Acute kidney injury in children hospitalized for acute gastroenteritis: prevalence and risk factors

Prevalence of common diarrheagenic enterobacteriaceae in Iran (2000-2023): a systematic review and meta-analysis

OBJECTIVE

Bacterial gastroenteritis is a significant public health concern, capable of causing severe infections. Among the various pathogens involved, those belonging to the Enterobacteriaceae family are the most frequently isolated and associated with gastrointestinal disorders. This study aimed to investigate the prevalence of common diarrheagenic Enterobacteriaceae in Iran over the past two decades, from 2000 to 2023.

METHODS

A comprehensive systematic search was conducted across multiple databases, including EMBASE, HINARI, MEDLINE, PubMed, Google Scholar, and the Cochrane Library. The focus was on observational published studies reporting the prevalence of diarrheagenic Enterobacteriaceae in Iran during 2000 and 2023. The criteria did not restrict patient demographics such as age, gender, health conditions, or occupation. This meta-analysis employed a 95% confidence interval (CI) for analysis. Evidence of heterogeneity was determined using an I² value greater than 50%. To explore potential sources of heterogeneity, subgroup analysis and meta-regression analysis were performed. Statistical analyses were executed using R version 4.3.2 along with the meta package. A p-value less than 0.05 was considered statistically significant.

RESULTS

Out of 3,701 papers reviewed, 56 studies met the inclusion criteria and were analyzed. The overall pooled prevalence of diarrheagenic Enterobacteriaceae species from 2000 to 2023 was 14.0% (95% CI: 0.11-0.17). Subgroup analysis revealed Shigella spp. had the highest prevalence at 18.0% (95% CI: 0.13-0.24; I²=99%), followed by diarrheagenic Escherichia coli at 11.0% (95% CI: 0.09-0.15; I²=97%), Salmonella spp. at 9.0% (95% CI: 0.05-0.17; I²=99%), and Yersinia spp. at 2.0% (95% CI: 0.00-0.10; I²=94%). Prevalence trends showed Shigella spp. increasing from 4% (95% CI: 0.03-0.08) in 2000-2004 to 36% (95% CI: 0.20-0.55) in 2021-2023. Diarrheagenic E. coli (DEC) showed no clear pattern, ranging from 5% (95% CI: 0.01-0.24) to 17% (95% CI: 0.07-0.36). Salmonella spp. exhibited more significant fluctuations, rising from 6% (95% CI) in both 2000-2004 and 2005-2008 periods to 20% (95% CI: 0.03-0.66) in 2009-2012 and 30% (95% CI: 0.11-0.60) in 2017-2020. Yersinia spp. was only determined in 2000-2004 with a pool prevalence of 12% (95% CI: 0.00-0.91). Sub-species analysis revealed Shigella sonnei was the most prevalent species among Shigella spp. in Iran, accounting for 42% of cases (95% CI: 0.33-0.52). Regarding DEC species, Enteroaggregative E. coli (EAEC) and Enterotpathogenic E. coli (EPEC) had the highest rate at 15% (95% CI). Furthermore, a pool prevalence of 2% (95% CI: 0.00-0.89) was reported for Yersinia enterocolitica among diarrheagenic Enterobacteriaceae in Iran.

CONCLUSION

This meta-analysis provides valuable insights into the prevalence of diarrheagenic Enterobacteriaceae in Iran over the past two decades. The findings highlight the significant impact of these pathogens on public health, with Shigella spp. showing the highest prevalence and increasing trends. Further research should investigate the factors contributing to the prevalence of diarrheagenic Enterobacteriaceae, including genetic diversity of diarrheagenic Enterobacteriaceae isolates, molecular mechanisms underlying the virulence of these pathogens, or antibiotic resistance patterns.

Heart rate to identify non-febrile children with dehydration and acute kidney injury in emergency department: a prospective validation study

