Acute Kidney Injury among Hospitalized Children in China

Relationship between intra-operative urine output and postoperative acute kidney injury in paediatric cardiac surgery: A retrospective cohort study

BACKGROUND

Intra-operative urine output (UO) has been shown to predict postoperative acute kidney injury (AKI) in adults; however, its significance in children undergoing cardiac surgery remains unknown.

OBJECTIVE

To explore the association between intra-operative UO and postoperative AKI in children with congenital heart disease.

DESIGN

A retrospective observational study.

SETTING

A tertiary hospital.

PATIENTS

Children aged >28 days and <6 years who underwent cardiac surgery at Fuwai Hospital from 1 April 2022 to 30 August 2022.

MAIN OUTCOME MEASURES

AKI was identified by the highest serum creatinine value within postoperative 7 days using Kidney Disease Improving Global Outcomes (KDIGO) criteria.

RESULTS

In total, 1184 children were included. The incidence of AKI was 23.1% (273/1184), of which 17.7% (209/1184) were stage 1, 4.2% (50/1184) were stage 2, and others were stage 3 (1.2%, 14/1184). Intra-operative UO was calculated by dividing the total intra-operative urine volume by the duration of surgery and the actual body weight measured before surgery. There was no significant difference in median [range] intra-operative UO between the AKI and non-AKI groups (2.6 [1.4 to 5.4] and 2.7 [1.4 to 4.9], respectively, P = 0.791), and multivariate logistic regression analyses showed that intra-operative UO was not associated with postoperative AKI [adjusted odds ratio (OR) 0.971; 95% confidence interval (CI), 0.930 to 1.014; P = 0.182]. Regarding the clinical importance of severe forms of AKI, we further explored the association between intra-operative UO and postoperative moderate-to-severe AKI (adjusted OR 0.914; 95% CI, 0.838 to 0.998; P = 0.046).

CONCLUSIONS

Intra-operative UO was not associated with postoperative AKI during paediatric cardiac surgery. However, we found a significant association between UO and postoperative moderate-to-severe AKI. This suggests that reductions in intra-operative urine output below a specific threshold may be associated with postoperative renal dysfunction.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT05489263.

Comparison of diagnostic criteria for sepsis-associated acute kidney injury in the pediatric intensive care unit: a retrospective cohort study

Background

pRIFLE (Pediatric Risk, Injury, Failure, Loss, End Stage Renal Disease), KDIGO (Kidney Disease Improving Global Outcomes) and pROCK (Pediatric Reference Change Value Optimized for AKI) are diagnostic criteria used for acute kidney injury (AKI) incidence evaluation. The aim of this study was to explore the diagnostic consistency, incidence and mortality rate, clinical signs, and influencing factors of renal injury related to sepsis in children diagnosed by three different AKI diagnostic criteria, and then evaluate which one was more valuable.

Methods

A retrospective analysis was performed on the clinical data of children with severe sepsis. The patients were diagnosed and staged according to the 2007 pRIFLE standard, the 2012 KDIGO standard, and the 2018 pROCK standard. The clinical characteristics and prognosis of children with different stages of sepsis were compared between the three diagnostic standards.

Results

A total of 62 patients with sepsis were included. Blood stream infection is common (11 cases, 17.74%). According to pRIFLE, KDIGO, and pROCK standards, the incidence of sepsis-associated AKI (SA-AKI) was 74.2%, 67.7%, and 56.5%, respectively. The pRIFLE had the highest diagnostic rate of early detection of SA-AKI. There was no statistical difference in SA-AKI incidence or staging consistency between the pRIFLE and KDIGO groups (κ=0.0671; κ>0.60); the consistency of SA-AKI diagnoses across the three standards was good (all P values <0.05), and pROCK demonstrated a higher specificity. A high Pediatric Risk of Mortality (PRISM) score and high procalcitonin level were independent risk factors. Shock and renal replacement therapy were independent risk factors for SA-AKI death. Death from admission to 28 days after admission was used as an endpoint to draw a survival graph, which revealed that the AKI group had a significantly higher risk of death than did the non-AKI group.

Conclusions

The consistency of diagnosing SA-AKI across the three classification criteria was similar, and mortality rate increased with increased SA-AKI staging. The pRIFLE criteria were more sensitive in the early detection of SA-AKI, while the pROCK had higher specificity. There was no significant difference between the pRIFLE and KDIGO in terms of incidence, diagnosis, or staging of SA-AKI.

Urinary biomarkers associated with acute kidney injury in pediatric mechanical circulatory support patients

BACKGROUND

In patients requiring mechanical circulatory support (MCS), the incidence of acute kidney injury (AKI) is between 37 and 63%. In this study, we performed an exploratory analysis evaluating the relationship of multiple urine biomarkers with AKI development in pediatric MCS patients.

METHODS

This is a single center retrospective study in a pediatric cohort receiving MCS from August 2014 to November 2020. We measured 14 urine biomarkers of kidney injury on day 1 following MCS initiation and analyzed their association with development of AKI in the first 7 days of MCS initiation.

RESULTS

Sixty patients met inclusion criteria. Patients with AKI were more likely to be supported by venoarterial extracorporeal membrane oxygenation (65% vs. 8.3%, p < 0.001), compared to the no AKI group and less likely to have ventricular assist devices (10% vs. 50%, p < 0.001). There was a significant increase in the median urine albumin and urine osteoactivin in the AKI group, compared to the no AKI group (p = 0.020 and p = 0.018, respectively). When normalized to urine creatinine (UCr), an increased log osteoactivin/UCr was associated with higher odds of AKI development (OR: 2.05; 95% CI: 1.07, 4.44; p = 0.028), and higher log epidermal growth factor (EGF)/UCr (OR: 0.41; 95% CI: 0.15, 0.96) was associated with decreased odds of AKI.

CONCLUSIONS

Early increase in urine osteoactivin is associated with AKI development within 7 days of MCS initiation in pediatric patients. Contrary, an increased urine EGF is associated with kidney protection. A higher resolution version of the Graphical abstract is available as Supplementary information.

Epidemiology and outcomes of post-AKI proteinuria

Background

Acute kidney injury (AKI) has been associated with increased risks of new-onset and worsening proteinuria. However, epidemiologic data for post-AKI proteinuria was still lacking. This study aimed to determine the incidence, risk factors and clinical correlations of post-AKI proteinuria among hospitalized patients.

Methods

This study was conducted in a multicenter cohort including patients aged 18-100 years with hospital-acquired AKI (HA-AKI) hospitalized at 19 medical centers throughout China. The primary outcome was the incidence of post-AKI proteinuria. Secondary outcomes included AKI recovery and kidney disease progression. The results of both quantitative and qualitative urinary protein tests were used to define post-AKI proteinuria. Cox proportional hazard model with stepwise regression was used to determine the risk factors for post-AKI proteinuria.

Results

Of 6206 HA-AKI patients without proteinuria at baseline, 2102 (33.9%) had new-onset proteinuria, whereas of 5137 HA-AKI with baseline proteinuria, 894 (17.4%) had worsening proteinuria after AKI. Higher AKI stage and preexisting CKD diagnosis were risk factors for new-onset proteinuria and worsening proteinuria, whereas treatment with renin-angiotensin system inhibitors was associated with an 11% lower risk of incident proteinuria. About 60% and 75% of patients with post-AKI new-onset and worsening proteinuria, respectively, recovered within 3 months. Worsening proteinuria was associated with a lower incidence of AKI recovery and a higher risk of kidney disease progression.

Conclusions

Post-AKI proteinuria is common and usually transient among hospitalized patients. The risk profiles for new-onset and worsening post-AKI proteinuria differed markedly. Worsening proteinuria after AKI was associated with adverse kidney outcomes, which emphasized the need for close monitoring of proteinuria after AKI.

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.

Risk factors associated with acute kidney injury in a pediatric intensive care unit in Addis Ababa Ethiopia: case-control study

BACKGROUND

Acute kidney injury (AKI) is a serious health problem in critically ill children. It is associated with poor treatment outcomes and high morbidity and mortality rates. Globally, one in three critically ill children suffers from acute kidney injury. However, limited data are available in Africa, particularly Ethiopia, which highlighting the risk factors related to acute kidney injury. Therefore, this study aimed to identify the risk factors associated with acute kidney injury among critically ill children admitted to the pediatric intensive care unit (PICU) at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia.

