Acute Kidney Injury Epidemiology in pediatrics

Acute kidney injury is associated with abnormal cefepime exposure among critically ill children and young adults

BACKGROUND

Elevated cefepime blood concentrations can cause neurotoxicity in adults. The consequences of elevated cefepime concentrations among pediatric patients are unknown. Future exploration of such effects requires first identifying patients at risk for elevated cefepime exposure. We investigated the role of acute kidney injury as a risk factor for increased cefepime concentrations in critically ill children.

METHODS

This was a retrospective analysis at a single pediatric intensive care unit. Analyzed patients received at least 24 h of cefepime and had at least two opportunistic samples collected for total cefepime concentration measurement. Individual pharmacokinetic (PK) profiles during treatment courses were reconstructed using Bayesian estimation with an established population PK model. Elevated trough concentration (Cmin) was defined as ≥ 30 mg/L based on adult toxicity studies. The effect of kidney dysfunction on cefepime PK profiles was interrogated using a mixed-effect model.

RESULTS

Eighty-seven patients were included, of which 13 (14.9%) had at least one estimated Cmin ≥ 30 mg/L. Patients with elevated Cmin were more likely to have acute kidney injury (AKI) during their critical illness (92% vs. 57%, p = 0.015 for any AKI; 62% vs. 26%, p = 0.019 for severe AKI). Patients who had AKI during critical illness had significantly higher cefepime exposure, as quantified by the area under the concentration-time curve over 24 h (AUC24h) and Cmin.

CONCLUSIONS

Among critically ill children, AKI is associated with elevated cefepime concentrations. Identifying these high-risk patients is the first step toward evaluating the clinical consequences of such exposures.

Total bilirubin level is associated with acute kidney injury in neonates admitted to the neonatal intensive care units: based on MIMIC-III database

OBJECTIVE

The objective of this study was to investigate the association between total bilirubin and acute kidney injury (AKI) in neonates admitted to neonatal intensive care units (NICU).

METHODS

All data utilized were extracted from Medical Information Mart for Intensive Care-III (MIMIC-III) in this retrospective cohort study. The primary outcome was the occurrence of AKI during hospitalization in the NICU, and the exposure was the initial measurement of total bilirubin levels within 24 h of neonatal admission to the NICU. The relationship between serum total bilirubin and AKI was evaluated by employing univariate and multivariate logistic regression models. Additionally, subgroup analyses were conducted based on birth weight, sepsis, and mechanical ventilation.

RESULTS

This retrospective cohort study included a population of 1,726 neonates, and 95 neonates developed AKI. Total bilirubin, as a continuous variable, was linked with decreased AKI risk among neonates admitted to the NICU [odds ratio (OR) = 0.77, 95% confidence interval (CI): 0.64-0.92]. Similarly, when total bilirubin levels were categorized by tertiles, tertiles 3 showed a significant association with decreased AKI risk (OR = 0.39, 95%CI: 0.19-0.83). The relationship of total bilirubin level and AKI was also existent among neonates admitted to the NICU who were underweight, had not sepsis, and received mechanical ventilation.

CONCLUSION

Total bilirubin level may be a protective factor for the risk of developing AKI.

Acute kidney injury requiring dialysis in children: a multicentric, emerging country perspective

BACKGROUND

Acute kidney injury (AKI) is a life-threatening condition, especially in extreme age groups and when kidney replacement therapy (KRT) is necessary. Studies worldwide report mortality rates of 10-63% in pediatric patients undergoing KRT.

METHODS

Over 13 years, this multicenter study analyzed data from 693 patients with AKI, all receiving KRT, across 74 hospitals and medical facilities in Rio de Janeiro, Brazil.

RESULTS

The majority were male (59.5%), under one year old (55.6%), and treated in private hospitals (76.5%). Sixty-six percent had comorbidities. Pneumonia and congenital heart disease were the most common admission diagnoses (21.5% and 20.2%, respectively). The mortality rate was 65.2%, with lower rates in patients over 12 years (50%). Older age was protective (HR: 2.35, IQR [1.52-3.62] for neonates), and primary kidney disease had a three-fold lower mortality rate. ICU team experience (HR: 0.74, IQR [0.60-0.91]) correlated with lower mortality, particularly in hospitals treating 20 or more patients. Among the deceased, 40% died within 48 h of KRT initiation, suggesting possible late referral or treatment futility.

