Pediatric Acute Kidney Injury Research Articles

Dialysis for paediatric acute kidney injury in Cape Town, South Africa.

Dialysis is lifesaving for acute kidney injury (AKI), but access is poor in less resourced settings. A "peritoneal dialysis (PD) first" policy for paediatric AKI is more feasible than haemodialysis in low-resource settings. Retrospective review of modalities and outcomes of children dialysed acutely at Red Cross War Memorial Children's Hospital between 1998 and 2020. Of the 593 children with AKI who received dialysis, 463 (78.1%) received PD first. Median age was 9.0 (range 0.03-219.3; IQR 13.0-69.6) months; 57.6% were < 1year old. Weights ranged from 0.9 to 2.0kg (median 7.0kg, IQR 3.0-16.0kg); 38.6% were < 5kg. PD was used more in younger children compared to extracorporeal dialysis (ECD), with median ages 6.4 (IQR 0.9-30.4) vs. 73.9 (IQR 17.5-113.9) months, respectively (p = 0.001). PD was performed with Seldinger soft catheters (n = 480/578, 83%), predominantly inserted by paediatricians at the bedside (n = 412/490, 84.1%). Complications occurred in 127/560 (22.7%) children receiving PD. Overall, 314/542 (57.8%) children survived. Survival was significantly lower in neonates (< 1month old, 47.5%) and infants (1-12months old, 49.2%) compared with older children (> 1year old, 70.4%, p < 0.0001). Survival was superior in the ECD (75.4%) than in the PD group (55.6%, p = 0.002). "PD First for Paediatric AKI" is a valuable therapeutic approach for children with AKI. It is feasible in low-resourced settings where bedside PD catheter insertion can be safely taught and is an acceptable dialysis modality, especially in settings where children with AKI would otherwise not survive.

Derivation and Validation of an Optimal Neutrophil Gelatinase-Associated Lipocalin Cutoff to Predict Stage 2/3 Acute Kidney Injury (AKI) in Critically Ill Children

IntroductionAcute kidney injury (AKI) defined by changes in serum creatinine (SCr), or oliguria is associated with increased morbidity and mortality in critically ill children. We derived and validated a clinical cutoff value for urine neutrophil gelatinase-associated lipocalin (NGAL), in a prospective multicenter study of critically ill children. We report the clinical performance of urine NGAL (uNGAL) to aid in pediatric AKI risk assessment. MethodsEligible subjects were aged > 90 days to < 22 years, admitted to an intensive care unit (ICU), and had one or more of the following: mechanical ventilation, vasoactive medication administration, solid organ or bone marrow transplantation, or hypotension within 24 hours of admission. uNGAL assessed within 24 hours of admission. The primary outcome was SCr-based Stage 2/3 AKI presence at 48-72 hours. ResultsTwenty-five (12.3%) derivation study patients had Stage 2/3 AKI at 48-72 hours. uNGAL concentration of 125 ng/mL was the optimal cutoff. Forty-seven (9.1%) validation study patients had Stage 2/3 AKI at 48-72 hours. The AUC-ROC for uNGAL performance was 0.83 (95%CI 0.77-0.90). Performance characteristics were sensitivity 72.3% (95%CI 57.4-84.4%), specificity 86.3% (95%CI 82.8-89.3%), positive predictive value 34.7% (95%CI 28.5-41.5%), and negative predictive value 96.9% (95%CI 95.1-98.0%). ConclusionsThese prospective, pediatric, multicenter studies demonstrate uNGAL in the first 24 hours performs very well to predict KDIGO Stage 2/3 AKI at 48-72 hours into an ICU course. We suggest that a urine NGAL cut point of 125 ng/mL can aid in the risk assessment for Stage 2/3 AKI persistence or development.

