International Journal of Current Research and Review
ISSN: 2231-2196 (Print)ISSN: 0975-5241 (Online)
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IJCRR - 5(20), October, 2013

Pages: 41-46

Date of Publication: 02-Nov-2013


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DIABETIC KETOACIDOSIS AS AN INITIAL PRESENTATION OF TYPE-1 DIABETIC CHILDREN IN ASEER REGION OF SAUDI ARABIA

Author: Mohammad A. Al Qahtani, Ayed A. Shati, Ali M. Alsuheel, Fuad I. Abbag

Category: Healthcare

Abstract:Objective: This study aimed to determine the frequency of diabetic ketoacidosis (DKA) as initial presentation among patients with type-1 Diabetes Mellitus (DM-1) following in Aseer Diabetes Center of Aseer Region, Southwestern of Saudi Arabia. Patients and Methods: Retrospectively we reviewed and analyzed medical records of type-1 DM children who were less than 15 years and diagnosed with DKA at initial presentation, over period of 7 years from February 2006 till January 2013. Results: Out of 508 diabetic patients, 244 (48%) patients had DKA at the initial presentation. The mean age was 8.5 years. 120 (49.1%) with DKA were males and 124 (50.9%) females. Six patients with type-1 DM were less than one year and 5 (83.3%) of them were in DKA, compared with the 239 patients (47.6%) of the remaining 502 patients beyond this age. Generally, frequency of DKA among patients from (1-5) year was 51.7% (N=176) and more than 5 years was 46.9% (N=153). No death, renal failure or permanent neurological damage was reported at the initial presentation. Conclusion: A significantly high percentage of children with newly diagnosed DM-1 still have DKA at the onset of DM. This calls for health education and awareness of the parents / public and primary health care physicians through continuous medical education and mass media to achieve early diagnosis of type-1 DM before the development of DKA.

Keywords: Type-1 DM, Diabetic ketoacidosis (DKA), Cerebral edema, Autoimmune, Beta-cells.

Full Text:

INTRODUCTION

Worldwide, diabetes mellitus (DM) is currently a major health problem. Type-1 DM is the most common type of diabetes in children and may present initially as diabetic ketoacidosis (DKA). Patients with type-1 DM are more susceptible to develop DKA than those with type-2 DM. DKA is a metabolic disorder characterized by hyperglycemia, acidosis and ketosis which occur in the presence of low levels of circulating insulin. The underlying cause of type-1 DM is insulinopenia (low or absolute zero levels of insulin) due to either autoimmune destruction of pancreatic B-cells or idiopathic1,4. This type of diabetes and its association with DKA carries high rate of morbidity, mortality and health cost5,6. WHO DIAMOND project group and other studies have clearly mentioned that type-1 DM or insulin dependent diabetes mellitus (IDDM) is the most prevalent and common chronic childhood disease in industrialized countries7,8. DKA as initial presentation in type-1 DM has been reported worldwide with varying prevalence as high as 67% and also up to 80% have been reported9,12. High rate of DKA, morbidity, and complications are due to the fact that most of the families are unaware of the symptoms of DKA. Parents and public awareness of these symptoms will lead to timely diagnosis of DM and prevention of DKA which is considered as acute complication of DM-1. The classic symptoms at initial presentation of type-1 DM are usually gradual, and include polyuria, polydipsia, polyphagia and weight loss. The symptoms of DKA may be mild starting with vomiting, polyuria and dehydration symptoms. DKA in severe cases may present with abdominal pain mimicking acute appendicitis or pancreatitis and sometimes presents with rapid breathing and Kaussmaul’s breathing followed by obtundation of consciousness and ultimately coma. In Saudi Arabia, families with inadequate knowledge about diabetes, especially in pediatric age groups, fail to recognize symptoms of DM. Hence, their children may persist to suffer from the disease and fail to seek medical advice until they present with DKA. Furthermore the primary health care providers may miss these symptoms especially in the presence of common acute infections such as URTI, GE or UTI. This is alarming as DKA carries high risk and complications if not timely diagnosed13,15. There are few studies from Saudi Arabia (Northwest and Madina Regions) and also Gulf Region for DKA at initial presentation16,19. However, there are no large scale studies at tertiary care diabetes center from Aseer Region of Saudi Arabia. So, we aimed from this study is to review the patients in Aseer Region who presented with DKA as an initial presentation of type-1 DM.

METHODS

This is a retrospective analytical study done in Aseer Diabetes Center of Aseer Central Hospital which is the largest tertiary care diabetes center in Aseer Region (Southwestern) of Saudi Arabia. Diabetic patients from all primary health care centers (PHCCs) are usually referred to Aseer Diabetes Center (ADC) for follow up after initial diagnosis. ADC has catchment area of 20 secondary care hospitals and 285 primary health care centers. ADC is equipped with all modern health care facilities.

In this 7 year study, retrospectively we reviewed and analyzed the records of diabetic patients seen regularly in Aseer Diabetes Center, from February 2006 till January 2013. The study was approved by the hospital research committee.

