From the Journals

Acute kidney injury common in children, young adults in ICU

View on the News

Identify and treat acute kidney injury promptly

A strength of this study is the definition of acute kidney injury, with the use of precise and validated criteria. Limitations of the study, beyond its observational nature, include the lack of data about diuretic and other treatment that may have influenced urine output, and the requirement for just a single baseline plasma creatinine level for study entry.

However, the study results indicate that acute injury is not only common among critically ill children and young adults, but is associated with adverse outcomes, implying that we should look more carefully for markers of acute kidney injury. Given the link between acute kidney injury and subsequent chronic kidney disease, it possible that identifying and treating acute kidney injury promptly might reduce the prevalence of chronic kidney disease, now estimated as roughly one in eight adults in the United States.

Julie R. Ingelfinger, MD, is a pediatric nephrologist at Massachusetts General Hospital and deputy editor of the New England Journal of Medicine. These comments are excerpted from an accompanying editorial (N Eng J Med. 2016 Nov 18. doi: 10.1056/NEJMe613456). No conflicts of interest were declared.



Acute kidney injury is common in children and young adults admitted to ICUs, and cannot always be identified by plasma creatinine level alone, according to the authors of a study presented at the meeting sponsored by the American Society of Nephrology.

The Assessment of Worldwide Acute Kidney Injury, Renal Angina, and Epidemiology (AWARE) study was a prospective, international, observational study in 4,683 patients aged 3 months to 25 years, recruited from 32 pediatric ICUs over the course of 3 months.

Hemera Technologies/Thinkstock
The study, published simultaneously in the New England Journal of Medicine, examined the epidemiology, risk factors, and morbidity associated with acute kidney injury in a pediatric cohort (N Eng J Med. 2016 Nov 18. doi: 10.1056/NEJMoa1611391).

Ahmad Kaddourah, MD, from the Center for Acute Care Nephrology at the Cincinnati Children’s Hospital Medical Center, and his coauthors found that 27% of the participants developed acute kidney injury and 12% developed severe acute kidney injury – defined as stage 2 or 3 acute kidney injury – within the first 7 days after admission.

The risk of death within 28 days was 77% higher among individuals with severe acute kidney injury, even after accounting for their original diagnosis when they were admitted to the ICU. Mortality among these individuals was 11%, compared with 2.5% among patients without severe acute kidney injury. These patients also had an increased use of renal replacement therapy and mechanical ventilation, and were more likely to have longer stays in hospital.

Researchers also saw a stepwise increase in 28-day mortality associated with maximum stage of acute kidney injury.

“The common and early occurrence of acute kidney injury reinforces the need for systematic surveillance for acute kidney injury at the time of admission to the ICU,” Dr. Kaddourah and his associates wrote. “Early identification of modifiable risk factors for acute kidney injury (e.g., nephrotoxic medications) or adverse sequelae (e.g., fluid overload) has the potential to decrease morbidity and mortality.”

Of particular note was the observation that 67% of the patients who met the urine-output criteria for acute kidney injury would not have been diagnosed using the plasma creatinine criteria alone. Furthermore, “mortality was higher among patients diagnosed with stage 3 acute kidney injury according to urine output than among those diagnosed according to plasma creatinine levels,” the authors reported.

There was a steady increase in the daily prevalence of acute kidney disease, from 15% on day 1 after admission to 20% by day 7. Patients with stage 1 acute kidney injury on day 1 also were more likely to progress to stage 2 or 3 by day 7, compared with patients who did not have acute kidney injury on admission.

However, around three-quarters of this increase in stage occurred within the first 4 days after admission, which the authors suggested would support a 4-day time frame for future studies on acute kidney injury in children. They also stressed that as their assessments for acute kidney injury stopped at day 7 after admission, there may have been incidents that were missed.

Dr. Kaddourah and his associates noted that although the rates of severe and acute kidney injury seen in the study were slightly lower than those observed in studies in adults, the associations with morbidity and mortality were similar.

“The presence of chronic systemic diseases contributes to residual confounding in studies of acute kidney injury in adults,” they wrote. “Children have a low prevalence of such chronic diseases; thus, although the incremental association between acute kidney injury and risk of death mirrors that seen in adults, our study suggests that acute kidney injury itself may be key to the associated morbidity and mortality.”

The study was supported by the Pediatric Nephrology Center for Excellence at Cincinnati Children’s Hospital Medical Center. The authors declared grants, consultancies, speaking engagements, and other support from private industry, some related to and some outside of the submitted work.

Recommended Reading

2016 Pediatric Hospital Medicine Award Winners Announced
The Hospitalist
Collaborative Approaches Improve Pediatric Discharges
The Hospitalist
Why Required Pediatric Hospital Medicine Fellowships Are Unnecessary
The Hospitalist
Pediatric Hospital Medicine 2016 Wrap Up
The Hospitalist
Pediatric Hospital Medicine Meetings Foster Engagement, Growth
The Hospitalist
Pediatric Hospitalist Michael Beck, MD, FAAP, Measures Success By Others’ Success
The Hospitalist
PHM16: Pediatric Hospital Medicine Leaders Kick Off 2016 Conference
The Hospitalist
PHM16: Promoting, Teaching Pediatric High Value Care
The Hospitalist
Get up to Speed on the Latest in Pediatric Hospital Medicine
The Hospitalist
Register for Pediatric Hospital Medicine 2016
The Hospitalist
   Comments ()