15 Mobile Health Intervention Development to Improve Patient-Centered Care in Pediatric Acute Kidney Injury

15 Mobile Health Intervention Development to Improve Patient-Centered Care in Pediatric Acute Kidney Injury

Assessment of South Asian Pediatric Acute Kidney Injury: Epidemiology and Risk Factors (ASPIRE)-a prospective study on "severe dialysis dependent pediatric AKI".

Pediatric acute kidney injury (AKI) is a global health concern with an associated mortality risk disproportionately pronounced in resource-limited settings. There is a pertinent need to understand the epidemiology of pediatric AKI in vulnerable populations. Here, we proposed a prospective study to investigate the epidemiology and associated risk factors of "severe dialysis dependent AKI" in children among South Asian nations which would be the first and largest of its kind. The ASPIRE study(part of PCRRT-ICONIC Foundation initiative) is a multi-center, prospective observational study conducted in South Asian countries. All children and adolescents ≤ 18years of age who required dialysis for AKI in any of the collaborating medical centers were enrolled. Data collection was performed until one of the following endpoints was observed: (1) discharge, (2) death, and (3) discharge against medical advice. From 2019 to 2022, a total of 308 children with severe AKI were enrolled. The mean age was 6.17years (63% males). Secondary AKI was more prevalent than primary AKI (67.2%), which predominantly occurred due to infections, dehydration, and nephrotoxins. Common causes of primary AKI were glomerulonephritis, hemolytic uremic syndrome, lupus nephritis, and obstructive uropathy. Shock, need for ventilation, and coagulopathy were commonly seen in children with severe AKI who needed dialysis. The foremost kidney replacement therapy used was peritoneal dialysis (60.7%). The mortality rate was 32.1%. Common causes of AKI in children in South Asia are preventable. Mortality is high among these children suffering from "severe dialysis dependent AKI." Targeted interventions to prevent and identify AKI early and initiate supportive care in less-resourced nations are needed.

Acute kidney injury requiring dialysis in children: a multicentric, emerging country perspective.

Acute kidney injury (AKI) is a life-threatening condition, especially in extreme age groups and when kidney replacement therapy (KRT) is necessary. Studies worldwide report mortality rates of 10-63% in pediatric patients undergoing KRT. Over 13years, this multicenter study analyzed data from 693 patients with AKI, all receiving KRT, across 74 hospitals and medical facilities in Rio de Janeiro, Brazil. The majority were male (59.5%), under one year old (55.6%), and treated in private hospitals (76.5%). Sixty-six percent had comorbidities. Pneumonia and congenital heart disease were the most common admission diagnoses (21.5% and 20.2%, respectively). The mortality rate was 65.2%, with lower rates in patients over 12years (50%). Older age was protective (HR: 2.35, IQR [1.52-3.62] for neonates), and primary kidney disease had a three-fold lower mortality rate. ICU team experience (HR: 0.74, IQR [0.60-0.91]) correlated with lower mortality, particularly in hospitals treating 20 or more patients. Among the deceased, 40% died within 48h of KRT initiation, suggesting possible late referral or treatment futility. This study confirms the high mortality in pediatric dialytic AKI in middle-income countries, underlining early mortality and offering critical insights for improving outcomes.

Clinical profile and outcome of acute kidney injury in children admitted to paediatric intensive care unit: A prospective observational study

Introduction: Acute kidney injury (AKI) is a commonly encountered problem in the paediatric intensive care unit (PICU). There are limited reports on paediatric AKI from the Indian subcontinent. Objective: To determine the incidence, aetiology and outcome in paediatric AKI using Acute Kidney Injury Network (AKIN) criteria. Method: This prospective observational study was conducted in the PICU of a teaching hospital in Western Maharashtra, India, from July 2016 to June 2017 on patients aged 1 month to 17 years. Results: The incidence of AKI was 18.8% (80/426). The mean age was 70 ± 60 months. Most (66.3%) cases had stage I AKI and 54% developed AKI within 72 hours. Sepsis (35%), pneumonia (25%) and tropical febrile illnesses (18.7%) were the common aetiologies. Complete recovery (CR) was seen in 79% and partial recovery (PR) in 21%. CR was highest in stage I (91%) as compared to stages II and III (p=0.005). Mortality was 22% (18/80). Mortality significantly increased with the stage of AKI (p=0.003). Mechanical ventilation, inotrope support, shock and the stage of AKI had a significant association with mortality on bivariate analysis. Mechanical ventilation was found to be a significant independent predictor of mortality (p= 0.011). Renal replacement therapy was needed in 6 (8%) cases. Conclusions: About one-fifth of children admitted to ICU developed AKI and most experienced mild transient AKI. Moderate to severe AKI carried high mortality suggesting a dose-response effect. Infections remain the commonest cause and mechanical ventilation was an independent predictor of mortality.