METHODS

A facility-based unmatched case-control study was carried out on 253 (85 cases and 168 controls) critically ill children admitted to the pediatric intensive care unit from January 2011 to December 2021. Participants were selected using a systematic random sampling technique for the control group and all cases consecutively. Data were collected using a structured checklist. Data were entered using Epi data version 4.6 and analyzed using SPSS version 25. Multivariable analysis was carried out using the adjusted odds ratio (aOR) with a 95% confidence interval (CI) to identify associated factors with acute kidney injury. Statistical significance was set at P < 0.05.

RESULTS

The median age of the participants was two years. Approximately 55.6% of cases and 53.1% of controls were females. The diagnosis of hypertension (aOR = 5.36; 95% CI: 2.06-13.93), shock (aOR = 3.88, 95% CI: 1.85-8.12), exposure to nephrotoxic drugs (aOR = 4.09; 95% CI: 1. 45- 11.59), sepsis or infection aOR = 3.36; 95% CI: 1.42-7.99), nephritic syndrome (aOR = 2.97; 95% CI:1.19, 7.43), and use of mechanical ventilation aOR = 2.25, 95% CI: 1.12, 4.51) were significantly associated factors with acute kidney injury.

CONCLUSION

The diagnosis of sepsis or infection, hypertension, shock, nephrotoxic drugs, demand for mechanical ventilation support, and nephritic syndrome increased the risk of AKI among critically ill children. Multiple risk factors for AKI are associated with illness and severity. All measures that ensure adequate renal perfusion must be taken in critically ill children with identified risk factors to prevent the development of AKI.

Development of a nomogram model for the early prediction of sepsis-associated acute kidney injury in critically ill patients

Sepsis-associated acute kidney injury is a common complication of sepsis, but it is difficult to predict sepsis-associated acute kidney injury. In this retrospective observational study, adult septic patients were recruited from the MIMIC-III database as the training cohort (n = 4764) and from Xiangya Hospital (n = 1568) and Zhang's database as validation cohorts. We identified eleven predictors with seven independent risk predictors of sepsis-associated acute kidney injury [fluid input_day1 ≥ 3390 ml (HR hazard ratio 1.42), fluid input_day2 ≥ 2734 ml (HR 1.64), platelet_min_day5 ≤ 224.2 × 109/l (HR 0.86), length of ICU stay ≥ 2.5 days (HR 1.24), length of hospital stay ≥ 5.8 days (HR 1.18), Bun_max_day1 ≥ 20 mmol/l (HR 1.20), and mechanical ventilation time ≥ 96 h (HR 1.11)] by multivariate Cox regression analysis, and the eleven predictors were entered into the nomogram. The nomogram model showed a discriminative ability for estimating sepsis-associated acute kidney injury. These results indicated that clinical parameters such as excess input fluid on the first and second days after admission and longer mechanical ventilation time could increase the risk of developing sepsis-associated acute kidney injury. With our study, we built a real-time prediction model for potentially forecasting acute kidney injury in septic patients that can help clinicians make decisions as early as possible to avoid sepsis-associated acute kidney injury.

NSAID-associated acute kidney injury in hospitalized children - a prospective Pediatric Nephrology Research Consortium study

BACKGROUND

Acute kidney injury (AKI) in children has serious short-term and long-term consequences. We sought 1) to prospectively describe NSAID-associated AKI in hospitalized children; 2) to determine if NSAID-associated AKI was more severe in younger children < 5 years; and 3) to follow outcomes after hospitalization for NSAID-associated AKI.

METHODS

This was a prospective, multi-center study in hospitalized children 1 month to 18 years. Parents/guardians were given a brief questionnaire to determine the dosing, duration, and type of NSAIDs given. Kidney Disease: Improving Global Outcomes (KDIGO) serum creatinine criteria were used to stage AKI severity. Patients with other causes of AKI were excluded (e.g., other nephrotoxins, sepsis, malignancy, etc.).

RESULTS

We identified 25 patients with NSAID-associated AKI, accounting for 3.1% of AKI. All 25 had AKI upon hospital presentation. The median age was 15.5 years, and 20/25 (80%) had volume depletion. Median duration of NSAID use was 2 days, and 63% of patients took the normal recommended NSAID dose. Median hospital length of stay was 4 days, and none required dialysis. At the most recent estimated glomerular filtration rate (eGFR) after discharge (available in 17/25 patients), only 4/17 (24%) had eGFR ≥ 90 ml/min/1.73 m2, and 13/17 (76%) had eGFR 60 to < 90 ml/min/1.73 m2, indicative of abnormal kidney function.

CONCLUSIONS

NSAID-associated AKI usually occurs with recommended NSAID dosing in the setting of dehydration. Follow-up after AKI showed a substantial rate of CKD. Therefore, we recommend that NSAIDs should not be used in dehydrated children. A higher resolution version of the Graphical abstract is available as Supplementary information.

Early recognition and prevention of acute kidney injury in hospitalised children

Acute kidney injury is common in hospitalised children and is associated with poor patient outcomes. Once acute kidney injury occurs, effective therapies to improve patient outcomes or kidney recovery are scarce. Early identification of children at risk of acute kidney injury or at an early injury stage is essential to prevent progression and mitigate complications. Paediatric acute kidney injury is under-recognised by clinicians, which is a barrier to optimisation of inpatient care and follow-up. Acute kidney injury definitions rely on functional biomarkers (ie, serum creatinine and urine output) that are inadequate, since they do not account for biological variability, analytical issues, or physiological responses to volume depletion. Improved predictive tools and diagnostic biomarkers of kidney injury are needed for earlier detection. Novel strategies, including biomarker-guided care algorithms, machine-learning methods, and electronic alerts tied to clinical decision support tools, could improve paediatric acute kidney injury care. Clinical prediction models should be studied in different paediatric populations and acute kidney injury phenotypes. Research is needed to develop and test prevention strategies for acute kidney injury in hospitalised children, including care bundles and therapeutics.

Detecting Neonatal AKI by Serum Cystatin C

SIGNIFICANCE STATEMENT

Serum creatinine is not a sensitive biomarker for neonatal AKI because it is confounded by maternal creatinine level, gestational age, and neonatal muscle mass. In this multicenter cohort study of 52,333 hospitalized Chinese neonates, the authors proposed serum cystatin C-related criteria (CyNA) for neonatal AKI. They found that cystatin C (Cys-C) is a robust and sensitive biomarker for identifying AKI in neonates who are at an elevated risk of in-hospital mortality and that CyNA detects 6.5 times as many cases as the modified Kidney Disease Improving Global Outcomes creatinine criteria. They also show that AKI can be detected using a single test of Cys-C. These findings suggest that CyNA shows promise as a powerful and easily applicable tool for detecting AKI in neonates.

BACKGROUND

Serum creatinine is not a sensitive biomarker for AKI in neonates. A better biomarker-based criterion for neonatal AKI is needed.

METHODS

In this large multicenter cohort study, we estimated the upper normal limit (UNL) and reference change value (RCV) of serum cystatin C (Cys-C) in neonates and proposed cystatin C-based criteria (CyNA) for detecting neonatal AKI using these values as the cutoffs. We assessed the association of CyNA-detected AKI with the risk of in-hospital death and compared CyNA performance versus performance of modified Kidney Disease Improving Global Outcomes (KDIGO) creatinine criteria.

RESULTS

In this study of 52,333 hospitalized neonates in China, Cys-C level did not vary with gestational age and birth weight and remained relatively stable during the neonatal period. CyNA criteria define AKI by a serum Cys-C of ≥2.2 mg/L (UNL) or an increase in Cys-C of ≥25% (RCV) during the neonatal period. Among 45,839 neonates with measurements of both Cys-C and creatinine, 4513 (9.8%) had AKI detected by CyNA only, 373 (0.8%) by KDIGO only, and 381 (0.8%) by both criteria. Compared with neonates without AKI by both criteria, neonates with AKI detected by CyNA alone had an increased risk of in-hospital mortality (hazard ratio [HR], 2.86; 95% confidence interval [95% CI], 2.02 to 4.04). Neonates with AKI detected by both criteria had an even higher risk of in-hospital mortality (HR, 4.86; 95% CI, 2.84 to 8.29).

