Research Article - (2021) Volume 12, Issue 9
Background: Diabetic ketoacidosis (DKA) is an acute and life-threatening situation that accounts for the majority of diabetes related morbidity and mortality in children and adolescents who suffer from type 1 diabetes mellitus (T1DM). Diabetic ketoacidosis is the most severe endocrine emergency in pediatrics, which is characterized by hyperglycemia (>250 mg/dl or 14 moll/l), metabolic acidosis (venous pH < 7.3), with associated glucosuria, ketonuria, and ketonemia.
Objective: To assess the precipitating factors, clinical presentation, and treatment outcome of diabetic ketoacidosis among diabetic patients in two tertiary hospital of Addis Ababa.
Methods: A retrospective analysis was done on the case records of 175 children with diabetic ketoacidosis admitted to our hospital from January 2015 to April 2020. They were managed using a standard protocol including intravenous fluids and insulin infusion. Blood glucose, serum electrolytes, blood urea, and urinary ketones were monitored at regular intervals. The outcomes were assessed. The data was checked for its ’ completeness and entered into Epi version 4.6, and imported to SPSS version 25 software for analysis. The Associations between independent and dependent variables were analyzed using binary logistic regression models. Result: The median age at presentation was 8 years ’ ranges from < 6 months to ≤ 12 years with male to female ratio of 1:1.5. One hundred thirtyseven children (78.3%) were detected to have diabetes mellitus at the time of presentation. Dehydration, Polyuria with polydipsia was the commonest clinical presentation. The precipitating factor of DKA was newly diagnosed, omission of insulin and infection respectively (137, 78.3%, 33, 21.7% and 5,2.9%). There was mortality which accounts 6.9%.
Conclusion and Recommendation: DKA were most prevalent in newly diagnosed TIDM cases. Newly diagnosed T1DM and insulin omission were the main factors associated with DKA. The age of presentation and clinical symptoms of studied subjects were similar to international studies. High frequency of DKA at presentation of T1DM requires careful attention to issues of early diagnosis before development of ketoacidosis and subsequently need prevention of DKA management complication. We recommend all the health facilities to give health education about the sign and symptoms of DM and the acute complications of DM.
Diabetic ketoacidosis; Treatment outcome; Precipitating factors
Diabetes mellitus is a chronic disease that occurs due to lack of insulin secondary to pancreas does not produce enough insulin or the body cannot effectively use the insulin which was produced [1]. The other definition of DM is a common endocrine disorder that results from either insufficiency or ineffectiveness insulin. DM is divided into two major types: type 1 and type 2 DM. Type 1 DM is caused due to insulin deficiency, and type 2 DM is caused due to insulin ineffectiveness. DKA is the most common acute complication of type 1 DM in children [2], while type 2 DM occurs during stressful conditions like surgery, trauma, infections [3,4]. DKA is the most severe endocrine emergency in pediatrics, which is characterized by hyperglycemia (>250 mg/dl or 14 moll/l), metabolic acidosis (venous pH < 7.3) with associated glycosuria, ketonuria, and ketonemia [5].
An estimated 96 000 children under 15 years old develop the disease each year worldwide, and the incidence continues to increase at a rate of 3% per year globally [6]. Estimates from the International Diabetes Federation [7] suggest that diabetes will expand in Africa by 98% to 28 million patients in 2030. The frequency and treatment outcome of DKA is different from country to country. The prevalence of DKA in children with newly diagnosed diabetes is 20–40% [8]. DKA has different clinical manifestations: Polyuria, polydipsia, polyphagia, vomiting, abdominal pain, dehydration; acetone breathing, fever, hypotension, coma, and confusion are the usual clinical signs and symptoms of DKA. Three Poly symptoms are presented in the majority of DKA patients. All patients in DKA are presented in the hospital with dehydration. Therefore rapid rehydration is necessary for a better outcome [8,9].
The most common risk factor of DKA is infections, insulin withdrawal, and undiagnosed T1DM [10]. There are also other factors like sex, negligence, poverty, and delay in diagnosis increase the prevalence of DKA [9]. DKA results with both short-term and long-term complications. Recent data have shown that DKA is responsible for up to 73% of the causes of deaths during the first decade of diabetes. Mortality is predominantly related to the occurrence of cerebral edema, whereas only a minority of deaths in DKA is occurred due to other causes [11].
