CASE REPORT

DIABETIC KETOACIDOSIS WITH ACUTE KIDNEY INJURY

AND SHORT STATURE IN A 15 YEARS OLD BOY

by :
Nanda Juwita

Tutors :
Dr. Harjoedi Adji Tjahjono, Sp.A (C)

1
ABBREVIATION
AKI Acute kidney Injury
ARF Acute Renal Failure
BA Bone Age
BG Blood Glucose
BP Blood Pressure
CA Chronological Age
CDC Centers for Disease Control
DKA Diabetic Ketoacidosis
DM Diabetic Mellitus
GCS Glasgow Coma Scale
GFR Glomerular Filtration Rate
HR Heart Rate
ICU Intensive Care Unit
IV Intravenous
RIFLE Risk Injury Failure Loss End
RSSA Rumah Sakit Saiful Anwar
SD Standard Deviations
T1DM Type 1 diabetes mellitus
T2DM Type 2 diabetes mellitus
WHO World Health Organization

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Introduction
Diabetic Ketoacidosis
An emergency condition due to lack of absolute or relative insulin with increased regulatory
hormone (Rewers, 2015)

Biochemical criteria
Blood Glucose > and/or a bicarbonate
11mmol/L or ≥ 200 with a venous pH of < 7.3 (HCO3) level of < 15 Ketonemia and ketonuria
mg/dL mmol/L
(Rewers, 2015)

Complications
cerebral edema, acute respiratory distress syndrome, hypokalemia, hypophosphatemia, acute kidney
injury (Poovazhagi, 2014)

Acute Kidney Injury

Incidences 64.2%, Mortality Rate up to 50% (Brendon, 2017)

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 Objective
describe a case of a 15 years old boy
with ketoacidosis diabetic, acute kidney
injury and short stature

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Case Report

5
Identity

■ Name : N.A.Z
■ Gender : Male
■ Age : 15 years old
■ Weight : 25 kgs
■ Address : Karang Tengah, Dau - Malang
■ Admission date : December 18th 2017

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 N.A.Z / M / 15 y.o / 25 kgs, refered by Sopraoen
Hospital

Chief Stomach ache since 3 days before

Complaint : admission, without nausea nor vomiting
Stomachache
headache for 3 days without fever,
nosebleed, nor bleeding.

lethargic and lost of appetite

The patient didn’t get the insulin shot

regularly and didn’t follow the strict diet

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Past medical history
• The patient was diagnosed with type 1 DM since 1 year ago
• He had history of hospitalization for 3 times because of DKA
• He doesn’t routinely control
• The last time he came as outpatients was in September 2017
and got insulin therapy with 12-12-12-0 IU rapid insulin injection
and 0-0-0-18 IU long acting insulin

Vaccination history
•Completed basic immunization, the last one was measles
vaccine when he was 9 months old

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Antenatal History
• Routinely had antenatal care every month by midwife
• never had the history of hypertension, DM, vaginal discharge,
bleeding, red rash in the first trimester, nor urinary problem
during the pregnancy period
• never had any traditional medicine nor traditional maternity
massage

Postnatal History:
• The patient was born spontaneously, assissted by a midwife, in
the 9th month of pregnancy. He was spontaneously crying,
without any difficulty of breathing nor cyanosis. His birth weight
was 2500 gr, and the amniotic fluid was clear
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Intake
• The patient eats rice more than 3 times a day, contained 1-2
servings of rice and some meats and vegetables.
• He had no restriction on eating.
• He had no diabetic diet

Growth and development

• the patient should be in second grade of elementary school but
he dropped out from school and doesn’t want to come back to
school again.

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FamilyHistory
•There was no history of familly with Type-1 DM

History of Allergy
•There was no history of allergy, urticaria, nor cold or dust
stimulated sneezing in the patient or the family

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Social and Economic History

•The patient is the 3rdchild in the family.

•The 1stchild is 22 years old and married.
•The 2ndchild is 19 years old senior high school student
•The 4thchild is 12 years old
•The father is 55 years old and he’s a farmer
•The mother is 42 years old and works as a housemaid.

