Epidemiology and outcomes of community-acquired and hospital-acquired acute kidney injury in children and adolescents

The development and validation of a prediction model for post-AKI outcomes of pediatric inpatients

Background

Acute kidney injury (AKI) is common in hospitalized children. A post-AKI outcomes prediction model is important for the early detection of important clinical outcomes associated with AKI so that early management of pediatric AKI patients can be initiated.

Methods

Three retrospective cohorts were set up based on two pediatric hospitals in China, in which 8205 children suffered AKI during hospitalization. Two clinical outcomes were evaluated, i.e. hospital mortality and dialysis within 28 days after AKI occurrence. A Genetic Algorithm was used for feature selection, and a Random Forest model was built to predict clinical outcomes. Subsequently, a temporal validation set and an external validation set were used to evaluate the performance of the prediction model. Finally, the stratification ability of the prediction model for the risk of mortality was compared with a commonly used mortality risk score, the pediatric critical illness score (PCIS).

Results

The prediction model performed well for the prediction of hospital mortality with an area under the receiver operating curve (AUROC) of 0.854 [95% confidence interval (CI) 0.816-0.888], and the AUROC was >0.850 for both temporal and external validation. For the prediction of dialysis, the AUROC was 0.889 (95% CI 0.871-0.906). In addition, the AUROC of the prediction model for hospital mortality was superior to that of PCIS (P < .0001 in both temporal and external validation).

Conclusions

The new proposed post-AKI outcomes prediction model shows potential applicability in clinical settings.

Pediatric acute kidney injury and adverse health outcomes: using a foundational framework to evaluate a causal link

Acute kidney injury (AKI) is a major global health problem, expensive to manage, and its associations with negative pediatric health outcomes have been clearly demonstrated. One of the most fundamental questions to consider as we use previous epidemiological information to advance research and care paradigms is the strength of the causal link between pediatric AKI and health outcomes. In this review, we apply the foundational framework of the Bradford Hill criteria to evaluate the extent to which a causal link exists between AKI and the associated adverse outcomes in children. Available data in children support a causal link between AKI and short-term outcomes including mortality, length of stay, and ventilation time. Clarifying the causal nature of longer term associations requires further high-quality observational studies in children, careful consideration of what defines the most meaningful and measurable longer term outcomes after pediatric AKI, and integration of evolving biological data related to mechanisms of disease. Preventing or mitigating AKI should lead to improved outcomes. Demonstrating such reversibility will solidify confidence in the causal relationship, improve child health, and highlight an aspect which is highly relevant to clinicians, scientists, and policy makers.

Gestational Exposure to Maternal Systemic Glucocorticoids and Childhood Risk of CKD

RATIONALE & OBJECTIVE

The potential effects of antenatal glucocorticoid exposure on the health of children are unclear. We examined the association of gestational exposure to maternal systemic glucocorticoids and the risk of developing chronic kidney disease (CKD) in childhood.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

Newborns cared for at the largest health care delivery system in Taiwan between 2004 and 2018.

EXPOSURE

Maternal prescriptions for systemic glucocorticoids between the last menstrual period and birth as a proxy for gestational exposure.

OUTCOME

Incidence of childhood CKD, including congenital anomalies of the kidney and urinary tract (CAKUT) and other kidney diseases (non-CAKUT), over 10 years.

ANALYTICAL APPROACH

Cox proportional hazards models with stabilized inverse probability of treatment weighting and robust sandwich estimator were used to estimate the average association between systemic glucocorticoids and incident CKD after adjustment for offspring characteristics (adjusted HR: AHR).

RESULTS

Among 23,363 singleton-born children, gestational systemic glucocorticoid exposure was significantly associated with a higher risk of childhood CKD (AHR, 1.69 [95% CI, 1.01-2.84]). Stratified analyses showed stronger associations between systemic glucocorticoids and childhood CKD within the strata of birth<37 weeks' gestational age (AHR, 2.38 [95% CI, 1.19-4.78]), male sex (AHR, 1.89 [95% CI, 1.00-3.55]), gestational exposure in the second trimester (AHR, 6.70 [95% CI, 2.17-20.64]), and total dose of>24mg hydrocortisone equivalent (AHR, 1.91 [95% CI, 1.05-3.47]).

LIMITATIONS

Study was limited to the Taiwan health care delivery system and childhood CKD events through the age of 10 years.

CONCLUSIONS

The findings of this study suggest that gestational exposure to systemic glucocorticoids is associated with the occurrence of kidney disease in childhood. If these findings are confirmed, they may inform clinicians who are considering prescribing systemic glucocorticoids during pregnancy.