The aim of this study was to assess the clinical profile, and treatment outcome of diabetic ketoacidosis among diabetic children of two hospitals.
A retrospective study was done in pediatrics departments of two tertiary level care hospitals at Addis Ababa, Ethiopia. The case records of children admitted with DKA from February 2015 to April 2020 were reviewed and personal data details, presenting complaints, clinical features, family history of type 1DM, laboratory parameters, management, death certificates and outcome was recorded using a structured questioner. We called for the family if the chart was incomplete data. We had taken the family’s phone number from the patient’s chart.
DKA was diagnosed when blood sugar at admission was >250mg/dl with poly symptoms (polyuria, polydipsia, polyphagia) and presence of ketonemia and ketonuria. Severity was graded as mild, moderate and severe depending on clinical features. Monitoring of heart rate, respiratory rate, blood pressure, level of consciousness and fluid registering was done hourly. Capillary blood glucose, urine ketones was measured hourly while serum electrolyte measured daily.
The study population consisted of children aged 0-12 years admitted with DKA at two tertiary hospitals of Addis Ababa.
Statistical analysis
Statistical analysis was performed using SPSS ver.25.0. Simple frequency, tables, and figures were used to present the processed information.
Binary logistic regression was done to see the crude significant relation (crude odds ratio with 95% CI) of each independent variable with dependent variables. All variables with P < 0.25 at a 95% confidence level during the bivariate analysis were included in the multivariate analysis to control all possible confounders. A P-value less than or equal to 0.05 was taken as a cut of value to be significant. The results were displayed by using frequency tables and charts.
Ethical consideration
The present study ethical approval was secured from the department of pediatrics and child health research and publication committee (DRPC) of Adds Ababa University of Collage of Health Science with the study number of 175. For the confidentiality purpose the name of the participant has omitted and the collected data was kept locked cupboard.
Socio-demographic characteristics of the respondents
We studied the medical records of 175 children admitted with DKA during the 5-year period (February 2015 to April 2020) preceding the study. All children who met the eligibility criteria during the study period were recruited. The median age of children was 8 years, ranging 6 months to 12 years. The majority of children (105, 60%) were males with the male to female ratio of 1.5:1. Half of the study participant 89, (50.86%) were between the ages of 5 and 10 years.
Parent educational level were; 48 (27.4%) of mothers were can read and write, and 44 (25.1%) of them were grades 1- 8; while 76 (43.4%) of fathers were above grade 12. One hundred twenty (68.6%) of their parents were married, and fifteen (8.7%) were widowed. The occupation of the parents, 74, (42.3%) of their mother was a housewife and a small number 5, (2.9%) of the mother were students. The fathers’ occupation was 76, (43.4%), civil servant 44, (25.1%), merchant and 23, (13.1%) Pensioned. The mean and standard deviation parental income was 4,663 birr and 2,273 respectively (Table 1).
| Variables | Frequency (175) | Percentage (100%) | |
|---|---|---|---|
| Sex | Male female |
105 70 |
60 40 |
| Age in yr/month | < 6 month >6 moths - 1years >1 -5 years >5-10 years > 10 years |
2 14 16 89 54 |
1.1 8 9.1 50.9 30.9 |
| Mother’s educational level | Unable to read and write Read and write Grade 1-8 Grade 9-12 Above 12 |
26
48 44 18 39 |
14.3
27.4 25.1 10.9 22.3 |
| Father’s educational level | Unable to read and write Read and write Grade 1-8 Grade 9-12 Above 12 |
4
36 17 42 76 |
2.3
20.6 9.7 24 43.4 |
| Occupation of father | Civil servant Daily labourer Pensioned Merchant |
76 32 23 44 |
43.4 18.3 13.1 25.1 |
| Family income per month |
≤2628 Birr 2629-4446 Birr 4447-6264 Birr >6264 Birr |
55 61 42 17 |
31.4 34.9 24 9.7 |
Table 1: Socio-demographic characteristics of children and their families admitted with DKA at Tikur Anbesa specialized and Yekatit 12 hospital from February 2015 - April 2020.
Clinical feature of DKA
The commonest clinical manifestation was dehydration which accounts 158 (90.3%), polydipsia 150, (85.7%), polyphagia 30, 17.1%) and impaired consciousness 80 (45.7%) while shock was account 15 (8.6%) (Figure 1).
