The Quiet Deterioration: Undetected Early Kidney Injury in Pediatric Diabetic Emergencies

Jonas Schneider¹, Anna Fischer², Lukas Weber³, Leon Zimmermann⁴

Abstract

Background:
Pediatric patients presenting with diabetic ketoacidosis (DKA) often undergo rapid clinical improvement. However, emerging signals suggest the presence of occult acute kidney injury (AKI) during early resuscitation, which is rarely identified and may have long-term implications.

Objective:
To evaluate the incidence, predictors, and short-term renal outcomes of subclinical AKI in children admitted with DKA in emergency settings.

Methods:
This prospective observational study included 376 children (aged 6–17 years) admitted with moderate to severe DKA across four German tertiary centres between January 2022 and December 2023. Renal biomarkers, including cystatin C, NGAL (neutrophil gelatinase-associated lipocalin), and serum creatinine, were measured at 0, 6, and 24 hours post-admission. Subclinical AKI was defined by biomarker elevation without creatinine-based criteria for AKI.

Results:
Subclinical AKI was detected in 31.4% (n=118) of patients, with elevated NGAL levels (>150 ng/mL) being the most common abnormality. These children had more extended hospital stays (4.6 vs. 3.1 days, p < 0.001) and higher 30-day readmission rates (9.3% vs. 2.8%, p = 0.005). Multivariable analysis identified hyperosmolarity >320 mOsm/kg and bicarbonate <10 mmol/L as independent predictors (p < 0.01). Serum creatinine alone failed to detect early injury in 72% of affected cases.

Conclusion:
Subclinical AKI in pediatric DKA is an under-recognised phenomenon with real clinical consequences. Conventional markers are insufficient, and early biomarker screening could enhance the identification and management of these conditions. Integrating renal risk scoring into pediatric diabetic emergency protocols may prevent silent renal damage and improve long-term kidney health.