We previously developed and retrospectively validated the estimated percentage of heart rate variation (EHRV) as a predictor of the composite outcome of ≥ 5% dehydration and/or acute kidney injury (AKI) in non-febrile children. The current study aimed to prospectively validate EHRV as a predictor for dehydration or AKI in a different cohort of children attending the Pediatric Emergency Department. From July 2022 to August 2023, 256 pediatric patients aged 0-18 years attending the Pediatric Emergency Department were enrolled. EHRV was calculated as follows: [(HR at admission - 50th percentile of HR for age and sex)/HR at admission] × 100. Dehydration was categorized as < 5% or ≥ 5% fluid deficit. AKI was defined according to KDIGO creatinine criteria. Statistical analyses included receiver-operating characteristic (ROC) curves and logistic regression analysis. Among enrolled patients, 52 had ≥ 5% dehydration, 50 had AKI, and 16 had both conditions. EHRV demonstrated significant predictive ability for both ≥ 5% dehydration (AUROC = 0.71; 95% confidence interval (CI), 0.63-0.78; p < 0.001) and AKI (AUROC = 0.78; 95% CI, 0.71-0.84; p < 0.001). An EHRV > 24.5% was associated with an increased odds ratio (OR), adjusted for confounders, of ≥ 5% dehydration (OR = 3.5; 95% CI, 1.6-8.0; p = 0.003) and AKI (OR = 3.4; 95% CI, 1.6-7.3; p = 0.002). The sensitivity and specificity of this cut-off were 34% and 83% for ≥ 5% dehydration and 36% and 84% for AKI, respectively.

CONCLUSIONS

This study prospectively validates the clinical utility of EHRV in predicting dehydration and AKI in a pediatric emergency care setting. An EHRV > 24.5% could serve as a marker for suspecting dehydration or AKI. Further validation across diverse patient populations and settings is needed.

WHAT IS KNOWN

• An increased heart rate (HR) is a readily detectable sign of dehydration in children. • In a retrospective validation cohort, an estimated HR variation (EHRV) greater than 24.5% compared to the 50th percentile of HR was predictive of ≥ 5% dehydration and/or acute kidney injury (AKI) in non-febrile patients.

WHAT IS NEW

• We prospectively validated the clinical utility of EHRV in predicting dehydration and AKI in a pediatric emergency care setting. • We confirmed that an EHRV greater than 24.5% is associated with increased odds of ≥ 5% dehydration and AKI.

Contrast-Enhanced Ultrasound (CEUS) and Ultra-Microangiography (UMA) in Critically Ill Children with Acute Kidney Injury

Acute kidney injury (AKI) is an acute condition of impaired kidney function with decreased glomerular filtration rate, which results in dysregulation in volume, electrolyte, and acid-base equilibrium. AKI can be a life-threatening condition and can also lead to chronic kidney disease. It is important to diagnose AKI early in the course of the disease or to predict its development, as this can influence therapeutic decisions, outcome, and, consequently, the prognosis. In clinical practice, an elevated serum creatinine concentration remains the most common laboratory indicator for diagnosing AKI. However, due to the delay in its rise, creatinine levels are often insensitive and inaccurate for early diagnosis. Novel biomarkers of kidney tubular injury and the renal angina index have shown promise in predicting AKI earlier and more accurately. Contrast-enhanced ultrasonography (CEUS) and ultra-microangiography (UMA) are radiological methods that can quantify renal microperfusion and may be able to predict the development of AKI. They have not yet been used for quantifying renal perfusion in children with risk factors for developing AKI. Further research is needed to compare these sonographic techniques with the renal angina index and emerging kidney injury biomarkers for predicting acute kidney injury (AKI) in both children and adults.

Acute Kidney Injury in Children: A Focus for the General Pediatrician

Acute kidney injury (AKI) presents significant challenges in pediatric care, often remaining underrecognized. This paper provides an overview of pediatric AKI, highlighting its epidemiology, pathophysiology, diagnosis, predisposing conditions, and treatment. AKI in children stems from diverse causes, including renal tubular damage, vasoconstriction, and inflammation. Diagnosis relies on traditional markers such as serum creatinine and urine output, alongside emerging biomarkers such as Cystatin C, NGAL, KIM-1, IL-18, TIMP-2 and IGFBP7, urinary calprotectin, URBP4, L-FABP, and clusterin. Various pediatric conditions predispose to AKI, including type 1 diabetes, pneumonia, bronchiolitis, appendicitis, gastroenteritis, COVID-19, multisystem inflammatory syndrome, sickle cell disease, and malignancies. Treatment entails supportive care with fluid management and, in severe cases, renal replacement therapy. Timely recognition and management are essential to mitigating adverse outcomes. Enhanced awareness and integration of novel biomarkers could improve pediatric AKI care, warranting further research for better diagnosis and management.

Acute kidney injury in children hospitalised for febrile urinary tract infection

AIM

To determine (i) prevalence and the risk factors for acute kidney injury (AKI) in children hospitalised for febrile urinary tract infection (fUTI) and (ii) role of AKI as indicator of an underlying VUR. AKI, in fact, is favoured by a reduced nephron mass, often associated to VUR.

METHODS

This retrospective Italian multicentre study enrolled children aged 18 years or younger (median age = 0.5 years) discharged with a primary diagnosis of fUTI. AKI was defined using Kidney Disease/Improving Global Outcomes serum creatinine criteria.