Figure 1: Clinical future of DKA children admitted with DKA at Tikur Anbesa specialized and Yekatit 12 hospital from February 2015 - April 2020.
Precipitating factors of diabetic ketoacidosis in children
In the current study the most common 137(78.3%) precipitating factor of DKA was being newly diagnosed type 1DM. The next common 38 (21.7%) were the omission of insulin in a known T1DM. Majority of the participant 145(82.9%) had preceding signs and symptoms of DM before the onset of DKA. Almost half of them (41.7%) had a family history of DM. One third (28.6%) of the parents had knowledge of the clinical sign and symptoms of DM/DKA. Most clinical sign and symptoms which were known by the parents were polydipsia (41%), polyuria (36.2%), and weight loss (30%). Ninety-nine (56.6%) of total participant with DKA had Preceding infection before the onset of DKA (Table 2).
| Variable | Frequency(175) | Percent (100%) | |
|---|---|---|---|
| Is the child known type 1 DM | YES NO |
38 137 |
21.7 78.3 |
| Preceding sign and symptoms of DM before the onset of DKA | Yes no |
145 30 |
82.9 17.1 |
| First degree relatives with DM? | Yes no |
73 102 |
41.7 58.3 |
| Child's parents' knowledge of the sign and symptoms of DKA/DM? | Yes | 50 | 28.6 |
| No | 125 | 71.4 | |
| Omit insulin before the onset of DKA? | Yes No Missing |
33 5 137 |
18.9 2.9 78.3 |
| Preceding infection before the onset of DKA | Yes No |
99 76 |
56.6 43.4 |
Table 2: Precipitating factors of DKA in children admitted with DKA at Tikur Anbesa specialized and Yekatit 12 hospital from February 2015 - April 2020.
Treatment outcome of DKA in children
The treatment outcome of the current study was 163 (93.1%) DKA patients has improved while 12 (6.9%) has died. The mean and standard deviation of random blood sugar (RBS) at presentation were 444 and 118 respectively. The mean and standard deviation of hospital stay in days were 7 and 4 respectively (Figure 2).
Figure 2: Treatment outcome of DKA in children admitted with DKA at Tikur Anbesa specialized and Yekatit 12 hospital from February 2015 - April 2020.
Bivariable analysis of factors associated with the prevalence of DKA in children among DM children
In bivariable logistic regression analysis; the educational level of mother and father, occupation of mother and father, monthly income, known type 1DM, preceding infection before the onset of DKA, family history of DM, knowledge of the parent, preceding sign and symptom of DM before onset of DKA and omission of insulin were significantly associated with the prevalence of DKA in children. But some variables like sex, age and parent’s marital status had no significant association by using bivariable logistic regression (Table 3).
| Variable | Categories | DKA | COR with 95% CI | P-value | |
|---|---|---|---|---|---|
| Yes | No | ||||
| Mother educational level | Unable to read and write | 25(96.2%) | 1(3.8%) | 2.083(0.25-21.199) | 0.535 |
| Read and write | 45(93.8%) | 3(6.3%) | 1.250(0.238-6.569) | 0.792 | |
| Grade 1-8 | 34(77.3%) | 10(22.7%) | 0.283(0.72-1.118) | 0.072* | |
| Grade 9-12 | 17(94.4%) | 1(5.6%) | 1.417(0.137-14.641) | 0.770 | |
| Above grade 12 | 36(92.3%) | 3(7.7%) | 1 | ||
