Hypertension During Diabetic Ketoacidosis in Children

Overview

Journal J Pediatr

Specialty Pediatrics

Date 2020 May 11

PMID 32387716

Citations 7

Authors

Andrew DePiero

Nathan Kuppermann

Kathleen M Brown

Jeff E Schunk

Julie K McManemy

Arleta Rewers

Michael J Stoner

Leah Tzimenatos

Aris Garro

Sage R Myers

Kimberly S Quayle

Jennifer L Trainor

Maria Y Kwok

Lise E Nigrovic

Cody S Olsen

T Charles Casper

Simona Ghetti

Nicole S Glaser

Affiliations

Soon will be listed here.

Abstract

Objectives: To characterize hemodynamic alterations occurring during diabetic ketoacidosis (DKA) in a large cohort of children and to identify clinical and biochemical factors associated with hypertension.

Study Design: This was a planned secondary analysis of data from the Pediatric Emergency Care Applied Research Network Fluid Therapies Under Investigation in DKA Study, a randomized clinical trial of fluid resuscitation protocols for children in DKA. Hemodynamic data (heart rate, blood pressure) from children with DKA were assessed in comparison with normal values for age and sex. Multivariable statistical modeling was used to explore clinical and laboratory predictors of hypertension.

Results: Among 1258 DKA episodes, hypertension was documented at presentation in 154 (12.2%) and developed during DKA treatment in an additional 196 (15.6%), resulting in a total of 350 DKA episodes (27.8%) in which hypertension occurred at some time. Factors associated with hypertension at presentation included more severe acidosis, (lower pH and lower pCO), and stage 2 or 3 acute kidney injury. More severe acidosis and lower Glasgow Coma Scale scores were associated with hypertension occurring at any time during DKA treatment.

Conclusions: Despite dehydration, hypertension occurs in a substantial number of children with DKA. Factors associated with hypertension include greater severity of acidosis, lower pCO and lower Glasgow Coma Scale scores during DKA treatment, suggesting that hypertension might be centrally mediated.

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References

Salleh H, Mujawar Q . Hypertension in severe pediatric diabetic ketoacidosis: case report and review of literature. Pediatr Emerg Care. 2013; 29(1):82-3. DOI: 10.1097/PEC.0b013e31827b564e. View

Ostchega Y, Porter K, Hughes J, Dillon C, Nwankwo T . Resting pulse rate reference data for children, adolescents, and adults: United States, 1999-2008. Natl Health Stat Report. 2011; (41):1-16. View

Lawrence S, Cummings E, Gaboury I, Daneman D . Population-based study of incidence and risk factors for cerebral edema in pediatric diabetic ketoacidosis. J Pediatr. 2005; 146(5):688-92. DOI: 10.1016/j.jpeds.2004.12.041. View

Bissler J, Welch T, Loggie J . Paradoxical hypertension in hypovolemic children. Pediatr Emerg Care. 1991; 7(6):350-2. DOI: 10.1097/00006565-199112000-00008. View

Edge J, Hawkins M, Winter D, Dunger D . The risk and outcome of cerebral oedema developing during diabetic ketoacidosis. Arch Dis Child. 2001; 85(1):16-22. PMC: 1718828. DOI: 10.1136/adc.85.1.16. View

Glaser N, Barnett P, McCaslin I, Nelson D, Trainor J, LOUIE J . Risk factors for cerebral edema in children with diabetic ketoacidosis. The Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. N Engl J Med. 2001; 344(4):264-9. DOI: 10.1056/NEJM200101253440404. View

Davies D, Beevers D, Briggs J, Medina A, Robertson J, SCHALEKAMP M . Abnormal relation between exchangeable sodium and the renin-angiotensin system in malignant hypertension and in hypertension with chronic renal failure. Lancet. 1973; 1(7805):683-6. DOI: 10.1016/s0140-6736(73)91476-1. View