RESULTS

Of 849 children hospitalised for fUTI (44.2% females, median age 0.5 years; IQR = 1.8), 124 (14.6%) developed AKI. AKI prevalence rose to 30% in the presence of underlying congenital anomalies of the kidney and urinary tract (CAKUT). The strongest AKI predictors were presence of CAKUT (OR = 7.5; 95%CI: 3.8-15.2; p = 9.4e-09) and neutrophils levels (OR = 1.13; 95%CI: 1.08-1.2; p = 6.8e-07). At multiple logistic regression analysis, AKI during fUTI episode was a significant indicator of VUR (OR = 3.4; 95%CI: 1.7-6.9; p = 0.001) despite correction for the diagnostic covariates usually used to assess the risk of VUR after the first fUTI episode. Moreover, AKI showed the best positive likelihood ratio, positive predictive value, negative predictive value and specificity for VUR.

CONCLUSION

AKI occurs in 14.6% of children hospitalised for fUTI and is a significant indicator of VUR.

Editorial on the Special Issue "Advances in Pediatric Acute Kidney Injury"

Acute kidney injury (AKI) refers to a swift decline in kidney function, marked by the reduced excretion of waste products and disturbances in fluid and electrolyte balance [...].

Infections and Acute Kidney Injury: A Global Perspective

Globally, there are an estimated 13.3 million cases of acute kidney injury (AKI) annually. Although infections are a common cause of AKI globally, most infection-associated AKI occurs in low- and lower-middle-income countries. There are marked differences in the etiology of infection-associated AKI across age groups, populations at risk, and geographic location. This article provides a global overview of different infections that are associated commonly with AKI, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), human immunodeficiency virus, malaria, dengue, leptospirosis, tick-borne illnesses, and viral hemorrhagic fevers. Further discussion focuses on infectious conditions associated with AKI including sepsis, diarrheal diseases and pregnancy, peripartum and neonatal AKI. This article also discusses the future of infection-associated AKI in the framework of climate change. It explores how increased investment in achieving the sustainable development goals may contribute to the International Society of Nephrology's 0 by 25 objective to curtail avoidable AKI-related fatalities by 2025.

Acute kidney injury in infants hospitalized for viral bronchiolitis

We investigated prevalence of and factors associated with acute kidney injury (AKI) in a group of patients hospitalized with viral bronchiolitis. We retrospectively enrolled 139 children (mean age = 3.2 ± 2.1 months; males = 58.9%) hospitalized for viral bronchiolitis in a non-pediatric intensive care unit (PICU) setting. The Kidney Disease/Improving Global Outcomes creatinine criterion was used to diagnose AKI. We estimated basal serum creatinine by back-calculating it by Hoste (age) equation assuming that basal eGFR were the median age-based eGFR normative values. Univariate and multivariate logistic regression models were used to explore associations with AKI. Out of 139 patients, AKI was found in 15 (10.8%). AKI was found in 13 out of 74 (17.6%) patients with and in 2 out of 65 (3.1%) without respiratory syncytial virus (RSV) infection (p = 0.006). No patient required renal replacement therapies, while 1 out of 15 (6.7%) developed AKI stage 3, 1 (6.7%) developed AKI stage 2, and 13 (86.6%) developed AKI stage 1. Among the 15 patients with AKI, 13 (86.6%) reached the maximum AKI stage at admission, 1 (6.7%) at 48 h, and 1 (6.7%) at 96 h. At multivariate analysis, birth weight < 10th percentile (odds ratio, OR = 34.1; 95% confidence interval, CI = 3.6-329.4; p = 0.002), preterm birth (OR = 20.3; 95% CI = 3.1-129.5; p = 0.002), RSV infection (OR = 27.0; 95% CI = 2.6-279.9; p = 0.006), and hematocrit levels > 2 standard deviation score (SDS) (OR = 22.4; 95% CI = 2.8-183.6; p = 0.001) were significantly associated with AKI.

CONCLUSION

About 11% of patients hospitalized with viral bronchiolitis in a non-PICU setting develop an AKI (frequently mild in degree). Preterm birth, birth weight < 10th percentile, hematocrit levels > 2SDS, and RSV infection are significantly associated with AKI in the setting of viral bronchiolitis.

WHAT IS KNOWN

• Viral bronchiolitis affects children in the first months of life and in 7.5% of cases it can be complicated by acute kidney injury (AKI). • No studies investigated associations with AKI in infants hospitalized for viral bronchiolitis.

