Risk factors of acute renal failure in critically ill children: A prospective descriptive epidemiological study

A Retrospective Analysis of Risk Factors and Impact of Acute Kidney Injury in Critically Ill Children

BACKGROUND

Acute kidney injury (AKI) is a serious clinical condition in critically ill children and is associated with worse outcomes. A few pediatric studies focused on the risk factors of AKI. We aimed to identify the incidence, risk factors, and outcomes of AKI in the pediatric intensive care unit (PICU).

PATIENTS AND METHODS

All the patients admitted to PICU over a period of 20 months were included. We compared both groups the risk factors between AKI and non-AKI.

RESULTS

A total of 63 patients (17.5%) of the 360 patients developed AKI during PICU stay. The presence of comorbidity, diagnosis of sepsis, increased PRISM III score, and positive renal angina index were found to be risk factors for AKI on admission. Thrombocytopenia, multiple organ failure syndrome, the requirement of mechanical ventilation, use of inotropic drugs, intravenous iodinated contrast media, and exposure to an increased number of nephrotoxic drugs were independent risk factors during the hospital stay. The patients with AKI had a lower renal function on discharge and had worse overall survival.

CONCLUSIONS

AKI is prevalent and multifactorial in critically sick children. The risk factors of AKI may be present on admission and during the hospital stay. AKI is related to prolonged mechanical ventilation days, longer PICU stays, and a higher mortality rate. Based on the presented results early prediction of AKI and consequent modification of nephrotoxic medication may generate positive effects on the outcome of critically ill children.

Ceftriaxone Pharmacokinetics and Pharmacodynamic Target Attainment for Three Pediatric Patients Receiving Continuous Kidney Replacement Therapy

Ceftriaxone is used commonly for sepsis, including in children requiring continuous kidney replacement therapy (CKRT). No reports exist of pharmacokinetic (PK) parameters for children receiving ceftriaxone on CKRT. We enrolled children admitted to our pediatric intensive care unit (PICU) who received CKRT for >24 hours and received >1 dose of ceftriaxone while on and off CKRT. We measured free ceftriaxone -concentrations from residual blood samples then used Bayesian estimation with PK modeling software to generate concentration-time profiles and determine PK parameters and the percentage of time free ceftriaxone concentrations were above 1× or 4× MIC (% fT >MIC). Three patients aged 2 to 17 years were included; all were anuric at CKRT initiation and received 50 mg/kg (max 2000 mg) ceftriaxone every 12 to 24 hours. Total ceftriaxone clearance (CL) was 0.50 to 3.67 L/hr while receiving CKRT and 0.29 to 2.71 L/hr while off, indicating CKRT provided 25% to 42% of total ceftriaxone CL. All achieved 100% fT >1× and 4× MIC using an estimated MIC (1 mg/L) for patients 1 to 2 (no culture data) and a measured MIC (0.016 mg/L) for patient 3. Therefore, CKRT contributed significantly to total ceftriaxone clearance in 3 children though the dosing strategies used in each patient attained PD targets.

Pediatric nephrologist-intensivist interaction in acute kidney injury

INTRODUCTION

Acute Kidney Injury (AKI) in the Intensive Care Unit (ICU) have concepts of diagnosis and management have water balance as their main point of evaluation. In our ICU, from 2004 to 2012, the nephrologist's participation was on demand only; and as of 2013 their participation became continuous in meetings to case discussion. The aim of this study was to establish how an intense nephrologist/intensivist interaction influenced the frequency of dialysis indication, fluid balance and pRIFLE classification during these two observation periods.

METHODS

Retrospective study, longitudinal evaluation of all children with AKI undergoing dialysis (2004 to 2016).

PARAMETERS STUDIED

frequency of indication, duration and volume of infusion in the 24 hours preceding dialysis; diuresis and water balance every 8 hours. Non-parametric statistics, p ≤ 0.05.

RESULTS

53 patients (47 before and 6 after 2013). There were no significant differences in the number of hospitalizations or cardiac surgeries between the periods. After 2013, there was a significant decrease in the number of indications for dialysis/year (5.85 vs. 1.5; p = 0.000); infusion volume (p = 0.02), increase in the duration of dialysis (p = 0.002) and improvement in the discrimination of the pRIFLE diuresis component in the AKI development.

CONCLUSION

Integration between the ICU and pediatric nephrology teams in the routine discussion of cases, critically approaching water balance, was decisive to improve the management of AKI in the ICU.

Acute kidney injury in children: incidence, awareness and outcome-a retrospective cohort study

The primary objective was to determine the epidemiologic influence of AKI awareness among physicians in a mixt paediatric population, including neonates. This single-centre, multiyear, observational retrospective study included all admitted patients between first of July 2014 and 31 December 2021. AKI was identified in 2194 patients out of the 128,036 hospital admissions with 129,936 serum creatinine measurements. Matching comparisons were used between AKI aware and AKI non-aware patients. The overall incidence of AKI was 1.65%. Stage 1 was identified in 24.24% of the AKI cases, stage 2 in 31.03% and stage 3 in 44.71%. The most prevalent cause of AKI was represented by prerenal AKI in 85.64% of the cases, followed by 12.16% renal causes respectively 2.18% postrenal causes. Exposure to sepsis, critical illness, hypovolemic shock and mechanical ventilation increased mortality by 2.09, 4.69, 4.64- and 4.93-times (p = 0.001). Cancer and heart failure increased mortality by 4.22 (p < 0.001) respectively 2.17 times (p = 0.001). The presence of AKI increased mortality by 79.11 times while only half of the AKI associated deaths were recognized by physicians. AKI increased hospitalization more than 4 times the average stay. AKI awareness was dependent of lower age and severity. Also, awareness increased mortality and prolonged hospitalization. 1 in 3 neonates and 1 in 4 children were AKI aware. The physician's awareness of AKI diagnosis is in general low due to lack of appliance of current guidelines in exploring exposures and susceptibilities for AKI screening.

Posterior urethral valve in thai boys

BACKGROUND

Posterior urethral valve (PUV) is the most common congenital bladder outlet obstruction in boys, causing renal damage beginning in utero. There are scarce data from Thailand regarding the long-term outcomes of PUV in boys, thus the aim of this study was to examine the presentation, clinical course, complications, outcomes and renal survival in PUV boys.

METHODS

We reviewed the medical records of PUV boys treated at the Pediatric Nephrology Clinic, Prince of Songkla University, Thailand, over a 30-year-period.

RESULTS

Seventy-seven PUV boys were identified, with a median age at diagnosis of 4.8 months. The most common presentations were urinary tract infection (UTI), poor urine stream and urinary dribbling in 26 (33.8%), 19 (24.7%) and 11 (14.3%) boys, respectively. Renal ultrasound results in 70 boys showed 8 (11.4%) unilateral and 56 (80%) bilateral hydronephroses. Of 72 voiding cystourethrograms, 18 (25.0%) showed unilateral and 22 (30.6%) bilateral vesicoureteral refluxes. 99mTc dimercaptosuccinic acid renal scans in 30 boys showed 12 (40%) unilateral and 8 (26.7%) bilateral renal damage. Fifty-nine (76.6%) boys had 149 UTIs; 42 (54.4%) had recurrent UTI. Forty-eight boys had valve ablation at the median age of 30.3 months. 22 boys (28.6%) developed chronic kidney disease (CKD) at a median age of 15.0 years.

CONCLUSION

Of 77 PUV Thai boys, UTI was the most common presentation. Recurrence of UTI and CKD was the most common consequence. Lifelong follow-up for renal and bladder functions is essential for all PUV patients.

Long-term outcomes of acute kidney injury in children

PURPOSE OF REVIEW

Acute kidney injury (AKI) affects up to 35% of all critically ill children and is associated with substantial short-term morbidity and mortality. However, the link between paediatric AKI and long-term adverse outcomes remains incompletely understood. This review highlights the most recent clinical data supporting the role of paediatric AKI as a risk factor for long-term kidney and cardiovascular consequences. In addition, it stresses the need for long-term surveillance of paediatric AKI survivors.

RECENT FINDINGS

Recent large-scale studies have led to an increasing understanding that paediatric AKI is a significant risk factor for adverse outcomes such as hypertension, cardiovascular disease and chronic kidney disease (CKD) over time. These long-term sequelae of paediatric AKI are most often observed in vulnerable populations, such as critically ill children, paediatric cardiac surgery patients, children who suffer from severe infections and paediatric cancer patients.

SUMMARY

A growing body of research has shown that paediatric AKI is associated with long-term adverse outcomes such as CKD, hypertension and cardiovascular disease. Although therapeutic pathways tailored to individual paediatric AKI patients are yet to be validated, we provide a framework to guide monitoring and prevention in children at the highest risk for developing long-term kidney dysfunction.

Subphenotypes of acute kidney injury in children

PURPOSE OF REVIEW

The purpose of this review is to describe acute kidney injury (AKI) phenotypes in children.