| Father educational level | Unable to read and write | 3(75%) | 1(25%) | 0,508(0.048-5.332) | 0.572 |
| Read and write | 35(97.2%) | 1(2.8%) | 5.923(0.734-47.790) | 0.095* | |
| Grade 1-8 | 15(88.2%) | 2(11.8%) | 1.269(0.254-6.336) | 0.771 | |
| Grade 9-12 | 39(92.9%) | 3(7.1%) | 2.200(0.578-8.376) | 0.248* | |
| Above grade 12 | 65(85.5%) | 11(14.5%) | 1 | ||
| Mother occupation | Unemployed | 16(88.9%) | 2(11.1%) | 0.421(0.035-5.083) | 0.496 |
| Civil servant | 32(91.4%) | 3(8.6%) | 0.561(0.054-5.789) | 0.628 | |
| Student | 2(40%) | 3(60%) | 0.035(0.002-0.518) | 0.015* | |
| Housewife | 67(90.5%) | 7(9.5%) | 0.504(0.058-4.352) | 0.533 | |
| Daily labourer | 18(90%) | 2(10%) | 0.474(0.039-5.688) | 0.556 | |
| Merchant | 19(95%) | 1(5%) | 1 | ||
| Occupation of father | Civil servant | 64(84.2%) | 13(15.8%) | 2.812(0.592-13.364) | 0.193* |
| Daily labourer | 30(93.8%) | 3(6.3%) | 1.969(0.407-9.520) | 0.400 | |
| Pensioned | 21(91.3%) | 2(8.7%) | 3.937(0.838-18.491) | 0.082* | |
| Merchant | 42(95.5%) | 2(4.5%) | 1 | Ref. | |
| Income per month | <2628 | 49(89.1%) | 6(10.9%) | 2.513(0.616-10.243) | 0.199* |
| 2629-4446 | 56(91.8%) | 5(8.2%) | 3.446(0.811-14.642) | 0.094* | |
| 4447-6264 | 39(92.9%) | 3(7.1%) | 4.000(0.789-20.278) | 0.094* | |
| >6264 | 13(76.5%) | 4(23.5%) | 1 | Ref. | |
| Preceding S/S of DM before on set of DKA | Yes | 134(92.4%) | 11(7.6%) | 3.708(1.303-10.550) | 0.014* |
| No | 23(76.7%) | 7(23.3%) | 1 | Ref | |
| Knowledge of parent on S/S of DM/DKA | Yes | 42(84%) | 8(16%) | 0.457(0.169-1.234) | 0.122* |
| No | 115(92%) | 10(8%) | 1 | Ref | |
NB: *variables were significant (P <0.25) in bivariable analysis. S/S sign and symptom
Table 3: Bivariate analysis for associated precipitating factors DKA in children admitted with DKA at Tikur Anbesa specialized and Yekatit 12 hospital from February 2015 - April 2020.
Multivariable analysis on factors associated with the prevalence of DKA among DM children
According to the result of multivariable analysis after controlling other factors (confounders), Known type 1 DM, family history of DM, preceding infection before the onset of DKA, and omission of insulin had a statistically significant association with the magnitude of DKA in children (Table 4).
| Variables | Categories | DKA | COR with 95% CI | AOR with 95% CI | P-value | |
|---|---|---|---|---|---|---|
| Yes | No | |||||
| Known type 1 DM | Yes | 30(79%) | 8(21%) | 0.295(0.107-0.812) | 0.051(0.003-0.898) | *0.042 |
| No | 127(93%) | 10(7%) | 1 | 1 | ||
| Family history of DM | Yes | 61(84%) | 12(16%) | 0.318(0.113-0.891) | 0.083(0.009-0.735) | *0.025 |
| No | 96(94%) | 6(6%) | 1 | 1 | ||
| Infection before the onset of DKA | Yes | 95(96%) | 4(4%) | 5.363(1.687-17.045) | 8.593(1.125-65.631) | *0.038 |
| No | 62(82%) | 14(18%) | 1 | 1 | ||
| Omission of insulin | Yes | 28(85%) | 5(15%) | 3.73 (1.124-32.470) | 6.648(1.064-41.544) | *0.043 |
| No | 3(60%) | 2(60%) | 1 | 1 | ||
NB: *variables were significant (P <0.25) in multivariable analysis
Table 4: Multivariate analysis for associated precipitating factors DKA in children admitted with DKA at Tikur Anbesa specialized and Yekatit 12 hospital from February 2015 - April 2020.