WHAT IS NEW

• About 11% of patients hospitalized with viral bronchiolitis can develop an AKI (frequently mild in degree). • Preterm birth, birth weight <10th percentile, hematocrit levels > 2 standard deviation score, and respiratory syncytial virus infection are associated with AKI development in infants with viral bronchiolitis.

Factors Associated with Acute Kidney Injury among Children with Severe Malaria at Kiryandongo General Hospital, Uganda

Background

Malaria remains one of the leading health problems of the developing world, and acute kidney injury (AKI) is a well-recognized complication of severe malaria in adults; but the clinical importance of AKI in paediatric severe malaria is not well documented. Knowledge of the prevalence and factors associated with AKI among children with severe malaria is among the key strategies, which can help to reduce the burden of AKI among this vulnerable group. Methodology. A hospital-based prospective cross-sectional descriptive and analytic study of children with severe malaria was carried out at Kiryandongo General Hospital. The study involved 350 children with severe malaria attending the study site from August to October 2021. Questionnaires were administered to caretakers to obtain sociodemographic characteristics. Medical data were obtained through physical examination followed by laboratory tests. Blood samples were tested for creatinine and blood smear for malaria. Data were analyzed using binary logistic regression (bivariate and multivariate) to assess for the factors associated with AKI. A p value < 0.05 was considered statistically significant.

Results

The mean age of children with severe malaria was 7.0 ± 3.8 years, and 54.3% of them were male. Of the 350 children enrolled, 167 had AKI, giving an overall AKI prevalence of 47.7% (95% CI: 42.5-53.0). The factors that were significantly associated with AKI among children with severe malaria included caretaker with no formal education (aOR = 21.0, 95% CI: 1.68-261.18, p = 0.018), caretaker with primary education level (aOR = 4.5, 95% CI: 1.41-14.12, p = 0.011), age of child < 5 years (aOR = 1.8, 95% CI: 1.07-2.88, p = 0.025), history of receiving NSAIDs (aOR = 5.6, 95% CI: 2.34-13.22, p < 0.001), moderate anemia (aOR = 3.1, 95% CI: 1.39-6.94, p = 0.006), and severe anemia (aOR = 3.8, 95% CI: 1.66-8.55, p = 0.002).

Conclusion

The prevalence of AKI was high among children with severe malaria in Kiryandongo General Hospital. Acute kidney injury among children with severe malaria was associated with low level of education of caretakers, age of children less than 5 years, history of receiving NSAIDs, and anemia. The management of severe malaria should include screening for AKI especially in children under five years of age, anemic, and those who have received NSAIDs.

Renin angiotensin aldosterone inhibitors in the treatment of proteinuria in children with congenital anomalies of the kidney and urinary tract: more evidence needed

INTRODUCTION

Congenital anomalies of the kidney and urinary tract (CAKUT) can be associated with proteinuria, possibly leading to a decline in kidney function. The aim of this review is to evaluate evidence on the efficacy of renin-angiotensin-aldosterone system inhibitors (RAASi) in children affected by CAKUT with proteinuria or chronic kidney disease (CKD).

AREAS COVERED

We conducted a bibliographic search between 1 December 2022 and 20 February 2023, including randomized controlled trials, case-control studies, observational studies, meta-analyses, and systematic reviews dealing with the efficacy of RAASi in reducing proteinuria and slowing the decline of kidney function in children.

EXPERT OPINION

RAASi are effective in reducing proteinuria and slowing CKD progression in many renal conditions; however, the efficacy of these drugs in patients affected by CAKUT with proteinuria is still unknown. While waiting for more evidence, when facing a child with CAKUT with isolated proteinuria or with proteinuria and CKD, a 6-12-month trial with RAASi with gradual increase to the maximal tolerated dose should be considered. If no improvement of proteinuria is obtained, the RAASi should be discontinued.

Acute and chronic kidney complications in children with type 1 diabetes mellitus

Children with type 1 diabetes mellitus (T1DM) have an increased risk of developing kidney involvement. Part of the risk establishes at the beginning of T1DM. In fact, up to 65% of children during T1DM onset may experience an acute kidney injury (AKI) which predisposes to the development of a later chronic kidney disease (CKD). The other part of the risk establishes during the following course of T1DM and could be related to a poor glycemic control and the subsequent development of diabetic kidney disease. In this review, we discuss the acute and chronic effects of T1DM on the kidneys, and the implications of these events on the long-term prognosis of kidney function.

Acute gastroenteritis-related acute kidney injury in a tertiary care center

BACKGROUND

Acute gastroenteritis (AGE) can cause acute kidney injury (AKI) via hypoperfusion mechanisms. Early detection of AKI caused by AGE can significantly decrease mortality rates. In Saudi Arabia, studies investigating the association between AGE and AKI are limited; thus, we aimed to fill this knowledge gap.