RECENT FINDINGS

AKI is a heterogenous disease that imposes significant morbidity and mortality on critically ill and noncritically ill patients across the age spectrum. As our understanding of AKI and its association with outcomes has improved, it is becoming increasingly apparent that there are distinct AKI subphenotypes that vary by cause or associated conditions. We have also learned that severity, duration, and repeated episodes of AKI impact outcomes, and that integration of novel urinary biomarkers of tubular injury can also reveal unique subphenotypes of AKI that may not be otherwise readily apparent.

SUMMARY

Studies that further delineate these unique AKI subphenotypes are needed to better understand the impact of AKI in children. Further delineation of these phenotypes has both prognostic and therapeutic implications.

Cardiorenal syndrome in the pediatric population: A systematic review

The concept of cardiorenal syndrome (CRS) is derived from the crosstalk between the heart and kidneys in pathological conditions. Despite the rising importance of CRS, there is a paucity of information on the understanding of its pathophysiology and management, increasing both morbidity and mortality for patients. This review summarizes the existing conceptual pathophysiology of different types of CRS and delves into the associated therapeutic modalities with a focus on pediatric cases. Prospective or retrospective observational studies, comparative studies, case reports, case-control, and cross-sectional studies that include pediatric patients with CRS were included in this review. Literature was searched using PubMed, EMBASE, and Google Scholar with keywords including "cardio-renal syndrome, type," "reno-cardio syndrome," "children," "acute kidney injury," and "acute decompensated heart failure" from January 2000 to January 2021. A total of 14 pediatric studies were ultimately included and analyzed, comprising a combined population of 3608 children of which 32% had CRS. Of the 14 studies, 57% were based on type 1 CRS, 14% on types 2 and 3 CRS, and 7% were on types 4 and 5 CRS. The majority of included studies were prospective cohort, although a wide spectrum was observed in terms of patient age, comorbidities, etiologies, and treatment strategies. Commonly observed comorbidities in CRS type 1 were hematologic, oncologic, cardiology-related side effects, muscular dystrophy, and pneumonia/bronchiolitis. CRS, particularly type 1, is prevalent in children and has a significant risk of mortality. The current treatment regimen primarily involves diuretics, extracorporeal fluid removal, and treatment of underlying etiologies and comorbidities.

Role of urinary NGAL and microalbuminuria in the detection of subclinical acute kidney injury in pediatric intensive care unit and diabetic children

Subclinical Acute Kidney Injury (AKI) describes patients who did not fulfill the classical criteria for AKI diagnosis but showed elevated levels of new biomarkers reflecting tubular injury. One of these biomarkers is Neutrophil Gelatinase-Associated Lipocalin (NGAL). The aim of this study is to investigate the role of urinary NGAL and microalbuminuria as non-invasive biomarkers in the detection of subclinical AKI. Analysis of urinary NGAL and microalbuminuria in 91 subjects [30 pediatric intensive care unit (PICU) patients, 31 diabetic patients and 30 healthy controls] recruited from Cairo University Pediatric Hospital was done. Our study revealed that urinary NGAL was significantly higher in the PICU group followed by the diabetic group and lowest in the controls group (p=0.022). A positive correlation was found between urinary NGAL and microalbuminuria in the PICU group (Rvalue= 0.585, p-value=0.001). In diabetic group, a positive correlation was found between urinary NGAL and fasting blood glucose, 2 hours post prandial and HbA1C (R-value=0.421; pvalue= 0.021; R-value=0.426; p-value=0.019; R-value=0.438; pvalue= 0.018 respectively). Urinary NGAL may be a potential biomarker to detect subclinical AKI before actual functional renal damage leading to early intervention and reduction of mortality.

Plants with Therapeutic Potential for Ischemic Acute Kidney Injury: A Systematic Review

Acute kidney injury (AKI) is a complex condition which has an intricate pathology mostly involving hemodynamic, inflammatory, and direct toxic effects at the cellular level with high morbidity and mortality ratios. Renal ischemic reperfusion injury (RIRI) is the main factor responsible for AKI, most often observed in different types of shock, kidney transplantation, sepsis, and postoperative procedures. The RIRI-induced AKI is accompanied by increased reactive oxygen species generation together with the activation of various inflammatory pathways. In this context, plant-derived medicines have shown encouraging nephroprotective properties. Evidence provided in this systemic review leads to the conclusion that plant-derived extracts and compounds exhibit nephroprotective action against renal ischemic reperfusion induced-AKI by increasing endogenous antioxidants and decreasing anti-inflammatory cytokines. However, there is no defined biomarker or target which can be used for treating AKI completely. These plant-derived extracts and compounds are only tested in selected transgenic animal models. To develop the results obtained into a therapeutic entity, one should apply them in proper vertebrate multitransgenic animal models prior to further validation in humans.

Comparative Analysis between Urinary Calprotectin and Serum Creatinine for Early Detection of Intrinsic Acute Kidney Injury

Background

Acute kidney injury (AKI) is a common and important clinical condition that may lead to chronic kidney disease if it is not diagnosed and treated in its early stages. Urinary calprotectin is a valuable recognized biomarker that can be used to differentiate prerenal and intrinsic AKI. However, till date only a few reports on urine calprotectin measurement in early diagnosis of intrinsic AKI are available. In this study, we compared the sensitivity and specificity of urinary calprotectin with those of serum creatinine in detecting early intrinsic AKI.

Methods

Over 6 months period (April to October 2018), 81 of 408 patients admitted to the pediatric intensive care unit met the criteria of this cross-sectional study. Their serum creatinine and urinary calprotectin were measured on the first and third day of admission using Jaffe and Elisa radioimmunoassay methods, respectively. The AKI was defined according to the pRIFLE criteria.

Results

Of the total 81 patients, 67 had the criteria of intrinsic AKI. Of these 62% were female and 38% were male. The mean age of the patients was 22 months. According to data analysis, the area under the curve of ROC of urinary calprotectin on day-1 to detect renal failure is 0.93 with the best cutoff point obtained at 530 ng/mL. The sensitivity, specificity, positive, and negative predictive values of urinary calprotectin levels in diagnosing AKI at this cutoff point are 92.5%, 92.8%, 98.4, and 72.2%, respectively. Besides, urinary calprotectin changes occur much earlier than the rising of serum creatinine.

Conclusion

Urinary level of calprotectin is a very sensitive biomarker for early diagnosis of intrinsic AKI in children and it can be used in intensive care units or anywhere critically ill children admitted to detect intrinsic AKI. Besides, this study shows that urine calprotectin may be a more sensitive and specific biomarker than serum creatinine in the early phases of intrinsic AKI.

Impact of acute kidney injury in patients prescribed angiotensin-converting enzyme inhibitors over the first two years of life

BACKGROUND

The association of long-term acute kidney injury (AKI) risk with angiotensin-converting enzyme (ACE) inhibitor use in neonates/infants is poorly understood. We examined this association to identify potential AKI risk factors.

METHODS

We retrospectively evaluated 119 children aged < 2 years (72 boys; median age, 5.0 months) who received ACE inhibitors for congenital heart disease for ≥ 6 months between January 2009 and June 2019. We monitored the occurrence of AKI, defined according to the Kidney Disease Improving Global Outcomes guidelines. Demographic and clinical data were extracted from medical records. Risk factors associated with AKI onset were identified by a Cox proportional hazards regression analysis of variables previously identified as risk factors of AKI and those significant in a univariate analysis.

RESULTS

Thirty-three of 119 patients (28%) developed AKI at a median follow-up of 1.3 years (interquartile range, 0.8-3.2 years). AKI incidence was 1257 events per 10,000 patient-years. Concomitant tolvaptan use (hazard ratio [HR], 3.81; 95% confidence interval [CI], 1.82-7.97; P < 0.01) and Down syndrome (HR, 3.22; 95% CI, 1.43-7.29; P < 0.01) were identified as independent risk factors of AKI onset.

CONCLUSIONS

AKI was strongly associated with concomitant tolvaptan use and Down syndrome in our study population. Physicians should consider these factors when prescribing ACE inhibitors for neonates/infants. Low-dose ACE inhibitors slow CKD progression because of their antifibrotic properties. ACE inhibitors may be beneficial for patients with Down syndrome who have underlying CKD in a non-acute setting. Therefore, they should be administered to such patients with caution.

Impact of and risk factors for pediatric acute kidney injury defined by the pROCK criteria in a Chinese PICU population

BACKGROUND

The definition of pediatric AKI continues to evolve. We aimed to find a better AKI definition to predict outcomes and identify risk factors for AKI in a Chinese PICU.

METHODS

This study consisted of 3338 patients hospitalized in a Chinese PICU between 2016 and 2018. AKI was defined and staged using pROCK criteria, which were compared with KDIGO criteria. AKI outcomes, including mortality, daily cost and length of stay (LOS), were assessed. Risk factors for AKI were also estimated.

RESULTS

The incidence of AKI in the PICU was 7.7% according to pROCK criteria. The characteristics of patients with KDIGO-defined AKI who did not meet the pROCK were similar to those without AKI. pROCK outperformed KDIGO in predicting mortality with a higher c index in the Cox models (0.81 versus 0.79, P = 0.013). AKI, as well as AKI stages, were associated with higher mortality (HR: 10.5, 95%CI: 6.66-19.5), daily cost (β = 2064, P < 0.01) and LOS (β = 2.30, P < 0.01). Age, comorbidities, mechanical ventilation (MV), pediatric critical illness score (PCIS) and exposure to drugs had significant influence on AKI occurrence.

