Diabetic Ketoacidosis in Adolescents and Children: A Prospective Study of Blood versus Urine Ketones in Monitoring Therapeutic Response

Authors

  • Aman Bhakti Pulungan Endocrinology Division, Department of Child Health, Faculty of Medicine, University of Indonesia-Cipto Mangunkusumo Hospital
  • Erlin Juwita Department of Child Health, Faculty of Medicine Universitas Indonesia – Cipto Mangunkusumo Hospital, Jakarta, Indonesia
  • Antonius H Pudjiadi Department of Child Health, Faculty of Medicine Universitas Indonesia – Cipto Mangunkusumo Hospital, Jakarta, Indonesia
  • Siti Rahmayanti Department of Child Health, Faculty of Medicine Universitas Indonesia – Cipto Mangunkusumo Hospital, Jakarta, Indonesia
  • Ireska Tsaniya Department of Child Health, Faculty of Medicine Universitas Indonesia – Cipto Mangunkusumo Hospital, Jakarta, Indonesia

Keywords:

capillary betahydroxybutirate, diabetic ketoacidosis, urine ketones, resolution time

Abstract

Background: diabetic ketoacidosis (DKA) is a potentially lethal complication of diabetes mellitus (DM). There is no study in Indonesia that compares the much-preferred capillary beta hydroxybutirate (β-OHB) measurement to urine acetoacetate in monitoring therapeutic response of DKA in adolescents. Methods: a prospective study of 37 adolescents and children with DKA in Cipto Mangunkusumo Hospital was done between June 2006 and March 2011. The patients were followed until the time of DKA resolution. Hourly measurement of random blood glucose, capillary β-OHB concentration, and urine ketones were done, while blood gas analysis and electrolyte were measured every four hours. Results: median time to resolution was 21 (9-52) hours. Compared to urine ketones, capillary β-OHB concentration showed stronger correlation with pH (r= -0,52, p= 0,003 vs r= -0,49, p= 0,005) and bicarbonate level (r=-0,60, p=0.000 vs r= -0.48, p=0.007) during the median time of DKA resolution. All capillary β-OHB measurement yielded negative results at median time of DKA resolution, while urine ketones were still detected up to 9 hours after resolution. Conclusion: blood ketone concentration showed better correlation with pH and bicarbonate level, as a tool to monitor therapeutic response in DKA in adolescent, compared to traditional urine ketones test in adolescents.

References

Wolfsdorf J, Glaser N, Sperling MA. Diabetic Ketoacidosis in Infants, Children, and Adolescents. Diabetes Care. 2006; 29(5):1150-1159

Wolfsdorf JI, Allgrove J, Craig ME, et al. Consensus Statement from the International Society for Pediatric and Adolescent Diabetes: Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatric Diabetes 2014; 15 (Suppl. 20): 154–179.

Rewers A, Klingensmith G, Davis C, Petitti D, Pihoker C, et al. Presence of diabetic ketoacidosis at diagnosis of diabetes mellitus in youth: The search for diabetes in youth study. Pediatrics. 2009; 93: 1258-65.

Division of Endocrinology. Department of Child Health Ciptomangunkusumo Hospital. Patients Medical Record of Type1 Diabetes Mellitus & Diabetic Ketoacidosis in Indonesian Children. 2010.

Taboulet P, Haas L, Porcher R, et al. Urinary Acetoacetate or Capillary Beta hydroxybutyrate for The Diagnosis of Ketoacidosis in The Emergency Department Setting. Eur J Emerg Med. 2004;11(5):251-8.

Koul P. Diabetic ketoacidosis: A current appraisal of pathophysiology and management. Clin Pediatr (Phila). 2009;48(2):135-44

Vanelli M, Chiari G, Capuano C et al. The direct measurement of 3-beta-hydroxy butyrate enhances the management of diabetic ketoacidosis in children and reduces time and costs of treatment. Diabetes Nutr Metab. 2003;16(5-6):312-6

Sacks D, Arnold M, Bakris G, et al. Guidelines and recommendation for laboratory analysis in the diagnosis and management of diabetes mellitus. Diabetes Care. 2011 Jun; 34(6): e61–e99.

