(264) Biphasic Serum Creatinine Levels in Children During Therapy for Diabetic Ketoacidosis

Introduction: During evolution of diabetic ketoacidosis (DKA), volume depletion can lead to impaired renal function with resultant elevation of serum creatinine (cr). During therapy for DKA, there is a progressive decline in Cr, however in some patients a second elevation in Cr may occur. This study assessed dynamics of Cr and factors associated with a biphasic response (BPR) in Cr in children with type 1 diabetes mellitus (T1DM) hospitalized for treatment of DKA.

Methods: Patients 1-20 years of age with T1DM hospitalized for DKA between July 1, 2016 to July 31, 2022 were included. Age, sex, duration of T1DM, conscious state at presentation and most recent glycosylated hemoglobin (A1c) were collected. Serum creatinine was measured at the time of presentation and then every 4 hours until DKA resolved. A biphasic response was defined as a post-nadir rise in Cr during the total hospital stay. Characteristics of Cr and hospital length of stay (LOS) in biphasic cases (BPR) and non-biphasic (NBPR) cases were compared with Wilcoxon rank-based hypothesis testing. Propensity for a BPR of Cr was analyzed with logistic regression analysis.

Results: 852 episodes of DKA occurred in 365 patients (46.3% female, median age: 14.7 years, IQR: 12.2,17.2), of which 158 (18.5%) episodes were new-onset T1DM. The most recent A1c was 12.1% (IQR:10.7, 13.7).Serum Creatinine progressively declined over the course of therapy for DKA. In 10.2% (87/852) of episodes, Cr showed a BPR. Biphasic response cases had significantly lower pre-nadir maximums Cr (0.93 +/- 0.03 mg/dL vs 1.24 +/- 0.01 mg/dL, P< 0.001) and earlier onset of nadir Cr following initiation of therapy for DKA (18.5 +/- 1.6 hrs vs 33 +/- 0.9 hrs, p< 0.001). Biphasic response cases had a longer hospital length of stay (79 +/- 7 hrs vs 67 +/- 1.2 hrs, p= 0.42), however this was not statistically significant. None of the patients required renal replacement therapy and all patients across all episodes survived.

Conclusions: Biphasic response in Cr occurs in the minority of children during therapy for DKA in children with T1DM and it appears to be transient in nature in this clinical setting.