PLAIN-LANGUAGE SUMMARY

In a singleton-born cohort of neonates, maternal exposure to antenatal systemic glucocorticoids was significantly associated with a 1.7-fold increased risk of the children developing chronic kidney disease over the first 10 years of life. Children of mothers who received>24mg of hydrocortisone equivalent, systemic glucocorticoid treatment in second trimester of gestation, and children born at<37 weeks of gestational age had a higher risk of childhood kidney disease after gestational systemic glucocorticoid exposure. If these findings are confirmed, they may inform clinicians who are considering prescribing systemic glucocorticoids during pregnancy.

The correlation between serum angiopoietin-2 levels and acute kidney injury (AKI): a meta-analysis

INTRODUCTION

The correlation between serum angiopoietin-2 levels and acute kidney injury (AKI) is a topic of significant clinical interest. This meta-analysis aims to provide a comprehensive evaluation of this relationship.

CONTENT

A systematic search was conducted in PubMed, Embase, Web of Science, and Cochrane databases up to October 11, 2023. The included studies were evaluated using the Newcastle-Ottawa Scale (NOS) and Methodological Index for Non-Randomized Studies (MINORS). Weighted mean differences (WMD) and odds ratios (OR) were calculated using random-effects models. Sensitivity analysis, funnel plots, and Egger's test were used to assess the robustness and publication bias of the findings. Subgroup analyses were performed to explore potential variations between adults and children.

SUMMARY

Eighteen studies encompassing a total of 7,453 participants were included. The analysis revealed a significant elevation in serum angiopoietin-2 levels in patients with AKI compared to those without (WMD: 4.85; 95 % CI: 0.75 to 0.27; I²=93.2 %, p<0.001). Subgroup analysis indicated significantly higher angiopoietin-2 levels in adults with AKI (WMD: 5.17; 95 % CI: 3.51 to 6.83; I²=82.6 %, p<0.001), but not in children. Additionally, high serum angiopoietin-2 levels were associated with an increased risk of AKI (OR: 1.58; 95 % CI: 1.39 to 1.8; I²=89.1 %, p<0.001). Sensitivity analysis validated the robustness of these results, showing no substantial change in the overall effect size upon the exclusion of individual studies.

OUTLOOK

This meta-analysis supports a significant association between elevated serum angiopoietin-2 levels and increased risk of AKI. The observed differential association between adults and children highlights the need for further targeted research to understand these age-specific variations.

Acute Kidney Disease following Acute Kidney Injury in Children-A Retrospective Observational Cohort Study on Risk Factors and Outcomes

Background: Acute kidney disease (AKD) is a known risk factor for increased mortality and evolution towards chronic kidney disease (CKD) in adults. The data regarding AKD in children are scarce. The purpose of our study was to explore the risk factors for developing AKD based on exposures and susceptibilities in children with AKI doubled by the biological parameters from the first day of identified AKI. In addition, we followed the trajectory of AKD following an acute kidney injury (AKI) episode in children during hospital admission and after discharge with special considerations towards mortality and progression to new-onset CKD. Methods: We retrospectively evaluated 736 children, ages between 2 and 18 years old, with identified AKI during hospital admission in a tertiary care hospital from west Romania over a 9-year period. Results: AKD incidence following an AKI episode was 17%. Patients who developed AKD were older, with higher baseline serum creatinine, urea, C reactive protein and lower proteins, haemoglobin and sodium levels. In the adjusted model, no biological parameters influenced AKD development. Regarding certain exposures and personal susceptibilities in children with AKI, only anaemia independently increased the risk of AKD development by 2.47 times. However, out of the AKI causes, only the intrinsic causes of AKI independently increased the risk of progressing to AKD (glomerulonephritis by 4.94 and acute tubule-interstitial nephritis by 2.76 times). AKD increased the overall mortality by 2.6 times. The factors that independently increased the risk of CKD were AKD, acute tubular necrosis and higher baseline serum creatinine values. Conclusions: Only anaemia, glomerulonephritis and acute tubule-interstitial nephritis increased the risk of AKD development in children with AKI. AKD was an independent risk factor for mortality and new-onset CKD in children.