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Nutritional State
December 18th 2018

■ Body weight was 25 kgs (<p3)

■ Body height was 142 cms
(<p3) equivalent with 10 years
and 6 months old boy.
■ Ideal body weight was 34 kgs
(73%)
■ Upper arm diameter was 18,5
cm (P5 to P10)
Conclussion:
undernourished and short stature

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Stage of Puberty
■ G2P2
■ Testicular volume about 4 ml and
there was sparse growth of long,
slightly pigmented, downy hair,
slightly curled, appearing
prominently at base of penis.

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Physical Examination

General condition :
Alert, spontaneously breath
Axillar temperature : 36.7°C
Pulse rate : 90 beats per minutes, regular, strong
pulse
Respiratory rate : 24 times per minute
SatO2 : 99%

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The chest examination
• Symmetrical movement
• No retractions
• Vesicular breathing,
• No ronchi and wheezing.

Heart auscultation
Heart auscultation revealed a normal 1st cardiac sound, normal
2nd cardiac sound, without murmur nor gallop

The abdominal and neurological examination was

normal

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 LABORATORY RESULT
18/12/2017 20/12/2017 21/12/2017 24/12/2017 27/12/2017 30/12/2017

Hb 13,70 13,30 12,70 9,40 11,10 9,10

Leucocyte 11.140 9000 10.030 13.160 17.660 12.760

Hematocrit 39,10% 36,70% 34,40% 25,80% 32,20% 25,30%

Thrombocytes 173.000 164.000 189.000 235.000 363.000 271.000

MCV 77,60 76,60 74,60 75,70 78,30 76,70

MCH 27,20 27,80 27,50 27,60 27,00 27,60

MCHC 35,00 36,20 36,90 36,40 34,50 36,00

Diff count :

Eosinophils 0,0 0,6 0,5 2,3 0,5 1,3

Basophils 0,3 0,2 0,2 0,2 0,4 0,2

Neutrophils 71,4 68,8 69,7 69,4 69,8 63,1

Lymphocytes 17,3 19,7 18 11,7 20,1 26,3

Monocyte 11,0 10,7 11,6 16,4 9,2 9,1

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 LABORATORY RESULT
18/12/17 20/12/17 21/12/17 23/12/17 25/12/17 27/12/17 28/12/17 19/12/17 31/12/17 01/1/18

Sodium 132 136 133 133 134 137 134 133 138 137
Potassium 3,32 2,83 3,18 3,12 3,50 4,94 5,24 2,92 3,06 3,32

chloride 113 117 111 105 102 107 102 99 99 100

Calcium 9,9 9,1 10,4 9,5 12,0 12,0 9,3 8,2 8,3
Phosphate 3,3 1,7 2,4 4,2 4,5

SGOT 20 15

SGPT 11 11

Albumin 3,27 3,45 3,52 3,15

RBS 215 122 44

Ketone
PCT 15,43 1,12 0,32

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Monitoring Blood Glucose
RBS

500

400

321
283
264
207
147 140

19/12/17 20/12/17 21/12/17 24/12/17 25/12/17 29/12/17 30/12/17 31/12/17

GDA

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 LABORATORY RESULT
18/12/2017 20/12/2017 21/12/2017 27/12/2017 01/1/2018
Renal
Function :
Ureum 16,6 - 48,5 117,50 143,90 86,3 110,80 40,50
Creatinine <1,2 3,91 5,86 4,11 3,65 0,77
BUN/Creatinine < 20 / > 20 15 12,2 10,4 15,7 26,2
GFR 19,9 6,5 24,9 27,8 131,8
79% 93% 74% 71%
Urine 0,9cc/kg/hr 0,1cc/kg/hr 1cc/kg/hr 1,05cc/kg/hr 1,4cc/kg/hr
Production
Uric acid 4,3 5,3

