|Year : 2016 | Volume
| Issue : 6 | Page : 1188-1193
|Incidence of pediatric acute kidney injury in hospitalized patients
Mohd. Ashraf1, Naveed Shahzad2, Altaf Hussain3, Shafat Ahmed Tak2, Syed Tariq Ahmed Bukhari2, Aliya Kachru2
1 Pediatric Nephrology Division, Department of Pediatrics, G. B. Pant Hospital, Government Medical College, Srinagar, Jammu and Kashmir, India
2 Department of Pediatrics, Government Medical College, Srinagar, Jammu and Kashmir, India
3 Department of Pediatric Hematology, Department of Pediatrics, G.B. Pant Hospital, Government Medical College, Srinagar, Jammu and Kashmir, India
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|Date of Web Publication||28-Nov-2016|
| Abstract|| |
Pediatric acute kidney injury (pAKI) is a common complication associated with high mortality in children. The objective of this study was to determine the incidence of acute kidney injury (AKI) and mortality in hospitalized (critically ill and non-critically ill) patients. This was a retrospective study conducted during the period of June 1, 2013, to May 31, 2014, at the Postgraduate Department of Pediatrics, G. B. Pant Hospital, an Associated Hospital of Government Medical College, Srinagar, Jammu and Kashmir, India. All patients between the ages of one month and 18 years were included in the study, who had AKI. In general, out of 23,794 patients, 197 developed AKI (0.8%). On subgroup analysis, 2460 were critically ill and had Intensive Care Unit (ICU) admission among whom 99 developed AKI (4%), whereas 21,334 had general pediatric ward admissions and 98 developed AKI (0.5%). Infantile age group was the most commonly 91 (46.2%) affected. The common causes of AKI were renal in 73 (37%), neurologic in 38 (19%), septicemia in 35 (18%), and inborn errors of metabolism in 30 (15.2%). Out of 197 pAKI patients, 42 (21.3%) died and all of them were critically sick (ICU admissions). The incidence of pAKI in general was 0.8%, whereas it was 4% in critically ill children and 0.5% in general ward admissions implying an eight-fold increased risk of pAKI in critically ill patients.
|How to cite this article:|
Mohd. Ashraf, Shahzad N, Hussain A, Tak SA, Bukhari ST, Kachru A. Incidence of pediatric acute kidney injury in hospitalized patients. Saudi J Kidney Dis Transpl 2016;27:1188-93
|How to cite this URL:|
Mohd. Ashraf, Shahzad N, Hussain A, Tak SA, Bukhari ST, Kachru A. Incidence of pediatric acute kidney injury in hospitalized patients. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2020 Jan 26];27:1188-93. Available from: http://www.sjkdt.org/text.asp?2016/27/6/1188/194608
| Introduction|| |
Pediatric acute kidney injury (pAKI) is a syndrome of renal dysfunction resulting in sudden onset decline in glomerular filtration rates (GFRs), and inability of kidneys to regulate acid, electrolyte, and fluid balance.  pAKI in children is increasingly being recognized as an important contributor to childhood morbidity and mortality in the Intensive Care Units (ICUs) and independently increases hospital costs, length of stay (LOS), and ventilator days. 
The incidence rates of pAKI vary between interand intra-continental studies due to lack of uniformity in defining the pAKI. To overcome these AKI definition variations, adult nephrologists, pediatric nephrologists, and critical care specialists standardized the definition of AKI using the RIFLE criteria in 2004,  which later on was modified in 2007 by Acute Kidney Injury Network (AKIN) group using AKIN criteria.  This standardized version of AKI definition has been validated in hospitalized patients. Since majority of studies related to the pAKI are from the developed countries, ,, and there is a paucity of the data regarding the pAKI from the developing world, we aimed to know the incidence rate of pAKI and its associated risk factors among the hospitalized patients to depict the disease burden and its impact, in general, an attempt from our part to fill the knowledge gap.
| Materials and Methods|| |
This retrospective, observational study is based on data analysis of the records of the discharged and deceased patients, hospitalized in ICUand non-ICUs during the period of June 1, 2013 to May 31, 2014 in our Tertiary Care G. B. Pant Hospital catering the whole pediatric population of the Kashmir valley of Jammu and Kashmir, India. Following patients were excluded from the study: (a) neonates and patients aged more than 18 years, (b) those with established renal disease at the time of hospitalization, (c) Stage 5 renal disease, (d) bilirubin level >5 mg/dL, (e) hospital stay for <24 h, (f) known AKI at admission, with serum creatinine (SCr) >1.5 mg/dL, and (g) SCr not done at admission or at 48 h. The following information was collected for data analysis: age, gender, height, weight, provisional diagnosis, and treatment given including nephrotoxic drugs, important underlying chronic condition(s), diagnoses, hospital LOS, and SCr concentrations. Baseline SCr was defined as the lowest within 3 months before treatment initiation.  Baseline estimated GFR (eGFR) was calculated using the modified Schwartz formula.  In the absence of non availability of baseline SCr, we assumed a Schwartz eGFR of 120 mL/min/1.73 m 2 from which SCr was calculated.  The patients were diagnosed and classified into various stages based on AKIN criteria.  During the hospital stay, creatinine clearance criteria using the Schwartz equation were used to assign the stage of pAKI. Based on the AKIN criteria, AKI was defined as abrupt (within 48 h) reduction in kidney function with an increase in creatinine level.  The illness was categorized as Stage 1 (increase of creatinine by ≥0.3 mg/dL, or to 1.5-1.99 times baseline), Stage 2 (increase to 2-2.99 times baseline), and Stage 3 (increase to ≥3 times baseline, or ≥4 mg/dL with an acute rise of >0.5 mg/dL). 