CONCLUSIONS

The mortality predictability of pROCK was slightly greater than that of KDIGO. Older age, underlying comorbidities, MV, decreased PCIS and exposure to drugs were potential risk factors for AKI.

IMPACT

Two AKI criteria, pROCK and KDIGO, were significantly associated with an increased risk of mortality and pROCK was slightly greater than that of KDIGO. Older age, comorbidities, mechanical ventilation, decreased PCIS and exposure to drugs were potential risk factors for AKI. This study first used the pROCK criteria to provide an epidemiologic description of pediatric AKI in Chinese PICU. This study compared the AKI outcomes across the pROCK and KDIGO AKI criteria, indicating the prior utility for AKI classification in Chinese children. This study indicated that the potential risk factors for AKI were older age, comorbidities, mechanical ventilation, decreased PCIS and exposure to drugs.

Impact of the use of nephrotoxic drugs in critically ill pediatric patients

OBJECTIVE

To evaluate the association between the use of nephrotoxic drugs and acute kidney injury in critically ill pediatric patients.

METHODS

This was a retrospective cohort study involving all children admitted to the intensive care unit of a pediatric hospital during a 1-year period. Acute kidney injury was defined according to the KDIGO classification. Patients with a length of hospital stay longer than 48 hours and an age between 1 month and 14 years were included. Patients with acute or chronic nephropathy, uropathy, congenital or acquired heart disease, chronic use of nephrotoxic drugs, rhabdomyolysis and tumor lysis syndrome were excluded. Patients were classified according to the use of nephrotoxic drugs during their stay at the pediatric intensive care unit.

RESULTS

The sample consisted of 226 children, of whom 37.1% used nephrotoxic drugs, 42.4% developed acute kidney injury, and 7.5% died. The following drugs, when used alone, were associated with acute kidney injury: acyclovir (p < 0.001), vancomycin (p < 0.001), furosemide (p < 0.001) and ganciclovir (p = 0.008). The concomitant use of two or more nephrotoxic drugs was characterized as an independent marker of renal dysfunction (p < 0.001). After discharge from the pediatric intensive care unit, renal function monitoring in the ward was inadequate in 19.8% of cases.

CONCLUSION

It is necessary for intensivist physicians to have knowledge of the main nephrotoxic drugs to predict, reduce or avoid damage to their patients.

Acute Kidney Injury in Pediatric Inflammatory Multisystem Syndrome Temporally Associated With Severe Acute Respiratory Syndrome Coronavirus-2 Pandemic: Experience From PICUs Across United Kingdom

OBJECTIVES

To study the prevalence, evolution, and clinical factors associated with acute kidney injury in children admitted to PICUs with pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus-2.

DESIGN

Multicenter observational study.

SETTING

Fifteen PICUs across the United Kingdom.

PATIENTS

Patients admitted to United Kingdom PICUs with pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus-2 between March 14, 2020, and May 20, 2020.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Deidentified data collected as part of routine clinical care were analyzed. All children were diagnosed and staged for acute kidney injury based on the level of serum creatinine above the upper limit of reference interval values according to published guidance. Severe acute kidney injury was defined as stage 2/3 acute kidney injury. Uni- and multivariable analyses were performed to study the association between demographic data, clinical features, markers of inflammation and cardiac injury, and severe acute kidney injury. Over the study period, 116 patients with pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus-2 were admitted to 15 United Kingdom PICUs. Any-stage acute kidney injury occurred in 48 of 116 patients (41.4%) and severe acute kidney injury in 32 of 116 (27.6%) patients, which was mostly evident at admission (24/32, 75%). In univariable analysis, body mass index, hyperferritinemia, high C-reactive protein, Pediatric Index of Mortality 3 score, vasoactive medication, and invasive mechanical ventilation were associated with severe acute kidney injury. In multivariable logistic regression, hyperferritinemia was associated with severe acute kidney injury (compared with nonsevere acute kidney injury; adjusted odds ratio 1.04; 95% CI, 1.01-1.08; p = 0.04). Severe acute kidney injury was associated with longer PICU stay (median 5 days [interquartile range, 4-7 d] vs 3 days [interquartile range, 1.5-5 d]; p < 0.001) and increased duration of invasive mechanical ventilation (median 4 days [interquartile range, 2-6 d] vs 2 days [interquartile range, 1-3 d]; p = 0.04).

CONCLUSIONS

Severe acute kidney injury occurred in just over a quarter of children admitted to United Kingdom PICUs with pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus-2. Hyperferritinemia was significantly associated with severe acute kidney injury. Severe acute kidney injury was associated with increased duration of stay and ventilation. Although short-term outcomes for acute kidney injury in pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus-2 appear good, long-term outcomes are unknown.

Frequency of Exposure of Nephrotoxic Drugs and Drug-Induced Acute Kidney Injury in Pediatric Intensive Care Unit: A Retrospective Review From a Tertiary Care Centre in Pakistan

Introduction

Acute kidney injury (AKI) is one of the most common problems seen in the pediatric intensive care unit (PICU), with an overall 27% incidence. Besides many other factors, nephrotoxic medications (Nephrotoxins; Ntx) are also responsible for a large proportion of potentially avoidable pediatric AKI, directly accounting for 16% of AKI events.

Objective

To assess potential associations between nephrotoxic drugs and the risk of developing AKI in children admitted in PICU.

Material and methods

This is a retrospective cross-sectional study. Children (aged 1 month - 18 years) admitted to the PICU, with a length of stay >24 hours, were included. AKI was defined as according to KDIGO (Kidney Disease Improving Global Outcomes) criteria. Mild AKI was defined as a rise in creatinine value of 0.3 mg/dl from presenting value at a 24-hour interval. Patients were grouped according to the presence or absence of AKI. All medications administered in the ICU were assessed for nephrotoxicity through a review of adverse reactions mentioned in the Pediatric Dosage Handbook, along with consultation with a clinical pharmacist.

Results

Among 752 patients, the mean age was 4.8 years ± 4.37. There were 57.3% male and 42.7% female children. Among the exposed children, 37.4% received one drug, 32.4% received two drugs and 12.1% had high nephrotoxin exposure. The most commonly used drug was vancomycin (16.8%), as a single Ntx; vancomycin/colistin (12.9%), in dual nephrotoxic combination; and vancomycin/colistin/amphotericin (2.9%) in highly exposed children (i.e., with equal or more than three). Overall, the incidence of AKI was 14.9%.

Conclusion

Nephrotoxins are potentially avoidable risk factors in critically ill children. Whenever a combination of medications is required, it’s advisable to review all medications for better protection of kidneys and preventing of acute kidney injury.

Acute Kidney Injury, Fluid Overload, and Outcomes in Children Supported With Extracorporeal Membrane Oxygenation for a Respiratory Indication

This study seeks to evaluate the association between acute kidney injury (AKI), fluid overload (FO), and mortality in children supported with extracorporeal membrane oxygenation (ECMO) for refractory respiratory failure. This retrospective observational cohort study was performed at six tertiary care children's hospital intensive care units, studying 424 patients < 18 years of age supported with ECMO for ≥ 24 hours for a respiratory indication from January 1, 2007, to December 31, 2011. In a multivariate analysis, FO level at ECMO initiation was not associated with hospital mortality, whereas peak FO level during ECMO was associated with hospital mortality. For every 10% increase in peak FO during ECMO, the odds of hospital mortality were approximately 1.2 times higher. Every 10% increase in peak FO during ECMO resulted in a significant relative change in the duration of ECMO hours by a factor of 1.08. For hospital survivors, every 10% increase in peak FO level during ECMO resulted in a significant relative change in the duration of mechanical ventilation hours by a factor of 1.13. In this patient population, AKI and FO are associated with increased mortality and should be considered targets for medical interventions including judicious fluid management, diuretic use, and renal replacement therapy.

NEUTROPHIL GELATINASE-ASSOCIATED LIPOCALIN AS AN EARLY BIOMARKER OF ACUTE KIDNEY INJURY IN NEWBORNS

The aim of the study was to determine the incidence, risk factors and efficiency of the neutrophil gelatinase-associated lipocalin (NGAL) biomarker in early diagnosis of acute kidney injury (AKI) in newborns. The study was designed as a prospective, clinical, epidemiological investigation conducted in the period of three years, which included 50 newborns with AKI hospitalized in the Neonatal Intensive Care Unit, University Children’s Hospital in Skopje. The estimated prevalence of AKI was 6.4%, while the prevalence according to RIFLE classification was 8.7%. Perinatal asphyxia was a common predisposing factor associated to kidney injury. The mortality rate was 32% and was significantly higher in the group of newborns with congenital heart diseases. There was a significant difference between NGAL values and creatinine values on the day of admission. There was a significant difference in NGAL values between newborns with AKI and lethal outcome and newborns without lethal outcome (p<0.001). In conclusion, AKI is a life-threatening condition. It is an independent contributor to mortality. Urinary NGAL is an early predictive biomarker of AKI in critically ill newborns.