Only type-1 DM children (aged <15 years) were included in the study. Patients who were considered to have DKA if they had a random blood sugar (RBS) greater than 300 mg/dl, pH less than 7.3, bicarbonate less than 15, glucosuria and ketonuria20,22 or if the patient had medical report from referring hospital documented with DKA as initial presentation (according to the above mentioned criteria). Patients with incomplete data for DKA were excluded from the study. Patients’ data were categorized for DKA presentation as less than 1 year, 1-5 years and more than 5 years of age.

RESULTS

The medical records of 508 patients with type-1 DM were reviewed. Of these 508 patients, 244 patients (48%) had DKA at initial presentation of illness while 264 patients did not present with DKA. Out of 244 patients, 120 patients (49.1 %) were males. The mean age was 8.5 years. In the patients with DKA, those who are less than one year have higher chance to present with DKA comparing with other age groups, 5 patients of 6 patients (83.3%) in comparison with 239 patients (47.6%) beyond that age. The frequency of DKA in children 1-5 years of age is 51.7% (91 out of 176) compared with 46.9% (153 out of 326) in older children as demonstrated in table 1 and figure 1. There was no mortality, permanent neurological or renal damage.

DISCUSSION

Type 1 DM represents about 5% of all types of DM22. The frequency of DKA at onset of diabetes varies by geographic location9,12,16,19. In well-developed countries such as the United States, around 25% of type-1 DM will first present in DKA23. By reviewing the other international studies, we found that it ranges between 16-80%24,28.

In our study, we found that 48% of our patients presented initially in DKA which is considered relatively high and may reflect a delay in diagnosing DM. This figure is similar to a previously reported figure (55%) from other region of Saudi Arabia16, 17, and from Kuwait which was 49%19. Although this percentage is alarming, none of our patients with DKA developed permanent neurological damage, renal failure or mortality. However, it is known that a delay in the diagnosis of DKA may result in cerebral edema with its complications such as renal failure, hypokalemia or hypekalemia, arrhythmias and/or other electrolyte abnormalities. It will also necessitate admission to the pediatric intensive care unit and prolong the hospital stay. The younger the child at the onset of DM, the higher the chance of having DKA at initial presentation; this may be explained by the fact that infants have non-specific symptoms such as excessive crying, irritability and excessive diaper changes29,30, which may be interpreted as being secondary to infections, particularly urinary tract infection. Furthermore, dehydration and acidosis develop quickly in young children which may explain the high frequency of DKA30.

In our data, there were 6 patients with age less than 1 year and 5 of them (83.3%) developed DKA. The remaining one patient did not develop DKA and was diagnosed early because the family was already aware about the symptoms of DM and the patient’s brother was previously diagnosed as type 1 DM. 

Although inadequate knowledge of DM among the family members play a role in delaying the diagnosis which leads to high frequency of DKA at onset. Other factors should be considered for example, symptoms of DM may be overlooked by the primary care physician as well. The presentation with symptoms and signs of coexisting common childhood infections like gastroenteritis, otitis media, flu-like illness, respiratory infections and urinary tract infections may mask the DM symptoms leading to a delay in the diagnosis of type-1 DM or DKA31. In such cases, diagnosis of type-1 DM can be judged simply by the lower serum C-peptide level in infants suggesting a more aggressive beta-cell destruction26.

Although DKA related mortality used to be high over 50 years ago, it has decreased significantly over the last few decades6. The reported mortality rate in Ontario (Canada) was 0.18% for all DKA admissions32, in comparison with 0.31% in UK13. In our study, no mortality was encountered which is in correlation with other reports from the gulf region19 and from the West11. This should not be overestimated as these rates reflect mortality for DKA admissions, and do not include DKA mortality outside the hospital; this consideration is particularly important in developing countries where DKA mortalities outside the hospital are undiagnosed. Diabetic children are missed and might be attributed to common infections like enteritis, viral influenza or encephalitis. The leading cause of mortality is cerebral edema accounting for 57-87% of DKA deaths13. The mortality from cerebral edema might be diminished by early diagnosis and management.

The relatively high frequency of DKA at initial presentation necessitates further studies to uncover other possible causes. Since the incidence of DM in general is increasing worldwide, we should emphasize the need for more public health education programs using the media and schools, beside evaluation of the children health care system; interventional measures like refreshing courses, workshops and training of medical and paramedical staff in the primary health care units are highly needed33, 34. Physicians should be aware of high index of suspicion of type-1 DM symptoms especially in infants.

CONCLUSION

Among type-1 DM patients from above study and data were obtained, DKA carries a high risk of morbidity and mortality. As type-1 DM represents lower percentage than type-2 DM which could lead to late diagnosis among junior doctors and parents. In particular, the early detection of symptoms of type-1 DM by parents / public and health care physicians is required at primary care levels to reduce hospital admissions, complications and the cost of health care, especially in young age group. The awareness and education of public and general practitioners are still highly recommended through continuous medical education and mass media to decrease the occurrence of DKA in newly diagnosed type 1 diabetic children.

