Chronic Kidney Disease (CKD) Outcomes Can be Predicted within 90 Days Following Pediatric Allogenic Hematopoietic Cell Transplantation (AlloHCT)

Abstract

Risk factors associated with progression of AKI to CKD in pediatric AlloHCT recipients is not well described. We investigated the association between AKI and progression to CKD. A retrospective observational study of 275 patients post-AlloHCT age 1-21 years was performed with longitudinal follow up of three years. KDIGO staging for AKI and CKD universally applied by nephrologists to assess renal function was used. AKI defined as >0.3mg/dl increase from baseline creatinine. CKD defined as GFR <60ml/min/1.73m2 for >3months. GFR analyzed 90 days from the initial AKI episode was termed CKD90. Among patients that developed CKD90, CKD incidence and risk factors were analyzed 1 and 3 years post-AlloHCT. Univariate model for CKD risk factors included pre-transplant characteristics, infections, nephrotoxic agents and AKI parameters; risk factors with p<0.01 were included in multivariable model. Median age of 9.5±6 years, 99.6% patients had AKI. The median time to AKI was 34 days (92.8±206). Incidence of Grade 1, 2 and 3 AKI was 43%, 41% and 15%, respectively.GFR of 76.4% (210/274) met criteria for CKD (≥ stage 2) (Table 1). Majority of CKD90 patients were stage 2 CKD (35.7%) followed by stage 3 CKD (22.9%) (Table 1). Among the CKD90 patients who met criteria for CKD 1-year post AlloHCT, CKD stage 2 andCKD stage 3 were 37.1% and 16.9%, respectively (Figure 1). Upon multivariable analysis of risk factors for development of CKD at 1 and 3 year- CKD90, estimated baseline GFRand proteinuria were associated with progression to CKD (Table 2). Common factors associated with AKI in 1st 100 days of AlloHCT, such as bacterial and viral infections, tacrolimus levels >15ng/dl, vancomycin levels >20ng/dl, exposure to ganciclovir, foscarnet, cidofivir and ambisome were individually not associated with progression to CKD, indicating the possibility of multi-factorial contribution. Estimated baseline GFR, GFR at 90 days from the time of initial AKI episode and proteinuria can identify children at risk for CKD 1 year and 3 years post-AlloHCT.