Clinical profile of pediatric acute renal failure patients requiring renal replacement therapy age less than 15 years: an ambivalent COHORT study

Background: Acute kidney injury (AKI) is characterized by a reversible increase in the blood concentration of creatinine and nitrogenous waste products and by the inability of the kidney to regulate fluid and electrolyte homeostasis appropriately. There is minimal data on the clinical profile of pediatric AKI patients age less than 15 years who required renal replacement therapy (RRT). Methods: A total of 301 patients (3%) were diagnosed with AKI, amongst them 66 patients who required RRT from January 2021 to December 2022 were enrolled. Their clinical, biochemical, and etiological profile were studied to find out their influence in modifying the outcome of AKI patients requiring RRT. Results: AKI was noted in 301 patients (3%), amongst them 66 patients we had analyzed who underwent RRT. Result were analyzed in three age group (0-2 month, 2 month-8 year, 8 year-15 year). Male preponderance was seen amongst all age groups with male: female ratio being 2:1, 5:1 and 1.8:1 respectively and rural area preponderance seen in all age groups. Birth asphyxia, neonatal sepsis and septicemia were leading etiologies in different groups. Peritoneal dialysis (PD) was only RRT modality in the 0-2 month age group, while hemodialysis and PD modalities were used in rest groups. Multi-organ dysfunction syndrome was commonly seen comorbidity associated with all groups along with pyogenic meningitis, and encephalopathy. Mortality rate was observed at 47% (n=31). Conclusions: From our study, we conclude that to expand the facility of point of care, hemodialysis facility in ICUs with a larger study or multicentric study in the pediatric age group is required.

Profile of Acute Kidney Injury in the Pediatric Age Group in a Tertiary Care Hospital: A Prospective Observational Study.

Acute kidney injury (AKI) is a menace in the pediatric intensive care unit (PICU) and is responsible for significant morbidity and mortality all over the world. There are limited data available on pediatric AKI in central India. Our primary objective is to determine the clinical, etiological, and outcome profile of AKI in the pediatric age group of 3 months to 15 years admitted to the All India Institute of Medical Sciences (AIIMS), Raipur. The secondary objective(s) is to predict the association of mortality in children diagnosed with AKI and to estimate the number of patients developing chronic kidney disease (CKD) at three-month follow-up. This observational study was conducted in the Department of Pediatrics at AIIMS Raipur, Chhattisgarh, from September 2021 to February 2023. All patients aged 3 months to 15 years of age satisfying the Kidney Disease: Improving Global Outcomes (KDIGO) criteria for AKI and presenting to the hospital were included, and those refusing consent or having CKD stage ≥3 were excluded. A total of 66 children were assessed for eligibility. Out of these 66 patients, 2 were excluded as they had AKI on CKD, and a total of 64 patients were included. For all included patients, details of their demography, clinical features, etiology workup, and hospital stay were collected. Their outcome was observed and categorized into complete response, partial response, no response, left against medical advice (LAMA), or death. Patients who were discharged were followed up for three months and observed for the recovery or development of CKD. The incidence of AKI in the PICU was 15.48% (64/413). Ventricular septal defect with pneumonia and pneumonia (12.5%, 8/64 each) were the most common diagnoses at presentation, resulting in AKI. The most common clinical presentations were fever (54.7%, 35/64) and respiratory distress (43.8%, 28/64). Out of them, 73.4% (47/64) had sepsis, and 62.5% (40/64) had shock. About 56.2% (36/64) of children had non-oliguric AKI as compared to 43.8% (28/64) who had oliguric AKI. Among total children with AKI, 54.7% (35/64) of patients had prerenal AKI, 43.8% (28/64) had renal AKI, and 1.6% (1/64) had postrenal AKI. Of all the children included, 32.8% (21/64) experienced complete resolution of AKI, while 18.8% (12/64) showed partial resolution, and 1.6% (1/64) remained unresolved. Among them, 3.1% (2/64) LAMA, and 43.8% (28/64) died. The median duration of the hospital stay in our study was 16.5 days. Out of them, 59.4% (38/64) of patients required renal replacement therapy (60.5% required peritoneal dialysis (PD), 36.8% required hemodialysis (HD), and 2.6% required both). Among survivors, 19.35% (6/31) developed CKD on a three-month follow-up. The incidence of AKI was seen in critically ill children in the PICU, and it was associated with high mortality.