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 LABORATORY RESULT
18/12/2017 22/12/2017
URINALISIS :
Density Keruh Jernih
Color Kuning Kuning
pH 6,0 6,0
gravity 1,015 1,005
Glucose Trace Negatif
Protein 3+ Trace
Ketone 2+ Negatif
Bilirubin Negatif Negatif
Urobilinogen Negatif Negatif
Nitrite Negatif Negatif
Leukocytes 3+ Negatif
Blood 3+ 3+

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 LABORATORY RESULT
18/12/2017 22/12/2017
URINALYSIS :
Erythrocytes 604,0 LPB 36,0 LPB
Eumorphic 98% 67%
Dysmorphic 2% 33%
Leucocytes 320,3 LPB 4 LPB
Bacteria 405,1 x 103/mL 98,2 x 103/mL

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LABORATORY RESULT
19/12/2017 20/12/2017 21/12/2017

BLOOD GAS ANALYSIS

pH 7,23 7,36 7,26

pCO2 13,3 12,8 18,8

pO2 126,8 187,5 143,4

Bicarbonate (HCO3) 5,6 7,3 8,5

Base Excess (BE) -22,3 -18,2 -18,8

SatO2 98,4 99% 98,6%

Hb 14,0 8,7 11,3

Temp 37,0 37,3 37,0

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LABORATORY RESULT
20/12/2017

APP

Patient 10

Control 10,2

INR 0,96

APTT

Patient 32,20

Control 25,6

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Discussion

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 Diabetic Ketoacidosis
Diabetic ketoacidosis (DKA) is a severe complication of diabetes in
children caused by a state of insulin deficiency

It is defined by hyperglycemia, metabolic acidosis, and the

production of ketoacids, and hyperglycemia leads to an osmotic
diuresis that causes volume depletion.

DKA occurs in 10 to 70% of children with type 1 diabetes

Diabetic ketoacidosis is the leading cause of hospitalization,

morbidity, and mortality in children with type 1 diabetes

(Dunger, 2014)
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 Signs and symptoms
Theoretically In this Case
■ Malaise, generalized weakness ■ Abdominal pain
■ Nausea and vomiting, ■ General weakness
abdominal pain, decreased
appetite ■ Headache
■ Rapid weight loss in patients ■ Lethargic and lost the appetite
newly diagnosed with type 1
diabetes ■ The patient didn’t get the insulin
■ History of failure to comply with shot regularly
insulin therapy or missed insulin
injections
■ Altered consciousness

(Rewers. 2015)
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 Laboratory Finding
Theoretically In this Case
■ Blood glucose over 11 ■ Blood Glucose 224mg/dL
mmol/L or > 200mg/dL or ■ Ketonuria +2
known as diabetes
mellitus ■ Bicarbonate 5,6 mmol/L
■ Ketonaemia > 3 mmol/L ■ pH 7,23
and over), or significant
ketonuria > 2+
■ Bicarbonate below 15
mmol/L and/or arterial pH
less than 7.3

(Rewers. 2015)
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The Main Characteristics Of DKA
Hyperglycemia

Ketosis and acidosis

(Poovazhagi, 2014)
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Dehydration
•Hyperglycemia raises extracellular fluid osmolality.
Fluid and electrolytes shift from the intracellular to
the extracellular spacedehydration and electrolyte
imbalance

Electrolyte imbalance
•Potassium is the electrolyte that is most affected in
DKA

(Poovazhagi, 2014)
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 Precipitating Factors
Theoretically In this Case
■ Infection (urinary tract ■ Known as type I diabetes
infection, pneumonia) ■ Not taking insulin regularly
■ Medication ■ Didn’t follow the strict diet
noncompliance
■ This patient didn’t control
■ Inadequate insulin dosing routinely
■ New-onset diabetes
mellitus
(Dunger, 2014)

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 Management of DKA
Oxygenation/ventilation
•Airway and breathing remain the first priority

Fluid replacement
• Fluid replacement should be initiated immediately
• Normal saline(0.9%NaCl) is most appropriate initially
• Initial bolus of fluid is 15-20ml/kg over an hour (1-1.5L),
and then 4-10ml/kg/hour for the following hours.
• Ideally 50% of the total body water deficit should be
replaced within the first eight hours and the other 50%
within the following 24 hours