CONCLUSIONS

This study confirms the high mortality in pediatric dialytic AKI in middle-income countries, underlining early mortality and offering critical insights for improving outcomes.

Assessment of South Asian Pediatric Acute Kidney Injury: Epidemiology and Risk Factors (ASPIRE)-a prospective study on "severe dialysis dependent pediatric AKI"

BACKGROUND

Pediatric acute kidney injury (AKI) is a global health concern with an associated mortality risk disproportionately pronounced in resource-limited settings. There is a pertinent need to understand the epidemiology of pediatric AKI in vulnerable populations. Here, we proposed a prospective study to investigate the epidemiology and associated risk factors of "severe dialysis dependent AKI" in children among South Asian nations which would be the first and largest of its kind.

METHODS

The ASPIRE study (part of PCRRT-ICONIC Foundation initiative) is a multi-center, prospective observational study conducted in South Asian countries. All children and adolescents ≤ 18 years of age who required dialysis for AKI in any of the collaborating medical centers were enrolled. Data collection was performed until one of the following endpoints was observed: (1) discharge, (2) death, and (3) discharge against medical advice.

RESULTS

From 2019 to 2022, a total of 308 children with severe AKI were enrolled. The mean age was 6.17 years (63% males). Secondary AKI was more prevalent than primary AKI (67.2%), which predominantly occurred due to infections, dehydration, and nephrotoxins. Common causes of primary AKI were glomerulonephritis, hemolytic uremic syndrome, lupus nephritis, and obstructive uropathy. Shock, need for ventilation, and coagulopathy were commonly seen in children with severe AKI who needed dialysis. The foremost kidney replacement therapy used was peritoneal dialysis (60.7%). The mortality rate was 32.1%.

CONCLUSIONS

Common causes of AKI in children in South Asia are preventable. Mortality is high among these children suffering from "severe dialysis dependent AKI." Targeted interventions to prevent and identify AKI early and initiate supportive care in less-resourced nations are needed.

The effects of antibiotic therapy on neonatal sepsis-associated acute kidney injury

AIM

Neonatal sepsis remains one of the most dangerous conditions in the neonatal intensive care units. One of the organs affected by sepsis is the kidney, making acute kidney injury (AKI) a common complication of sepsis. Treatment of sepsis almost always involves antibiotic therapy, which by itself may cause some adverse effects, including nephrotoxicity. We analyzed the mutual effect of antibiotic therapy and sepsis on AKI in an experimental and clinical study in infants and neonatal rats.

MATERIALS AND METHODS

We evaluated the influence of therapy with different antibiotics on the appearance of AKI markers (blood urea nitrogen (BUN), neutrophil gelatinase-associated lipocalin (NGAL), clusterin, interleukin-18 (IL-18), kidney injury molecule-1 (KIM-1), monocyte chemoattractant protein 1 (MCP-1), calbindin, glutation-S-transferase subtype π (GST-π)) and liver injury markers in newborns with or without clinical signs of sepsis in the intensive care unit. In parallel, we analyzed the development of AKI in experimental lipopolysaccharide (LPS)-induced systemic inflammation in newborn rats accompanied by antibiotic therapy.

KEY FINDINGS

We showed that therapy with metronidazole or ampicillin in combination with sulbactam had a beneficial effect in children with suspected sepsis, resulting in a decrease in AKI markers levels. However, treatment of newborns with netilmicin, cefepime, linezolid, or imipenem in combination with cilastatin worsened kidney function in these patients.

SIGNIFICANCE

This prospective study indicates which antibiotics are preferable in neonatal sepsis and which should be used with caution in view of the risk of AKI development.

Nutritional and clinical factors associated with acute kidney injury development in critically ill children

BACKGROUND

Acute kidney injury (AKI) is common in the pediatric intensive care unit (ICU) and is associated with poorer clinical outcomes. There is scarce data to support an association between nutritional status and nutrient delivery in critically ill pediatric patients. Therefore, the present study aimed to identify the nutritional and clinical factors associated with the development of AKI during pediatric ICU stay.