OBJECTIVES

Analyze all cases of AGE reported in tertiary-care hospitals to assess the prevalence of AKI among AGE patients.

DESIGN

Retrospective cohort SETTINGS: Single tertiary-care center PATIENTS AND METHODS: The study included patients treated for AGE between October 2017 and October 2022. Stool culture was used to diagnose AGE. Inclusion criteria were infective diarrhea and/ or vomiting, and availability of data (demographics, comorbidities, malignancies, length of hospital stay, vital signs at the time of diagnosis, dehydration, causative agents of diarrhea, hemodialysis status, and laboratory data.

MAIN OUTCOME MEASURES

Prevalence of AKI among AGE patients and factors associated with development of AKI.

SAMPLE SIZE

300 patients diagnosed with AGE.

RESULTS

Of the 300 patients with AGE, 41 (13.6%) had AKI, those older than 60 years were more likely to develop AKI. The most frequent cause of AGE was Salmonella spp. (n=163, 53.3%), whereas AKI was most common in Clostridium difficile AGE patients (n=21, 51.2%). Furthermore, the most common comorbidity in the present study was malignancy, especially leukemia and lymphoma the risk of AKI was independently associated with mild dehydration, higher serum urea concentrations and low GFR values.

CONCLUSIONS

Patients hospitalized for diarrheal disease are at an increased risk of developing AKI due to dehydration and comorbid conditions. It is crucial to keep kidney function in mind for AGE patients as this is associated with a high mortality rate and poor prognosis.

LIMITATIONS

The main limitation of this study was its retrospective design. Another limitation is that it is limited to a single center.

CONFLICTS OF INTEREST

None.

Diagnostic Performance of the Acute Kidney Injury Baseline Creatinine Equations in Children and Adolescents with Type 1 Diabetes Mellitus Onset

Three new equations for calculating the estimated basal serum creatinine (ebSCr) in hospitalized children have been developed: the simplified acute kidney injury (AKI) baseline creatinine (ABC) equation which considered only age in the formula; the equation including age and minimum creatinine (Crmin) within the initial 72 h from hospitalization (ABC-cr); and the equation including Crmin and height, weight, and age as squared values (ABC-advanced). We aimed to test the diagnostic performance of the ABC, ABC-cr and ABC-advanced equations in diagnosing AKI in 163 prospectively enrolled children with type 1 diabetes mellitus (T1DM) onset. We considered measured basal serum creatinine (mbSCr), the creatinine measured 14 days after T1DM onset. AKI was defined by the highest/basal serum creatine (HC/BC) ratio > 1.5. On the basis of the mbSCr, the AKI was diagnosed in 66/163 (40.5%) patients. This prevalence was lower than the prevalence of AKI diagnosed on the basis of ABC ebSCr (122/163 patients; 74.8%) (p < 0.001) and similar to the prevalence of AKI diagnosed on the basis of ABC-cr ebSCr (72/163 patients; 44.2%) (p = 0.5) and to the prevalence of AKI diagnosed on the basis of ABC-advanced ebSCr (69/163; 42.3%) (p = 0.73). AKI determined using ABC ebSCr, ABC-cr ebSCr and ABC-advanced ebSCr showed, respectively, 63.5% (kappa = 0.35; p < 0.001), 87.7% (kappa = 0.75; p < 0.001), and 87.1% (kappa = 0.74; p < 0.001) agreement with AKI determined using mbSCr. Using the HC/BC ratio calculated on the basis of mbSCr as gold standard, for Bland−Altman plots the HC/BC ratio calculated on the basis of ABC formula presented higher bias and wider limits of agreement compared with the HC/BC ratio calculated on the basis of ABC-cr and ABC-advanced formulas. In the receiver−operating characteristics (ROC) curve analysis the HC/BC ratio calculated on the basis of ABC ebSCr presented lower area under the ROC curve (AUROC) (AUROC = 0.89; 95%CI: 0.85−0.95; p < 0.001) compared with HC/BC ratio calculated on the basis of ABC-cr (AUROC = 0.94; 95%CI: 0.91−0.98; p < 0.001) or ABC-advanced ebSCr (AUROC = 0.914; 95%CI: 0.91−0.97; p < 0.001). In both Bland−Altman plots and ROC curve analysis, the ABC-cr and ABC-advanced formulas performed similarly. In conclusion, the ABC-cr and ABC-advanced formulas present very good diagnostic performance toward AKI identification in a population of children with T1DM onset.

