Mounting evidence continues to show that acute kidney injury (AKI) occurs frequently in children and is associated with adverse outcomes, including development of chronic kidney disease. Still, AKI in children is poorly understood and specific standards for managing the condition in children have not been available. But a panel of 46 global experts in various medical specialties who convened at the first international pediatric AKI conference recently published consensus statements in JAMA Network Open to guide research and provide children-focused treatment recommendations.
“At this stage, we are only at the cusp of understanding why AKI occurs, how to diagnose it early, track it in real time, prevent it, nor how to care for it,” conference chair Rajit Basu, MD, MS, Division Head of Critical Care Medicine at Ann & Robert H. Lurie Children’s Hospital of Chicago, said in a statement prepared by the hospital. “We don’t have standards to manage care for children and have been using adult recommendations.”
Dr Basu, who is a professor of pediatrics at Northwestern University Feinberg School of Medicine in Chicago, also stated, “In order to improve care and reduce the morbidity and mortality associated with AKI in kids, we need to understand more about the unique aspects of which populations of children are at highest risk, how to modernize our diagnostics, ways to incorporate and optimize therapeutics, how development and age (differences between babies and teenagers for instance) impact this wide-ranging condition, and the importance of nutrition, fluid accumulation and other factors that are unique to children.”
Using a modified Delphi process, conference workgroups arrived at recommendations and suggestions in 6 areas:
- AKI epidemiology: Further studies are needed in non-intensive care unit and ambulatory settings, in low-middle income countries, and for socioeconomic and long-term outcomes. Strategies are needed to improve primary, secondary, and tertiary AKI prevention in at-risk patient groups.
- AKI risk stratification and diagnosis: Validated tools that incorporate patient characteristics and exposure should be used to estimate the risk of AKI in children, including kidney fitness assessment prior to intervention. Unique AKI phenotypes in children may overlap and change over time. Differentiating AKI phenotypes informs prognosis and therapy.
- Fluid assessment: Fluid balance is the difference between total input and output that can be expressed as “daily” and/or “cumulative” over a time period. Fluid overload is positive fluid balance associated with 1 or more clinically observable events, which may vary by age, case-mix, acuity, and phase of illness.
- Kidney support and extracorporeal therapies: A dedicated multidisciplinary team made up of kidney health care workers, patients, and families along with institutional investments of personnel, time, materials, and quality assurance/improvement systems are essential to a pediatric acute kidney support therapy program. Goals of care and degree of recovery inform decisions for de-escalation, liberation, transition, and follow-up.
- Pathobiology, nutrition, and pharmacology: Successful pediatric translational AKI research programs and nutrition measures prioritize child development.
- Education and advocacy for AKI in children: Given the adverse immediate and lifelong outcomes for children with AKI, education and advocacy are essential, starting with the patient and family and expanding across health care teams, systems, and communities.
In an accompanying editorial, Kianoush B. Kashani, MD, MS, of Mayo Clinic in Rochester, Minnesota, lauded the conference proceedings. “This report has the potential to affect clinical practice and open multiple avenues for investigation in pediatric AKI,” Dr Kashani wrote.
Studies Characterize Pediatric AKI
The publication of these recommendations comes amid recent studies characterizing the incidence, clinical course, and outcomes of AKI among hospitalized children. For example, in a study published in the Journal of the American Society of Nephrology, investigators matched and compared 1688 hospitalized children (aged 0 to 18 years) with a dialysis-treated AKI episode and 6752 hospitalized children without AKI. Among the children with AKI, 53.7% underwent mechanical ventilation and 33.6% had cardiac surgery.
During a median 9.6-year follow-up, children who survived AKI had a significant 3-fold increased risk of a composite outcome of kidney failure or death compared with children with no AKI, Rahul Chanchlani, MD, MS, of McMaster Children’s Hospital in Hamilton, Ontario, Canada, and colleagues reported.
Among the children who survived AKI, death occurred in 6.7%, kidney failure in 2.6%, hypertension in 12.1%, chronic kidney disease in 13.1%, and subsequent AKI in 14.0%. AKI survivors had significant 8.7- and 3.4-fold increased risks for CKD and hypertension, respectively, compared with children without AKI. Risks were greatest in the first year after discharge and gradually decreased over time.
Lack of Nephrology Follow-up
In a study looking at the same cohort, Dr Chanchlani and colleagues found that children with dialysis-treated AKI had a higher rate of outpatient visits within 1 year of discharge and higher rates of re-hospitalization and emergency department visits for up to 10 years compared with children who did not have AKI. In addition, children with dialysis-treated AKI had significant 46% and 16% increased risks of re-hospitalization and outpatient visits, respectively, Dr Chanchlani’s team reported in the American Journal of Kidney Diseases. Health care costs also were higher with dialysis-treated AKI. Despite the complications associated with dialysis-treated AKI, only 18.6% of patients saw a nephrologist in the first year of discharge.
A lack of nephrology follow-up also emerged in a separate study of 2041 children in the pediatric intensive care units of 2 medical centers. Of these, AKI developed in 355 patients (17%). Of the 355 patients, only 64 (18%) had a nephrology consult within the first year of discharge, Michael Zappitelli, MD, MS, of The Hospital for Sick Children in Toronto, Ontario, Canada, and colleagues reported in Pediatric Research. In addition, only 44 (31%) of 142 patients with stage 2-3 AKI had a nephrology follow-up by 1 year. The odds of nephrology follow-up within 1 year significantly increased 7.8-fold with inpatient nephrology consults, 4.3-fold with kidney admission diagnosis, and 2.7-fold with AKI non-recovery by discharge.
Disclosure: Some authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original references for a full list of authors’ disclosures.
Goldstein SL, Akcan-Arikan A, Alobaidi R, et al. Consensus-based recommendations on priority activities to address acute kidney injury in children: a modified Delphi consensus statement. JAMA Netw Open. Published online September 30, 2022. doi:10.1001/jamanetworkopen.2022.29442
Kashani KB. Highlights of consensus-based recommendations for acute kidney injury in children. JAMA Netw Open. Published online September 30, 2022. doi:10.1001/jamanetworkopen.2022.29511
First ever in pediatrics: World experts set agenda to improve care of acute kidney injury in kids [news release]. Ann and Robert H. Lurie Children’s Hospital of Chicago; September 28, 2022.
Robinson CH, Jeyakumar N, Luo B, et al. Long-term kidney outcomes following dialysis-treated childhood acute kidney injury: A population-based cohort study. J Am Soc Nephrol. 2021 Aug;32(8):2005-2019. doi: 10.1681/ASN.2020111665
Robinson CH, Klowak JA, Jeyakumar N, et al. Long-term health care utilization and associated costs after dialysis-treated acute kidney injury in children. Am J Kidney Dis. Published online August 16, 2022. doi:10.1053/j.ajkd.2022.07.005
Robinson C, Hessey E, Nunes S, et al. Acute kidney injury in the pediatric intensive care unit: outpatient follow-up. Pediatr Res. 2022 Jan;91(1):209-217. doi:10.1038/s41390-021-01414-9
Selewski DT, Askenazi DJ, Kashani K, et al. Quality improvement goals for pediatric acute kidney injury: pediatric applications of the 22nd Acute Disease Quality Initiative (ADQI) conference. Pediatr Nephrol. 2021;36:733–746. doi:10.1007/s00467-020-04828-5