CONCLUSIONS

Serum Cys-C is a robust and sensitive biomarker for detecting neonatal AKI. Compared with modified KDIGO creatinine criteria, CyNA is 6.5 times more sensitive in identifying neonates at elevated risk of in-hospital mortality.

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.

Serum N-terminal pro-B-type natriuretic peptide and cystatin C for acute kidney injury detection in critically ill adults in China: a prospective, observational study

OBJECTIVE

Serum N-terminal pro-B-type natriuretic peptide (NT-proBNP) and cystatin C (sCysC) are available clinically and beneficial in diagnosing acute kidney injury (AKI). Our purpose is to identify the performance of their combined diagnosis for AKI in critically ill patients.

DESIGN

A prospectively recruited, observational study was performed.

SETTING

Adults admitted to the intensive care unit of a tertiary hospital in China.

PARTICIPANTS

A total of 1222 critically ill patients were enrolled in the study.

MAIN OUTCOME MEASURES

To identify the performance of the combined diagnosis of serum NT-proBNP and sCysC for AKI in critically ill patients. The area under the receiver operating characteristic curve (AUC-ROC), category-free net reclassification index (NRI) and incremental discrimination improvement (IDI) were utilised for comparing the discriminative powers of a combined and single biomarker adjusted model of clinical variables enriched with NT-proBNP and sCysC for AKI.

RESULTS

AKI was detected in 256 out of 1222 included patients (20.9%). AUC-ROC for NT-proBNP and sCysC to detect AKI had a significantly higher accuracy than any individual biomarker (p<0.05). After multivariate adjustment, a level of serum NT-proBNP ≥204 pg/mL was associated with 3.5-fold higher odds for AKI compared with those below the cut-off value. Similar results were obtained for sCysC levels (p<0.001). To detect AKI, adding NT-proBNP and sCysC to a clinical model further increased the AUC-ROC to 0.859 beyond that of the clinical model with or without sCysC (p<0.05). Moreover, the addition of these two to the clinical model significantly improved risk reclassification of AKI beyond that of the clinical model alone or with single biomarker (p<0.05), as measured by NRI and IDI.

CONCLUSIONS

In critically ill individuals, serum NT-proBNP, sCysC and clinical risk factors combination improve the discriminative power for diagnosing AKI.

Machine Learning-Based Prediction of Acute Kidney Injury Following Pediatric Cardiac Surgery: Model Development and Validation Study

BACKGROUND

Cardiac surgery-associated acute kidney injury (CSA-AKI) is a major complication following pediatric cardiac surgery, which is associated with increased morbidity and mortality. The early prediction of CSA-AKI before and immediately after surgery could significantly improve the implementation of preventive and therapeutic strategies during the perioperative periods. However, there is limited clinical information on how to identify pediatric patients at high risk of CSA-AKI.

OBJECTIVE

The study aims to develop and validate machine learning models to predict the development of CSA-AKI in the pediatric population.

METHODS

This retrospective cohort study enrolled patients aged 1 month to 18 years who underwent cardiac surgery with cardiopulmonary bypass at 3 medical centers of Central South University in China. CSA-AKI was defined according to the 2012 Kidney Disease: Improving Global Outcomes criteria. Feature selection was applied separately to 2 data sets: the preoperative data set and the combined preoperative and intraoperative data set. Multiple machine learning algorithms were tested, including K-nearest neighbor, naive Bayes, support vector machines, random forest, extreme gradient boosting (XGBoost), and neural networks. The best performing model was identified in cross-validation by using the area under the receiver operating characteristic curve (AUROC). Model interpretations were generated using the Shapley additive explanations (SHAP) method.

RESULTS

A total of 3278 patients from one of the centers were used for model derivation, while 585 patients from another 2 centers served as the external validation cohort. CSA-AKI occurred in 564 (17.2%) patients in the derivation cohort and 51 (8.7%) patients in the external validation cohort. Among the considered machine learning models, the XGBoost models achieved the best predictive performance in cross-validation. The AUROC of the XGBoost model using only the preoperative variables was 0.890 (95% CI 0.876-0.906) in the derivation cohort and 0.857 (95% CI 0.800-0.903) in the external validation cohort. When the intraoperative variables were included, the AUROC increased to 0.912 (95% CI 0.899-0.924) and 0.889 (95% CI 0.844-0.920) in the 2 cohorts, respectively. The SHAP method revealed that baseline serum creatinine level, perfusion time, body length, operation time, and intraoperative blood loss were the top 5 predictors of CSA-AKI.

CONCLUSIONS

The interpretable XGBoost models provide practical tools for the early prediction of CSA-AKI, which are valuable for risk stratification and perioperative management of pediatric patients undergoing cardiac surgery.

Comparison of diagnostic criteria for acute kidney injury in critically ill children: a multicenter cohort study

Background

Substantial interstudy heterogeneity exists in defining acute kidney injury (AKI) and baseline serum creatinine (SCr). This study assessed AKI incidence and its association with pediatric intensive care unit (PICU) mortality under different AKI and baseline SCr definitions to determine the preferable approach for diagnosing pediatric AKI.

Methods

In this multicenter prospective observational cohort study, AKI was defined and staged according to the Kidney Disease: Improving Global Outcome (KDIGO), modified KDIGO, and pediatric reference change value optimized for AKI (pROCK) definitions. The baseline SCr was calculated based on the Schwartz formula or estimated as the upper normative value (NormsMax), admission SCr (AdmSCr) and modified AdmSCr. The impacts of different AKI definitions and baseline SCr estimation methods on AKI incidence, severity distribution and AKI outcome were evaluated.

Results

Different AKI definitions and baseline SCr estimates led to differences in AKI incidence, from 6.8 to 25.7%; patients with AKI across all definitions had higher PICU mortality ranged from 19.0 to 35.4%. A higher AKI incidence (25.7%) but lower mortality (19.0%) was observed based on the Schwartz according to the KDIGO definition, which however was overcome by modified KDIGO (AKI incidence: 16.3%, PICU mortality: 26.1%). Furthermore, for the modified KDIGO, the consistencies of AKI stages between different baseline SCr estimation methods were all strong with the concordance rates > 90.0% and weighted kappa values > 0.8, and PICU mortality increased pursuant to staging based on the Schwartz. When the NormsMax was used, the KDIGO and modified KDIGO led to an identical AKI incidence (13.6%), but PICU mortality did not differ among AKI stages. For the pROCK, PICU mortality did not increase pursuant to staging and AKI stage 3 was not associated with mortality after adjustment for confounders.

Conclusions

The AKI incidence and staging vary depending on the definition and baseline SCr estimation method used. The modified KDIGO definition based on the Schwartz method leads AKI to be highly relevant to PICU mortality, suggesting that it may be the preferable approach for diagnosing AKI in critically ill children and provides promise for improving clinicians’ ability to diagnose pediatric AKI.

Pediatric Reference Change Value Optimized for Acute Kidney Injury: Multicenter Retrospective Study in China

OBJECTIVES

The standard definition of pediatric acute kidney injury (AKI) is evolving, especially for critically ill in the PICU. We sought to validate the application of the Pediatric Reference Change Value Optimized for Acute Kidney Injury in Children (pROCK) criteria in critically ill children.

DESIGN

Multicenter retrospective study.

SETTING

Six PICUs in mainland China.