National Consensus for the Management of Acute Gastroenteritis in Jordanian Children: Consensus Recommendations Endorsed by the Jordanian Paediatric Society

Diarrhoeal diseases are one of the leading worldwide preventable causes of death among children under 5 years of age. Almost half of children do not receive optimal acute gastroenteritis (AGE) treatment in Jordan. With neither regional nor local guidelines available for AGE, consensus recommendations on the management of paediatric AGE in Jordan were developed by a panel of senior paediatricians and paediatric gastroenterologists and are endorsed by the Jordanian Paediatric Society. Recommendations are based on international guidelines and available relevant literature in relation to the AGE landscape and the healthcare system in Jordan. The prevention of diarrhoeal diseases should focus on the improvement of nutrition, hygiene, and sanitation, the introduction of routine vaccination against rotavirus, and the adoption of a standardised approach for AGE management (oral rehydration solution (ORS) use±adjunct therapies, continued feeding, and avoiding routine antibiotic use). Ondansetron, diosmectite, racecadotril, probiotics, and zinc can be considered adjunct to ORS, if needed. Local data gaps should be addressed. The clinical algorithm for the management of paediatric AGE could promote adherence to practice recommendations and by extension improve health outcomes in children.

Diagnostic Performance of Height-Estimated Baseline Creatinine in Diagnosing Acute Kidney Injury in Children with Type 1 Diabetes Mellitus Onset

At type 1 diabetes mellitus (T1DM) onset, acute kidney injury (AKI) is very common. To diagnose AKI, the availability of a baseline serum creatinine (bSCr) is pivotal. However, in most hospitalized children the bSCr is unknown. We aimed to test whether the bSCr estimated on the basis of height (ebSCr) could be a reliable surrogate for AKI diagnosis compared with the measured bSCr (mbSCr). As the mbSCr, we considered the creatinine measured 14 days after T1DM onset while ebSCr (mg/dL) = (k × height [cm])/120 mL/min/1.73 m2, where k = 0.55 for children and adolescent girls and k = 0.7 for adolescent boys. AKI was defined as serum creatinine values >1.5 times the baseline creatinine. Kappa statistics and the percentage of agreement in AKI classification by ebSCr−AKI versus mbSCr−AKI definition methods were calculated. Bland−Altman plots were used to show the agreement between the creatinine ratio (highest/baseline creatinine; HC/BC) calculated with mbSCr and ebSCr. The number of 163 patients with T1DM onset were included. On the basis of mbSCr, 66/163 (40.5%) presented AKI while, on the basis of ebSCr, 50/163 (30.7%) accomplished AKI definition. ebSCr showed good correlation with mbSCr using both the Spearman test (rho = 0.67; p < 0.001) and regression analysis (r = 0.68; p < 0.001). Moreover, at the Bland−Altman plots, the bias of the highest/baseline creatinine ratio calculated on the basis of the mbSCr compared to ebSCr was minimal (bias = −0.08 mg/dL; 95% limits of agreement = −0.23/0.39). AKI determined using ebSCr showed 90% agreement with AKI determined using mbSCr (kappa = 0.66; p < 0.001). Finally, we compared the area under a receiver−operating characteristic curve (AUROC) of HC/BC ratio calculated on the basis of ebSCr with AUROC of the gold standard HC/BC ratio calculated on the basis of mbSCr. As expected, the gold standard had an AUROC = 1.00 with a 95% confidence interval (CI) between 0.98 and 1.00, p < 0.001. The HC/BC ratio calculated on the basis of ebSCr also had significant AUROC (AUROC = 0.94; 95% CI: 0.90−0.97; p < 0.001). The comparison of the two ROC curves showed a p < 0.001. In conclusion, when mbSCr is unknown in patients with T1DM onset, the ebSCr calculated on the basis of height could be an alternative to orientate clinicians toward AKI diagnosis.

Heart rate cut-offs to identify non-febrile children with dehydration and acute kidney injury