Characteristics of Hospitalized Children With SARS-CoV-2 in the New York City Metropolitan Area

OBJECTIVES

To describe the characteristics of hospitalized children with severe acute respiratory syndrome coronavirus 2 in New York City metropolitan area.

PATIENTS AND METHODS

This was a multicenter, retrospective cohort study at 4 hospitals comprising 82 hospitalized children (0-21 years) who tested positive for severe acute respiratory syndrome coronavirus 2 after symptoms and risk screening between March 1 and May 10, 2020. We subdivided patients on the basis of their admission to acute or critical care units and by age groups. Further subanalyses were performed between patients requiring respiratory support or no respiratory support.

RESULTS

Twenty-three (28%) patients required critical care. Twenty-nine (35%) patients requiring respiratory support, with 9% needing mechanical ventilation, and 1 required extracorporeal support. All patients survived to discharge. Children with any comorbidity were more likely to require critical care (70% vs 37%, P = .008), with obesity as the most common risk factor for critical care (63% vs 28%, P = .02). Children with asthma were more likely to receive respiratory support (28% vs 8%, P = .02), with no difference in need for critical care (P = .26). Children admitted to critical care had higher rates of renal dysfunction at presentation (43% vs 10%, P = .002).

CONCLUSIONS

Children with comorbidities (obesity and asthma in particular) were at increased risk for critical care admission and/or need for respiratory support. Children with renal dysfunction at presentation were more likely to require critical care.

Impact of the development of acute kidney injury on patients admitted to the pediatric intensive care unit

OBJECTIVE

To identify the risk factors for the development of acute kidney injury and for short and long-term mortality of patients with acute kidney injury after admission to the Pediatric Intensive Care Unit.

MATERIALS AND METHODS

Retrospective analysis of patients admitted to the Pediatric Intensive Care Unit from January 2004 to December 2008. Acute kidney injury was defined by the KDIGO criterion. Risk factors for acute kidney injury, in-hospital, and long-term mortality were obtained through multivariate logistic regression analysis. Long-term mortality (up to 2011) was obtained by searching the institution's database and by telephone contact with patients' family members.

RESULTS

A total of 434 patients were evaluated and the incidence of acute kidney injury was 64%. Most acute kidney injury episodes (78%) occurred within the first 24hours after admission to the Pediatric Intensive Care Unit. The risk factors for the development of acute kidney injury were: low volume of diuresis, younger age, mechanical ventilation, vasoactive drugs, diuretics, and amphotericin. Lower weight, positive fluid balance, acute kidney injury, dopamine use and mechanical ventilation were independent risk factors for in-hospital mortality. Long-term mortality was 17.8%. Systolic blood pressure, PRISM score, low volume of diuresis, and mechanical ventilation were independent risk factors associated with long-term mortality after admission to the Pediatric Intensive Care Unit.

CONCLUSION

Acute kidney injury was a frequent, early event, and was associated with in-hospital mortality and long-term mortality after admission to the Pediatric Intensive Care Unit.

Community-Based Epidemiology of Hospitalized Acute Kidney Injury

BACKGROUND

Acute kidney injury (AKI) may lead to short- and long-term consequences in children, but its epidemiology has not been well described at a population level and outside of ICU settings.

METHODS

In a large, diverse pediatric population receiving care within an integrated health care delivery system between 2008 and 2016, we calculated age- and sex-adjusted incidences of hospitalized AKI using consensus serum creatinine (SCr)-based diagnostic criteria. We also investigated the proportion of AKI detected in non-ICU settings and the rates of follow-up outpatient SCr testing after AKI hospitalization.

RESULTS

Among 1 500 546 children, the mean age was 9.8 years, 49.0% were female, and 33.1% were minorities. Age- and sex-adjusted incidence of hospitalized AKI among the entire pediatric population did not change significantly across the study period, averaging 0.70 (95% confidence interval: 0.68-0.73) cases per 1000 person-years. Among the subset of hospitalized children, the adjusted incidence of AKI increased from 6.0% of hospitalizations in 2008 to 8.8% in 2016. Approximately 66.7% of AKI episodes were not associated with an ICU stay, and 54.3% of confirmed, unresolved Stage 2 or 3 AKI episodes did not have outpatient follow-up SCr testing within 30 days postdischarge.

CONCLUSIONS

Community-based pediatric AKI incidence was ∼1 per 1000 per year, with two-thirds of cases not associated with an ICU stay and more than one-half not receiving early outpatient follow-up kidney function testing. Further efforts are needed to increase the systematic recognition of AKI in all inpatient settings with appropriate, targeted postdischarge kidney function monitoring and associated management.

Acute Kidney Injury Associated With Urinary Stone Disease in Children and Young Adults Presenting to a Pediatric Emergency Department

Background: Acute kidney injury (AKI) due to urinary stone disease (USD) is rare in adults; AKI rates in children with USD may be higher, and emerging data links stones to chronic kidney disease (CKD) development in adults. Methods: This study is a retrospective analysis of USD patients at a single pediatric hospital system's emergency department (ED). Patients were initially identified by USD ICD codes; USD was then confirmed by imaging or physician documentation; patients had to have baseline creatinine (Cr) and Cr in the ED for comparison to be included. AKI was defined by Kidney Disease: Improving Global Outcomes (KDIGO), Acute Kidney Injury Network (AKIN), and Pediatric Risk, Injury, Failure, Loss, End Stage (pRIFLE). Results: Of the 589 total visits, 264/589 (45%) had data to evaluate for AKI, 23% were AKI(+) and 77% were AKI(-). pRIFLE was most common (82%) and 18% were only positive by AKIN/KDIGO. AKI(+) were more likely to be younger (16.7 vs. 17.4 years, p = 0.046) and more likely to present with vomiting {odds ratio [OR] [95% confidence interval (CI)]: 2.4 [1.4-4.3], p = 0.002}; also, the proportion of AKI(+) was significantly higher in <18 vs. ≥18 years [26.9 vs. 15.5%, p = 0.032, OR (95% CI): 2.0 (1.1-3.9)]. Urinary tract infection (UTI) and obstruction rates were similar between groups. AKI(+) patients had a significant OR <1 suggesting less risk of receiving non-steroidal anti-inflammatory drugs (NSAIDs); however, 51% of them did receive NSAIDs during their ED encounter. AKI(+) patients were more likely to require admission to the hospital (53 vs. 32%, p = 0.001). Conclusion: We have demonstrated a novel association between USD-induced renal colic and AKI in a group of young adults and children. AKI(+) patients were younger and were more likely to present with vomiting. AKI(+) patients did not have higher rates of obstruction or UTI, and 51% of AKI(+) received NSAIDs.

Piperacillin/Tazobactam and Antibiotic-Associated Acute Kidney Injury in Critically Ill Children

BACKGROUND

There continues to be uncertainty about whether piperacillin/tazobactam (TZP) increases the risk of AKI in critically ill pediatric patients. We sought to compare rates of AKI among critically ill children treated with TZP or cefepime, an alternative frequently used in intensive care units, with and without vancomycin.

METHODS

We conducted a retrospective cohort study assessing the risk of AKI in pediatric intensive care unit patients after exposure to vancomycin, TZP, and cefepime, alone or in combination, within 48 hours of admission. The primary outcome was development of stage 2 or 3 AKI or an increase in AKI stage from 2 to 3 within the 6 days after the 48-hour exposure window. Secondary outcomes included lengths of stay, need for RRT, and mortality.

RESULTS

Of 5686 patients included, 494 (8.7%) developed stage 2 or 3 AKI. The adjusted odds of developing AKI after medication exposure were 1.56 for TZP (95% confidence interval [95% CI], 1.23 to 1.99), 1.13 for cefepime (95% CI, 0.79 to 1.64), and 0.86 for vancomycin (95% CI, 0.69 to 1.07). The adjusted odds of developing AKI for vancomycin plus TZP versus vancomycin plus cefepime was 1.38 (95% CI, 0.85 to 2.24).

CONCLUSIONS

Observational data in critically ill children show that TZP use is associated with increased odds of AKI. A weaker, nonsignificant association between vancomycin plus TZP and AKI compared with vancomycin plus cefepime, creates some uncertainty about the nature of the association between TZP and AKI. However, cefepime is an alternative not associated with AKI.