PATIENTS

One thousand six hundred seventy-eight hospitalized children admitted to the PICU with at least two creatinine values within 7 days.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

AKI was diagnosed and staged according to the Pediatric Risk, Injury, Failure, Loss, End-Stage Renal Disease (pRIFLE), the Kidney Disease Improving Global Outcomes (KDIGO), and the pROCK criteria. Multiple clinical parameters were assessed and analyzed along with 90-day follow-up outcomes. According to the definitions of pRIFLE, KDIGO, and pROCK, the prevalence of AKI in our cohort of 1,678 cases was 52.8% (886), 39.0% (655), and 19.0% (318), respectively. The presence of AKI, as defined by pROCK, was associated with increased number of injured organs, occurrence of sepsis, use of mechanical ventilation, use of continuous renal replace therapy ( p < 0.05), higher Pediatric Risk of Mortality III score, and higher Pediatric Logistic Organ Dysfunction-2 score ( p < 0.001). The survival curve of 90-day outcomes showed that pROCK was associated with shorter survival time (LogRank p < 0.001), and pROCK definition was associated with better separation of the different stages of AKI from non-AKI ( p < 0.001).

CONCLUSIONS

In this retrospective analysis of AKI criteria in PICU admissions in China, pROCK is better correlated with severity and outcome of AKI. Hence, the pROCK criteria for AKI may have better utility in critically ill children.

Drug-induced kidney injury in Chinese critically ill pediatric patients

Background: Drug-induced acute kidney injury (DIKI) is a common adverse drug reaction event but is less known in pediatric patients. The study explored the DIKI in Chinese pediatric patients using the Pediatric Intensive Care database (PIC).

Method: We screened pediatric patients with acute kidney injury (AKI) using the KDIGO criteria from the PIC and then assessed the relationship between their drugs and DIKI using the Naranjo scale. For the fifteen frequently used DIKI-suspected drugs, we divided patients into drug-exposed and non-exposed groups, using the outcome of whether DIKI was presented or not. Propensity score matching (PSM) was used to control for the effects of four confounders, age, gender, length of hospital stay, and major diagnosis. Unconditional logistic regression was used to identify statistically significant differences between the two groups.

Results: A total of 238 drugs were used 1,863 times by the 81 patients with DIKI during their hospital stay. After screening the Naranjo scale to identify the top 15 suspected DIKI drugs with a high frequency of use, we found that furosemide injection (p = 0.001), midazolam injection (p = 0.001), 20% albumin prepared from human plasma injection (p = 0.004), fentanyl citrate injection (p = 0.001), compound glycyrrhizin injection (p = 0.026), vancomycin hydrochloride for intravenous (p = 0.010), and milrinone lactate injection (p = 0.009) were associated with DIKI.

Conclusion: In critically ill pediatric patients, DIKI is more likely to occur after using furosemide injection, midazolam injection, 20% albumin prepared from human plasma injection, fentanyl citrate injection, compound glycyrrhizin injection, vancomycin hydrochloride for intravenous, milrinone lactate injection.

Loop Diuretics Are Associated with Increased Risk of Hospital-Acquired Acute Kidney Injury in Adult Patients: A Retrospective Study

Background: The association between loop diuretics and acute kidney injury (AKI) remains unclear. Methods: The population studied was selected from the Epidemiology of AKI in Chinese Hospitalized patients (EACH) study. Exposure to loop diuretics was defined as any filled prescription prior to the date when AKI was detected in patients with HA-AKI, and prior to the last date of SCr testing in those without AKI. The outcome was AKI, defined by the Kidney Disease Improving Global Outcomes criteria. Associations between loop diuretics and HA-AKI were examined by Cox proportional hazards models adjusted for baseline and time-dependent covariates. Results: Of the 150,020 patients, 16,437 (11.0%) were prescribed loop diuretics, and 5717 (3.8%) experienced HA-AKI events. The crude rates of HA-AKI in patients who were and were not prescribed loop diuretics were 1632 (9.9%) and 3262 (2.8%), respectively. A multivariate cox proportional hazards analysis showed that exposure to loop diuretics was associated with significantly increased risks of HA-AKI compared with non-users (hazard ratio (HR), 1.61; 95% CI (confidence interval), 1.55–1.67), other diuretics (HR, 1.09; 95% CI, 1.03–1.15), and osmotic diuretics (HR, 1.30; 95% CI, 1.20–1.42). Compared with other diuretics, the use of loop diuretics was associated with higher risks of HA-AKI in women, in patients without hypertension, in patients without heart failure, in patients without liver cirrhosis, and in patients not requiring surgery. Conclusions: Loop diuretics are widely used and are associated with increased risks of HA-AKI in hospitalized adults. Renal function should be more closely monitored during the use of loop diuretics.

Outcome prediction for acute kidney injury among hospitalized children via eXtreme Gradient Boosting algorithm

Acute kidney injury (AKI) is common among hospitalized children and is associated with a poor prognosis. The study sought to develop machine learning-based models for predicting adverse outcomes among hospitalized AKI children. We performed a retrospective study of hospitalized AKI patients aged 1 month to 18 years in the Second Xiangya Hospital of Central South University in China from 2015 to 2020. The primary outcomes included major adverse kidney events within 30 days (MAKE30) (death, new renal replacement therapy, and persistent renal dysfunction) and 90-day adverse outcomes (chronic dialysis and death). The state-of-the-art machine learning algorithm, eXtreme Gradient Boosting (XGBoost), and the traditional logistic regression were used to establish prediction models for MAKE30 and 90-day adverse outcomes. The models’ performance was evaluated by split-set test. A total of 1394 pediatric AKI patients were included in the study. The incidence of MAKE30 and 90-day adverse outcomes was 24.1% and 8.1%, respectively. In the test set, the area under the receiver operating characteristic curve (AUC) of the XGBoost model was 0.810 (95% CI 0.763–0.857) for MAKE30 and 0.851 (95% CI 0.785–0.916) for 90-day adverse outcomes, The AUC of the logistic regression model was 0.786 (95% CI 0.731–0.841) for MAKE30 and 0.759 (95% CI 0.654–0.864) for 90-day adverse outcomes. A web-based risk calculator can facilitate the application of the XGBoost models in daily clinical practice. In conclusion, XGBoost showed good performance in predicting MAKE30 and 90-day adverse outcomes, which provided clinicians with useful tools for prognostic assessment in hospitalized AKI children.

Acute Kidney Disease in Hospitalized Pediatric Patients With Acute Kidney Injury in China

Objective

The epidemiology and outcomes of acute kidney disease (AKD) after acute kidney injury (AKI) in hospitalized children are poorly described. The aim of this study is to investigate the prevalence, predictive factors, and clinical outcomes of AKD in hospitalized children with AKI.

Methods

Children (1 month-18 years) with AKI during hospitalization in the Second Xiangya Hospital from January 2015 to December 2020 were identified. AKD was defined based on the consensus report of the Acute Disease Quality Initiative 16 workgroup. The endpoints include adverse outcomes in 30 and 90 days. Multivariable logistic regression analyses were used to estimate the odds ratio of 30- and 90-day adverse outcomes associated with AKD and identify the risk factors of AKD.

Results

AKD was developed in 42.3% (419/990) of the study patients, with 186 in AKD stage 1, 107 in AKD stage 2, and 126 in AKD stage 3. Pediatric patients with AKD stages 2-3 had significantly higher rates of developing 30- and 90-day adverse outcomes than those with AKD stage 0 and 1. The adjusted odds ratio of AKD stage 2-3 was 12.18 (95% confidence interval (CI), 7.38 - 20.09) for 30-day adverse outcomes and decreased to 2.49 (95% CI, 1.26 - 4.91) for 90-day adverse outcomes. AKI stages 2 and 3, as well as glomerulonephritis, were the only predictive factors for AKD stage 2-3.

Conclusion

AKD is frequent among hospitalized pediatric AKI patients. AKD stage 2-3 represents a high-risk subpopulation among pediatric AKI survivors and is independently associated with 30- and 90-day adverse outcomes. Awareness of the potential risks associated with AKD stage 2-3 and its risk factors may help improve outcomes through careful monitoring and timely intervention.