METHODS

This prospective study included critically ill pediatric patients aged < 15 years who were admitted to the medical and surgical pediatric ICU. Clinical, laboratory, nutritional status, nutritional therapy parameters, and AKI data were recorded. Adjusted logistic regression was applied and expressed as odds ratio (OR) and 95% confidence interval (95%CI). P-value < 0.05 was considered significant.

RESULTS

We enrolled 108 patients with a median age of 9 months (interquartile range/IQR 2.4-62.5), and 43.5% developed AKI. Sepsis/septic shock (OR 8.00; 95% CI 2.06-32.51, p = 0.003), higher severity of illness (OR 1.89; 95% CI 1.24-2.90, p = 0.003), hypoalbuminemia (OR 4.11; 95% CI 1.61-10.46, p = 0.006), edema (OR 3.42, 95% CI 1.10-10.67, p = 0.034), fluid overload (OR 3.52, 95% CI 1.56-7.96, p = 0.003), need for mechanical ventilation (OR 3.62, 95% CI 1.45-9.04, p = 0.006) and adequate protein intake (OR 0.79, 95% CI 0.63-1.00, p = 0.048) were associated with development of AKI.

CONCLUSIONS

Hypoalbuminemia, need for mechanical ventilation, fluid overload, severity of illness, sepsis/septic shock, and edema were risk factors for AKI in pediatric ICU. Furthermore, adequate protein intake is associated with AKI during pediatric ICU stay, making it important to implement nutritional assessment and nutritional therapy protocols for critically ill pediatric patients.

Optimizing Outcomes in Extracorporeal Membrane Oxygenation Postcardiotomy in Pediatric Population

Extracorporeal membrane oxygenation (ECMO) is a rapidly emerging advanced life support technique used in cardiorespiratory failure refractory to other treatments. There has been an influx in the number of studies relating to ECMO in recent years, as the technique becomes more popular. However, there are still significant gaps in the literature including complications and their impacts and methods to predict their development. This review evaluates the available literature on the complications of ECMO postcardiotomy in the pediatric population. Areas explored include renal, cardiovascular, hematological, infection, neurological, and hepatic complications. Incidence, risk factors and potential predictors, and scoring systems for the development of these complications have been evaluated.

Gut microbiota and neonatal acute kidney injury biomarkers

One of the most frequent issues in newborns is acute kidney injury (AKI), which can lengthen their hospital stay or potentially raise their chance of dying. The gut-kidney axis establishes a bidirectional interplay between gut microbiota and kidney illness, particularly AKI, and demonstrates the importance of gut microbiota to host health. Since the ability to predict neonatal AKI using blood creatinine and urine output as evaluation parameters is somewhat constrained, a number of interesting biomarkers have been developed. There are few in-depth studies on the relationships between these neonatal AKI indicators and gut microbiota. In order to gain fresh insights into the gut-kidney axis of neonatal AKI, this review is based on the gut-kidney axis and describes relationships between gut microbiota and neonatal AKI biomarkers.

Malaria is the leading cause of acute kidney injury among a Zambian paediatric renal service cohort retrospectively evaluated for aetiologies, predictors of the need for dialysis, and outcomes

BACKGROUND

Whilst malaria is a prominent aetiology associated with acute kidney injury (AKI) in many parts of Africa, a shift in the traditional AKI aetiologies has been witnessed in sections of the continent. Additionally, limited access to dialysis worsens patient outcomes in these low-resource settings. This retrospective cross-sectional study aimed to determine the associated aetiologies, predictors of need for dialysis and malaria-associated AKI (MAKI), and outcomes of AKI and dialysis among children evaluated by the renal service in Lusaka, Zambia.

METHODS

The study sampled all children aged 16 years or below, diagnosed with AKI between 2017 and 2021, by the renal unit at the University Teaching Hospitals- Children's Hospital (UTH-CH), and retrospectively abstracted their records for exposures and outcomes. AKI was defined using the Kidney Disease Improving Global Outcomes (KDIGO) 2012 criteria. Frequency and percentage distributions were used to describe the occurrence of AKI aetiologies and treatment outcomes. Predictors of the need for dialysis, MAKI, and poor treatment outcome were identified by using multivariable logistic regression models.

