Early and late acute kidney injury: temporal profile in the critically ill pediatric patient

Amanda Ruth; Rajit K Basu; Scott Gillespie; Catherine Morgan; Joshua Zaritsky; David T Selewski; Ayse Akcan Arikan

doi:10.1093/ckj/sfab199

Early and late acute kidney injury: temporal profile in the critically ill pediatric patient

Clin Kidney J. 2021 Oct 19;15(2):311-319. doi: 10.1093/ckj/sfab199. eCollection 2022 Feb.

Authors

Amanda Ruth¹, Rajit K Basu², Scott Gillespie³, Catherine Morgan⁴, Joshua Zaritsky⁵, David T Selewski⁶, Ayse Akcan Arikan¹

Affiliations

¹ Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.
² Division of Critical Care Medicine, Children's Healthcare of Atlanta, Emory University Department of Pediatrics, Atlanta, GA, USA.
³ Biostatistics core of Emory Pediatric Research Center, Emory University School of Medicine, Atlanta, GA, USA.
⁴ Department of Pediatrics, Division of Pediatric Nephrology, University of Alberta, Alberta, Canada.
⁵ St Christophers Children Hospital for Children, Philadelphia, PA, USA.
⁶ Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA.

Abstract

Background: Increasing AKI diagnosis precision to refine the understanding of associated epidemiology and outcomes is a focus of recent critical care nephrology research. Timing of onset of acute kidney injury (AKI) during pediatric critical illness and impact on outcomes has not been fully explored.

Methods: This was a secondary analysis of the Assessment of Worldwide Acute Kidney Injury, Renal Angina and Epidemiology (AWARE) database. AKI was defined as per Kidney Disease: Improving Global Outcomes criteria. Early AKI was defined as diagnosed at ≤48 h after intensive care unit (ICU) admission, with any diagnosis >48 h denoted as late AKI. Transient AKI was defined as return to baseline serum creatinine ≤48 h of onset, and those without recovery fell into the persistent category. A second incidence of AKI ≥48 h after recovery was denoted as recurrent. Patients were subsequently sorted into distinct phenotypes as early-transient, late-transient, early-persistent, late-persistent and recurrent. Primary outcome was major adverse kidney events (MAKE) at 28 days (MAKE28) or at study exit, with secondary outcomes including AKI-free days, ICU length of stay and inpatient renal replacement therapy.

Results: A total of 1262 patients had AKI and were included. Overall mortality rate was 6.4% (n = 81), with 34.2% (n = 432) fulfilling at least one MAKE28 criteria. The majority of patients fell in the early-transient cohort (n = 704, 55.8%). The early-persistent phenotype had the highest odds of MAKE28 (odds ratio 7.84, 95% confidence interval 5.45-11.3), and the highest mortality rate (18.8%). Oncologic and nephrologic/urologic comorbidities at AKI diagnosis were associated with MAKE28.

Conclusion: Temporal nature and trajectory of AKI during a critical care course are significantly associated with patient outcomes, with several subtypes at higher risk for poorer outcomes. Stratification of pediatric critical care-associated AKI into distinct phenotypes is possible and may become an important prognostic tool.

Keywords: acute kidney injury; outcome; pediatric critical care; prognostication; renal recovery.