Bivariable and Multivariable analysis on factors associated with treatment outcome of DKA in children
In multivariable logistic regression only cerebral edema, infection, electrolyte imbalance, and renal failure had a significant association with treatment outcome of DKA in children (Table 5).
| Variable | Categories | Treatment outcome | COR with 95% CI | AOR with 95% CI | P-value | |
|---|---|---|---|---|---|---|
| No\Improved | Yes/Died | |||||
| Cerebral oedema | Yes | 6(40%) | 9(60%) | 1 | 1 | *0.001 |
| No | 157(98.1%) | 3(1.9%) | 0.013(0.003-0.059)* | 0.007(0.00-0.114)** | ||
| Pulmonary oedema | Yes | 5(41.7%) | 7(58.3%) | 1 | 1 | 0.990 |
| No | 158(96.9%) | 5(3.1%) | 0.923(0.005-0.097)* | 0.042(0.003-0.700) | ||
| Infection | Yes | 43(82.7%) | 9(17.9%) | 0.119(0.031-0.462)* | 8.085(1.016-59.67)** | *0.04 |
| No | 120(97.6%) | 3(2.4%) | 1 | 1 | ||
| Electrolyte imbalance | Yes | 29(82.9%) | 6(17.1%) | 0.216(0.065-0.719)* | 7.754(1.054-57.059)** | *0.044 |
| No | 134(95.7%) | 6(4.3%) | 1 | 1 | ||
| Hypoglycaemia | Yes | 23(76.7%) | 7(23.3%) | 1 | 0.058 | |
| No | 140(96.6%) | 5(3.4%) | 0.117(0.034-0.401)* | 0.042(0.003-0.715) | ||
| Renal failure | Yes | 20(69%) | 9(31%) | 1 | 1 | *0.001 |
| No | 143(97.9%) | 3(2.1%) | 0.947(0.012-0.187)* | 0.018(0.002-0.203)** | ||
NB: *variables having a (P <0.25) in bivariable analysis, **statistically significant at p-value ≤0.05 in the multivariable analysis
Table 5: Bivariate and multivariate analysis for associated factors of treatment outcome of DKA in children admitted with DKA at Tikur Anbesa specialized and Yekatit 12 hospital from February 2015 - April 2020.
This retrospective study described the sociodemographic data and clinical profile of children with DKA in two tertiary care hospitals. The initial presentation of DKA, was encountered by the vast majority of patients. The usual symptoms of DKA are polyuria, polydipsia, abdominal pain, vomiting, and decreased level of consciousness were the presenting complaints in most cases. New onset diabetes and insulin omission in those with established T1DM were the most common precipitants of DKA this was the finding of in the current study, which is concordant with the study done in Milwaukee, Addis Ababa, Saudi Arabia and Pakistan respectively [12-15].
Approximately, half of patients (50.8%) were between 5 and 10 years old. The finding may be explained by the fact that a high number of patients were newly diagnosis of T1DM. These data were attributed to the high number of new-onset cases presenting with DKA. The commonest age of presentation in our children was between 5 to 10 years, this was similar with the study done [16] in contrary with our study [17] reported that 55% of children presenting with DKA were above 10 years old. In the current study male is predominant than female, with male to female ratio 1.5:1 this finding is concordant with the study [18] while, discordant with study done [19,20] females were predominant.
Infection 1-2 weeks before the onset of DKA was significantly associated with the prevalence of DKA in children this finding similar with the study done in India [21-25].
The explanation can be infection cause body to produce higher levels of adrenaline or cortisol these counter regulate the production of insulin.
The most frequent clinical features of DKA in our study were dehydration (90.3%), polydipsia (86.9%), polyuria (85.7%), weight loss (74.3%), abdominal pain (66.9%), vomiting (58.9%) and rapid breathing (58.3%). This is consistent to the study conducted in Indore, India [21], Pakistan [15], Egypt [22], while discordant with Milwaukie [12] study the poly symptoms were not the main clinical manifestation.
The treatment outcome in our study was 12 (6.9%) children with DKA have died. This finding is higher in study done in Pakistan 4% [25], and Indore, India 3.4% [21], while lower than Madras Medical College, Chennai 12.8 % [23].
In the current study cerebral edema, infection, renal failure and electrolyte imbalance were the risk factor of death this was consistent with the study conducted in Bangladesh [9], Iran [24], and the Himalayan state of north India [18].
Citation: Muluwork TD (2021) Assessment of Clinical Profile, And Treatment Outcome of Diabetic Ketoacidosis among Diabetic Children, In Two Selected Hospital, Addis Ababa, Ethiopia, 2020. J Diabetes Metab. 12:896.
Received: 23-Jun-2021 Published: 22-Sep-2021, DOI: 10.35248/2155-6156.21.12.895
Copyright: © 2021 Muluwork TD. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