Deeter K, Roberts J, Bradford H, Richards T, Shaw D, Marro K . Hypertension despite dehydration during severe pediatric diabetic ketoacidosis. Pediatr Diabetes. 2011; 12(4 Pt 1):295-301. PMC: 3103609. DOI: 10.1111/j.1399-5448.2010.00695.x. View

Glaser N, Wootton-Gorges S, Marcin J, Buonocore M, DiCarlo J, Neely E . Mechanism of cerebral edema in children with diabetic ketoacidosis. J Pediatr. 2004; 145(2):164-71. DOI: 10.1016/j.jpeds.2004.03.045. View

10.

Ba Aqeel S, Sanchez A, Batlle D . Angiotensinogen as a biomarker of acute kidney injury. Clin Kidney J. 2017; 10(6):759-768. PMC: 5716162. DOI: 10.1093/ckj/sfx087. View

11.

Glaser N, Ghetti S, Casper T, Dean J, Kuppermann N . Pediatric diabetic ketoacidosis, fluid therapy, and cerebral injury: the design of a factorial randomized controlled trial. Pediatr Diabetes. 2013; 14(6):435-46. PMC: 3687019. DOI: 10.1111/pedi.12027. View

12.

Katz M . Hyperglycemia-induced hyponatremia--calculation of expected serum sodium depression. N Engl J Med. 1973; 289(16):843-4. DOI: 10.1056/NEJM197310182891607. View

13.

Kumar Tiwari L, Jayashree M, Muralindharan J, Singhi S . Risk factors for cerebral edema in diabetic ketoacidosis in a developing country: role of fluid refractory shock. Pediatr Crit Care Med. 2012; 13(2):e91-6. DOI: 10.1097/PCC.0b013e3182196c6d. View

14.

Allison D, Paultre F, Maggio C, Mezzitis N, Pi-Sunyer F . The use of areas under curves in diabetes research. Diabetes Care. 1995; 18(2):245-50. DOI: 10.2337/diacare.18.2.245. View

15.

Glaser N, Wootton-Gorges S, Buonocore M, Marcin J, Rewers A, Strain J . Frequency of sub-clinical cerebral edema in children with diabetic ketoacidosis. Pediatr Diabetes. 2006; 7(2):75-80. DOI: 10.1111/j.1399-543X.2006.00156.x. View

16.

Kuppermann N, Ghetti S, Schunk J, Stoner M, Rewers A, McManemy J . Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. N Engl J Med. 2018; 378(24):2275-2287. PMC: 6051773. DOI: 10.1056/NEJMoa1716816. View

17.

Marcin J, Glaser N, Barnett P, McCaslin I, Nelson D, Trainor J . Factors associated with adverse outcomes in children with diabetic ketoacidosis-related cerebral edema. J Pediatr. 2002; 141(6):793-7. DOI: 10.1067/mpd.2002.128888. View

18.

Glaser N, Tancredi D, Marcin J, Caltagirone R, Lee Y, Murphy C . Cerebral hyperemia measured with near infrared spectroscopy during treatment of diabetic ketoacidosis in children. J Pediatr. 2013; 163(4):1111-6. PMC: 3792791. DOI: 10.1016/j.jpeds.2013.06.008. View

19.

Sottosanti M, Morrison G, Singh R, Sharma A, Fraser D, Alawi K . Dehydration in children with diabetic ketoacidosis: a prospective study. Arch Dis Child. 2012; 97(2):96-100. DOI: 10.1136/archdischild-2011-300173. View

20.

Feldt-Rasmussen B, Mathiesen E, Deckert T, Giese J, Christensen N, Nielsen M . Central role for sodium in the pathogenesis of blood pressure changes independent of angiotensin, aldosterone and catecholamines in type 1 (insulin-dependent) diabetes mellitus. Diabetologia. 1987; 30(8):610-7. DOI: 10.1007/BF00277316. View