Early Diagnosis and Prognostic Value of Acute Kidney Injury in Critically Ill Patients

Background and objectives: In hospitalized children, acute kidney injury (AKI) remains to be a frequent and serious condition, associated with increased patient mortality and morbidity. Identifying early biomarkers of AKI and patient groups at the risk of developing AKI is of crucial importance in current clinical practice. Specific human protein urinary neutrophil gelatinase-associated lipocalin (uNGAL) and interleukin 18 (uIL-18) levels have been reported to peak specifically at the early stages of AKI before a rise in serum creatinine (sCr). Therefore, the aim of our study was to determine changes in uNGAL and uIL-18 levels among critically ill children and to identify the patient groups at the highest risk of developing AKI. Materials and methods: This single-center prospective observational study included 107 critically ill children aged from 1 month to 18 years, who were treated in the Pediatric Intensive Care Unit (PICU) of Lithuanian University of Health Sciences Hospital Kauno Klinikos from 1 December 2013, to 30 November 2016. The patients were divided into two groups: those who did not develop AKI (Group 1) and those who developed AKI (Group 2). Results: A total of 68 (63.6%) boys and 39 (36.4%) girls were enrolled in the study. The mean age of the patients was 101.30 ± 75.90 months. The mean length of stay in PICU and hospital was 7.91 ± 11.07 and 31.29 ± 39.09 days, respectively. A total of 32 (29.9%) children developed AKI. Of them, 29 (90.6%) cases of AKI were documented within the first three days from admission to hospital. In all cases, AKI was caused by diseases of non-renal origin. There was a significant association between the uNGAL level and AKI between Groups 1 and 2 both on day 1 (p = 0.04) and day 3 (p = 0.018). Differences in uNGAL normalized to creatinine in the urine (uCr) (uNGAL/uCr) between the groups on days 1 and 3 were also statistically significant (p = 0.007 and p = 0.015, respectively). uNGAL was found to be a good prognostic marker. No significant associations between uIL-18 or Uil-18/uCr and development of AKI were found. However, the uIL-18 level of >69.24 pg/mL during the first 24 h was associated with an eightfold greater risk of AKI progression (OR = 8.33, 95% CI = 1.39–49.87, p = 0.023). The AUC for uIL-18 was 73.4% with a sensitivity of 62.59% and a specificity of 83.3%. Age of <20 months, Pediatric Index of Mortality 2 (PIM2) score of >2.5% on admission to the PICU, multiple organ dysfunction syndrome with dysfunction of three and more organ systems, PICU length of stay more than three days, and length of mechanical ventilation of >five days were associated with a greater risk of developing AKI. Conclusions: Significant risk factors for AKI were age of <20 months, PIM2 score of >2.5% on admission to the PICU, multiple organ dysfunction syndrome with dysfunction of 3 and more organ systems, PICU length of stay of more than three days, and length of mechanical ventilation of > five days. uNGAL was identified as a good prognostic marker of AKI. On admission to PICU, uNGAL should be measured within the first three days in patients at the risk of developing AKI. The uIL-18 level on the first day was found to be as a biomarker predicting the progression of AKI.

23.4% Hypertonic Saline and Intracranial Pressure in Severe Traumatic Brain Injury Among Children: A 10-Year Retrospective Analysis

OBJECTIVE

To explore the effect of 23.4% hypertonic saline for management of elevated intracranial pressure in children admitted to our institution for severe traumatic brain injury.

DESIGN

Single-center, retrospective medical chart analysis.

SETTING

A PICU at a level 1 pediatric trauma center in the United States.

PATIENTS

Children admitted for severe traumatic brain injury from 2006 to 2016 who received 23.4% hypertonic saline and whose intracranial pressures were measured within 5 hours of receiving 23.4% hypertonic saline.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Over the 10-year period, 1,587 children were admitted for traumatic brain injury, 155 of whom were deemed severe per this study's criteria. Forty of these children received at least one dose of hypertonic saline, but 14 were excluded for insufficient intracranial pressure data. Among the remaining 26 children, one hundred one 23.4% hypertonic saline boluses were used in the analysis. Use of 23.4% hypertonic saline was associated with a decrease in intracranial pressure of approximately 7 mm Hg at both within 1 hour after the bolus (p < 0.01) and 4 hours after the bolus (p < 0.01) when compared with the intracranial pressure measured within 1 hour before the hypertonic saline bolus. These effects remained significant after adjusting for Functional Status Scale score and CT Marshall scores. There was no statistically significant association between adjunctive therapies, such as antiepileptics and analgesics, and changes in intracranial pressure. There was no laboratory evidence of hyperkalemia or renal injury after use of 23.4% hypertonic saline. Across all hospitalizations, 65% of the study population demonstrated an abnormally elevated creatinine at least once, but only three episodes of acute kidney injury occurred in total, all before hypertonic saline administration. Eight of the 26 children in this analysis died during their hospitalization. The Functional Status Scale scores ranged from 6 to 26 with a mean of 12.2 and SD of 5.7.

CONCLUSIONS

Use of 23.4% hypertonic saline with children admitted for severe traumatic brain injury is associated with a statistically significant decrease in intracranial pressure within 1 hour of use.

Acute Kidney Injury among Hospitalized Children in China

BACKGROUND AND OBJECTIVES

High-quality epidemiologic data on AKI in children are particularly lacking in developing countries. This study aimed to assess the epidemiology and clinical correlates of AKI among hospitalized children in China.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We performed a multicenter study, in a cohort of hospitalized children aged 1 month to 18 years, from 25 general and children's hospitals in China during 2013-2015. We obtained patient-level data from the electronic hospitalization information system and laboratory databases of all children who had at least two serum creatinine tests within any 7-day window during their first 30 days of hospitalization. We identified AKI events according to the creatinine criteria of Kidney Disease Improving Global Outcomes. The in-hospital outcomes of AKI, including mortality, kidney recovery, and length of stay, were assessed. We estimated the corresponding hazard ratios using a Cox proportional hazard model, with adjustment for age, sex, comorbidities, and clinical procedures.

RESULTS

A total of 19,908 (20%) patients with AKI were identified among 101,836 pediatric inpatients, of which 7220 (7%) were community acquired and 12,688 (13%) were hospital acquired. Up to 96% of these AKI events were not diagnosed on the discharge records. The cumulative incidence of AKI in infants (28%) was twice that in adolescents (12%). The profiles of risk factors differed between community-acquired and hospital-acquired AKI and varied with age. Diarrhea and sepsis were the top risk factors for community-acquired AKI, each contributing 6% of the risk. Congenital heart disease/cardiac surgery was the major risk factor for hospital-acquired AKI, contributing to 19% of cases. Exposure to nephrotoxic drugs, mostly nonsteroidal anti-inflammatory drugs and proton pump inhibitors, was common in hospitalized children and was associated with a higher risk of AKI. Death occurred in 842 out of 19,908 patients (4%) with AKI versus 450 out of 81,478 children (0.5%) without AKI. The risk of in-hospital death was higher among children with severe AKI, shock, and respiratory failure. Pediatric AKI was associated with longer hospital stay and higher daily cost, even after adjustment for covariates.

CONCLUSIONS

Pediatric AKI is common and is substantially underdiagnosed in China.

Gamma Glutamyl Transferase and Uric Acid Levels Can Be Associated with the Prognosis of Patients in the Pediatric Intensive Care Unit

Introduction: Gamma glutamyl transferase (GGT) and uric acid (UA) are reported to be predictive markers in various disorders. It has been reported that these biomarkers can be used to indicate increased risk of mortality in critically ill patients. Herein, we aimed to evaluate the effects of the initial serum GGT and UA levels on the outcomes of patients in the pediatric intensive care unit (PICU) and to investigate if these biomarkers can be used to predict pediatric mortality. Materials and Methods: The relationship between the initial GGT and UA levels and invasive mechanical ventilation (IMV) and noninvasive mechanical ventilation (NIV) support, inotropic drug need, acute renal kidney injury (AKI), continuous renal replacement therapy (CRRT), presence of sepsis, mortality, and hospitalization period were investigated retrospectively. Results: In all, 236 patients (117 males and 119 females) were included in the study. The age distribution of the patients was 1–12 years. There was a statistically significant relationship between GGT levels in the first biochemical analysis performed during admission and inotropic drug use, AKI, duration of hospitalization in intensive care unit, and sepsis. There was a statistically significant relationship between initial UA levels and inotropic drug use, AKI, CCRT, and sepsis. Conclusion: We suggest that initial GGT and UA levels during admission could be used to predict the outcomes of patients in PICU.

Pediatric continuous renal replacement therapy: have practice changes changed outcomes? A large single-center ten-year retrospective evaluation

Background

To evaluate changes in population characteristics and outcomes in a large single-center pediatric patient cohort treated with continuous renal replacement therapy (CRRT) over a 10 year course, coincident with multiple institutional practice changes in CRRT delivery.

Methods

A retrospective cohort study with comparative analysis of all patients treated from 2004 to 2013 with CRRT in the neonatal, pediatric, and cardiovascular intensive care units within a free-standing pediatric tertiary care hospital.

Results

Three hundred eleven total patients were identified, 38 of whom received concurrent treatment with extracorporeal membrane oxygenation. 273 patients received CRRT only and were compared in two study eras (2004–2008 n = 129; 2009–2013 n = 144). Across eras, mean patient age decreased (9.2 vs 7.7 years, p = 0.08), and the most common principal diagnosis changed from cardiac to liver disease. There was an increase in patients treated with continuous renal replacement therapy between cohorts for acute kidney injury of multi factorial etiology (44% vs 56%) and a decrease in treated patients with sepsis (21% vs 11%, p = 0.04). There was no significant difference in survival to hospital discharge between eras (47% vs 49%). Improvement in outpatient follow-up after discharge amongst survivors was seen between study eras (33% vs 54%).

Conclusions

Despite multiple institutional practice changes in provision of CRRT, few changes were seen regarding patient demographics, diseases treated, indications for therapy, and survival over 10 years at a single tertiary care. Recognition of need for follow-up nephrology care following CRRT is improving. Ongoing assessment of the patient population in a changing landscape of care for critically ill pediatric patients remains important.

