The Prevalence of Hypophosphatemia and its Associated Risk Factors in Diabetic Ketoacidosis Patients
DOI:
https://doi.org/10.15605/jafes.040.01.13Keywords:
diabetes mellitus, prevalence, hypophosphatemia, risk factors, diabetic ketoacidosis, childrenAbstract
Objective. We aimed to study the prevalence of hypophosphatemia and its associated risk factors in Diabetic Ketoacidosis (DKA) patients in the pediatric population.
Methodology. We included 65 subjects aged 7 months to 18 years old who were admitted to Hospital Universiti Sains Malaysia (HUSM) for DKA. Patients’ socio-demographic and clinical characteristics, and biochemical examinations from their first admission for DKA were analyzed. The diagnosis of DKA was based on the International Society for Pediatric and Adolescent Diabetes (ISPAD) criteria. Multiple logistic regression models examined associations between different variables and DKA.
Result. The prevalence of hypophosphatemia in DKA was highest on day 1, at 70.8%, with a mean age of 11 on presentation. Multiple logistic regression analysis showed plasma bicarbonate at day 3 [adjusted odds ratio (OR) 1.2, with a p-value of 0.027] and baseline hemoglobin [adjusted OR 0.62, with p-value 0.009] were significantly associated with hypophosphatemia during DKA.
Conclusion. The prevalence of hypophosphatemia in DKA pediatric patients admitted to our center was highest on day 1 of admission. There were many factors associated with hypophosphatemia from simple logistic regression analysis. However, our final model revealed that plasma bicarbonate on day 3 and baseline Hb were the only significant risk factors for hypophosphatemia in DKA patients in the pediatric population.
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References
1. CDC. Diabetes in Youth. 2021. Accessed date , April 4, 2022. https://www.cdc.gov/diabetes/library/reports/reportcard/diabetes-in-youth.html
2. Wolfsdorf J, Craig ME, Daneman D, et al. Diabetic ketoacidosis in children and adolescents with diabetes. Pediatr Diabetes. 2009;10(Suppl 12):118–33. https://pubmed.ncbi.nlm.nih.gov/19754623 https://doi.org/10.1111/j.1399-5448.2009.00569.x
3. Hong JYH, Jalaludin MY, Mohamad Adam B, et al. Diabetic ketoacidosis at diagnosis of type 1 diabetes mellitus in Malaysian children and adolescents. Malaysian Fam Physician. 2016;10(3):11–8. https://pubmed.ncbi.nlm.nih.gov/27570603 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4992349
4. Ho J, Huang C, Pacaud D. Management of type 1 diabetes mellitus in children. Malaysia Health Technology Assessment Section (MaHTAS). 2015. https://www.moh.gov.my/moh/resources/maklumat%20terkini/DRAF%20CPG/Draft_CPG_T1DM_301115.pdf
5. Lervang H-H, Ditzel J. Disturbance of inorganic phosphate metabolism in diabetes mellitus: Clinical manifestations of phosphorus-depletion syndrome during recovery from diabetic ketoacidosis. Diabetes, Metab Syndr Obes Targets Ther. 2010;3:319-24. https://pubmed.ncbi.nlm.nih.gov/21437101 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3047968 https://doi.org/10.2147/DMSOTT.S13476
6. Brunelli SM, Goldfarb S. Hypophosphatemia: Clinical consequences and management. J Am Soc Nephrol. 2007;18(7):1999–2003. https://pubmed.ncbi.nlm.nih.gov/17568018 https://doi.org/10.1681/ASN.2007020143
7. Yoshida T, Takemoto M. Impaired cardiac and neurological function with mild hypophosphatemia during insulin therapy for diabetic ketoacidosis and marked improvement with phosphate supplementation: A case report. J Diabetes Investig. 2021;12(3):454–8. https://pubmed.ncbi.nlm.nih.gov/ 32654423 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7926208 https://doi.org/10.1111/jdi.13357