Lesión renal aguda en el paciente pediátrico: revisión integrativa

Introducción: La lesión renal aguda se ha convertido en una complicación común en los niños hospitalizados, especialmente cuando están en una situación clínica crítica. Objetivo: Conocer y sintetizar la bibliografía científica más actualizada sobre la lesión renal aguda en la población pediátrica. Metodología: Estudio descriptivo de revisión integrativa. La búsqueda de artículos se ha realizado en las bases de datos Pubmed, Scopus y Google Scholar. La estrategia de búsqueda se estableció con los siguientes términos MeSH: ”acute kidney injury”, “children” y “pediatric”. La calidad metodológica se realizó mediante la escala STROBE. Resultados: Se incluyeron 35 artículos, 19 de diseño observacional retrospectivo, 12 observacionales prospectivos, 3 revisiones bibliográficas y 1 estudio cualitativo. No hay variables sociodemográficas destacables que impliquen mayor probabilidad de presentar lesión renal aguda. Tanto la etiología como los factores de riesgo son muy variables. La lesión renal aguda se asocia a mayor número de complicaciones y estancia hospitalaria. No hay evidencia de cuidados enfermeros en la lesión renal aguda en pacientes pediátricos. Conclusiones: Se observa una falta de homogeneidad en los criterios de definición, incidencia, etiología, factores de riesgo y de tratamiento en los pacientes pediátricos con lesión renal aguda, y escasez de artículos originales de investigación. La lesión renal aguda pediátrica se asocia a mayor mortalidad, morbilidad, mayor estancia hospitalaria y mayor duración de la ventilación mecánica. El papel de enfermería en el manejo del tratamiento conservador y de las terapias de reemplazo renal de este cuadro, es fundamental en la supervivencia de estos pacientes.

AKI in Hospitalized Children: Poorly Documented (and Underrecognized)

Background: Acute kidney injury (AKI) is common in hospitalized children. We hypothesized that hospital-acquired AKI would be underrecognized and under-reported, with potential implications for prevention of future AKI and CKD risk stratification. Methods: Five hundred thirty-two cases of AKI occurring over a 1 year period in a tertiary children's hospital in the United States were studied. AKI documentation was defined as any mention of AKI in the admission history and physical note, progress notes, or discharge summary. Nephrology follow-up was defined as a completed outpatient clinic visit within 1 year of discharge. Logistic regression was used to assess factors associated with documentation, consultation, and follow-up. Results: AKI developed during 584/7,640 (7.6%) of hospitalizations: 532 cases met inclusion criteria. Documentation was present in 34% (185/532) of AKI cases and 90 (16.9%) had an inpatient nephrology consult. Among 501 survivors, 89 (17.8%) had AKI in their hospital discharge summary and 54 had outpatient nephrology follow up. Stage 3 AKI, peak creatinine >1 mg/dL and longer length of stay were associated with documentation. Stage 3 AKI and higher baseline creatinine were associated with inpatient nephrology consultation. Inpatient nephrology consultation was positively associated with outpatient nephrology follow up, but documentation in the discharge summary was not. Conclusion: Most cases of AKI were not documented and the proportion of children seen by a nephrologist was low, even among those with more severe injury. Increased severity of AKI was associated with documentation and inpatient consultation. Poor rates of documentation has implications for AKI recognition and appropriate management and follow up.

Frequency of Drug Induced Acute Kidney Injury in Pediatric Intensive Care Unit

Background: Acute kidney injury (AKI) is known to complicate one-third of cases in pediatric intensive care units (PICU), and almost one-fourth of these are due to nephrotoxic drugs (NTDs). Although stopping NTDs seems the most obvious option, it is not practically applicable. Many NTDs are the only existing option, and their potential benefits outweigh the risk of drug-induced AKI.

Objectives: To assess the proportion of children receiving NTDs in the PICU and highlight the children who developed AKI.

Methods: A prospective observational study was conducted in the PICU of the National Institute of Child Health, Karachi. All children admitted to the PICU for at least 72 hours not diagnosed with any acute or chronic kidney disease were included. Serum creatinine (SCr) was done at admission and then after 72 hours. Data was entered and analyzed using IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.

Results: Of 99 children, 53 (53.5%) were male. NTD exposure was positive in 97 (97.9%), and 72 (72.7%) had high exposure (≥3 NTDs). Drug-induced AKI was diagnosed in 46 (46.5%). It was significantly related to high SCr even at admission and high NTDs exposure. The mortality rate in the AKI group was 17% compared to 4% in the non-AKI (p=0.02).

Conclusion: Almost half of all PICU admissions were infants. Almost all patients were exposed to NTDs, and three-fourth experienced high exposure. AKI developed in 46% of patients and may be predicted by raised creatinine at the time of admission. Children exposed to ≥3 NTDs had a higher chance of drug-induced AKI.

Nonsteroidal anti-inflammatory drugs associated acute kidney injury in hospitalized children: A systematic review and meta-analysis

INTRODUCTION

Nonsteroidal anti-inflammatory drugs (NSAIDs) are regarded as nephrotoxins. Children commonly use NSAIDs and are susceptible to nephropathy, but the relationship between acute kidney injury (AKI) and use of NSAIDs is not well examined yet.

OBJECTIVE

To evaluate the relationship between AKI and use of NSAIDs in hospitalized pediatric patients who are susceptible to nephropathy.

METHODS

We conducted this systematic review and meta-analysis of observational studies by searching PubMed, Embase, and Cochrane Database for articles published up to June 1, 2020. Reports included involved children (age < 18 years) who used NSAIDs for various reasons and were admitted in the hospital. The main outcome measure was whether AKI occurred, and pooled odds ratio (OR) and 95% confidence intervals (CI) were calculated using generic inverse variance methods.

RESULTS

Seven studies reporting risk of AKI in the hospitalized pediatric patients receiving NSAIDs were included applying a random-effects model. In the hospitalized pediatric population, the pooled OR of AKI for present NSAID exposure was 1.55 (95%CI 1.26-1.92).

CONCLUSIONS

NSAID exposure was associated with an approximate 1.6-fold rise in the odds of developing AKI in hospitalized pediatric patients. Avoidance, cautious use of NSAIDs and further evidence are needed. This study was registered with PROSPERO (identifier: CRD42021219779).

Acute pediatric kidney replacement therapies in Europe: demographic results from the EurAKId Registry

BACKGROUND

Acute kidney injury (AKI), particularly that requiring dialysis, is a severe complication in hospitalized children associated with high morbidity and mortality. A prospective European AKI registry (EurAKId registry, NCT02960867) was created to describe the epidemiology and outcomes of pediatric patients treated with acute dialysis.

METHODS

Children were recruited who were between 0 and 18 years of age and were treated both in and outside the Pediatric Intensive Care Unit (PICU) with peritoneal dialysis (PD), hemodialysis (HD) or continuous kidney replacement therapy (CKRT) for AKI or metabolic derangement, fluid overload (FO), sepsis, or respiratory distress. Five age groups and 12 categories of primary diseases were defined.

RESULTS

Data on 340 patients were analyzed, of whom 86% received dialysis for AKI and 14% for reasons other than AKI. Boys accounted for 60% of the patients. Illness severity was greater in children with cardiac and hematologic diseases than those with kidney diseases. Most patients received dialysis in the PICU (84%). The most frequently used dialysis modality was CKRT (64%), followed by PD (14%) and HD (14%). The overall survival rate was 65%. Survival was significantly lower in children with three comorbidities than in children with no comorbidities (41% and 83%, p < 0.001).

CONCLUSIONS

The EurAKId registry is the first prospective registry considering pediatric acute kidney replacement therapies (KRT) in both critical and non-critical care settings, focusing on the three dialysis modalities in Europe. The clinical indications for KRT have expanded; our population was characterized by critically ill patients, primarily boys, who frequently received dialysis in the PICU with CKRT.

Drugs in Focus: Proton Pump Inhibitors

Proton pump inhibitors (PPIs) are amongst the most commonly prescribed drugs in infants and children with the last decades witnessing a dramatic rise in their utilization. Although PPIs are clearly effective when used appropriately and have been regarded as safe drugs, there is growing evidence regarding their potential adverse effects. Although, largely based on adult data it is clear that many of these are also relevant to pediatrics. PPI use potentially affects gastrointestinal microbiota composition and function, decreases defence against pathogens resulting in increased risk for infections, interferes with absorption of minerals and vitamins leading to specific deficiencies and increased risk for bone fractures as well as interferes with protein digestion resulting in increased risk of sensitization to allergens and development of allergic diseases and eosinophilic esophagitis. An association with gastric, liver and pancreatic cancer has also been inferred from adult data but is tenuous and causation is not proven. Overall, evidence for these adverse events is patchy and not always compelling. Overall, the use of PPIs, for selected indications with a good evidence base, has significant potential benefit but carries more caution in infants and children. Pediatricians should be aware of the concerns regarding the potential adverse events associated with their use.