RESULTS

A total of 126 children diagnosed with AKI were included in this study. Malaria was the most frequent aetiology of AKI(61.1% (77/126, 95% Confidence Interval (CI): 52.0%-69.7%)). Of the 126 children with AKI, 74.6% (94) underwent dialysis. Predictors of the need for dialysis were oliguria (p = 0.0024; Odds ratio (OR) = 7.5, 95% CI: 2.1-27.7) and anuria (p = 0.0211; OR = 6.4, 95% CI = 1.3, 30.7). A fifth (18.3%, 23/126) of the children developed chronic kidney disease (CKD), 5.6% (7/126) died and, a year later, 77% (97/126) were lost to follow-up.

CONCLUSION

At UTH-CH, malaria is the most frequent aetiology among children with AKI undergoing dialysis and children from low-medium malaria incidence areas are at risk; a considerable proportion of children with AKI need dialysis and Tenchoff catheter use in AKI is advocated.

Cefepime pharmacokinetics in critically ill children and young adults undergoing continuous kidney replacement therapy

OBJECTIVES

Cefepime is an antibiotic commonly used to treat sepsis and is cleared by renal excretion. Cefepime dosing requires adjustment in patients with decreased kidney function and in those receiving continuous kidney replacement therapy (CKRT). We aimed to characterize cefepime PK in a diverse cohort of critically ill paediatric patients on CKRT.

METHODS

Patients were identified from an ongoing pharmacokinetic/pharmacodynamic (PK/PD) study of beta-lactam antibiotics, and were included if they had received at least two cefepime doses in the ICU and were on CKRT for at least 24 h. PK parameters were estimated using MwPharm++ with Bayesian estimation and a paediatric population PK model. Target attainment was assessed as time of free cefepime concentrations above minimum inhibitory concentration (fT > 1× or 4 × MIC).

RESULTS

Seven patients were included in the study (ages 2 to 20 years). CKRT indications included liver failure (n = 1), renal failure (n = 4) and fluid overload (n = 2). Total effluent flow rates ranged from 1833 to 3115 (mean 2603) mL/1.73 m2/h, while clearance was 2.11-3.70 (mean 3.0) L/h/70 kg. Effluent flows were lower, but clearance and fT > MIC were similar to paediatric data published previously. Using Pseudomonas aeruginosa MIC breakpoints, all patients had 100% of dosing interval above MIC, but only one had 100% of dosing interval above 4× MIC.

CONCLUSIONS

Since most patients failed to attain stringent targets of 100% fT > 4×  MIC, model-informed precision dosing may benefit such patients.

Acute intermittent hemodialysis management in childhood: A single center experience

INTRODUCTION

The objective of this study was to determine the common indications of acute intermittent hemodialysis (IHD) treatment in childhood and to assess the characteristics of the procedure, complications, and prognosis.

METHODS

The study included 102 patients aged between 0 and 18 years, who had been acute dialysis indication and treated with IHD.

RESULTS

In terms of acute kidney injury (AKI) etiology, glomerular diseases were prominent in 56% of the patients, and 8.6% of surviving patients progressed to end-stage renal disease. Regarding the cause of AKI, having the glomerular disease was determined to be directly associated (p = 0.01) with the risk of progression to chronic kidney disease (CKD) regardless of age, gender, onset time of renal replacement therapy.

CONCLUSION

Glomerular diseases were the most common in AKI etiology and were associated with the progression to CKD, independent of age, gender and the time of IHD onset in our study.

Incidence of Acute Kidney Injury in Hospitalized Children: A Meta-analysis

BACKGROUND AND OBJECTIVES

There is limited literature on the incidence of acute kidney injury (AKI) and associated mortality in hospitalized children. To systematically assess the worldwide incidence of AKI in hospitalized children to inform policymakers regarding appropriate health resource allocation.

