Clin J Am Soc Nephrol 2008; 3:948–954
5. Hursh BE, Ronsley R, Islam N, et al: Acute kidney injury in children
with type 1 diabetes hospitalized for diabetic ketoacidosis. JAMA
Pediatr 2017; 171:e170020
DOI: 10.1097/PCC.0000000000001951
Acute Kidney Injury in Children With Diabetic
Ketoacidosis: A Real Concern
To the Editor:
T
he literature on occurrence and predictors of devel-
opment of acute kidney injury (AKI) in children with
diabetic ketoacidosis (DKA) is limited (1–3) (Table 1).
A recent study by Weissbach et al (4), published in a recent
issue of Pediatric Critical Care Medicine, is an important addi-
tion to limited literature in this area. Authors demonstrated
that in children (< 18 yr old) (n = 82) admitted to PICU
with DKA, the incidence of AKI (Kidney Disease: Improving
Global Outcomes classification) was 30% (n = 24). Majority
(75%) had stage 1 AKI. Cases with AKI had higher admission
levels of corrected sodium, lactate, and glucose as compared
with cases with no AKI. On multivariate logistic regression
analysis, only corrected sodium was found to be significantly
associated with AKI (odds ratio [OR], 1.22). The duration of
PICU and hospital stay and fluid balance at discharge from
590 www.pccmjournal.org June 2019 • Volume 20 • Number 6
Copyright © 2019 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.
Unauthorized reproduction of this article is prohibited
PICU was similar in two groups. None of the cases with AKI
needed renal replacement therapy (RRT) and AKI recovered
in majority of patients at discharge (n = 20) and rest had
normal renal functions at first follow-up. Authors empha-
sized that development of AKI in children with DKA had
minor clinical implications and kidney function returns to
normal.
A similar study was published from our institute involv-
ing children with DKA (n = 79) admitted to PICU. Two-
third cases had severe DKA, and AKI (Pediatric Risk, Injury,
Failure, Loss, End Stage Renal Disease classification) was
noted in 35.4% cases (46.4% at admission and rest within
24 hr of admission). On multivariable analysis, elevated chlo-
ride levels at 24 hours was independently associated with
AKI progression (adjusted OR, 1.20; 95% CI, 1.04–1.27; p =
0.007). Also, serum chloride greater than 112 mmol/L at 24
hours had a sensitivity, specificity, and area under receiver
operating characteristic curve of 73.3%, 82.4%, and 0.835,
respectively for development of AKI (p < 0.001). Children
with AKI took longer time for resolution of acidosis (median
[interquartile range (IQR)] 31 hr [24–77 hr] vs 26 hr [20–5
hr]; p = 0.006) and had longer PICU stay (median [IQR] 3
d [2–5 d] vs 2 d [1–2 d]; p < 0.001). In addition, they had
higher odds for requiring vasoactive support (OR, 5.1) and
ventilation (OR, 7.6), developing cerebral edema (OR, 7.6),
and mortality (13.6).
Findings of our study (3) are in contrast to the study by
Weissbach et al (4). The AKI in children with DKA has signif-
icant implication in terms of requirement of RRT and higher
mortality (1–3). The development of hyperchloremia in DKA
may be due to the large volume of isotonic fluid administra-
tion (3). Hyperchloremia has been linked to development of
AKI due to its smooth muscle constrictor effect on renal ves-
sels (5). The serial measurement of chloride and following the
trend while managing DKA could guide fluid therapy and help
in preventing AKI.
The authors have disclosed that they do not have any poten-
tial conflicts of interest.
Biraj Parajuli, DM, Suresh Kumar Angurana, DM,
FCCP, FIMSA, Division of Pediatric Critical Care,
Department of Pediatrics, Advanced Pediatric Center (APC),
Postgraduate Institute of Medical Education and Research
(PGIMER), Chandigarh, India; Mullai Baalaaji, DM,
Department of Pediatrics, Kovai Medical Center and Hospital,
Coimbatore, India; Vijai Williams, DM, Division of Pediatric
Critical Care, Department of Pediatrics, Advanced Pediatric
Center (APC), Postgraduate Institute of Medical Education
and Research (PGIMER), Chandigarh, India
REFERENCES
1. Hursh BE, Ronsley R, Islam N, et al: Acute kidney injury in children
with type 1 diabetes hospitalized for diabetic ketoacidosis. JAMA
Pediatr 2017; 171:e170020
2. Abbas Q, Arbab S, Haque AU, et al: Spectrum of complications of
severe DKA in children in pediatric intensive care unit. Pak J Med Sci
2018; 34:106–109
 Letters to the Editor