The Japanese clinical practice guideline for acute kidney injury 2016

Acute kidney injury (AKI) is a syndrome which has a broad range of etiologic factors depending on different clinical settings. Because AKI has significant impacts on prognosis in any clinical settings, early detection and intervention is necessary to improve the outcomes of AKI patients. This clinical guideline for AKI was developed by a multidisciplinary approach with nephrology, intensive care medicine, blood purification, and pediatrics. Of note, clinical practice for AKI management which was widely performed in Japan was also evaluated with comprehensive literature search.

The Japanese Clinical Practice Guideline for acute kidney injury 2016

Acute kidney injury (AKI) is a syndrome which has a broad range of etiologic factors depending on different clinical settings. Because AKI has significant impacts on prognosis in any clinical settings, early detection and intervention are necessary to improve the outcomes of AKI patients. This clinical guideline for AKI was developed by a multidisciplinary approach with nephrology, intensive care medicine, blood purification, and pediatrics. Of note, clinical practice for AKI management which was widely performed in Japan was also evaluated with comprehensive literature search.

Association Between Early Postoperative Acetaminophen Exposure and Acute Kidney Injury in Pediatric Patients Undergoing Cardiac Surgery

IMPORTANCE

Acute kidney injury (AKI) is a common and serious complication for pediatric cardiac surgery patients associated with increased morbidity, mortality, and length of stay. Current strategies focus on risk reduction and early identification because there are no known preventive or therapeutic agents. Cardiac surgery and cardiopulmonary bypass lyse erythrocytes, releasing free hemoglobin and contributing to oxidative injury. Acetaminophen may prevent AKI by reducing the oxidation state of free hemoglobin.

OBJECTIVE

To test the hypothesis that early postoperative acetaminophen exposure is associated with reduced risk of AKI in pediatric patients undergoing cardiac surgery.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective cohort study, the setting was 2 tertiary referral children's hospitals. The primary and validation cohorts included children older than 28 days admitted for cardiac surgery between July 1, 2008, and June 1, 2016. Exclusion criteria were postoperative extracorporeal membrane oxygenation and inadequate serum creatinine measurements to determine AKI status.

EXPOSURES

Acetaminophen exposure in the first 48 postoperative hours.

MAIN OUTCOMES AND MEASURES

Acute kidney injury based on Kidney Disease: Improving Global Outcomes serum creatinine criteria (increase by ≥0.3 mg/dL from baseline or at least 1.5-fold more than the baseline [to convert to micromoles per liter, multiply by 88.4]) in the first postoperative week.

RESULTS

The primary cohort (n = 666) had a median age of 6.5 (interquartile range [IQR], 3.9-44.7) months, and 341 (51.2%) had AKI. In unadjusted analyses, those with AKI had lower median acetaminophen doses than those without AKI (47 [IQR, 16-88] vs 78 [IQR, 43-104] mg/kg, P < .001). In logistic regression analysis adjusting for age, cardiopulmonary bypass time, red blood cell distribution width, postoperative hypotension, nephrotoxin exposure, and Risk Adjustment for Congenital Heart Surgery score, acetaminophen exposure was protective against postoperative AKI (odds ratio, 0.86 [95% CI, 0.82-0.90] per each additional 10 mg/kg). Findings were replicated in the validation cohort (n = 333), who had a median age of 14.1 (IQR, 3.9-158.2) months, and 162 (48.6%) had AKI. Acetaminophen doses were 60 (95% CI, 40-87) mg/kg in those with AKI vs 70 (95% CI, 45-94) mg/kg in those without AKI (P = .03), with an adjusted odds ratio of 0.91 (95% CI, 0.84-0.99) for each additional 10 mg/kg.

CONCLUSIONS AND RELEVANCE

These results indicate that early postoperative acetaminophen exposure may be associated with a lower rate of AKI in pediatric patients who undergo cardiac surgery. Further analysis to validate these findings, potentially through a prospective, randomized trial, may establish acetaminophen as a preventive agent for AKI.

Community-acquired Acute Kidney Injury Among Children Seen in the Pediatric Emergency Department

OBJECTIVES

Acute kidney injury (AKI) is a significant risk factor for morbidity and mortality in children. Little is known about community-acquired AKI (CA-AKI) in the pediatric emergency department (PED). Early recognition of AKI allows for nephroprotective measures. The goal of this investigation was to determine the incidence of CA-AKI and the frequency of clinician identified CA-AKI to better inform future nephroprotective interventions.

METHODS

This was a retrospective cross-sectional study in the PED of a children's hospital. Children 1 month to 18 years of age seen in the PED from January 1 to December 31, 2015, and in whom at least one creatinine level was obtained were included. Patients with chronic kidney disease or end-stage renal disease or who died in the PED were excluded. Patients had CA-AKI based on modified Kidney Disease-Improving Global Outcomes criteria using the creatinine obtained in the PED compared to age-specific norms. Patients were considered identified if the PED clinician diagnosed AKI. The primary outcome was the incidence of CA-AKI. Secondary outcomes included frequency of AKI identification, nephrotoxic medication use, hospital length of stay, renal replacement therapy, and death. Fisher exact test or Pearson's chi-square test was used to calculate odds ratio (OR) with 95% confidence intervals (CIs); multivariable analyses were performed using logistic regression.

RESULTS

In 2015 there were 119,151 PED visits; 15,486 met inclusion criteria. CA-AKI was present in 239 of 15,486 (1.5%) encounters. AKI was identified by PED clinicians in 46 of 239 (19%) of encounters and by the inpatient team in 123 of 199 (62%) of the encounters admitted. AKI was never recognized by a PED or inpatient clinician in 74 of 199 (37%) encounters. Encounters with AKI correctly diagnosed were older (13 years old vs. 10 years old, p = 0.0114), had more severe (stage 2 or 3) AKI (OR = 5.5, 95% CI = 2.6-11.8), and were more likely to be admitted (OR = 10.3, 95% CI = 1.38-77.4) than encounters with missed AKI.

CONCLUSIONS

CA-AKI remains an underrecognized entity in the PED. Better tools for early recognition of AKI in the busy PED environment are needed.

Acute kidney injury epidemiology, risk factors, and outcomes in critically ill patients 16-25 years of age treated in an adult intensive care unit

Background

Most studies of acute kidney injury (AKI) have focused on older adults, and little is known about AKI in young adults (16–25 years) that are cared for in an adult intensive care unit (ICU). We analyzed data from a large single-center ICU database and defined AKI using the Kidney Disease Improving Global Outcomes criteria. We stratified patients 16–55 years of age into four age groups for comparison and used multivariable logistic regression to identify associations of potential susceptibilities and exposures with AKI and mortality.

Results

AKI developed in 52.6% (n = 8270) of the entire cohort and in 39.8% of the young adult age group (16–25 years). The AUCs for the age categories were similar at 0.754, 0.769, 0.772, and 0.770 for the 16–25-, 26–35-, 36–45-, and 45–55-year age groups, respectively. For the youngest age group, diabetes (OR 1.89; 95% CI 1.09–3.29), surgical reason for admission (OR 1.79; 95% CI 1.44–2.23), severity of illness (OR 1.02; 95% CI 1.02–1.03), hypotension (OR 1.13; 95% CI 1.04–1.24), and certain medications (vancomycin and calcineurin inhibitors) were all independently associated with AKI. AKI was a significant predictor for longer length of stay, ICU mortality, and mortality after discharge.

Conclusions

AKI is a common event for young adults admitted to an adult tertiary care center ICU with an associated increased length of stay and risk of mortality. Potentially modifiable risk factors for AKI including medications were identified for all stratified age groups.

Outcome of pediatric acute kidney injury: a multicenter prospective cohort study

BACKGROUND

Acute kidney injury (AKI) is a common problem encountered in critically ill children with an increasing incidence and evolving epidemiology. AKI carries a serious morbidity and mortality in patients requiring admission to a pediatric intensive care unit (PICU).

METHODS

We undertook a prospective cohort study of PICU admissions at three tertiary care hospitals in the Kingdom of Saudi Arabia over 2 years. The Kidney Disease Improving Global Outcomes (KDIGO) definition was used to diagnose AKI.

RESULTS

A total of 1367 pediatrics PICU admissions were included in the study. AKI affected 511 children (37.4%), with 243 children (17.8%) classified as stage I (mild), 168 patients (12.3%) stage II (moderate), and 100 children (7.3%) were classified as stage III (severe). After adjustment for age, sex, and underlying diagnosis, in-hospital mortality was six times more likely among patients with AKI as compared to patients with normal renal function (adjusted OR: 6.5, 95% CI: 4.2-10). AKI was also a risk factor for hypertension (adjusted OR: 4.1, 95% CI: 2.8-5.9) and prolonged stay in the PICU and hospital, as it increased the average number of admission days by 10 (95% CI: 8.6-11) days in the PICU and 12 (95% CI: 10-14) days in the hospital.

CONCLUSIONS

One-third of PICU admissions were complicated with AKI. AKI was associated with increased hospital mortality and the length of stay in both PICU and hospital.