Pediatric Stercoral Colitis and Acute Kidney Injury From Chronic Constipation.

Pediatric Stercoral Colitis and Acute Kidney Injury From Chronic Constipation.

Diversity of kidney care referral pathways in national child health systems of 48 European countries.

Primary, secondary and tertiary healthcare services in Europe create complex networks covering pediatric subspecialties, sociology, economics and politics. Two surveys of the European Society for Paediatric Nephrology (ESPN) in 1998 and 2017 revealed substantial disparities of kidney care among European countries. The purpose of the third ESPN survey is to further identify national differences in the conceptualization and organization of European pediatric kidney health care pathways during and outside normal working hours. In 2020, a questionnaire was sent to one leading pediatric nephrologist from 48 of 53 European countries as defined by the World Health Organization. In order to exemplify care pathways in pediatric primary care nephrology, urinary tract infection (UTI) was chosen. Steroid sensitive nephrotic syndrome (SSNS) was chosen for pediatric rare disease nephrology and acute kidney injury (AKI) was analyzed for pediatric emergency nephrology. The care pathways for European children and young people with urinary tract infections were variable and differed during standard working hours and also during night-time and weekends. During daytime, UTI care pathways included six different types of care givers. There was a shift from primary care services outside standard working hours to general outpatient polyclinic and hospital services. Children with SNSS were followed up by pediatric nephrologists in hospitals in 69% of countries. Patients presenting with community acquired AKI were admitted during regular working hours to secondary or tertiary care hospitals. During nights and weekends, an immediate shift to University Children's Hospitals was observed where treatment was started by intensive care pediatricians and pediatric nephrologists. Gaps and fragmentation of pediatric health services may lead to the risk of delayed or inadequate referral of European children with kidney disease to pediatric nephrologists. The diversity of patient pathways outside of normal working hours was identified as one of the major weaknesses in the service chain.

Objectified kidney ultrasound echogenicity and size metrics as potential predictors for kidney function in children.