TABLE 1. Summary of Studies Showing Incidence of Acute Kidney Injury in Children With
Diabetic Ketoacidosis, Requirement of Renal Replacement Therapy, Mortality, and
Predictors of Developing Acute Kidney Injury
Children
With Diabetic Renal
Ketoacidosis, Replacement Mortality, Predictors of
No. References n AKI, % Therapy, n n Developing AKI

1 Hursh et al (1) 165 64.2 2 None Serum bicarbonate < 10 (aOR, 5.22)
Each increase of 5 beats/min in initial
heart rate (aOR, 1.22)
Initial corrected sodium ≥ 145 mEq/L
(aOR, 3.29)
2 Abbas et al (2) 37 27 1 2
3 Baalaaji et al (3) 79 35.4 8 7 Elevated chloride levels at 24 hr
(aOR, 1.20)
4 Weissbach 82 30 None None Admission corrected sodium (OR, 1.22)
et al (4)
AKI = acute kidney injury, aOR = adjusted odds ratio.

3. Baalaaji M, Jayashree M, Nallasamy K, et al: Predictors and outcome
of acute kidney injury in children with diabetic ketoacidosis. Indian
Pediatr 2018; 55:311–314
4. Weissbach A, Zur N, Kaplan E, et al: Acute Kidney Injury in Critically
Ill Children Admitted to the PICU for Diabetic Ketoacidosis. A
Retrospective Study. Pediatr Crit Care Med 2019; 20:e10–e14
5. Marttinen M, Wilkman E, Petäjä L, et al: Association of plasma chlo-
ride values with acute kidney injury in the critically ill - a prospective
observational study. Acta Anaesthesiol Scand 2016; 60:790–799
DOI: 10.1097/PCC.0000000000001928
The author replies:
recovery. This might be explained by different preadmission
patient management and differences in treatment protocols at
different centers. Therefore, our study results and conclusions
are truly limited to the population on which it was performed.
Further multicenter international trials are needed to assess
the prevalence, risk factors for and significance of AKI in chil-
dren with DKA.
Dr. Weissbach has disclosed that he does not have any
­potential conflicts of interest.
Avichai Weissbach, MD, Pediatric Intensive Care Unit,
Schneider Children’s Medical Center of Israel, Petach Tikva,
Israel

W
e thank Parajuli et al (1) for their comments to our
recent article (2) published in Pediatric Critical Care
Medicine describing the prevalence and clinical sig-
nificance of acute kidney injury (AKI) in critically ill children
admitted to the PICU for diabetic ketoacidosis (DKA).
Parajuli et al (1) cite a similar study that was undertaken at
their institution (3). In their study, they found a similar rate of
AKI (35.4%) among children with DKA admitted to PICU. In
contrast to our results, they found AKI to be associated with
a longer PICU length of stay, higher odds for requiring vaso-
active support, requiring mechanical ventilation, increased rate
of cerebral edema development, and mortality. Some of their
children with AKI required renal replacement therapy. They
observed that only eight out of 79 children were treated with in-
sulin and appropriate fluids prior to referral to their center (3).
In our cohort, none of the patients required mechanical ventila-
REFERENCES
1. Parajuli B, Angurana SK, Baalaaji M, et al: Acute Kidney Injury in
Children With Diabetic Ketoacidosis: A Real Concern. Pediatr Crit
Care Med 2019; 20:590–591
2. Weissbach A, Zur N, Kaplan E, et al: Acute kidney injury in critically ill
children admitted to the PICU for diabetic ketoacidosis. A retrospec-
tive study. Pediatr Crit Care Med 2019; 20:e10–e14
3. Baalaaji M, Jayashree M, Nallasamy K, et al: Predictors and outcome
of acute kidney injury in children with diabetic ketoacidosis. Indian
Pediatr 2018; 55:311–314
DOI: 10.1097/PCC.0000000000001952
Let’s Do It Right
To the Editor:

tion, vasoactive support, or renal replacement therapy. Further-
more, in our cohort, all patients survived, and only one patient
was treated with hyperosmolar therapy for clinically suspected
cerebral edema that was not demonstrated on head CT.
Although both studies included patients with similarly se-
vere degree of DKA, it seems like the patients in the study by
Parajuli et al (1) had a worse course of disease with a slower
I
appreciate the effort put into the recently published article
by Conlon et al (1) in Pediatric Critical Care Medicine. The
results are quite interesting, but I have some questions about
the study. Although the response rate was good, I wonder if the
appropriate persons were surveyed, despite the best intention of
the authors. I am an expert in pediatric critical care ultrasound
(PCCUS), having taught ultrasound at the American College

Pediatric Critical Care Medicine www.pccmjournal.org 591

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