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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2016  |  Volume : 27  |  Issue : 4  |  Page : 740-747
Acute kidney injury in critically ill child

1 Pediatric Intensive Care Unit, Queen Rania Abdulla Children Hospital, Amman, Jordan
2 Department of Pediatric Nephrology, Queen Rania Abdulla Children Hospital, Amman, Jordan
3 Department of Pediatric Neonatology, Queen Rania Abdulla Children Hospital, Amman, Jordan
4 King Hussein Medical Center, Amman, Jordan

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Date of Web Publication5-Jul-2016


Acute kidney injury (AKI) is a common and serious complication in patients in the Pediatric Intensive Care Unit (PICU). We conducted this study to estimate the incidence and the mortality rate of AKI in critically ill children as well as to describe some other related factors. A retrospective study was conducted at PICU of Queen Rania Abdulla Children Hospital, Amman, Jordan for the period extending from May 2011 to June 2013. The medical records of all patients admitted during this period, and their demographic data were reviewed. Patients with AKI were identified, and management and outcomes were reviewed and analyzed. AKI was evaluated according to modified RIFLE criteria. Of the 372 patients admitted to PICU, 64 (17.2%) patients developed AKI. Of these 64 patients who had AKI, 28 (43.7%) patients reached RIFLE max of risk, 21 (32.8%) patients reached injury, and 15 (23.4%) reached failure. Mean Pediatric Risk of Mortality II score at admission was significantly higher in patients with AKI than those without P <0.001. The age ranged between one month and 14 years with the median age as 5.4 year. Thirty-five (54.7%) were males. Sepsis was the most common cause of AKI. The mortality rate in critically ill children without AKI was 58.7%, whereas increased in children with AKI to 73.4%. The mortality rate in patients who received renal replacement therapy was 71.4% and was higher (81.5%) in patients who received mechanical ventilation (95%, [confidence interval (CI)] 79.3-83.4%) and was significantly higher in patients with multi-organ system dysfunction 90.3% (95%, [CI] 88.7-92.5%). The incidence of AKI in critically ill children is high and increased their mortality rate and higher mortality seen in the younger age group, especially those below one year. High mortality rate was associated with multi-organ system dysfunction and the need for mechanical ventilation.

How to cite this article:
Al-jboor W, Almardini R, Al Bderat J, Frehat M, Al Masri H, Alajloni MS. Acute kidney injury in critically ill child. Saudi J Kidney Dis Transpl 2016;27:740-7

How to cite this URL:
Al-jboor W, Almardini R, Al Bderat J, Frehat M, Al Masri H, Alajloni MS. Acute kidney injury in critically ill child. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2021 Dec 3];27:740-7. Available from: https://www.sjkdt.org/text.asp?2016/27/4/740/185236

   Introduction Top

Acute kidney injury (AKI) was previously known as acute renal failure due to ischemic and hypoxic processes. It takes place in the kidneys much earlier than the rise in creatinine level. [1] AKI is clinical syndrome characterized by reversible increase in the concentration of creatinine and nitrogenous waste products in the blood and the inability of the kidney to regulate fluid and electrolyte balance. [2] It is an important and serious clinical problem, especially in children with critical illnesses of different diagnosis. [3] The differentiation between so-called "pre-renal" and "renal" causes is more difficult because renal hypo-perfusion may coexist with any stage of AKI; this means that patients with renal hypo-perfusion may have AKI according to oliguria criteria without an overtly demonstrable decrement in the GFR, particularly as assessed by a change in serum creatinine (SCr) concentration. [4]

Most recent classification scheme for AKI was established by acute dialysis quality initiative work group that defines grades of increasing severity of AKI as R-risk, I-injury, F-failure, and two outcome classes (L for loss and E for end-stage renal failure), [5] the so-called RIFLE classification. The pediatric RIFLE criteria are based on a modification of adult RIFLE criteria. RIFLE criteria were created to provide a unifying definition for AKI, [6] making it simple to apply in a variety of clinical and research setting. [7] The use of such definition in the literature has increased gradually over the last six years. [6],[8] The RIFLE criteria represent a simple tool for the detection and classification of AKI and for correlation with clinical outcome. [9],[10] It depends mainly on SCr and urine outputs. Hence, the introduction of the RIFLE classification has certainly increased our conceptual understanding of the AKI syndrome, and this classification already has been tested successfully in a number of clinical studies and facilitate research across disciplines. [11],[12]