Epidemiology of acute kidney injury in children: a report from the 26th Acute Disease Quality Initiative (ADQI) consensus conference

The nephrology and critical care communities have seen an increase in studies exploring acute kidney injury (AKI) epidemiology in children. As a result, we now know that AKI is highly prevalent in critically ill neonates, children, and young adults. Furthermore, children who develop AKI experience greater morbidity and higher mortality. Yet knowledge gaps still exist that suggest a more comprehensive understanding of AKI will form the foundation for future efforts designed to improve outcomes. In particular, the areas of community acquired AKI, AKI in non-critically ill children, and cohorts from low-middle income countries have not been well studied. Longer-term functional outcomes and patient-centric metrics including social determinants of health, quality of life, and healthcare utilization should be the foci of the next phase of scholarship. Current definitions identify AKI-based upon evidence of dysfunction which serves as a proxy for injury; biomarkers capable of identifying injury as it occurs are likely to more accurately define populations with AKI. Despite the strength of the association, the causal and mechanistic relationships between AKI and poorer outcomes remain inadequately examined. A more robust understanding of the relationship represents a potential to identify therapeutic targets. Once established, a more comprehensive understanding of AKI epidemiology in children will allow investigation of preventive, therapeutic, and quality improvement interventions more effectively.

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.

Acute Kidney Injury: Gaps and Opportunities for Knowledge and Growth

Acute kidney injury (AKI) occurs frequently in hospitalized patients, regardless of age or prior medical history. Increasing awareness of the epidemiologic problem of AKI has directly led to increased study of global recognition, diagnostic tools, both reactive and proactive management, and analysis of long-term sequelae. Many gaps remain, however, and in this article we highlight opportunities to add significantly to the increasing bodies of evidence surrounding AKI. Practical considerations related to initiation, prescription, anticoagulation, and monitoring are discussed. In addition, the importance of AKI follow-up evaluation, particularly for those surviving the receipt of renal replacement therapy, is highlighted as a push for global equity in the realm of critical care nephrology is broached. Addressing these gaps presents an opportunity to impact patient care directly and improve patient outcomes.

Incidence and Outcome of Community-Acquired Acute Kidney Injury in Pediatric Patients Seen at an Emergency Department: A Retrospective Cohort Study

OBJECTIVES

Acute kidney injury (AKI) has significant morbidity and mortality rates among young patients. This study aimed to determine the incidence and outcome of community-acquired AKI among pediatric patients seen in the emergency department of King Abdulaziz University Hospital for more than 3 years.

METHODS

This retrospective study reviewed electronic medical records for all pediatric patients aged 1 month to 18 years who visited the emergency department of King Abdulaziz University Hospital from January 1, 2015, until December 31, 2017. Acute kidney injury was diagnosed and classified according to the Kidney Disease: Improving Global Outcomes criteria.

RESULTS

Of 6038 patients, 1581 were included. Acute kidney injury occurred in 135 patients (8.5%), of which 77 (57%) were in stage 1, 42 (31.1%) were in stage 2, and 16 (11.9%) were in stage 3. Mortality was higher in the AKI group (4.4%) than in the non-AKI group (0.2%; P < 0.01). On long-term observation, 14.8% did not return for follow-up, 58.5% of survivors recovered completely, and 22.2% progressed to chronic kidney disease. The most affected age group was 1 month to 2 years (26%). Common admission causes were chemotherapy-induced AKI (31.9%) and pneumonia (10.4%). There was a significant inverse relationship between AKI and age group (P < 0.001) and a positive association between AKI and death (P < 0.001). However, no association was found between AKI stages and outcomes.

CONCLUSIONS

Community-acquired AKI remains a common condition affecting the pediatric population. It is associated with a higher mortality rate. Infants were more susceptible to AKI, and a significant number of patients with AKI progressed to chronic kidney disease.

Changing trends in dialysis modalities utilization and mortality in children, adolescents and young adults with acute kidney injury, 2010-2017

The aim of the study was to assess trends in the relative use of dialysis modalities in the hospital-based pediatric cohort and to determine risk factors associated with in-hospital morality among pediatric patients receiving dialysis for acute kidney injury (AKI). Patients aged < 20 years who received dialysis between 2010 and 2017 were identified from electronic health records databases of a Taiwan's healthcare delivery system. The annual uses of intermittent hemodialysis (HD), continuous and automated peritoneal dialysis (PD) and continuous kidney replacement therapy (CKRT) were assessed using Cochran-Armitage Tests for trend. Among patients who received their first dialysis as inpatients for AKI, a multivariate logistic regression model was employed to assess mortality risks associated with dialysis modalities, patient demographics, complexity of baseline chronic disease, and healthcare service use during their hospital stays. Kidney dialysis was performed 37.9 per patient per year over the study period. Intermittent hemodialysis (HD) (73.3%) was the most frequently used dialysis modality. In the inpatient setting, the relative annual use of CKRT increased over the study period, while HD use concomitantly declined (P < 0.0001). The overall in-hospital mortality rate after dialysis for AKI was 33.6%, which remained steady over time (P = 0.2411). Patients aged < 2 years [adjusted odds ratio: (aOR) 3.36; 95% confidence interval (CI) 1.34-8.93] and greater vasoactive regimen use (aOR: 17.1; 95% CI: 5.3-55.21) were significantly associated with dialysis-related mortality. Overall treatment modality used for dialysis in pediatric patients increased slowly in the study period, and HD and CRKT modality uses largely evolved in the inpatient setting. Younger ages and use of more vasoactive medication regimens were independently associated with increased early mortality in patients on AKI-dialysis.