Kidney echogenicity is typicallydetermined subjectively but may have a quantifiable relationship to kidney function. Similarly, kidney length has been shown to correlate with kidney function. This study sought to quantify echogenicity using readily available software. Secondarily, we aimed to evaluate the correlation between quantified echogenicity and kidney length to the estimated glomerular filtration rate (eGFR) in children with acute kidney injury (AKI) and chronic kidney disease (CKD). In a single-center retrospective observational study, echogenicity index (EI) was determined using a ratio of right kidney to liver mean pixel density. The kidney length ratio (KLR) was determined by the actual to predicted lengths of both kidneys. Both variables were correlated to eGFR using correlation analyses and predictive capacity was determined with receiver operating characteristic curve (ROC) analysis. Of 94 subjects, 46% (43/94) had AKI, 28% (26/95) had CKD and 26% (25/95) were controls. The higher the EI the lower the eGFR (r = -0.46, p < 0.0001). EI between 1.0 and 1.1 predicted an eGFR < 90ml/min/1.73m2 with an AUC of 0.71-0.78 while an EI between 1.1 and 1.2 predicted an eGFR < 60ml/min/1.73m2 with AUC of 0.75-0.80. Overall, the larger the KLR the lower the eGFR (r = -0.25, p 0.018). We have developed an accessible methodology to quantify kidney echogenicity. Overall, there was an inverse correlation between EI and eGFR in pediatric CKD and AKI. However, these correlations did not persist within subgroups which could be due to small sample size and heterogeneity of etiologies. Overall, KLR had a weaker correlation to eGFR, compared to EI. Despite these correlations, both EI and KLR had "fair" to "good" performance as a biomarker for an eGFR < 60ml/min/1.73m2.

Kidney Disease Awareness and Knowledge Among Families and Pediatric Survivors of Severe Acute Kidney In

Background: Acute kidney injury (AKI) is common in pediatric patients and is associated with poor outcomes including increased risk of chronic kidney disease. It is unknown whether pediatric AKI survivors and their families are aware of their AKI diagnosis and understand the associated risks. We are seeking to identify awareness and disease-specific knowledge among pediatric AKI survivors and their families.&#x0D; Objectives: We hypothesize that pediatric AKI survivors and their families have a low awareness of their diagnosis and want more information about kidney health.&#x0D; Design/Methods: We performed a cross-sectional survey of AKI awareness and knowledge in pediatric patients with KDIGO Stage II or III AKI and their families near the time of discharge from Riley Hospital for Children. Families answered questions on AKI diagnosis awareness and AKI knowledge using the Kidney Knowledge Survey (KiKS).&#x0D; Results: Of 16 families included in this analysis, 75% were unaware they had experienced AKI and 94% were unaware they had a ‘problem with their kidneys’. Overall, the median AKI objective knowledge score was 60% (IQR: 31%, 69%). There was no difference in knowledge score between those that recognized their episode of AKI and those that did not. In total, 69% of families correctly defined AKI as when ‘your kidneys suddenly stop working well’. Most families recognized dehydration (56%) and infection (81%) as risk factors for AKI, however fewer recognized other risk factors such as ibuprofen use (31%). Only 38% of families reported that someone had discussed AKI during their admission, and 88% stated they wanted to learn more about AKI.&#x0D; Conclusion: Most families of pediatric survivors of severe AKI were unaware that their child had AKI or problems with their kidneys. Many lacked understanding of AKI risk factors and knowledge of kidney health and desired more information.

Prevalence, risk factors, and outcomes of acute kidney injury in a pediatric cardiac intensive care unit: A cross-sectional study.

Acute kidney injury (AKI) is a common complication in pediatric cardiac intensive care unit (CICU). This study aims to identify the prevalence, risk factors, and outcomes of AKI in pediatrics admitted to a CICU unit of a tertiary hospital. We retrospectively gathered the data of 253 randomly selected patients admitted to the CICU unit from March 2018 to March 2022. Data were collected from EHRs. We used the Kidney Disease Improving Global Outcomes (KDIGO) criteria for identifying AKI in patients. Overall, AKI prevalence was 22.9% in our population. In the multivariable analysis, vancomycin intake (odds ratio [OR]: 2.109, 95% confidence interval [CI]: 1.15-3.84), angiography (OR: 4.38, 95% CI: 1.28-14.93), and mechanical ventilation (OR: 2.08, 95% CI: 1.02-4.23) were independent risk factors of AKI development and patients with AKI had a higher in-hospital mortality rate (OR: 5.81, 95% CI: 2.55-13.19), higher need for cardiopulmonary resuscitation(OR: 3.08, 95% CI: 1.17-8.09), and longer ICU length of stay(OR: 6.49, 95% CI: 3.31-9.67). Furthermore, furosemide administration was associated with lower risk of developing AKI (OR: 0.52, 95% CI: 0.27-0.97). AKI is common and is associated with worse outcomes in patients with congenital heart disease. Our results emphasize the importance of early identification and monitoring of AKI in the pediatric CICU setting.

