title: Diabetic ketoalkalosis in children and adults.
abstract: OBJECTIVE
  Diabetic ketoacidosis (DKA) with metabolic alkalosis (diabetic ketoalkalosis [DKALK]) in adults has been described in the literature, but not in the pediatric population. The discordance in the change in the anion gap (AG) and the bicarbonate is depicted by an elevated delta ratio (DR; rise in AG/drop in bicarbonate), which is normally approximately 1. The primary aim of this study was to determine whether DKALK occurs in the pediatric population, as has been seen previously in the adult population. The secondary aim was to determine the factors that may be associated with DKALK.
  
  
  METHODS
  A retrospective analysis of adult and pediatric cases with a primary or secondary discharge diagnosis of DKA between May 2008 and August 2010 at a large urban hospital was performed. DKALK was assumed to be present if the DR was >1.2 or in cases of elevated bicarbonate.
  
  
  RESULTS
  Of 190 DKA cases, 91 were children, with 21% fulfilling the criterion for DKALK. There were 99 adult cases, 35% of which fulfilled the criterion for DKALK. Our final logistic model revealed that among patients with a discharge diagnosis of DKA, male patients, patients with a history of renal failure, and patients presenting with abdominal findings on physical examination were at greater odds of having a concomitant metabolic alkalosis.
  
  
  CONCLUSIONS
  Although DKALK has been described in adults, it can occur in a significant number of children presenting with DKA. The recognition of DKA can be obscured in such situations unless the AG and DR are calculated because the pH and bicarbonate may be near normal or even elevated. In addition to having interesting biochemical features as a complex acid-base disorder, DKALK can pose diagnostic and/or therapeutic challenges.
authors.affiliation: From the Department of Medicine, University of South Carolina School of Medicine, the Department of Epidemiology and Biostatistics, University of South Carolina Arnold School of Public Health, and the Department of Clinical Research, Palmetto Health Richland, Columbia, South Carolina.
authors.forename: Emily A
authors.initials: EA
authors.lastname: Huggins
authors.forename: Shawn A
authors.initials: SA
authors.lastname: Chillag
authors.forename: Ali A
authors.initials: AA
authors.lastname: Rizvi
authors.forename: Robert R
authors.initials: RR
authors.lastname: Moran
authors.forename: Martin W
authors.initials: MW
authors.lastname: Durkin
mesh_terms: D000328:Adult; D000471:Alkalosis / Q000097:blood / Q000175:diagnosis*; D001639:Bicarbonates / Q000097:blood*; D001786:Blood Glucose / Q000378:metabolism; D002648:Child; D003922:Diabetes Mellitus, Type 1 / Q000097:blood / Q000175:diagnosis*; D016883:Diabetic Ketoacidosis / Q000097:blood / Q000175:diagnosis*; D005260:Female; D006784:Hospitals, Teaching; D006801:Humans; D006863:Hydrogen-Ion Concentration; D016015:Logistic Models; D008297:Male; D012189:Retrospective Studies; D012307:Risk Factors
chemical_list: D001639:Bicarbonates; D001786:Blood Glucose