(Smith, 2017) 41
Electrolyte replacement
• Potassium : Hyperkalemia may result from reduced renal
function, the patient is more likely to have total body
potassium depletion
• Early hyponatremia in DKA does not usually require
specific treatment, it is an artefact arising from dilution by
the hyperglycemia induced water shifts

(Smith, 2017)

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Insulin therapy
• Insulin is initially given as an intravenous bolus of
0.1units/kg or a bolus of 5 or 10 units.
• Then a continuous insulin infusion of 50 units of
Actrapid in 50ml N/Saline is commenced.
• The infusion rate is 0.05-0.1 units/kg/hour for
children

(Smith, 2017)

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 Management of DKA
Theoretically In this Case
■ Fluid replacement ■ IVFD NaCl 0.9%
4450cc/48h (equivalent with
■ Electrolyte replacement
92cc/h)
■ Insulin therapy
■ IV KCl 7,4% 20mEq in 500cc
(Smith, 2017)
NaCl 0.9%,
■ IV insulin continuous 2,5
unit/h (0,1 unit/kgBW/h)

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 Acute Kidney Injury
The majority of children with DKA developed AKI up to 64.2%
of whom 34.9% had stage 1, 45.3% had stage 2, and 19.8%
had stage 3

DKA with AKI is associated with increased morbidity, including

greater need for and duration of ventilation, increased length
of stay, higher hospitalization costs, and increased mortality

Estimated mortality rate about 50%

(Brandon, 2017)

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 . . . Acute Kidney Injury

Acute kidney injury (AKI) is commonly defined as an abrupt

deterioration in kidney function, manifested by an increase in
serum creatinine level with or without reduced urine output

The etiology of AKI associated with DKA is probably

multifactorial, most likely due to hypovolemia

The cause of AKI in ketoacidosis patient is assumed to be pre-

renal

(Goldstein, 2015)

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 …. Acute Kidney Injury

(KDIGO, 2012)
Figure Stage of AKI

(Goldstein, 2015)
Figure RIFLE Criteria 50
 Acute Kidney Injury
Theoretically In this Case
■ GFR ↓ 93%
■ Creatinin 5,86
■ Urine output : 0,1 cc/kg/hr

(Goldstein,2015. KDIGO,2013)

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 Short Stature
Height below 3rd centile or more than 2 standard deviations
below the median height for age and sex

Accurate height assessment

• Assessment of body proportions

• Assessment of height velocity
• Comparison with population norms
• Comparison with child’s own genetic potential
• Sexual maturity rating
(Baron, 2015)

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 … Short Stature

Familial
Physiological

Constitutional

Short Stature Chronic

disease
proportional
Pathological Undernutrition
not
proportional

(Bonfig, 2016)

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 Short Stature
Theoretically In this Case
■ Normal height & weight at ■ Weight at birth 2500 grams
birth
■ Height and weight below P3
■ Catch down in growth
■ Normal Puberty: Tanner
■ by 2 years height weight lies stage 2 (G2P2)
on target centile
■ Height low but within target
■ Growth velocity normal range
■ Bone age = chronological age
■ Normal puberty
■ Final height low but within
target range

(Baron, 2015) 66
Sumarry
A success case of diabetic ketoacidosis with acute kidney
injury and short stature

The patient suffered from stomachache, headache,

lethargic and lost of appetite

The patient was diagnosed with type 1 DM since 1 year

ago

He doesn’t routinely control and got insulin therapy of 12-

12-12-0 IU rapid insulin injection and 0-0-0-18 IU long
acting insulin injection

69
 …summary

Laboratory finding indicated hyperglycemia, ketosis and

acidosis, electrolyte imbalance

Treatment consist of fluid replacement, electrolyte

replacement and insulin therapy

The majority of children with DKA developed AKI are 64.2%

The poor outcome of AKI associated with DKA underlines

the importance of early initiation and recognition

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 …summary

Diagnosis short stature more likely familial short stature

The evaluation cause of short stature is needed to be

confirm

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Thank You

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