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.

Cumulative Application of Creatinine and Urine Output Staging Optimizes the Kidney Disease: Improving Global Outcomes Definition and Identifies Increased Mortality Risk in Hospitalized Patients With Acute Kidney Injury

OBJECTIVES

Acute kidney injury is diagnosed according to creatinine and urine output criteria. Traditionally, both are applied, and a severity stage (1-3) is conferred based upon the more severe of the two; information from the other criteria is discarded. Physiologically, however, rising creatinine and oliguria represent two distinct types of renal dysfunction. We hypothesized that using the information from both criteria would more accurately characterize acute kidney injury severity and outcomes.

DESIGN

Prospective cohort study.

SETTING

Multicenter, international collaborative of ICUs.

PATIENTS

Three thousand four hundred twenty-nine children and young adults admitted consecutively to ICUs as part of the Assessment of the Worldwide Acute Kidney Injury, Renal Angina and Epidemiology Study.

MEASUREMENTS AND MAIN RESULTS

The Kidney Disease: Improving Global Outcomes creatinine and urine output acute kidney injury criteria were applied sequentially, and the two stages were summed, generating an Acute Kidney Injury (AKI) Score ranging from 1 to 6. The primary outcome was 28-day mortality; secondary outcomes were time until ICU discharge and nonrecovery from acute kidney injury. Models considered associations with AKI Score, assessing the relationship unadjusted and adjusted for covariates. Twenty-eight-day mortality and nonrecovery from acute kidney injury were modeled using logistic regression. For 28-day ICU discharge, competing risks analysis was performed. Although AKI Scores 1-3 had similar mortality to no Acute Kidney Injury, AKI Scores 4-6 were associated with increased mortality. Relative to No Acute Kidney Injury, AKI Scores 1-6 were less likely to be discharged from the ICU within 28 days. Relative to AKI Score 1, AKI Scores 2-6 were associated with higher risk of nonrecovery. Within the traditional Kidney Disease: Improving Global Outcomes Stage 3 acute kidney injury cohort, when compared with AKI Score 3, AKI Scores 4-6 had increased mortality, AKI Scores 5-6 had prolonged time to ICU discharge, and AKI Score 6 experienced higher nonrecovery rates.

CONCLUSIONS

Cumulative application of the creatinine and urine output criteria characterizes renal excretory and fluid homeostatic dysfunction simultaneously. This Acute Kidney Injury score more comprehensively describes the outcome implications of severe acute kidney injury than traditional staging methods.

Association of Ibuprofen Prescription With Acute Kidney Injury Among Hospitalized Children in China

IMPORTANCE

Ibuprofen is widely used in children worldwide, especially in those with cancer, fever, or trauma. However, large and high-quality studies of the association between ibuprofen and acute kidney injury (AKI) in children have been lacking.

OBJECTIVE

To examine the association between the use of ibuprofen and the risk of hospital-acquired AKI in hospitalized children in China.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed the cohort of the Epidemiology of AKI in Chinese Hospitalized Patients (EACH) study, a large, multicenter retrospective study of 3 044 023 patients who were admitted to 1 of 25 academic medical centers in China between January 1, 2013, and December 31, 2015. Patient-level data were obtained from the electronic health record system of the participating centers. Hospitalized children aged 1 month to 18 years who had prescriptions and a certain number of serum creatinine (SCr) tests were included. Children with end-stage renal disease, community-acquired AKI, low baseline SCr level (<10 μmol/L), high standardized baseline SCr level (>4 times the sex- and age-specific reference value), or missing diagnosis code were excluded. Data analysis was conducted from January 1, 2020, to August 30, 2020.

EXPOSURES

Exposure to ibuprofen was coded as a time-dependent dichotomous variable.

MAIN OUTCOMES AND MEASURES

Baseline SCr level was calculated for each patient as the mean of all available SCr values between the 30 days prior to admission and the first SCr testing within the first 3 days of hospitalization. Acute kidney injury was defined as an increase in SCr level of 26.5 μmol/L or higher within 48 hours or by 50% or more over the baseline value, according to the Kidney Disease: Improving Global Outcomes guidelines.

RESULTS

Among the 50 420 children (mean [SD] age, 5.0 [5.2] years; 30 640 boys [60.8%]) included in this study, 5526 (11.0%) used ibuprofen and 3476 (6.9%) developed hospital-acquired AKI during hospitalization. Ibuprofen use was associated with a statistically significantly increased risk of hospital-acquired AKI (hazard ratio [HR], 1.23; 95% CI, 1.14-1.34) after adjusting for confounders. Ibuprofen use was associated with a greater hazard in children who had chronic kidney disease vs those without (HR, 2.31 [95% CI, 1.73-3.10] vs 1.19 [95% CI, 1.09-1.29]), required intensive care vs those without this need (HR, 1.47 [95% CI, 1.24-1.75] vs 1.18 [95% CI, 1.07-1.29]), or were older vs younger (>10 years and >1 year to 10 years vs 1 month to 1 year) (HR, 1.64 [95% CI, 1.32-2.05]; 1.36 [95% CI, 1.23-1.52] vs 0.99 [95% CI, 0.86-1.13]). Dose-response analysis suggested that the association of ibuprofen with the risk of hospital-acquired AKI was dose-dependent.

CONCLUSIONS AND RELEVANCE

This study found that ibuprofen was widely used and associated with an increased risk of hospital-acquired AKI in hospitalized children in China. The judicious use of ibuprofen and close monitoring of kidney function in children are needed.

Lansoprazole promotes cisplatin-induced acute kidney injury via enhancing tubular necroptosis

Acute kidney injury (AKI) is the main obstacle that limits the use of cisplatin in cancer treatment. Proton pump inhibitors (PPIs), the most commonly used class of medications for gastrointestinal complications in cancer patients, have been reported to cause adverse renal events. However, the effect of PPIs on cisplatin-induced AKI remains unclear. Herein, the effect and mechanism of lansoprazole (LPZ), one of the most frequently prescribed PPIs, on cisplatin-induced AKI were investigated in vivo and in vitro. C57BL/6 mice received a single intraperitoneal (i.p.) injection of cisplatin (18 mg/kg) to induce AKI, and LPZ (12.5 or 25 mg/kg) was administered 2 hours prior to cisplatin administration and then once daily for another 2 days via i.p. injection. The results showed that LPZ significantly aggravated the tubular damage and further increased the elevated levels of serum creatinine and blood urea nitrogen induced by cisplatin. However, LPZ did not enhance cisplatin-induced tubular apoptosis, as evidenced by a lack of significant change in mRNA and protein expression of Bax/Bcl-2 ratio and TUNEL staining. Notably, LPZ increased the number of necrotic renal tubular cells compared to that by cisplatin treatment alone, which was further confirmed by the elevated necroptosis-associated protein expression of RIPK1, p-RIPK3 and p-MLKL. Furthermore, LPZ deteriorated cisplatin-induced inflammation, as revealed by the increased mRNA expression of pro-inflammatory factors including, NLRP3, IL-1β, TNF-α and caspase 1, as well as neutrophil infiltration. Consistently, in in vitro study, LPZ increased HK-2 cell death and enhanced inflammation, compared with cisplatin treatment alone. Collectively, our results demonstrate that LPZ aggravates cisplatin-induced AKI, and necroptosis may be involved in the exacerbation of kidney damage.

Be aware of acute kidney injury in critically ill children with COVID-19

BACKGROUND

Acute kidney injury (AKI) is a common complication of critically ill adult patients with COVID-19. However, currently, no studies investigate kidney impairment in children with COVID-19. We investigated incidence and treatment of AKI in pediatric patients with COVID-19 in Wuhan Children's Hospital during the early stages of the COVID-19 pandemic and discuss possible mechanisms of AKI related to SARS-CoV-2 infection.