ACKNOWLEDGEMENT

The Authors of this study would like to thank Dr. Kamran Mahmood Ahmed, Diabetologist at Aseer Diabetes Center, for his valuable advises and suggestions for the improvement of this article.

Conflict of interest

The authors declare no conflict of interest.

 

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A Study by Sonali Banerjee and Mary Mathews N. entitled "Exploring Quality of Life and Perceived Experiences Among Couples Undergoing Fertility Treatment in Western India: A Mixed Methodology" is awarded Best Article for Vol 12 issue 18
A Study by Jabbar Desai et al. entitled "Prevalence of Obstructive Airway Disease in Patients with Ischemic Heart Disease and Hypertension" is awarded Best Article for Vol 12 issue 17
A Study by Juna Byun et al. entitled "Study on Difference in Coronavirus-19 Related Anxiety between Face-to-face and Non-face-to-face Classes among University Students in South Korea" is awarded Best Article for Vol 12 issue 16
A Study by Sudha Ramachandra & Vinay Chavan entitled "Enhanced-Hybrid-Age Layered Population Structure (E-Hybrid-ALPS): A Genetic Algorithm with Adaptive Crossover for Molecular Docking Studies of Drug Discovery Process" is awarded Best article for Vol 12 issue 15
A Study by Varsha M. Shindhe et al. entitled "A Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi" is awarded Best article of Vol 12 issue 14, July 2020
A study by Amruta Choudhary et al. entitled "Family Planning Knowledge, Attitude and Practice Among Women of Reproductive Age from Rural Area of Central India" is awarded Best Article for special issue "Modern Therapeutics Applications"
A study by Raunak Das entitled "Study of Cardiovascular Dysfunctions in Interstitial Lung Diseas epatients by Correlating the Levels of Serum NT PRO BNP and Microalbuminuria (Biomarkers of Cardiovascular Dysfunction) with Echocardiographic, Bronchoscopic and HighResolution Computed Tomography Findings of These ILD Patients" is awarded Best Article of Vol 12 issue 13 
A Study by Kannamani Ramasamy et al. entitled "COVID-19 Situation at Chennai City – Forecasting for the Better Pandemic Management" is awarded best article for  Vol 12 issue 12
A Study by Muhammet Lutfi SELCUK and Fatma entitled "Distinction of Gray and White Matter for Some Histological Staining Methods in New Zealand Rabbit's Brain" is awarded best article for  Vol 12 issue 11
A Study by Anamul Haq et al. entitled "Etiology of Abnormal Uterine Bleeding in Adolescents – Emphasis Upon Polycystic Ovarian Syndrome" is awarded best article for  Vol 12 issue 10
A Study by entitled "Estimation of Reference Interval of Serum Progesterone During Three Trimesters of Normal Pregnancy in a Tertiary Care Hospital of Kolkata" is awarded best article for  Vol 12 issue 09
A Study by Ilona Gracie De Souza & Pavan Kumar G. entitled "Effect of Releasing Myofascial Chain in Patients with Patellofemoral Pain Syndrome - A Randomized Clinical Trial" is awarded best article for  Vol 12 issue 08
A Study by Virendra Atam et. al. entitled "Clinical Profile and Short - Term Mortality Predictors in Acute Stroke with Emphasis on Stress Hyperglycemia and THRIVE Score : An Observational Study" is awarded best article for  Vol 12 issue 07
A Study by K. Krupashree et. al. entitled "Protective Effects of Picrorhizakurroa Against Fumonisin B1 Induced Hepatotoxicity in Mice" is awarded best article for issue Vol 10 issue 20
A study by Mithun K.P. et al "Larvicidal Activity of Crude Solanum Nigrum Leaf and Berries Extract Against Dengue Vector-Aedesaegypti" is awarded Best Article for Vol 10 issue 14 of IJCRR
A study by Asha Menon "Women in Child Care and Early Education: Truly Nontraditional Work" is awarded Best Article for Vol 10 issue 13
A study by Deep J. M. "Prevalence of Molar-Incisor Hypomineralization in 7-13 Years Old Children of Biratnagar, Nepal: A Cross Sectional Study" is awarded Best Article for Vol 10 issue 11 of IJCRR
A review by Chitra et al to analyse relation between Obesity and Type 2 diabetes is awarded 'Best Article' for Vol 10 issue 10 by IJCRR. 
A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09

List of Awardees

A Study by Ese Anibor et al. "Evaluation of Temporomandibular Joint Disorders Among Delta State University Students in Abraka, Nigeria" from Vol 13 issue 16 received Emerging Researcher Award


A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" from Vol 13 issue 06 received Emerging Researcher Award


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International Journal of Current Research and Review (IJCRR) provides platform for researchers to publish and discuss their original research and review work. IJCRR can not be held responsible for views, opinions and written statements of researchers published in this journal

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