To use this classification, in different studies, Piccinni et al reported that it can be done in centers where 6 and 12 h urine outputs are measured routinely which are the criteria used for risk and injury. [6] In the Pediatric Intensive Care Unit (PICU) of Queen Rania Abdulla Children Hospital (QRCH), both SCr measurement, 6 and 12 h urine output were routinely measured, which allowed us to do a retrospective study by collecting and analysis data from the medical records. Fluid overload was unfortunately not monitored in our critically ill patients.

The problem of the unknown baseline creatinine (bCr) remains unresolved, for example, a patient who presents to the emergency room with an elevated SCr most probably would not have a bCr value. In this scenario, only a retrospective diagnosis of AKI is possible, from the SCr during the hospitalization. [13] However, in our PICU where this study was conducted, we found that rising SCr and decreased urine output were seen frequently in critically ill children of different diagnoses, and it is believed to be associated with increased mortality. Therefore, this retrospective study was made to estimate the frequency of AKI, its effect on length of stay at hospital and its association with increased mortality.

According to the best of our knowledge, there are only a few studies about AKI in critically ill children. [13],[14] We thought that this study will increase our knowledge about mortality in AKI and associated risk factors.

   Patients and Methods Top

A retrospective analysis of the medical records data of all children admitted to PICU, during the period from April 31, 2011, to May 1, 2013. The QRCH is a tertiary care unit that deals with complex clinical pediatric diseases. It has 18 beds including four incubators and two isolation rooms and provides care for children from one month to 14 years.

We included in this study, 372 children who were admitted to PICU during the study period due to critical illness of different causes and diagnosis. Reviewed their medical data regarding patients weight, age, gender, hourly urine output, and SCr.

Any patient known to have chronic kidney disease was excluded from this study. Those below one month and above 14 years were also excluded from this study. All patients with AKI were classified based on RIFLE criteria either at admission or subsequently during their PICU stay. When baseline SCr was unknown in patients with no history of chronic kidney disease, baseline estimated creatinine clearance was calculated using Schwartz equation from SCr measured if available before this admission, or patients were assumed to have bCr clearance >100 mL/min/1.73 m 2 . Maximum RIFLE stage reached during PICU stay was recorded.

Two groups of critically ill children were identified; the first group, the patients who developed AKI without multi-organ dysfunction syndrome (MODS)-failure of three organs or more excluding the kidney, and the second group, the patients who developed AKI associated with MODS. All children with a rise in creatinine more than 1.5 mg/dL, or had decreased urine output, oliguria: <1 mL/kg/h, anuria: <0.5 mL/kg/h, which lasted more than 6 h were included in this study. Each patient was evaluated for AKI risk factors, and assessment of organ dysfunction was done.

   Results Top

Among the 372 patients enrolled in this study, 64 (17.2%) children were identified to have AKI. Twenty-nine (45.3%) were females and 35 (54.7%) were males. Their age range was between one month and 14 years, with a median age of 5.4 years. Twenty-one (32.8%) children were below the age of one year, and 15 (23.4%) children were between one and three years. Twelve (18.7%), nine (14%), and seven (11%) were between three and six years, six to 10 years, and 10-14 years, respectively, as shown in [Table 1]. Mean Pediatric Risk of Mortality II score at PICU admission was 16.5. Sixty-five percent (42/64) patients with AKI had preexisting chronic conditions. Forty-two percent (27/64) patients received vasoactive medications.
Table 1: Age distribution of patients with AKI according to pRIFLE classification.

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Total children on ventilator were 122 (32.8%) over the period of the study, of them 23 (6.2%) children were on ventilator had AKI, which represents 23/64 (36%) of children with AKI.