Serum Creatinine Reference Limits in Pediatric Population-A Single Center Electronic Health Record-Based Database in Taiwan

Objective: To assess age- and sex-specific serum creatinine levels in a pediatric population using a hospital-based database in Taiwan. Study Design: Data on serum creatinine levels were obtained from the National Taiwan University Hospital-integrated Medical Database (NTUH-iMD). Due to the possibility of having acute kidney injury or chronic kidney disease, individuals with multiple serum creatinine measurements were excluded, and outliers in each age- and sex-specific group were also subsequently removed. The remaining creatinine measurements in each group were analyzed, and 95% reference limits were established. Results: Serum creatinine data of individuals aged between 1 month and 18 years from May 2011 to January 2018 were retrieved. After applying the exclusion criteria, 27,911 individuals with a single corresponding serum creatinine measurement were enrolled. Creatinine level reference limits for each age- and sex-specific group were generated. The upper reference limits (URLs), which are particularly useful in clinical practice, followed the natural trend of increasing serum creatinine with age. Conclusion: We generated serum creatinine reference limits from a single hospital-integrated medical database in Taiwan for different age- and sex-specific groups of children. Our results will aid physicians in clinical practice regarding renal function evaluation, especially for patients without a recent baseline serum creatinine level.

Acute Kidney Injury in Hospitalized Pediatric Patients: A Review of Research

INTRODUCTION

Pediatric patients who develop acute kidney injury (AKI) while hospitalized have longer hospital stays, increased morbidity and mortality, and are at an increased risk for developing chronic kidney disease. Early recognition of AKI is becoming a major clinical focus. There is little research focusing on nursing interventions that may affect a pediatric patient's risk for developing AKI. The purpose of this review is to summarize reported predictors of AKI to improve its early recognition and treatment among hospitalized pediatric patients.

METHODS

A review of research was conducted to further identify risk factors of AKI among noncritically ill hospitalized pediatric patients.

RESULTS

The current literature demonstrated inconsistent findings in early recognition of AKI among hospitalized pediatric patients.

DISCUSSION

Interventions for early recognition and treatment of AKI should consider other variables, such as previous history of AKI and fluid status as risk factors, warranting additional research.

Defining pediatric community-acquired acute kidney injury: an observational study

BACKGROUND

Pediatric acute kidney injury (AKI) is associated with long-term morbidity and mortality; however, outcomes improve when AKI is detected earlier. Current definitions of AKI use baseline creatinine; community-acquired AKI (CA-AKI) is difficult to define and detect in the pediatric emergency department (ED) when no baseline creatinine is available. Our objective was to compare age- and gender-based creatinine norms to the traditional baseline (lowest creatinine in previous 3 months) to diagnose CA-AKI.

METHODS

This was a retrospective cross-sectional study conducted in children 1 month-18 years of age seen in the pediatric ED in whom a creatinine was obtained.

RESULTS

Per the Kidney Disease Improving Global Outcomes AKI definition in encounters with baseline creatinine available, 343/2338 (14.7%) had CA-AKI. When the upper limit of the age- and gender-based creatinine norm was applied as a surrogate baseline creatinine, CA-AKI was diagnosed in 1.5% of encounters (239/15,486). Additionally, CA-AKI was diagnosed in 178 cases using the upper limit of age- and gender-based creatinine norms only, as these cases did not have a baseline creatinine.

CONCLUSIONS

Age- and gender-based creatinine norms can be applied as a surrogate baseline to detect CA-AKI in all children regardless of whether baseline creatinine is available, potentially detecting it earlier.

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

IMPORTANCE

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

OBJECTIVE

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

DESIGN, SETTING, AND PARTICIPANTS

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

EXPOSURES

Acetaminophen exposure in the first 48 postoperative hours.

MAIN OUTCOMES AND MEASURES

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

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