METHODS

Three different databases were searched (PubMed, Embase, Web of Sciences) from March 2012 to January 2022 without language or geographical restrictions. We included cohort and cross-sectional studies that reported AKI incidence in hospitalized children. Eligible studies had at least 100 participants and used the standard Kidney Disease Improving Global Outcomes criteria to define AKI. Two authors extracted data on the study and patients' characteristics and outcomes (incidence and AKI-associated mortality) and performed the risk of bias assessment. We used a random-effects meta-analysis to generate pooled estimates.

RESULTS

We included 94 studies (202 694 participants) from 26 countries. The incidence of any AKI was 26% (95% confidence interval: 22-29), and that of moderate-severe AKI was 14% (11-16). The incidence of AKI was similar in high-income 27% (23-32), low-middle-income 25% (13-38), and low-income 24% (12-39) countries. Overall, AKI-associated mortality was observed in 11% (9-13) of the pediatric population. AKI-associated mortality rate was highest at 18% (11-25) and 22% (9-38) in low-income and low-middle-income countries, respectively.

CONCLUSIONS

AKI was observed in one-quarter of the hospitalized children and is associated with increased mortality risk. Low-income and low-middle-income countries had observed higher mortality rates compared with high-income countries despite a similar AKI burden.

Determinants of Acute Kidney Injury in Children Undergoing Cardiopulmonary Bypass: Single-Center Experience in Saudi Arabia

Introduction Cardiopulmonary bypass (CPB) is a machine used in open cardiac surgeries and has been linked to many complications, one of which is acute kidney injury (AKI). Also, the Kidney Disease Improving Global Outcomes (KDIGO) criteria are used to diagnose AKI in the pediatric population. The study aimed to investigate the association between cardiopulmonary bypass duration and renal function impairment in pediatric patients who had cardiac surgery. Methods  This was an observational, cross-sectional study conducted at the King Abdulaziz Medical City, King Faisal Cardiac Center, the section of the Pediatric Cardiac Intensive Care Unit (PICU), Ministry of National Guard Health Affairs, from January 2016 to December 2019. Patients younger than 14 years old, those having a cardiac surgery where CPB was implemented, normal pre-operative kidney functions, and having a cardiac surgery longer than 60 minutes (min) were included. The exclusion criteria were patients known to have pre-operative renal impairment and patients with pre-operative hemodynamic instability or cardiac arrest. Demographics of pre-operative, intra-operative, and post-operative data were extracted, and Statistical Package for the Social Sciences (SPSS) version 25 (Armonk, NY: IBM Corp.) was used for analysis. For descriptive statistics, frequencies and percentages for qualitative data were examined, while mean and standard deviation (SD) or median and interquartile range (IQR) quantitative data were used accordingly. Student's t-test, Mann-Whitney (median test), chi-square, or Fisher's exact tests were used for univariate analysis accordingly. Logistic regression analysis was used to determine significant predictors for developing AKI. A p-value of <0.05 would be considered significant. Results Of the 111 patients, 87 patients were included in the analysis. The median age was six months, IQR two to 13 months, body mass index (BMI) mean of 13.8, and SD 3.6. There was similar sex distribution, male 47.1% vs. female 52.9%. There were no patients in Risk Adjustment for Congenital Heart Surgery (RACHS) who scored 5 or 6. The AKI prevalence was 31% (27/87) within three days after surgery. One patient had stage 2 AKI; the rest were mild. One patient (3.7%) died. The CPB time was significantly longer in patients who developed AKI 150 (104-202), vs. non-AKI 104 (82-142) min, p=0.004. In the AKI group, the mean baseline (pre-operative) serum creatinine (sCr) was significantly lower, whereas, it was significantly higher at 24 hours (h), and 48 h post-operation (p=0.001, 0.001, and 0.036, respectively). Additionally, the estimated Glomerular Filtration Rate (eGFR) was significantly higher in the AKI group at 24 h (p=0.007).  In logistical regression analysis, CPB time (per min unit time) was a significant predictor for developing AKI, OR 1.015, p=0.011 as a measured outcome. However, only CPB time >180 min was highly significant with OR 16.2, p=00.6 compared to CPB time 121-180 min OR 2.3, p=0.29 and CPB time 91-120 min OR 1.2, p=0.84. Conclusion Acute kidney injury is an expected complication of pediatric congenital heart surgery receiving CPB. Although in our single-center experience, CPB duration was a significant predictor for AKI; however, it is considered a mild complication that does not contribute significantly to short-term morbidity or mortality. A larger multicenter, national prospective data registry is recommended to explore long-term effects.