The creatinine level was measured using the Jaffe method,  and the GFR was determined using the updated Schwartz formula [height in cm × K/creatinine (mg/dL), where K = 0.413].  Urine output criterion was not used for defining or staging AKI in our study.
Acute kidney injury (AKI): AKI was defined according to the recent AKIN staging,  whereby acute changes in SCr (rather than eGFR) are considered. The AKIN definition stipulates that SCr rise should occur within 48 h to classify as AKI.
Documented bacteremia: Conditions where source of infection is known, or at least two of the following findings: idiopathic hyperventilation or hypotension, fever higher than 38°C, or leukocytosis over 15,000/mm. 
Multiple organ failure: Failure of three or more organs, excluding the kidney.
Anuria: No urine output for a period of 24 h.  Average LOS in the hospital: period starting with admission to the hospital and ending on the day of death or discharge from the hospital.
The study was approved by the Research and Ethics Committee of the Government Medical College, Srinagar, wherein informed consent was not a prerequisite.
| Statistical Analysis|| |
All the case records meeting the inclusion criteria were recorded and analyzed using SPSS version 17.0. The parametric and non-parametric data were presented as mean ± standard deviation and median (inter-quartile range), respectively. Student's t-test and Mann-Whitney Utest were applied for continuous variables accordingly, and Chi-square test was applied for categorical variables.
| Results|| |
Total number of patients, aged between one month and 18 years admitted in our hospital were 23,794, as described in [Table 1]. AKI was most common (91/197, 46%) in <1 year age group followed by school age (>6-12 years) children accounting (49/197, 24.9%).
In general, incidence of pAKI observed in our patients was 8/1000 among the hospitalized patients. On subgroup analysis, 2460 patients were admitted in pediatric ICU (PICU) and among them 99 developed AKI [Table 2], implying an incidence of 40/1000, whereas among the 21,334 non-ICU patients, incidence was 5/1000. Stage-I AKI was the most common and Stage III AKI was the least common in non-ICU patients. However, in PICU patients, Stage I and II was equally common. In our study, 42 patients died, giving an overall mortality rate of 21.3%, and all the 42 deaths occurred among the PICU patients giving a mortality rate of 42.2% in PICU pAKI patients [Table 3].
|Table 2: ICU and non-ICU patients. Classified as per age and stage of AKI.|
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| Discussion|| |
Among the hospitalized patients, incidence of pAKI ranges from 1% to 31%, whereas mortality ranges from 28% to 82%.  This broad variation of pAKI incidence is influenced by population characteristics and SCr criteria in children by applying recently validated pRIFLE  and AKIN.  Applying same AKIN criteria, we analyzed one year's data of 23,794 children aged between one month and 18 years. Out of 23,794 patients, 2460 patients had PICU and 21,334 patients had general pediatric ward admissions. The incidence of pAKI in our PICU patients was 4% and in non-PICU was 0.5%, a trend which shares same results with earlier studies. ,,
In our study, the incidence of pAKI was 8fold higher in PICU patients than non-PICU patients which is showing a similar trend to the study done by Mehta et al  Patients who had inborn errors of metabolism, sepsis, shock, multiorgan failure, and respiratory failure developed advanced stages of pAKI, and they were at a higher risk for mortality as has been observed in other studies.  As per the Turkish Society for Pediatric Nephrology AKI Study Group,  this could be because of maladaptation of the kidneys to various derangements of milieu interior of the body or overreaction of renal system.
An etiological shift of AKI in children from primary kidney diseases to secondary renal diseases as the cause of pAKI is evidenced in recent studies. In developed countries, common causes are malignancies, nephrotoxic medications, and major surgeries,  whereas in developing countries, common causes of pAKI are hemolytic uremic syndrome, sepsis, postinfectious acute glomerulonephritis, and diarrheal diseases.  However, we had maximum proportion of pAKI from intrinsic renal impairments 37% (73/197), followed by pAKI secondary to neurological impairments 19% (38/197) and sepsis 18% (35/197), which is congruent with the studies conducted by Mehta et al  and Creda et al.  Among the renal etiologies, urinary tract infections, nephrotic and nephritic syndromes were the main entities responsible for pAKI, a finding needs more research for valid conclusions.
The underlying etiology of the AKI will dictate the future prospects of the pAKI patient, in terms of recovery to the normal, chronicity, and mortality. Any child who had AKI with multisystem failure will have higher mortality rate than children with isolated renal disease. Although various disease states such as nephrotoxic AKI and hypoxic AKI/ischemic AKI usually recover to normal, several recent studies have shown AKI as a risk factor for chronic kidney disease. , Evidence-based studies in adults have demonstrated that AKI is an independent risk factor for renal outcomes, , and the mortality in adults from AKI remains high, particularly in intensive care patients, in whom mortality was 53% in the ATN trial and 44.7% in the RENAL trial. Several well-powered studies have demonstrated the development of chronic kidney disease, end-stage kidney disease, and increased mortality from episodes of AKI. ,, Pertaining to shortand long-term implications of the pAKI, our study depicts a mortality rate of 21% (42/197) among the pAKI-affected children as an immediate outcome, all of whom were critically sick PICU patients. Comparable mortality rates (15%-83%) were also observed in various earlier studies. ,,,
Conflict of interest: None declared.
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Pediatric Nephrology Division, Department of Pediatrics, G.B. Pant Hospital, Government Medical College, Srinagar, Jammu and Kashmir
[Table 1], [Table 2], [Table 3]
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