Goldstein DE, Little RR, Rodney AL, et al. Tests of Glycemia in Diabetes. Diabetes Care. 2004; 27 (7): 1761-1773.

Tantiwong P, Gobchai P, Boonsong O, et al. Capillary blood beta hydroxybutyrate measurement by reagent strip in diagnosing diabetic ketoacidosis. Clin Lab Sci. 2005;18(3):139-44.

Guerci B, Benichou M, Floriot M, Bohme P, et al. Accuracy of an electrochemical sensor for measuring capillary blood ketone by fingerstick samples during metabolic deterioration after continuous subcutaneous insulin infusion interruption in type 1 diabetic patients. Diabetes Care. 2003;26:1137

American Diabetes Association. Tests of glycemia in diabetes. Diabetes Care. 2003; 26( Suppl.1)

Wright J, Ruck K, Rabbits R, et al. Diabetic ketoacidosis in Birmingham 2000-2009 an evaluation of risk factors for recurrence and mortality. Br J Diabet Vasc. 2009;9 : 278-82 .

Rustama DS, Subardja D, Oentario MC, et al. Buku ajar endokrinologi. Edisi ke-1. Jakarta: Badan penerbit IDAI; 2010;p173- 4.

Umpierrez G, Watts N, Phillips L. Clinical utility of beta hydroxybutyrate determined by reflectance meter in the management of diabetic ketoacidosis. Diabetes Care. 1995 Jan;18(1):137-8.

Mrozik LT, Yung M. Hyperchloraemia metabolic acidosis slows recovery in children with diabetic ketoacidosis a retrospective audit. Aust Crit Care. 2009;22(4):172-7.

Taylor D, Durward A, Tibby SM, et al. The influence of hyperchloraemia on acid base interpretation in diabetic ketoacidosis. Intensive Care Med. 2006 Feb;32(2):295-301.

Ham MR, Okada P, White PC. Bedside ketone determination in diabetic ketoacidosis with hyperglycemia and ketosis in the acute care settting. Pediatr Diabetes. 2004; 5: 39-43.

Naunheim R, Jang T, Banet G, et al. Point of care test identifies diabetic ketoacidosis at triage. Acad Emerg Med. 2006;13(6):683-5.

Ali M, Karon B, Basu A, Kudva Yet al. Can serum beta hydroxybutyrate be used to diagnose diabetic ketoacidosis? Diabetes Care. 2008; 31: 643-7.

Turan S, Omar A, Bereket A. Comparison of capillary blood ketone measurement by electrochemical method and urinary ketone in treatment of diabetic ketosis and ketoacidosis in children. Acta Diabetol.2008; 45(2): 83-5.

Orlowski J, Cramer C, Fiallos M. Diabetic ketoacidosis in the pediatric ICU. Pediatr Clin N Am. 2008;55:577-87

Maciel AT, Park M. A physicochemical acid base approach for managing diabetic ketoacidosis. Clinics. 2009;64:714-8.

Salem M, Mujais SK. Gaps in the anion gap. Arch Intern Med. 1992;152:1625-9.

Sefedini E, Prasek M, Metelko Z, Novak B, Pinter Z. Use of capillary beta hydroxybutyrate for the diagnosis of diabetic ketoacidosis at emergency room one year experience. Diabetologia Croatia. 2008; 37: 73-7.

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Published

2018-04-20

How to Cite

Pulungan, A. B., Juwita, E., Pudjiadi, A. H., Rahmayanti, S., & Tsaniya, I. (2018). Diabetic Ketoacidosis in Adolescents and Children: A Prospective Study of Blood versus Urine Ketones in Monitoring Therapeutic Response. Acta Medica Indonesiana, 50(1), 46. Retrieved from https://actamedindones.org/index.php/ijim/article/view/528

Issue

Vol. 50 No. 1 (2018): Acta Medica Indonesiana

Section

ORIGINAL ARTICLE

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