Pediatric acute kidney injury – Prevalence, clinical spectrum and outcome in a tertiary care institute of Eastern India

In this study, we wanted to determine the incidence and prevalence of AKI in admitted patients of our institution in relation to their age, sex and clinical conditions. We also wanted to study the various aetiologies causing acute kidney injury in children, its severity in admitted patients, the time interval of onset of disease and onset of AKI, it’s mode of management and outcomes in children.This study was conducted in the paediatric ward of a tertiary care hospital in Eastern India. Total 147 cases of hospitalized AKI patients were studied.The incidence of AKI was found to be 1.27% in all hospitalized children. Maximum no. of cases were found in the age group &amp;#62;10 years (44.2%). Male children outnumbered female children by a ratio of 2:1. Fever (72.8%) and Oliguria/anuria (72.1%) were the most common presenting features. Pallor was the most common presenting sign in 66% followed by oedema (42.2%), encephalopathy (31.9%) and respiratory distress (16.3%). 32% of cases presented within 24hrs with an H/O oliguria/anuria and 64% in within 72hrs. Most patients were managed with conservative management (53%) but 36.7% were managed with HD and 10.3% were managed with PD.Acute Kidney Injury cases were more common in children of age group &amp;#62;10 years, males being affected more. Fever and oliguria/anuria were the commonest mode of presentations with malaria as the most frequent clinical condition associated with AKI followed by sepsis. The renal type was the commonest type of AKI. There was a moderate derangement of kidney function in the majority of cases with hyperkalaemia in a significant group of patients. 47% of patients required dialytic support and case fatality was 13%. The presence of dysnatremia, hyperkalaemia, encephalopathy and shock were poor predictors of the outcome of AKI.

Pediatric AKI in the real world: changing outcomes through education and advocacy—a report from the 26th Acute Disease Quality Initiative (ADQI) consensus conference

BackgroundAcute kidney injury (AKI) is independently associated with increased morbidity and mortality across the life course, yet care for AKI remains mostly supportive. Raising awareness of this life-threatening clinical syndrome through education and advocacy efforts is the key to improving patient outcomes. Here, we describe the unique roles education and advocacy play in the care of children with AKI, discuss the importance of customizing educational outreach efforts to individual groups and contexts, and highlight the opportunities created through innovations and partnerships to optimize lifelong health outcomes.MethodsDuring the 26th Acute Disease Quality Initiative (ADQI) consensus conference, a multidisciplinary group of experts discussed the evidence and used a modified Delphi process to achieve consensus on recommendations on AKI research, education, practice, and advocacy in children.ResultsThe consensus statements developed in response to three critical questions about the role of education and advocacy in pediatric AKI care are presented here along with a summary of available evidence and recommendations for both clinical care and research.ConclusionsThese consensus statements emphasize that high-quality care for patients with AKI begins in the community with education and awareness campaigns to identify those at risk for AKI. Education is the key across all healthcare and non-healthcare settings to enhance early diagnosis and develop mitigation strategies, thereby improving outcomes for children with AKI. Strong advocacy efforts are essential for implementing these programs and building critical collaborations across all stakeholders and settings.

Predicting pediatric cardiac surgery-associated acute kidney injury using machine learning.