Management of Fluid Balance in Continuous Renal Replacement Therapy: Technical Evaluation in the Pediatric Setting

Fluid overload control and fluid balance management represent very important factors in critically ill children requiring renal replacement therapy A relatively high fluid volume administration in children and neonates is often necessary to deliver adequate amounts of blood derivatives, vasopressors, antibiotics, and parenteral nutrition. Fluid balance errors during pediatric continuous renal replacement therapy (CRRT) might significantly impact therapy delivery and have been described as potentially lethal. The aim of this study was to evaluate the accuracy of delivered vs. prescribed net ultrafiltration (UF) during CRRT applied to 2 neonates and 2 small children, either as dialytic treatment alone or during extracorporeal membrane oxygenation (ECMO). In accordance with an Acute Dialysis Quality Initiative workgroup statement, net UF was defined as the “overall amount of fluid extracted from the patient in a given time”. Mean prescribed net UF was 18.5 ml/h (SD=6.7) during neonatal treatments and 70.3 ml/h (SD=22.5) during CRRT in small children. Daily net UF ranged from 200 mL to about 600 mL in the 2 neonates and from 1,200 to 1800 mL in the 2 children. The percentage error of delivered net UF ranged from −1.6% to 5.8% of the prescribed level. The mean error of the ECMO/CRRT patients was 3.024 ml/h vs. 0.45 m/h for the CRRT patients (p<0.001). The same difference was not evident when the 2 neonates were compared with the 2 small children (without considering the presence of ECMO). CRRT and net UF delivery appeared to be accurate, safe, and effective in this small cohort of high-risk pediatric patients.

Epidemiology and outcomes of children with renal failure in the pediatric ward of a tertiary hospital in Cameroon

Background

Pediatric nephrology is challenging in developing countries and data on the burden of kidney disease in children is difficult to estimate due to absence of renal registries. We aimed to describe the epidemiology and outcomes of children with renal failure in Cameroon.

Methods

We retrospectively reviewed 103 medical records of children from 0 to 17 years with renal failure admitted in the Pediatric ward of the Douala General Hospital from 2004 to 2013. Renal failure referred to either acute kidney injury (AKI) or Stage 3–5 chronic kidney disease (CKD). AKI was defined and graded using either the modified RIFLE criteria or the Pediatrics RIFLE criteria, while CKD was graded using the KDIGO criteria. Outcomes of interest were need and access to dialysis and in-hospital mortality. For patients with AKI renal recovery was evaluated at 3 months.

Results

Median age was 84 months (1QR:15–144) with 62.1% males. Frequent clinical symptoms were asthenia, anorexia, 68.8% of participants had anuria. AKI accounted for 84.5% (n = 87) and CKD for 15.5% (n = 16). Chronic glomerulonephritis (9/16) and urologic malformations (7/16) were the causes of CKD and 81.3% were at stage 5. In the AKI subgroup, 86.2% were in stage F, with acute tubular necrosis (n = 50) and pre-renal AKI (n = 31) being the most frequent mechanisms. Sepsis, severe malaria, hypovolemia and herbal concoction were the main etiologies. Eight of 14 (57%) patients with CKD, and 27 of 40 (67.5%) with AKI who required dialysis, accessed it. In-hospital mortality was 50.7% for AKI and 50% for CKD. Of the 25 patients in the AKI group with available data at 3 months, renal recovery was complete in 22, partial in one and 2 were dialysis dependent. Factors associated to mortality were young age (p = 0.001), presence of a coma (p = 0.021), use of herbal concoction (p = 0.024) and acute pulmonary edema (p = 0.011).

Conclusion

Renal failure is severe and carries a high mortality in hospitalized children in Cameroon. Limited access to dialysis and lack of specialized paediatric nephrology services may explain this dismal picture.

Identifying Risk for Acute Kidney Injury in Infants and Children Following Cardiac Arrest

OBJECTIVES

Our goal was to identify risk factors for acute kidney injury in children surviving cardiac arrest.

DESIGN

Retrospective analysis of a public access dataset.

SETTING

Fifteen children's hospitals associated with the Pediatric Emergency Care Applied Research Network.

PATIENTS

Two hundred ninety-six subjects between 1 day and 18 years old who experienced in-hospital or out-of-hospital cardiac arrest between July 1, 2003, and December 31, 2004.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Our primary outcome was development of acute kidney injury as defined by the Acute Kidney Injury Network criteria. An ordinal probit model was developed. We found six critical explanatory variables, including total number of epinephrine doses, postcardiac arrest blood pressure, arrest location, presence of a chronic lung condition, pH, and presence of an abnormal baseline creatinine. Total number of epinephrine doses received as well as rate of epinephrine dosing impacted acute kidney injury risk and severity of acute kidney injury.

CONCLUSIONS

This study is the first to identify risk factors for acute kidney injury in children after cardiac arrest. Our findings regarding the impact of epinephrine dosing are of particular interest and suggest potential for epinephrine toxicity with regard to acute kidney injury. The ability to identify and potentially modify risk factors for acute kidney injury after cardiac arrest may lead to improved morbidity and mortality in this population.

Electronic health record-based predictive models for acute kidney injury screening in pediatric inpatients

BackgroundAcute kidney injury (AKI) is common in pediatric inpatients and is associated with increased morbidity, mortality, and length of stay. Its early identification can reduce severity.MethodsTo create and validate an electronic health record (EHR)-based AKI screening tool, we generated temporally distinct development and validation cohorts using retrospective data from our tertiary care children's hospital, including children aged 28 days through 21 years with sufficient serum creatinine measurements to determine AKI status. AKI was defined as 1.5-fold or 0.3 mg/dl increase in serum creatinine. Age, medication exposures, platelet count, red blood cell distribution width, serum phosphorus, serum transaminases, hypotension (ICU only), and pH (ICU only) were included in AKI risk prediction models.ResultsFor ICU patients, 791/1,332 (59%) of the development cohort and 470/866 (54%) of the validation cohort had AKI. In external validation, the ICU prediction model had a c-statistic=0.74 (95% confidence interval 0.71-0.77). For non-ICU patients, 722/2,337 (31%) of the development cohort and 469/1,474 (32%) of the validation cohort had AKI, and the prediction model had a c-statistic=0.69 (95% confidence interval 0.66-0.72).ConclusionsAKI screening can be performed using EHR data. The AKI screening tool can be incorporated into EHR systems to identify high-risk patients without serum creatinine data, enabling targeted laboratory testing, early AKI identification, and modification of care.

Epidemiology of acute kidney injury in children worldwide, including developing countries

In this review we summarize the world-wide epidemiology of acute kidney injury (AKI) in children with special emphasis on low-income countries, notably those of the sub-Saharan continent. We discuss definitions and classification systems used in pediatric AKI literature. At present, despite some shortcomings, traditional Pediatric Risk Injury Failure Loss and End Stage Kidney Disease (pRIFLE) and Kidney Disease Improving Global Outcomes (KDIGO) systems are the most clinically useful. Alternative definitions, such as monitoring serum cystatin or novel urinary biomarkers, including cell cycle inhibitors, require more long-term studies in heterogenous pediatric AKI populations before they can be recommended in routine clinical practice. A potentially interesting future application of some novel biomarkers could be incorporation into the "renal angina index", a concept recently introduced in pediatric nephrology. The most reliable epidemiological data on AKI in children come from high-outcome countries and are frequently focused on critically ill pediatric intensive care unit populations. In these patients AKI is often secondary to other systemic illnesses or their treatment. Based on a recent literature search performed within the framework of the "AKI 0by25" project of the International Society of Nephrology, we discuss the scarce and often inaccurate data on AKI epidemiology in low-income countries, notably those on the African continent. The last section reflects on some of the many barriers to improvement of overall health care in low-income populations. Although preventive strategies for AKI in low-income countries should essentially be the same as those in high-income countries, we believe any intervention for earlier detection and better treatment of AKI must address all health determinants, including educational, cultural, socio-economic and environmental factors, specific for these deprived areas.

[Fluid balance and acute kidney injury in septic shock]

BACKGROUND

In patients with septic shock, excessive fluid administration can lead to increased morbidity and mortality. The aim of this study was to evaluate the association between fluid balance, acute kidney injury and mortality in patients with septic shock.

METHODS

A study of cases and controls was conducted in a Pediatric Intensive Care Unit. The fluid balance in the first 72h and the presence of acute kidney injury was compared in patients diagnosed with septic shock who died against patients who survived the same condition. Univariate and multivariate analyses were performed.

RESULTS

Forty-five cases and forty-five controls were included in the analysis. Mortality was associated with Pediatric Risk of Mortality (PRISM III) ≥ 26 points (OR 7.5, 95% CI 2.8-18.7; p=0.000), Pediatric Logistic Organ Dysfunction (PELOD) ≥ 24 points (OR 11.0, 95% CI 4.1-29.4; p=0.000), creatinine ≥ 0.65mg/dl (OR 5.6, 95% CI 2.2-13.9; p=0.000), lactate ≥ 2.5 mmol/l (OR 2.5, 95% CI 1.1-5.9; p=0.033), SvO2 < 60% (OR 4.6, 95% CI 4.5-4.5; p=0.001), positive balance > 9% in 72h (OR 4.3, 95% CI 1.6-11.7; p=0.003), acute kidney injury (OR 5.7, 95% CI: 2.2-15.1; p=0.000). In the multivariate model, the values of PRISM ≥26 and PELOD ≥24 points were significant.