We hypothesized that the heart rate (HR) variation in an acute setting compared with HR in wellbeing status could be a good marker of both dehydration and acute kidney injury (AKI). Since HR in wellbeing status is unknown in most cases, we assumed as reliable surrogate the 50th percentile of HR according to age and gender. We evaluated if the estimated percentage of heart rate variation in acute setting compared with 50th percentile of HR (EHRV) could be marker of dehydration and AKI in children. Two independent cohorts, one prospective comprehending 185 children at type 1 diabetes mellitus onset (derivation) and one retrospective comprehending 151 children with acute gastroenteritis and pneumonia (validation), were used to develop and externally validate EHRV as predictor of the ≥ 5% dehydration and/or AKI composite outcome. Febrile patients were excluded. EHRV was calculated as ((HR at admission-50th percentile of HR)/HR at admission) × 100. The prevalences of ≥ 5% dehydration and AKI were 61.1% and 43.8% in the derivation and 34.4% and 24.5% in the validation cohort. For the ≥ 5% dehydration and/or AKI composite outcome, the area under receiver-operating characteristic curve of the EHRV in the derivation cohort was 0.69 (95%CI, 0.62-0.77; p < 0.001) and the best EHRV cut-off was > 24.5%. In the validation cohort, EHRV > 24.5% showed specificity = 100% (95%CI, 96.2-100.0), positive predictive value = 100%, and negative predictive value = 67.1% (95%CI, 64.7-69.5). The positive likelihood ratio was infinity, and odds ratio was not calculable because all the patients with EHRV > 24.5% showed ≥ 5% dehydration and/or AKI.    Conclusions: EHRV appears a rather reliable marker of dehydration and AKI. Further validations could allow implementing EHRV in the clinical practice. What is Known: • Increased heart rate (HR) is an easily and quickly detectable sign of dehydration in childhood, but its cut-off to suspect dehydration or acute kidney injury (AKI) is not defined. What is New: • We found that a percentage of estimated HR variation in acute setting in comparison with 50th percentile of HR (EHRV)>24.5% predicted ≥5% dehydration and/or AKI in non-febrile patients. • We provide a one-page tool to suspect ≥5% dehydration and/or AKI on the basis of the HR. If furtherly validated, this tool could be implemented in the daily clinical practice.

Acute Kidney Injury in Children with Acute Appendicitis

We hypothesized that-as in other common pediatric conditions-acute appendicitis (AA) could be complicated by acute kidney injury (AKI). We aimed to investigate the prevalence of, and the factors associated with AKI in a cohort of patients with AA. We retrospectively collected data of 122 children (63.9% of male gender; mean age 8.6 ± 2.9 years; range: 2.2-13.9 years) hospitalized for AA. AKI was defined according to the Kidney Disease/Improving Global Outcomes creatinine criteria. We considered a basal serum creatinine value as the value of creatinine estimated with the Hoste (age) equation, assuming that the basal estimated glomerular filtration rate (eGFR) was 120 mL/min/1.73 m2. Explorative univariate logistic regression analysis was used to explore the associations with AKI. Out of 122 patients, nine (7.4%) presented with AKI. One patient had stage two AKI and the remaining had stage one AKI. The maximum AKI stage was found at admission. The patients with AKI showed a higher prevalence of fever ≥ 38.5 °C (p = 0.02), vomiting (p = 0.03), ≥5% dehydration (p = 0.03), and higher levels of both C-reactive protein (CRP) (p = 0.002) and neutrophils (p = 0.03) compared with patients without AKI. Because all patients with AKI also presented with vomiting, an Odds Ratio (OR) for the vomiting was not calculable. The exploratory univariate logistic regression analysis confirmed that fever ≥ 38.5 °C (OR = 5.0; 95% CI: 1.2/21.5; p = 0.03), ≥5% dehydration (OR = 8.4; 95% CI: 1.1/69.6; p = 0.04), CRP (OR = 1.1; 95% CI: 1.05/1.2; p = 0.01), and neutrophil levels (OR = 1.1; 95% CI: 1.01/1.3; p = 0.04) were all predictive factors of AKI. AKI can occur in 7.4% of patients with AA. Particular attention should be paid to the kidney health of patients with AA especially in the presence of vomiting, ≥5% dehydration, fever ≥ 38.5 °C, and high CRP and neutrophils levels.

New Insights from Metabolomics in Pediatric Renal Diseases

Renal diseases in childhood form a spectrum of different conditions with potential long-term consequences. Given that, a great effort has been made by researchers to identify candidate biomarkers that are able to influence diagnosis and prognosis, in particular by using omics techniques (e.g., metabolomics, lipidomics, genomics, and transcriptomics). Over the past decades, metabolomics has added a promising number of 'new' biomarkers to the 'old' group through better physiopathological knowledge, paving the way for insightful perspectives on the management of different renal diseases. We aimed to summarize the most recent omics evidence in the main renal pediatric diseases (including acute renal injury, kidney transplantation, chronic kidney disease, renal dysplasia, vesicoureteral reflux, and lithiasis) in this narrative review.

Acute kidney injury in children hospitalized for community acquired pneumonia

BACKGROUND

Acute kidney injury (AKI) enhances the risk of later chronic kidney disease. Significant prevalence of AKI is reported in adults with community acquired pneumonia (CAP). We investigated prevalence of and prognostic factors for AKI in children hospitalized for CAP.