Prediction of cardiac surgery-associated acute kidney injury (CS-AKI) in pediatric patients is crucial to improve outcomes and guide clinical decision-making. This study aimed to develop a supervised machine learning (ML) model for predicting moderate to severe CS-AKI at postoperative day 2 (POD2). This retrospective cohort study analyzed data from 402 pediatric patients who underwent cardiac surgery at a university-affiliated children's hospital, who were separated into an 80%-20% train-test split. The ML model utilized demographic, preoperative, intraoperative, and POD0 clinical and laboratory data to predict moderate to severe AKI categorized by Kidney Disease: Improving Global Outcomes (KDIGO) stage 2 or 3 at POD2. Input feature importance was assessed by SHapley Additive exPlanations (SHAP) values. Model performance was evaluated using accuracy, area under the receiver operating curve (AUROC), precision, recall, area under the precision-recall curve (AUPRC), F1-score, and Brier score. Overall, 13.7% of children in the test set experienced moderate to severe AKI. The ML model achieved promising performance, with accuracy of 0.91 (95% CI: 0.82-1.00), AUROC of 0.88 (95% CI: 0.72-1.00), precision of 0.92 (95% CI: 0.70-1.00), recall of 0.63 (95% CI: 0.32-0.96), AUPRC of 0.81 (95% CI: 0.61-1.00), F1-score of 0.73 (95% CI: 0.46-0.99), and Brier score loss of 0.09 (95% CI: 0.00-0.17). The top ten most important features assessed by SHAP analyses in this model were preoperative serum creatinine, surgery duration, POD0 serum pH, POD0 lactate, cardiopulmonary bypass duration, POD0 vasoactive inotropic score, sex, POD0 hematocrit, preoperative weight, and POD0 serum creatinine. A supervised ML model utilizing demographic, preoperative, intraoperative, and immediate postoperative clinical and laboratory data showed promising performance in predicting moderate to severe CS-AKI at POD2 in pediatric patients.

Fluid assessment, fluid balance, and fluid overload in sick children: a report from the Pediatric Acute Disease Quality Initiative (ADQI) conference

BackgroundThe impact of disorders of fluid balance, including the pathologic state of fluid overload in sick children has become increasingly apparent. With this understanding, there has been a shift from application of absolute thresholds of fluid accumulation to an appreciation of the intricacies of fluid balance, including the impact of timing, trajectory, and disease pathophysiology.MethodsThe 26th Acute Disease Quality Initiative was the first to be exclusively dedicated to pediatric and neonatal acute kidney injury (pADQI). As part of the consensus panel, a multidisciplinary working group dedicated to fluid balance, fluid accumulation, and fluid overload was created. Through a search, review, and appraisal of the literature, summative consensus statements, along with identification of knowledge gaps and recommendations for clinical practice and research were developed.ConclusionsThe 26th pADQI conference proposed harmonized terminology for fluid balance and for describing a pathologic state of fluid overload for clinical practice and research. Recommendations include that the terms daily fluid balance, cumulative fluid balance, and percent cumulative fluid balance be utilized to describe the fluid status of sick children. The term fluid overload is to be preserved for describing a pathologic state of positive fluid balance associated with adverse events. Several recommendations for research were proposed including focused validation of the definition of fluid balance, fluid overload, and proposed methodologic approaches and endpoints for clinical trials.

Advances in pediatric acute kidney injury pharmacology and nutrition: a report from the 26th Acute Disease Quality Initiative (ADQI) consensus conference

BackgroundIn the past decade, there have been substantial advances in our understanding of pediatric AKI. Despite this progress, large gaps remain in our understanding of pharmacology and nutritional therapy in pediatric AKI.MethodsDuring the 26th Acute Disease Quality Initiative (ADQI) Consensus Conference, a multidisciplinary group of experts reviewed the evidence and used a modified Delphi process to achieve consensus on recommendations for gaps and advances in care for pharmacologic and nutritional management of pediatric AKI. The current evidence as well as gaps and opportunities were discussed, and recommendations were summarized.ResultsTwo consensus statements were developed. (1) High-value, kidney-eliminated medications should be selected for a detailed characterization of their pharmacokinetics, pharmacodynamics, and pharmaco-“omics” in sick children across the developmental continuum. This will allow for the optimization of real-time modeling with the goal of improving patient care. Nephrotoxin stewardship will be identified as an organizational priority and supported with necessary resources and infrastructure. (2) Patient-centered outcomes (functional status, quality of life, and optimal growth and development) must drive targeted nutritional interventions to optimize short- and long-term nutrition. Measures of acute and chronic changes of anthropometrics, body composition, physical function, and metabolic control should be incorporated into nutritional assessments.ConclusionsNeonates and children have unique metabolic and growth parameters compared to adult patients. Strategic investments in multidisciplinary translational research efforts are required to fill the knowledge gaps in nutritional requirements and pharmacological best practices for children with or at risk for AKI.