The most common cause of AKI in children seen at our PICU was sepsis 29 (45.3%) followed by acute gastroenteritis 10 (15.6%). Diseases due to inborn errors of metabolism accounted for five (7.8%) children, postsurgical for five (7.8%) children, malignancies for four (6.3%) children, hemolytic uremic syndrome (HUS) for three (4.7%) children, congenital heart diseases for three (4.7%) children, neurological and musculoskeletal diseases accounted for three (4.7%) children and cystic fibrosis for two (3.1%) children as shown in [Table 2].
Table 2: Distribution of patients with AKI according to their critical diseases.

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The days of hospitalization ranged from five to 28 days, the median stay in PICU for children with AKI was 11.3 ± 2 days, whereas the median stay for critical children without AKI was 6.4 ± 2 days. Children with AKI on ventilator had longer hospitalization stay in PICU. The median stay was 13.7 ± 2 days. According to RIFLE, critical children diagnosed as AKI risk in 28 (43.7%), injury in 21 (32.8%), and failure in 15 (23.4 %), which represented of total critical children, 7.5%, 5.6%, and 4%, respectively.

MODS with AKI was seen in 26/64 (40.6%) children. While children without AKI and with MODS were 83/308 (27%). Seven children (11%; 95%, confidence interval [CI] 9.5-13.6) during their stay in PICU need renal replacement therapy (RRT). Seven children (11%; 95%, CI 9.5-13.6) during their stay in PICU needed RRT.

In our study, 47 (73.4%) children with AKI died. As seen in [Table 3] per RIFLE classification, the mortality seen in groups was in risk 19/28 (67.8%), injury 15/21 (71.4%), and failure 13/15 (86.6%).
Table 3: Outcome of critically ill children with AKI.

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Five children required peritoneal dialysis. Three of them died. The first patient aged 2.5 months died due to septic shock, the second patient aged nine-months died due to severe hypernatremia, hyperkalemia, and dehydration The third patient died during peritoneal dialysis who was diagnosed as a case of HUS. The other two patients survived. One of them aged eight months with AKI occurring following acute gastroenteritis recovered his kidney function back to normal, and the last child aged 11 months was discharged from PICU with CKD.

Two children needed hemodialysis and both died. First child was a 9-year-old female with non-Hodgkin lymphoma who was on mechanical ventilator developed disseminated intravascular coagulation. The second child aged 13 years with cystic fibrosis due to severe attack of acute respiratory distress syndrome. The mortality rate in critical children without AKI was estimated as 58.7% (95%, [CI] 56.3-61.2%), but was higher in AKI children, 73.4% (95%, [CI] 71.3-75.7%). Among in AKI children who received RRT, the mortality rate was 71.4% (95% [CI] 68.7-73.5%), whereas in children on mechanical ventilator, it was 81.5% (95%, [CI] 79.3-83.4%) and in AKI children associated with MODS, the mortality rate was significantly high 90.3% (95%, [CI] 88.7-92.5%).

   Discussion Top

In this retrospective study, we analyzed the data from their medical files using RIFLE criteria to diagnose AKI so that we could identify the risk factors, estimate the incidence of AKI, and its association with mortality in PICU.

The assessment of AKI on admission to the hospital can be performed easily using the RIFLE classification. [15] AKI is common among critically ill patients admitted to the Intensive Care Unit (ICU), up to 25% depending on the population studied. [1],[2],[3],[4] The overall incidence of AKI is difficult to assess and varies among different study populations in developing countries, with an overall range from 1% to 25% in critically ill patients. [16] However, in other studies in critically ill patients, the development of AKI is more frequent and occurs in 15-64% of ICU patients. [17],[18],[19],[20] In our study, the incidence of AKI was estimated to be 17.2% among critically ill children who were admitted in PICU during the period of this study. Sepsis (45.3%) was the most frequent cause for AKI, similar to the findings of other studies. [21],[22],[23]

Sepsis is a well-known risk factor for the development of AKI, and nearly half of all patients with AKI have sepsis. [24],[25] The other most significant factors of AKI in critically ill children are the younger age (1 month to 1 year) (42.2%), male sex (54.7%), and MODS (40.6%). These factors are also associated with higher mortality rate.