METHODS

By extracting data from electronic medical records, we conducted a retrospective observational study of kidney involvement in confirmed pediatric COVID-19 cases in Wuhan Children's Hospital during the coronavirus outbreak, from January 24 to March 20, 2020. Clinical presentations, clinical courses, laboratory findings, and medical interventions are described below.

RESULTS

Among 238 confirmed COVID-19 cases, only three were critically ill and needed intensive care unit (ICU) admission. All three developed AKI, but AKI was not detected in any non-critically ill patients outside the ICU. Two of the three patients with AKI had prodromal gastrointestinal symptoms. Significantly elevated interleukin-6 (IL-6) levels and complement activation were observed in these patients with AKI. The three patients with AKI were treated with plasma exchange (PE) and continuous kidney replacement therapy (CKRT), resulting in one complete recovery, one partial recovery, and one mortality due to critical illness.

CONCLUSIONS

Critically ill children with COVID-19 may develop AKI, especially following prodromal gastrointestinal symptoms. An inflammatory storm and complement-mediated injury may underlie AKI development in children with COVID-19. Our study supports implantation of PE and CKRT in management of critically ill patients with AKI.

Acute kidney injury among hospitalized children with cancer

BACKGROUND

Few studies to date have analyzed the epidemiology of acute kidney injury (AKI) in children with cancer in developing countries. The aim of this study was to assess the incidence, risk profile and outcomes of AKI in Chinese children hospitalized with cancer.

METHODS

This multi-center study analyzed Chinese children hospitalized with cancer in 2013-2015. Electronic hospital and laboratory databases were screened to select pediatric patients with malignancy who had at least two Scr results within any 7-day window during their first 30 days of hospitalization. AKI events were identified and staged according to Kidney Disease Improving Global Outcomes (KDIGO) criteria. The incidence of and risk factors for AKI were analyzed, as were mortality rate, incidence of kidney recovery, and length of hospital stay.

RESULTS

Of the 9828 children with cancer, 1657 (16.9%) experienced AKI events, including 549 (5.6%) community-acquired (CA-AKI) and 1108 (11.3%) hospital-acquired AKI (HA-AKI) events. The three types of cancer with the highest incidence of AKI were urinary system cancer (25.8%), hepatic cancer (19.4%), and retroperitoneal malignancies (19.1%). The risk factor profiles of CA-AKI and HA-AKI events differed, with many HA-AKI events due to treatment with nephrotoxic agents. In-hospital death rates were 5.4% (90 of 1657) in children with and 0.9% (74 of 8171) in children without AKI events. AKI events were also associated with longer hospitalization and higher daily costs.

CONCLUSIONS

AKI events are common among Chinese children hospitalized for cancer and are associated with adverse in-hospital outcomes.

Pediatric Acute Kidney Injury to the Subsequent CKD Transition

BACKGROUND

Both acute kidney injury (AKI) and CKD are complex syndromes caused by multiple etiologies and presented with various degrees of severity. Studies on adults provide strong evidence that AKI is an independent risk factor for both the initiation and progression of CKD, and the severity, frequency, and duration of AKI are crucial factors in the subsequent development of CKD. However, without consensus definitions of AKI and CKD and long-term follow-up studies using predictive biomarkers, it is difficult to clarify the potential for transition from AKI to CKD in pediatric populations. The goal of this review is to describe the most recent studies in epidemiology of pediatric AKI and biomarkers aiding in the earlier detection of AKI and CKD.

SUMMARY

KDIGO criteria for AKI have been widely applied for pediatric AKI studies. AKI in critically ill and non-critically ill children is common. CKD is highly prevalent in pediatric AKI survivors. Compared with traditional biomarkers such as serum Cr, proteinuria, and estimated glomerular filtration rate, urinary biomarkers earlier identifying AKI may also detect CKD earlier, but additional studies are required to determine their clinical utility.

KEY MESSAGES

The use of consensus AKI criteria has improved our understanding of pediatric AKI epidemiology, and an association between AKI and CKD in pediatric populations has been endorsed. However, further studies are needed to better answer a definitive causal relationship between pediatric AKI and the subsequent development of CKD.

Community-Acquired AKI in Asia: An Update

Community-acquired acute kidney injury (CA-AKI) is the dominant form of AKI encountered in developing countries in Asia. Economic disparities, variations in access to health care services, geographic conditions, environmental risk factors, and sociocultural circumstances shape the causes and outcomes of CA-AKI. Infections, drugs, plant and chemical toxins, envenomations, and obstetric complications are common causes of CA-AKI. Previously healthy young individuals who often work outdoors in fields or farms are exposed to a wide variety of work-related or environmental risk factors for CA-AKI. Improving disease definitions, better data, and evolving host-pathogen interactions have changed disease descriptions and presentations over the past 20 years. Among infections, although the incidence of malaria has decreased, the number of cases with dengue and scrub typhus have increased sharply. The recognition of AKI in relation to Plasmodium knowlesi, Plasmodium vivax, scrub typhus, and leptospirosis in areas not traditionally considered at risk, association of infections with the future development of chronic kidney disease, and the role of complement dysregulation in infection-associated AKI are important new findings. Snake-bite-related toxic envenomation continues to be an important cause of AKI in some counties and is a neglected public health problem. On the other hand, significant decreases in the incidence of AKI related to acute diarrheal illness or obstetric causes are signs of hope. Coordinated efforts between administrative stakeholders, society, and health care delivery services at all levels have the potential to propel research and improve outcomes in CA-AKI.

Proton pump inhibitors and the risk of hospital-acquired acute kidney injury in children

Background

To evaluate the association between use of proton pump inhibitor (PPI) and the risk of hospital-acquired acute kidney injury (HA-AKI) in hospitalized children.

Methods

We conducted a multicenter retrospective cohort study in hospitalized children aged 1 month to 18 years from 25 tertiary hospitals across China from 2013 to 2015. Patient-level data were obtained from the electronic hospitalization databases. AKI was defined and staged using the serum creatinine (SCr) data according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria.

Results

Among 42,232 children analyzed, 11,496 (27.2%) used PPI, 1,760 (4.2%) used histamine 2 receptor antagonist (H2RA), and 3,514 (8.3%) had HA-AKI during hospitalization. Over 85% of PPIs were prescribed for prophylaxis of gastro-duodenal lesions in children. The use of PPI was associated with a significantly increased risk of HA-AKI compared with both non-users [odds ratio (OR), 1.37; 95% confidence interval (CI), 1.23–1.53)] and H2RA users (OR, 1.24; 95% CI, 1.01–1.52). The associations were consistent across children of different age range, gender, subtypes of PPIs and methods of administration. A larger effect was observed in children with chronic kidney disease (OR, 3.37; 95% CI, 2.46–4.62) and those needed intensive care (OR, 1.54; 95% CI, 1.33–1.78). The risk of HA-AKI was increased even within the recommended dosage range of PPI.

Conclusions

PPIs were widely used and associated with an increased risk of HA-AKI in hospitalized children in China.

Nephrotoxins and nephrotoxic acute kidney injury

Although the concept of nephrotoxicity has been recognized for more than 80 years, interest in nephrotoxins has intensified dramatically over the past two decades. Much of this attention has rightfully been focused on pharmaceutical agents and iatrogenic harm; however, it is important for providers to recognize that nephrotoxins can be found in naturally occurring substances as well. Although nephrotoxins exist in a myriad of forms, the means by which they induce injury can be organized into a few categories. For most of these agents, regardless of the mechanism, the final common pathway is acute kidney injury (AKI). Unfortunately, therapeutic options are limited and no treatments currently exist to reverse nephrotoxic AKI once it occurs. As a result, current strategies focus on increased awareness, nephrotoxin avoidance, early injury detection, and mitigation of disease severity. The goal of this review is to summarize our current understanding of nephrotoxic mechanisms and the epidemiology of nephrotoxic AKI. Additionally, avoidance and preventative strategies are discussed, screening approaches are suggested, and chronic monitoring recommendations are made.