Safety Summary of the Selective Cytopheretic Device: A Review of Safety Data Across Multiple Clinical Trials in ICU Patients With Acute Kidney Injury and Multiple Organ Failure.

Acute kidney injury (AKI) requiring continuous kidney replacement therapy is a significant complication in ICU patients with mortality rates exceeding 50%. A dysregulated immune response can lead to systemic inflammation caused by hyperactivity of pro-inflammatory neutrophils and monocytes leading to tissue damage. The selective cytopheretic device (SCD) is an investigational medical device in a new class of cell-directed extracorporeal therapies distinct from cytokine adsorbers or filters, as it targets activated leukocytes. These leukocytes are the cellular sources driving this hyperinflammatory process. The objective of this report is to summarize the safety experience from clinical studies of the SCD in ICU patients with AKI or acute respiratory distress syndrome (ARDS) and multiple organ dysfunction (MOD). The studies included in this report represent all relevant trials of the SCD conducted in patients with AKI or ARDS and MOD. Adverse event data, clinical laboratory data and mortality rates were described and summarized in this report. Five clinical studies were included in this report, including four adult studies of AKI and/or ARDS and one pediatric AKI study, which involved 151 patients treated with the SCD in an ICU setting. Over 800 SCD sessions were deployed with an estimated 19,000 exposure hours with no device-related infections or attributable serious adverse events. Furthermore, there were no safety signals of leukopenia, thrombocytopenia, or other indications of immunodepletion or immunosuppression. The SCD has shown to be a promising extracorporeal therapy with promising clinical results and a favorable safety profile. These studies support that the SCD can be added as a therapeutic intervention in critically ill AKI patient populations with multiple organ failure without adding additional safety risks.

Advances in pediatric acute kidney injury pathobiology: a report from the 26th Acute Disease Quality Initiative (ADQI) conference

BackgroundIn the past decade, there have been substantial advances in our understanding of the pathobiology of pediatric acute kidney injury (AKI). In particular, animal models and studies focused on the relationship between kidney development, nephron number, and kidney health have identified a number of heterogeneous pathophysiologies underlying AKI. Despite this progress, gaps remain in our understanding of the pathobiology of pediatric AKI.MethodsDuring the 26th Acute Disease Quality Initiative (ADQI) Consensus conference, a multidisciplinary group of experts discussed the evidence and used a modified Delphi process to achieve consensus on recommendations for opportunities to advance translational research in pediatric AKI. The current state of research understanding as well as gaps and opportunities for advancement in research was discussed, and recommendations were summarized.ResultsConsensus was reached that to improve translational pediatric AKI advancements, diverse teams spanning pre-clinical to epidemiological scientists must work in concert together and that results must be shared with the community we serve with patient involvement. Public and private research support and meaningful partnerships with adult research efforts are required. Particular focus is warranted to investigate the pediatric nuances of AKI, including the effect of development as a biological variable on AKI incidence, severity, and outcomes.ConclusionsAlthough AKI is common and associated with significant morbidity, the biologic basis of the disease spectrum throughout varying nephron developmental stages remains poorly understood. An incomplete understanding of factors contributing to kidney health, the diverse pathobiologies underlying AKI in children, and the historically siloed approach to research limit advances in the field. The recommendations outlined herein identify gaps and outline a strategic approach to advance the field of pediatric AKI via multidisciplinary translational research.