8. Miszczuk K, Mroczek-Wacinska J, Piekarski R, Wysocka-Lukasik B, Jawniak R, Ben-Skowronek I. Ventricular bigeminy and trigeminy caused by hypophosphataemia during diabetic ketoacidosis treatment: A case report. Ital J Pediatr. 2019;45(1):42. https://pubmed.ncbi.nlm.nih.gov/30940174 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6444668 https://doi.org/10.1186/s13052-019-0633-y
9. Choi HS, Kwon A, Chae HW, Suh J, Kim DH, Kim HS. Respiratory failure in a diabetic ketoacidosis patient with severe hypophosphatemia. Ann Pediatr Endocrinol Metab. 2018;23(2):103–6. https://pubmed.ncbi.nlm.nih.gov/29969883 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6057019 https://doi.org/10.6065/apem.2018.23.2.103
10. Shah SK, Shah L, Bhattarai S, Giri M. Rhabdomyolysis due to severe hypophosphatemia in diabetic ketoacidosis. JNMA J Nepal Med Assoc. 2015;53(198):137–40. https://pubmed.ncbi.nlm.nih.gov/26994037
11. De Oliveira Iglesias SB, Pons Leite H, de Carvalho WB. Hypophosphatemia-induced seizure in a child with diabetic ketoacidosis. Pediatr Emerg Care. 2009;25(12):859–61. https://pubmed.ncbi.nlm.nih.gov/20016359 Dhttps://doi.org/10.1097/PEC.0b013e3181c399f6
12. Fenelli GS, Aded CB, Lagger J, et al. [Prevalence of hypophosphatemia in children with diabetic ketoacidosis and treatment with subcutaneous regular insulin. Observational study]. Andes Pediatr. 2024;95(2):183-9. https://pubmed.ncbi.nlm.nih.gov/38801366 https://doi.org/10.32641/andespediatr.v95i2.4924
13. Shen T, Braude S. Changes in serum phosphate during treatment of diabetic ketoacidosis: Predictive significance of severity of acidosis on presentation. Intern Med J. 2012;42(12):1347–50. https://pubmed.ncbi.nlm.nih.gov/23252999 https://doi.org/10.1111/imj.12001
14. Hasan RA, Hesen JZ, Millican N, Pederson JM, Michael. Serum phosphorus and hypophosphatemia during therapy of diabetic ketoacidosis in children: Single-center, retrospective cohort 2016–2022. Pediatr Crit Care Med. 2024;26(1):e77–85. https://pubmed.ncbi.nlm.nih.gov/39785552 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11706349 https://doi.org/10.1097/PCC.0000000000003649
15. Van Der Vaart A, Waanders F, Van Beek AP, Vriesendorp TM, Wolffenbutel BHR, Van Dijk PR. Incidence and determinants of hypophosphatemia in diabetic ketoacidosis: An observational study. BMJ Open Diabetes Res Care. 2021;9(1):e002018. https://pubmed.ncbi.nlm.nih.gov/33597187 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7893606 https://doi.org/10.1136/bmjdrc-2020-002018
16. El-Naggar A, Sameer G, Sadek A. Impact of hypophosphatemia and hypomagnesaemia on diabetic ketoacidosis patient’s outcome in medical intensive care unit. Zagazig Univ Med J. 2021. https://doi.org/10.21608/zumj.2021.65424.2156
17. Colantonio DA, Kyriakopoulou L, Chan MK, et al. Closing the gaps in pediatric laboratory reference intervals: A caliper database of 40 biochemical markers in a healthy and multiethnic population of children. Clin Chem. 2012;58(5):854–68. https://pubmed.ncbi.nlm.nih.gov/22371482 https://doi.org/10.1373/clinchem.2011.177741
18. Lim JL. T20, M40, B40 Household income update 2023. Malaysian Employers Federation. 2023 https://mefacademy.mef.org.my/Attachments/MSN20230731a.pdf
19. Centers for Disease Control and Prevention, National Center for Health Statistics. CDC growth charts. Accessed May 30, 2000. http://www.cdc.gov/growthcharts/.
20. Arifin WN. Sample size calculator; 2024. http://wnarifin.github.io
21. Anand LA, Syahirah MN, Jalaludin MY, Zaini AA. Prevalence of hypophosphatemia in children with diabetic ketoacidosis. J ASEAN Fed Endocr Soc. 2022;37:10. https://doi.org/10.15605/jafes.037.S2.96
22. Puttanna A, Padinkakara RNK. Diabetic ketoacidosis in type 2 diabetes mellitus. Pract Diabetes. 2014;31(4):155–8.
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