Most children with serious acute illness do not have underlying chronic conditions. This prospective study involving patients in pediatric intensive care units showed that acute kidney injury is ...common and is associated with poor outcomes, including increased mortality.
Epidemiologic studies involving adults have shown that acute kidney injury is associated with increased mortality, prolonged mechanical ventilation, and prolonged length of stay in intensive care units (ICUs).
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A multinational, prospective study involving 1802 adults
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initiated the use of Kidney Disease: Improving Global Outcomes (KDIGO) guidelines to describe the epidemiology of acute kidney injury; the guidelines
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define and stage acute kidney injury according to the plasma creatinine level and urine output (Table S1 in the Supplementary Appendix, available with the full text of this article at NEJM.org). That study showed graded associations between the severity of acute kidney injury and . . .
Objectives We sought to characterize factors and outcomes associated with postoperative acute kidney injury in infants undergoing cardiac surgery. Methods We retrospectively studied 430 infants (<90 ...days) who underwent heart surgery for congenital defects. With a pediatric modified version of the Acute Kidney Injury Network classification, we performed statistical analyses to detect factors and outcomes associated with postoperative acute kidney injury. Results Postoperative acute kidney injury occurred in 225 patients (52%): 135 patients (31%) reached maximum acute kidney injury stage I, 59 (14%) reached stage II, and 31 (7%) reached stage III. On multivariable analysis, single-ventricle status (odds ratio, 1.6; 95% confidence interval, 1.08–2.37; P = .02), cardiopulmonary bypass (odds ratio, 1.2; 95% confidence interval 1.01–1.47; P = .04), and higher reference serum creatinine (odds ratio, 5.1; 95% confidence interval, 1.94–13.2; P = .0009) were associated with postoperative acute kidney injury. Thirty-two (7%) patients died in the hospital. Multivariable logistic regression showed that more severe acute kidney injury was associated with in-hospital mortality (maximum acute kidney injury stage II odds ratio, 5.1; 95% confidence interval, 1.7–15.2; P = .004; maximum acute kidney injury stage III odds ratio, 9.46; 95% confidence interval, 2.91–30.7; P = .0002) and longer mechanical ventilation and inotropic support. All acute kidney injury stages were associated with longer intensive care durations. Stage III acute kidney injury was associated with systemic ventricular dysfunction at hospital discharge. Conclusions Perioperative acute kidney injury is common in infant heart surgery and portends a poor clinical outcome.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Consensus definitions have been reached for both acute kidney injury (AKI) and chronic kidney disease (CKD) and these definitions are now routinely used in research and clinical practice. The KDIGO ...guideline defines AKI as an abrupt decrease in kidney function occurring over 7 days or less, whereas CKD is defined by the persistence of kidney disease for a period of >90 days. AKI and CKD are increasingly recognized as related entities and in some instances probably represent a continuum of the disease process. For patients in whom pathophysiologic processes are ongoing, the term acute kidney disease (AKD) has been proposed to define the course of disease after AKI; however, definitions of AKD and strategies for the management of patients with AKD are not currently available. In this consensus statement, the Acute Disease Quality Initiative (ADQI) proposes definitions, staging criteria for AKD, and strategies for the management of affected patients. We also make recommendations for areas of future research, which aim to improve understanding of the underlying processes and improve outcomes for patients with AKD.
Acute kidney injury (AKI) in hospitalized children results in increased patient morbidity and mortality. Nephrotoxic-medication exposure is a common cause of AKI. Currently, no data exist to quantify ...the risks of developing AKI for various nephrotoxic medications in children. The primary aim of the current study is to assess for a potential association between nephrotoxic medications and the risk of developing AKI in hospitalized noncritically ill children with no pre-existing renal insufficiency.
We performed a retrospective case-control study in pediatric hospitalized noncritically ill patients aged 1 day to 18 years. The cases were patients who developed AKI, as defined by the pediatric modified RIFLE (pRIFLE) criteria; patients without AKI served as controls and were matched by age category, gender, and disease state.
561/1660 (33.8%) patients identified for inclusion had AKI (441 category "R," 117 category "I," three category "F"); 357 cases were matched with 357 controls. Patients with AKI had longer length of hospital stay and increased hospital costs. Patients with AKI had exposure to more nephrotoxic medications for a longer period of time compared with controls. Odds of exposure for at least one nephrotoxic medication was significant for development of AKI. Exposure to more nephrotoxic medications was associated with an increased risk of AKI.
Increasing exposure to three or more nephrotoxic medications places pediatric patients at greater risk of acute kidney injury with resultant increased hospital costs and patient morbidity.