Williams et al over 20 years of pediatric experience in AKI found that an important and a significant risk factor for mortality was age. In their study, the youngest patients showed a higher mortality rate. [26] The most important factor associated with higher mortality rate seen in our study was MODS with dramatically increased mortality rate of 90.3%, these findings are supported by similar data by Lafrance et al, they found a relatively high incidence of AKI and that younger age, MODS, and male sex are associated with a higher risk of AKI and higher mortality rate. [27] Similar findings were seen by Williams et al. [26] On the other hand, critical illness leading to MODS and associated AKI is less common in children compared to adult patients. [28]

AKI children on mechanical ventilation, considered as an associated risk factor, had increased mortality rate compared with AKI children without the need for mechanical ventilation. Longer length of stay and prolonged mechanical ventilation in critically ill children are risk factors for increased mortality as was seen in a two-center retrospective cohort study. [29] Therefore, the RIFLE classification was useful for predicting in-hospital mortality. [23] In this study, the children with AKI were found to have increased mortality rate by comparing with children without AKI (73.4% vs. 58.7%), respectively. In other centers, the hospital mortality varied from 50.5% to 76.8% between centers. [30]

Regardless of the current treatment protocols and the availability of RRT, AKI-related hospitality mortality remains unacceptably high ranging between 36% and 70%. [31],[32],[33] Unfortunately mortality rate after RRT of AKI children is still high (71.4%) and use of RRT did not show a significant decrease in mortality of AKI children (73.4%). Despite significant technical advances in therapeutics, the mortality and morbidity rates associated with AKI remain dismally high and have not appreciably improved during the past four decades. However, this has increased duration of stay in ICU [34],[35],[36],[37] which imposes a huge burden on society in terms of cost, suffering, health outcomes, and costs across a broad spectrum of conditions. [38],[39],[40]

According to RIFLE, a worse RIFLE classification is associated with higher mortality rate and a longer ICU stay or hospital stay. [5],[7],[41] Also Mortality was higher with an odds ratio (OR) of 6.3 (95% CI 5.6-7.4) for one class increase by RIFLE and the worse, the RIFLE class was, the higher was the mortality rate (P <0.001), as was seen in other studies which showed excellent association of outcome variables with worse outcome among those with higher severity of AKI. [7],[42] According to Massimo et al, the most important topics in this context is the question if and how AKI can be prevented and how it can be managed. Therefore, they highlighted the need of a list of recommendations from the working group within the European Society of Intensive Care Medicine. One of the most important recommendations is the need for prompt resuscitation of the circulation. [21]

We confirm in this study that AKI affecting critically ill patients is associated with higher mortality rate even after RRT, longer length of stay and increased in-hospital mortality, especially if AKI was associated with MOD. Patients on ventilators had deterioration in the clinical condition of PICU patients and in the end had dramatically increased mortality rate as reported in other studies. [7],[20],[22],[29],[31],[41],[42],[43],[44],[45],[46]

Our study had some limitations. Children with burns and post-cardiac surgery, who are highly vulnerable for AKI, were not included in this study as the burn patients were treated in burn units and cardiac surgery were being conducted in our cardiac center. Second, most of our patients were not treated by RRT as they were hemodynamically unstable had increased bleeding tendency and rapid deterioration in their general condition. Our database did not include long-term follow-up, and thus, the outcomes for patients following hospital discharge are unknown. The absence of post-discharge information is a significant limitation of our study.

Further studies are needed to find out AKI incidence and to recognize and estimate its risk factors so as to find new strategies to prevent, decrease, and treat AKI in critically ill children and to improve their survival, decrease mortality, and decrease the need for RRT and in general, to decrease suffering of critically ill children.

   Conclusion Top

AKI in critically ill children is found to have a high incidence, higher mortality, and prolonged hospitalization stay. Highest mortality rate was seen in younger age group, especially in those below one year of age. Further studies are needed in future to evaluate techniques to monitor and manage AKI to improve the overall prognosis.

Conflict of interest: None declared.

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Correspondence Address:
Wejdan Al-jboor
Pediatric Intensive Care Unit, Queen Rania Abdulla Children Hospital, Amman
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DOI: 10.4103/1319-2442.185236

PMID: 27424691

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  [Table 1], [Table 2], [Table 3]

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