METHODS

We retrospectively collected clinical and biochemical data of 186 children (48.4% male; mean age 2.6±2.4 years) hospitalized for X-ray-confirmed CAP. AKI was defined according to Kidney Disease/Improving Global Outcomes creatinine criteria. We considered as basal serum creatinine the value estimated with Hoste (age) equation assuming basal eGFR were median age-based eGFR normative values for children ≤ 2 years of age and eGFR= 120 mL/min/1.73m2 for children > 2 years. Univariate and multivariate logistic regression models were used to explore associations with AKI.

RESULTS

AKI was found in 38/186 (20.4%) patients. No patient required hemodialysis nor reached AKI stage 3, 5 (2.7%) reached AKI stage 2, and 33 (17.7%) AKI stage 1. Mean length of stay was 6.0±1.7, 6.9±2.3, and 12.2±1.5 days, for patients without AKI, stage 1 AKI, and stage 2 AKI (p < 0.001), respectively. Duration of symptoms before hospitalization (OR 1.2; 95%CI 1.09-1.43; p = 0.001), severe pneumonia (OR 11.9; 95%CI 4.3-33.3; p < 0.001), and serum C-reactive protein levels (OR 1.1; 95%CI 1.04-1.23; p = 0.004) were independent AKI predictors.

CONCLUSIONS

About 1/5 of children hospitalized for CAP present a generally mild AKI with a longer stay for those with more severe AKI. Attention should be paid to kidney health of children with CAP especially in presence of higher duration of symptoms before hospitalization, severe pneumonia and higher serum CRP levels.

Renal Involvement in Children with Type 2 Diabetes Mellitus Onset: A Pilot Study

Type 2 Diabetes Mellitus (T2DM) is a main cause of chronic kidney disease (CKD) in adulthood. No studies have examined the occurrence of acute kidney injury (AKI)-that enhances the risk of later CKD-and renal tubular damage (RTD)-that can evolve to AKI-in children with onset of T2DM. We aimed to evaluate the prevalence and possible features of AKI and RTD in a prospectively enrolled population of children with onset of T2DM. We consecutively enrolled 10 children aged 12.9 ± 2.3 years with newly diagnosed T2DM. AKI was defined according to the KDIGO criteria. RTD was defined by abnormal urinary beta-2-microglobulin and/or tubular reabsorption of phosphate (TRP) <85% and/or fractional excretion of Na >2%. None of the patients developed AKI, whereas 3/10 developed RTD with high beta-2-microglobulin levels (range: 0.6-1.06 mg/L). One of these three patients also presented with reduced TRP levels (TRP = 70%). Proteinuria was observed in two out of three patients with RTD, while none of patients without RTD had proteinuria. Patients with RTD presented higher beta-2-microglobulin, acute creatinine/estimated basal creatinine ratio, and serum ketones levels compared with patients without RTD. In conclusion, in our pilot observation, we found that none of the 10 children with T2DM onset developed AKI, whereas three of them developed RTD.

Retrospective Study on Acute Kidney Injury among Cholera Patients in an Outbreak in Whitefield, Bengaluru

Introduction

Cholera is gastroenteritis caused by Vibrio cholerae. It presents with vomiting, severe secretory diarrhoea, and dehydration. It can cause severe complications with severe electrolyte imbalances and oligoanuric acute kidney injury due to acute tubular necrosis secondary to dehydration or infection itself. However, cholera presenting with significant proteinuria and acute kidney injury has not been reported. Hence, this study was conducted. Aims and Objectives. This aim of this study was to assess clinical features, treatment, and prognosis of AKI in cholera patients; to correlate proteinuria with AKI in cholera patients; and to compare cholera patients with normal kidney function and those with AKI. Material and Methods. It was a retrospective observational study involving patients with cholera. Information regarding cholera patients with acute kidney injury, proteinuria, and prognosis were collected.

Results

Most of the patients had significant vomiting, moderate-to-severe diarrhoea, dehydration, and hypovolaemic shock. Cholera caused severe complications such as severe electrolyte imbalances including hyponatraemia and hypokalaemia, acute kidney injury, and proteinuria secondary to dehydration or infection. A surprising finding noted was the lack of significant association between the onset of acute kidney injury and usual risk factors such as hypovolaemic shock and dehydration. It was found that proteinuria had influenced the onset of acute kidney injury, but it did not influence recovery. As there was complete recovery in kidney function, none of the cases required kidney biopsy. There was no mortality noted.

Conclusions

This study points towards the rare occurrence of proteinuria and acute kidney injury in Vibrio cholerae infection with spontaneous remission of kidney disease with appropriate therapy.