Abstract Background Increases in serum creatinine (ΔSCr) from baseline signify acute kidney injury (AKI) but offer little granular information regarding its characteristics. The 10th Consensus ...Conference of the Acute Dialysis Quality Initiative (ADQI) suggested that combining AKI biomarkers would provide better precision for AKI course prognostication. Objectives This study investigated the value of combining a functional damage biomarker (plasma cystatin C pCysC) with a tubular damage biomarker (urine neutrophil gelatinase-associated lipocalin uNGAL), forming a composite biomarker for prediction of discrete characteristics of AKI. Methods Data from 345 children after cardiopulmonary bypass (CPB) were analyzed. Severe AKI was defined as Kidney Disease Global Outcomes Initiative stages 2 to 3 (≥100% ΔSCr) within 7 days of CPB. Persistent AKI lasted >2 days. SCr in reversible AKI returned to baseline ≤48 h after CPB. The composite of uNGAL (>200 ng/mg urine Cr = positive +) and pCysC (>0.8 mg/l = positive +), uNGAL+/pCysC+, measured 2 h after CPB initiation, was compared to ΔSCr increases of ≥50% for correlation with AKI characteristics by using predictive probabilities, likelihood ratios (LR), and area under the curve receiver operating curve (AUC-ROC) values. Results Severe AKI occurred in 18% of patients. The composite uNGAL+/pCysC+ demonstrated a greater likelihood than ΔSCr for severe AKI (+LR: 34.2 13.0:94.0 vs. 3.8 1.9:7.2) and persistent AKI (+LR: 15.6 8.8:27.5 versus 4.5 2.3:8.8). In AKI patients, the uNGAL−/pCysC+ composite was superior to ΔSCr for prediction of transient AKI. Biomarker composites carried greater probability for specific outcomes than ΔSCr strata. Conclusions Composites of functional and tubular damage biomarkers are superior to ΔSCr for predicting discrete characteristics of AKI.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Objectives We investigated the temporal pattern and predictive value (alone and in combination) of 4 urinary biomarkers (neutrophil gelatinase-associated lipocalin NGAL, interleukin IL-18, liver ...fatty acid-binding protein L-FABP, and kidney injury molecule KIM-1) for cardiac surgery–associated acute kidney injury (AKI). Background Serum creatinine (SCr ) is a delayed marker for AKI after cardiopulmonary bypass (CPB). Rapidly detectable AKI biomarkers could allow early intervention and improve outcomes. Methods Data from 220 pediatric patients were analyzed. Urine samples were obtained before and at intervals after CPB initiation. AKI was defined as a ≥50% increase in SCr from baseline within 48 h after CPB. The temporal pattern of biomarker elevation was established, and biomarker elevations were correlated with AKI severity and clinical outcomes. Biomarker predictive abilities were evaluated by area under the curve (AUC), net reclassification improvement, and integrated discrimination improvement. Results AKI occurred in 27% of patients. Urine NGAL significantly increased in AKI patients at 2 h after CPB initiation. IL-18 and L-FABP increased at 6 h, and KIM-1 increased at 12 h. Biomarker elevations were correlated with AKI severity and clinical outcomes and improved AKI prediction above a clinical model. At 2 h, addition of NGAL increased the AUC from 0.74 to 0.85 (p < 0.0001). At 6 h, NGAL, IL-18, and L-FABP each improved the AUC from 0.72 to 0.91, 0.84, and 0.77, respectively (all p < 0.05). The added predictive ability of the biomarkers was supported by net reclassification improvement and integrated discrimination improvement. Biomarker combinations further improved AKI prediction. Conclusions Urine NGAL, IL-18, L-FABP, and KIM-1 are sequential predictive biomarkers for AKI and are correlated with disease severity and clinical outcomes after pediatric CPB. These biomarkers, particularly in combination, may help establish the timing of injury and allow earlier intervention in AKI.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
The 2012 KDIGO (Kidney Disease: Improving Global Outcomes) Clinical Practice Guideline for Anemia in Chronic Kidney Disease provides clinicians with comprehensive evidence-based recommendations to ...improve patient care. In this commentary, we review these recommendations and the underlying evidence. Most recommendations are well reasoned. For some, the evidence is unclear and recommendations require some qualification. While the KDIGO guideline stresses the potential risks of intravenous iron therapy, withholding iron might have its own risks. The recommendation to avoid hemoglobin levels falling below 9 g/dL sets a lower bound of “acceptability” that may increase blood transfusion. Given the lack of research supporting the optimal transfusion strategy for end-stage renal disease patients, it is difficult to weigh the risks and benefits of red blood cell transfusion. We find a paucity of evidence that hemoglobin concentration targeted between 11 and 11.5 g/dL is associated with a safety risk. Although the evidence that erythropoiesis-stimulating agent use improves patient quality of life is poor, it is possible that the instruments used to measure quality of life may not be well attuned to the needs of chronic kidney disease or dialysis patients. Our last section focuses specifically on the recommendations to treat anemia in children.
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