Derivation and evaluation of baseline creatinine equations for hospitalized children and adolescents: the AKI baseline creatinine equation

BACKGROUND

Acute kidney injury (AKI) definitions incorporate baseline creatinine (Cr_b) values, but Cr_b are frequently unknown in pediatrics. Our primary aim was to derive and validate a novel AKI Baseline Creatinine (ABC) estimation equation and compare it to existing methods of estimating Cr_b values.

METHODS

We conducted a single-center retrospective analysis of pediatric patients (0-25 years) admitted from 2012 to 2019. Included patients required at least one outpatient Cr_b prior to hospitalization (gold standard). Novel equations were developed with demographic and initial creatinine data. Existing methods included back-calculating Cr_b based on Schwartz, Full Age Spectrum (FAS), and CKiD-under-25 (U25) equations. To determine an optimal equation, we compared novel and existing equations to the gold standard.

RESULTS

The optimal simplified equation (ABC) included only age and had R² = 59.9% and 73.2% of values within 30% of true Cr_b. The precision increased significantly when the equation included age and minimum creatinine within initial 72 h (ABC-cr): R² = 75.4% and 86.5% of values within 30% of true Cr_b. The best performing existing equation was the age-based FAS, which had R² = 61.0% and 78.0% of values within 30% of true Cr_b. All other existing equations performed worse, some methods as low as 52.6% within 30% of true Cr_b.

CONCLUSIONS

The newly derived ABC equation is simple, and the ABC-cr equation can more accurately estimate Cr_b by ≥ 25% compared to previous methods. The potential applicability of these equations is vast, including faster recognition of AKI on initial patient contact and improved standardization of pediatric AKI definitions, enhancing health services research. A higher resolution version of the Graphical abstract is available as Supplementary information.

R, Rehman EU. Etiology, Clinical Profile, and Short-Term Outcome of Children With Acute Kidney Injury

Background: Acute kidney injury (AKI) is a common clinical syndrome in hospitalized children and it imposes heavy burden of mortality and morbidity. In resource-constraint settings, management of AKI is very challenging and associated with adverse outcomes. The aim of this study was to determine the clinico-etiological profile and outcome of AKI.

Methodology: This prospective observational study was done at the department of pediatric nephrology and pediatric intensive care unit, National Institute of Child Health, Karachi, Pakistan from December 2020 to May 2021. A total of 130 children aged 1 month to 15 years, diagnosed with AKI irrespective of the underlying cause were included. Detailed medical information of each child including medical history, examination, and baseline investigations were obtained. Clinical and etiological profile of patients was noted. The patients were followed up to three months and the outcome was noted.

Results: In a total of 130 children, 82 (63.1%) were male. The mean age was 5.5±4.4 years (ranging between 1 month and 15 years). There were 117 (90.0%) children who were referred from other centers for either dialysis or surgical treatment. Prerenal cause of AKI was found in 66 (50.8%) children, followed by renal 53 (40.8%) and postrenal in 11 (8.5%) cases. Fever and shortness of breath were the most common clinical presenting symptoms in 102 (78.5%) and 100 (76%) cases, respectively. There were 45 (34.6%) cases who were managed conservatively, 80 (61.5%) needed dialysis, while three children were managed with plasmapheresis and two required surgical intervention in the emergency department. At three-month follow-up period, 64 (49.2%) children recovered (including nine with partial recovery), 46 (36.1%) expired, 9 (6.9%) developed end-stage renal disease, while 11 (8.5%) had chronic kidney disease.

Conclusion: Sepsis, nephrotoxic drugs, and acute glomerulonephritis were the major causes of AKI at our center. Mortality was high among children presenting with AKI. A relatively high proportion of children with younger age, septic AKI, and presentation in critical condition could be the reasons for this high mortality.