CONCLUSIONS

In patients who died due to septic shock, the multivariate model showed an association with PRISM ≥26 and PELOD ≥24 and a trend toward association with SvO2 <60% and positive balance of liquids > 9%.

Incidence and Outcome of Acute Cardiorenal Syndrome in Hospitalized Children

OBJECTIVES

To determine the incidence, etiology and outcome of Cardiorenal syndrome (CRS) in hospitalized children.

METHODS

A prospective cohort study was carried out in 242 children between 6 mo to 18 y of age hospitalized with primary cardiac, renal or any systemic disorder at a tertiary care center in India. The primary outcome was the development of CRS. Univariate and multivariate logistic regression analysis were performed to determine the risk of mortality secondary to CRS.

RESULTS

Among 242 children, 67 (27.7%) children developed CRS and the rest 175 (72.3%) did not. Among those with CRS, 40.3%, 20.9%, and 38.8% had CRS-1, 3 and 5, respectively. Cardiac diseases leading to CRS were myocarditis (40.7%) followed by congenital heart disease (25.9%), rheumatic heart disease (18.5%), and dilated cardiomyopathy (7.4%); renal disease associated with CRS was acute glomerulonephritis (100%) and major systemic disorders leading to CRS were septicemia (53.8%), malaria (23.1%), scrub typhus (7.7%), and acute gastroenteritis (3.8%). The occurrence of CRS was associated with an increased risk of mortality (OR 6.3, 95% CI: 2.8, 14.1; p 0.000). A subgroup analysis revealed that children with CRS having acute kidney injury stage 2 and 3 also had a higher risk of mortality (p 0.001).

CONCLUSIONS

The incidence of CRS is quite high in children with cardiac, renal or systemic diseases and is associated with a significant risk of mortality. Children presenting with these illnesses should be monitored for the occurrence of CRS so that early intervention may reduce mortality.

Incidence, risk factors and outcome of acute kidney injury in critically ill children - a developing country perspective

BACKGROUND

Acute kidney injury (AKI) is common in critically ill children and is associated with poor outcome.

OBJECTIVE

To study the incidence, risk factors and outcome of AKI in children admitted to paediatric intensive care unit (PICU) of a developing country.

MATERIALS AND METHODS

This prospective observational study was conducted in a tertiary care PICU over one-year period. Critically ill children aged from 2 months to 18 years were included. RIFLE criteria based on GFR, and urine output was used for categorisation.

RESULTS

Of 380 children, 53 children (14%) had AKI (met any of the RIFLE criteria). The most common diagnoses underlying AKI were acute lower respiratory tract infection, CNS illness and severe dehydration. Subjects with AKI had a higher PRISM score (>10) at admission, longer duration of stay and high mortality. Significant risk factors for AKI following multivariate analysis were: age 1-5, PRISM score (>10) at admission, shock, infection, thrombocytopenia, hypo-albuminaemia and multi-organ dysfunction. Twenty-six of 53 subjects fulfilled the maximum RIFLE criteria within 72 h after admission and the mean (SD) time to first RIFLE attend was 1.6 (1.2) day. Subjects with AKI (RIFLE criteria) had 4.5 times higher mortality than those without AKI (36 vs 8%, P< etc).

CONCLUSION

A high incidence of AKI was noted in the PICU that was associated with high mortality. The RIFLE criterion is an effective tool which can be used not only for predicting the outcomes, but may help in the early identification of patients at risk for AKI.

Identifying High-Risk Medications Associated with Acute Kidney Injury in Critically Ill Patients: A Pharmacoepidemiologic Evaluation

BACKGROUND

Nephrotoxic medications are a common cause of acute kidney injury (AKI). Critically ill children receive more medication than other inpatients; however, the risk of nephrotoxic medication-induced AKI in these children is not well understood.

OBJECTIVE

The aim of this study was to determine the association between exposure to nephrotoxic medications in the intensive care unit (ICU) and the development of AKI amongst critically ill children, adjusting for differences in underlying risk.

METHODS

We conducted a nested case-control study among a cohort of patients admitted to a paediatric intensive care unit between January 2006 and June 2009. Cases were identified according to the RIFLE criteria. Using incidence density sampling, controls were matched 1:1 according to pre-ICU nephrotoxic drug exposure. Administration of nephrotoxic medications and other known risk factors of AKI were evaluated during the ICU stay prior to the diagnosis of AKI.

RESULTS

A total of 914 patients in the cohort developed AKI and had an identifiable matched control. Eighty-seven percent of cases and 74% of controls were exposed to one or more nephrotoxic medications in the ICU during the study period. Furosemide (administered to 67.8% of patients), vancomycin (28.7%), and gentamicin (21.4%) were the most frequently administered nephrotoxic drugs. Patients who developed AKI were more likely to be exposed to at least one nephrotoxic medication and risk increased with increasing number of nephrotoxic medications. Ganciclovir (adjusted odds ratio [AOR] 4.7; 95% CI 1.7-13.0), furosemide (AOR 1.9; 95% CI 1.4-2.4), and gentamicin (AOR 1.8; 95% CI 1.4-2.4) significantly increased the odds of developing AKI after adjusting for underlying differences in risk factors of AKI.

CONCLUSION

This is the first study to assess the association between risk-adjusted nephrotoxic medication exposure and the development of AKI in critically ill children. Nephrotoxic medication exposure was common amongst children in the ICU and we found AKI was associated with the administration of specific drugs after adjustment for important risk factors.

Epidemiology of Acute Kidney Injury in Critically Ill Children and Young Adults

BACKGROUND

The epidemiologic characteristics of children and young adults with acute kidney injury have been described in single-center and retrospective studies. We conducted a multinational, prospective study involving patients admitted to pediatric intensive care units to define the incremental risk of death and complications associated with severe acute kidney injury.

METHODS

We used the Kidney Disease: Improving Global Outcomes criteria to define acute kidney injury. Severe acute kidney injury was defined as stage 2 or 3 acute kidney injury (plasma creatinine level ≥2 times the baseline level or urine output <0.5 ml per kilogram of body weight per hour for ≥12 hours) and was assessed for the first 7 days of intensive care. All patients 3 months to 25 years of age who were admitted to 1 of 32 participating units were screened during 3 consecutive months. The primary outcome was 28-day mortality.

RESULTS

A total of 4683 patients were evaluated; acute kidney injury developed in 1261 patients (26.9%; 95% confidence interval [CI], 25.6 to 28.2), and severe acute kidney injury developed in 543 patients (11.6%; 95% CI, 10.7 to 12.5). Severe acute kidney injury conferred an increased risk of death by day 28 after adjustment for 16 covariates (adjusted odds ratio, 1.77; 95% CI, 1.17 to 2.68); death occurred in 60 of the 543 patients (11.0%) with severe acute kidney injury versus 105 of the 4140 patients (2.5%) without severe acute kidney injury (P<0.001). Severe acute kidney injury was associated with increased use of mechanical ventilation and renal-replacement therapy. A stepwise increase in 28-day mortality was associated with worsening severity of acute kidney injury (P<0.001 by log-rank test). Assessment of acute kidney injury according to the plasma creatinine level alone failed to identify acute kidney injury in 67.2% of the patients with low urine output.

CONCLUSIONS

Acute kidney injury is common and is associated with poor outcomes, including increased mortality, among critically ill children and young adults. (Funded by the Pediatric Nephrology Center of Excellence at Cincinnati Children's Hospital Medical Center and others; AWARE ClinicalTrials.gov number, NCT01987921 .).

Predictive factors of mortality in pediatric patients with acute renal injury associated with sepsis

OBJECTIVE

To evaluate the prognosis factors of children with sepsis and acute kidney injury.

METHODS

This was a retrospective study of children with sepsis and acute kidney injury that were admitted to the pediatric intensive care unit (PICU) of a tertiary hospital. A multivariate analysis was performed to compare risk factors for mortality.

RESULTS

Seventy-seven children (47 males) were retrospectively studied, median age of 4 months. Mean length of hospital stay was 7.33±0.16 days, 68.9% of patients received mechanical ventilation, 25.9% had oligo-anuria, and peritoneal dialysis was performed in 42.8%. The pRIFLE criteria were: injury (5.2%) and failure (94.8%), and the staging system criteria were: stage 1 (14.3%), stage 2 (29.9%), and stage 3 (55.8%). The mortality rate was 33.7%. In the multivariate analysis, the risk factors for mortality were PICU length of stay (OR=0.615, SE=0.1377, 95% CI=0.469-0.805, p=0.0004); invasive mechanical ventilation (OR=14.599, SE=1.1178, 95% CI=1.673-133.7564, p=0.0155); need for dialysis (OR=9.714, SE=0.8088, 95% CI=1.990-47.410, p=0.0049), and hypoalbuminemia (OR=10.484, SE=1.1147, 95% CI=1.179-93.200, p=0.035).

CONCLUSIONS

The risk factors for mortality in children with acute kidney injury were associated with sepsis severity.