The Epidemiology and Management of Pediatric AKI in Asia

Because of the lack of early recognition and referral, the incidence of pediatric acute kidney injury (AKI) in Asia still is underestimated. Although each diagnostic criteria has its own merits, the Kidney Disease Improving Global Outcomes classification now is widely accepted. In Asia, the spectrum of pediatric AKI is wide-ranging, from pediatric AKI in highly sophisticated tertiary-care pediatric intensive care units in resource-rich regions due to advanced procedures such as transplantation, cardiac surgery, and other hospital-acquired causes, to primary care preventable causes, such as infectious diseases, snakebite, and so forth in rural parts of the developing world. The development and application of novel biomarkers, concepts such as the Renal Angina Index and advanced renal replacement therapy have revolutionized the era of treating AKI, but the cost and feasibility are the key determinants, especially in rural areas. In view of availability and expenses, peritoneal dialysis should be the first choice in less-developed areas, however, because of various barriers, it still needs more effort. Effective educational steps to both medical carers and families are needed urgently.

Acute kidney injury following colistin treatment in critically-ill patients: may glucocorticoids protect?

Nephrotoxicity following colistin administration is common and factors alleviating nephrotoxicity are yet to be determined. We retrospectively evaluated outcomes of subjects who were treated with colistin (n = 133) and with antibiotics other than colistin (control, n = 133) in intensive care units. Acute kidney injury (AKI) occurred in 69.2% and 29.3% of patients in colistin and control groups, respectively (p < 0.001). In the colistin group, glucocorticoid exposure was more common in subjects who did not develop AKI (p < 0.001). This was not the case in the control group. In the colistin cohort, older age (per 10 years, odds ratio [OR] 1.41, 95% CI 1.05-1.91; p = 0.025), PPI use (OR 3.30, 95% CI 1.18-9.23; p = 0.023) and furosemide treatment (OR 2.66, 95% CI 1.01-6.98; p = 0.047) were independently associated with the development of AKI while glucocorticoid treatment (OR 0.23, 95% CI 0.10-0.53; p = 0.001) was independently associated with reduced risk of AKI. Mortality was observed in 74 patients in the colistin cohort (55.6%). A higher APACHE-II score (OR 1.17, 95% CI 1.08-1.26; p < 0.001) was independently associated with mortality while a higher serum albumin level (per 1 g/dL increase, OR 0.20, 95% CI 0.070-0.60; p = 0.004) was associated with a lower risk of mortality. In conclusion, glucocorticoid exposure is associated with a lower risk of AKI caused by colistin therapy in critically-ill patients. Prospective studies are needed to confirm these findings and determine the optimal type, dose and duration of glucocorticoid therapy.

Global case studies for chronic kidney disease/end-stage kidney disease care

The prevalence of chronic kidney disease and its risk factors is increasing worldwide, and the rapid rise in global need for end-stage kidney disease care is a major challenge for health systems, particularly in low- and middle-income countries. Countries are responding to the challenge of end-stage kidney disease in different ways, with variable provision of the components of a kidney care strategy, including effective prevention, detection, conservative care, kidney transplantation, and an appropriate mix of dialysis modalities. This collection of case studies is from 15 countries from around the world and offers valuable learning examples from a variety of contexts. The variability in approaches may be explained by country differences in burden of disease, available human or financial resources, income status, and cost structures. In addition, cultural considerations, political context, and competing interests from other stakeholders must be considered. Although the approaches taken have often varied substantially, a common theme is the potential benefits of multistakeholder engagement aimed at improving the availability and scope of integrated kidney care.

Effect of Prophylactic Levosimendan on All-Cause Mortality in Pediatric Patients Undergoing Cardiac Surgery-An Updated Systematic Review and Meta-Analysis

Background: Levosimendan, a calcium sensitizer, enhances the myocardial function by generating more energy-efficient myocardial contractility than that achieved through adrenergic stimulation with catecholamines. We conducted this meta-analysis to primarily investigate the effects of levosimendan on all-cause mortality in pediatric patients undergoing cardiac surgery under cardiopulmonary bypass. Methods: The databases of Pubmed, Embase, and Cochrane Library were searched till 21st March 2020. The eligible criteria were participants with age<18 year and undergoing cardiac surgery for congenital heart disease (CHD), and studies of comparison between levosimendan and placebo or other inotropes. Stata version 12.0 was used to perform statistical analyses. Results: Six randomized controlled trials (RCTs) and 1 case-control trial (CCT) including 436 patients were included. The results showed that levosimendan did not significantly decrease all-cause mortality compared with control drugs (and placebo) in children undergoing cardiac surgery (P = 0.403). Perioperative prophylactic levosimendan administration strikingly decreased the low cardiac output syndrome (LCOS) incidence (P = 0.016) but did not significantly reduce acute kidney injury (AKI) incidence (P = 0.251) and shorten mechanical ventilation and ICU stay time compared with other inotropes and placebo by analyzing the included literatures [mechanical ventilation (or intubation) time: P = 0.188; ICU stay time: P = 0.620]. Conclusions: Compared with other inotropes and placebo, perioperative prophylactic administration of levosimendan did not decrease the rates of mortality and AKI and shorten the time of mechanical ventilation (or intubation) and ICU stay but demonstrated a significant reduction in LCOS incidence after corrective surgery in pediatric patients for CHD. Due to limited number of included studies, the current data were insufficient to make the conclusions.

Risk factors and clinical characteristics of tacrolimus-induced acute nephrotoxicity in children with nephrotic syndrome: a retrospective case-control study

PURPOSE

Acute nephrotoxicity is a common adverse reaction of tacrolimus therapy; however, its risk factors in pediatric nephrotic syndrome (NS) remain to be evaluated. The objective of this study was to investigate the risk factors and characteristics of tacrolimus-induced acute nephrotoxicity in children with NS.

METHODS

Past records of children with NS admitted to our hospital from 2014 to 2018 were reviewed. The incidence and characteristics of nephrotoxicity were analyzed. Multivariate logistic regression analysis was used to identify the risk factors of nephrotoxicity. A clinically applicable risk score was developed and validated.

RESULTS

Tacrolimus-induced nephrotoxicity occurred in 25 of 129 patients, 13 patients were grade 1, and the renal function was recovered in 22 patients. Multivariate regression analysis showed that the maximum trough concentrations (C_12h) of tacrolimus (OR, 1.48; 95% CI, 1.16 to 1.88; P < 0.001), huaiqihuang granules (OR, 0.095; 95% CI, 0.014 to 0.66; P = 0.017), and diarrhea (OR, 22.00; 95% CI, 1.58 to 306.92; P = 0.022) were independently associated with tacrolimus-induced nephrotoxicity. The maximum C_12h were significantly higher in patients with nephrotoxicity (median 9.0 ng/ml) and the cut-off value for acute nephrotoxicity was 6.5 ng/ml. The area under the receiver operating characteristic curve was 0.821 for the proposed model based on the observations used to create the model and 0.817 obtained from k-fold cross-validation.

CONCLUSIONS

High trough concentration of tacrolimus and diarrhea can potentiate the risk of tacrolimus-induced acute nephrotoxicity in children with NS, while huaiqihuang granules can protect this condition.

Big Data and Pediatric Acute Kidney Injury: The Promise of Electronic Health Record Systems

Over the last decade, our understanding of acute kidney injury (AKI) has evolved considerably. The development of a consensus definition standardized the approach to identifying and investigating AKI in children. As a result, pediatric AKI epidemiology has been refined and the consequences of renal injury are better established. Similarly, "big data" methodologies experienced a dramatic evolution and maturation, leading the critical care community to explore potential AKI/big data synergies. One such concept with tremendous potential is electronic health record (EHR) enabled informatics. Much of the promise surrounding these approaches is due to the unique position of the EHR which sits at the intersection of data accumulation and care delivery. EHR data is generated simply via the provision of routine clinical care and should be considered "big" from the standpoint of volume, variety, and velocity as a myriad of diverse elements accumulate rapidly in real time, spontaneously generating an immense dataset. This massive dataset interfaces directly with providers which creates tremendous opportunity. AKI can be diagnosed more accurately, AKI-related care can be optimized, and subsequent outcomes can be improved. Although applying big data concepts to the EHR has proven more challenging than originally thought, we have seen much success and continue to explore its potential. In this review article, we will discuss the EHR in the context of big data concepts, describe approaches applied to date, examine the challenges surrounding optimal application, and explore future directions.