Use of non-conventional biomarkers in the early diagnosis of acute kidney injury in preterm newborns with sepsis

Acute kidney injury (AKI) is a common finding in Neotatal Intensive Care Units (NICU). Sepsis is one the main causes of AKI in preterm newborns. AKI has been associated with significant death rates. Early detection of the condition is the first step to improving prevention, treatment, and outcomes, while decreasing length of hospitalization, care costs, and morbimortality. AKI may progress to chronic kidney disease (CKD), a condition linked with dialysis and greater risk of cardiovascular disease. This review article aims to discuss cases of AKI in preterm newborns with sepsis, the use of biomarkers in lab workup, and the use of non-conventional biomarkers for the early identification of AKI.

Access to treatment for chronic kidney disease by children and adolescents in Brazil

BACKGROUND

This study aimed to identify main factors associated with child and adolescent access to chronic kidney disease (CKD) treatment in Brazil.

METHODS

Multi-center cross-sectional study conducted in eight pediatric nephrology centers across all Brazilian geographic regions. Information was collected on characteristics associated with referral and treatment of patients with CKD. The following outcomes were analyzed as follows: (1) age at first consultation, and (2) time elapsed between referral and treatment at the specialized service.

RESULTS

Three hundred thirty-five children were assessed. Variables associated with age at first consultation were as follows: CAKUT (HR=1.7; 95%CI 1.3-2.2, p<0.01); private health plan (HR=1.54; 95%CI 1.06-2.23, p=0.02); modified Medical Outcomes Study Social Support Survey mMOS-SS score (HR=1.02; 95%CI 1.00-1.03, p=0.024); maternal age (HR=0.96; 95%CI 0.95-0.97, p<0.01); and number of siblings in the household (HR=0.86; 95%CI 0.79-0.83, p<0.01). Significant variables associated with time elapsed between referral and treatment at the specialized service were as follows: each additional occupant sharing the household (HR=0.94; 95%CI:0.89-0.99, p=0.02), residing in the Northeast (HR=0.81; 95%CI:0.67-0.98, p=0.03) and having someone to take them to the physician (HR=1.36; 95%CI 1.07-1.74, p=0.01). The median time interval between patient referral and treatment by the service was 11 days (IQR 10-31).

CONCLUSION

There are potentially modifiable factors hampering access of children with CKD to specialized treatment. The importance of the role of social support for the two outcomes should serve as an alert for health managers and professionals to consider this aspect throughout all steps of the care process of children with CKD.

Long-term survival of children following acute peritoneal dialysis in a resource-limited setting

BACKGROUND

There is a paucity of data on long term-outcomes of children who undergo acute peritoneal dialysis (PD) in resource-limited settings. We reviewed the outcomes of children who underwent PD after 18 months of follow-up.

METHODS

We conducted a prospective cohort study in children with acute kidney injury (AKI) who underwent PD. Diagnosis of AKI was based on the 2012 Kidney Disease: Improving Global Outcomes definition. We assessed outcomes of in-hospital mortality, 18-month post-dialysis survival, factors associated with survival, and progression to chronic kidney disease (CKD).

RESULTS

Twenty-nine children with a median age of 6 (3 to 11) years underwent acute PD. In-hospital mortality was 3/29 (10.3%) and rose to 27.6% during follow-up. Seven (24.1%) children were lost to follow-up. Of the 14 remaining children, six (42.9%) experienced full recovery of renal function, while eight (57.1%) progressed to CKD. Among those who experienced full recovery, median (interquartile range) estimated glomerular filtration rate (eGFR) rose from 12.67 (7.05, 22.85) mL/min/1.73 m2 to 95.56 (64.50, 198.00) mL/min/1.73 m2, P = 0.031. No significant changes in median eGFR from baseline were observed among those who progressed to CKD (P = 0.383) or in non-survivors (P = 0.838). According to Kaplan-Meier curve analyses, 18-month survival during follow-up was 66.0% (95% CI, 45.0% to 86.5%). Age < 5 was associated with greater likelihood of survival (OR, 3.217; 95% CI, 1.240 to 8.342).

CONCLUSION

Progression of post-PD AKI to CKD occurred in more than half of survivors. Age < 5 was associated with greater likelihood of survival.

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.

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.

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.