|Year : 2018 | Volume
| Issue : 2 | Page : 52-55
Epidemiology of acute kidney injury in critically ill children living in the Kingdom of Saudi Arabia
Jameela Abdulaziz Kari
Department of Pediatrics, Paediatric Nephrology Center of Excellence, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
|Date of Web Publication||27-Dec-2018|
prof Jameela Abdulaziz Kari
Department of Pediatrics, Paediatric Nephrology Center of Excellence, Faculty of Medicine, King Abdulaziz University, P. O. Box 80215, Jeddah 21589
Kingdom of Saudi Arabia
Source of Support: None, Conflict of Interest: None
Acute kidney injury (AKI) is very common in children admitted to pediatric intensive care and affected children are at increased risk of morbidity and mortality. The epidemiologic characteristics of children with AKI have not been well described in children living in the Kingdom of Saudi Arabia (KSA). This review of the epidemiology of AKI in critically ill children in KSA shows that AKI is common in this population and is chiefly attributed to sepsis, other infections and postcardiac surgery. The occurrence of AKI is linked to increased mortality and length of hospital stay. The severity of AKI correlates with increased inhospital mortality as well as risk of mortality after discharge. A considerable proportion of survivors develop evidence of chronic kidney disease. Cystatin C and urinary neutrophil gelatinase-associated lipocalin are useful in enabling early diagnosis of AKI in critically ill children.
Keywords: Acute renal failure, pediatric, Saudi Arabia
|How to cite this article:|
Kari JA. Epidemiology of acute kidney injury in critically ill children living in the Kingdom of Saudi Arabia. Asian J Pediatr Nephrol 2018;1:52-5
|How to cite this URL:|
Kari JA. Epidemiology of acute kidney injury in critically ill children living in the Kingdom of Saudi Arabia. Asian J Pediatr Nephrol [serial online] 2018 [cited 2019 Jul 22];1:52-5. Available from: http://www.ajpn-online.org/text.asp?2018/1/2/52/248648
| Introduction|| |
Acute kidney injury (AKI) is very common in critically ill children and is associated with considerable mortality and morbidity. The AWARE study, which included 4683 children, revealed AKI in 26.9% children admitted to the pediatric intensive care unit (PICU). An initiative of the International Society of Nephrology has the ambitious goal of reaching zero preventable deaths from AKI across the world by 2025. However, reliable epidemiological data from developing countries regarding AKI in children are lacking. This is also true for Arab countries, including the Kingdom of Saudi Arabia (KSA). This review summarizes recent literature focusing on the epidemiology, risk factors, and outcomes of pediatric AKI in KSA.
| Definitions|| |
AKI network (AKIN) defined AKI as “functional or structural abnormalities, or markers of kidney damage, including abnormalities in blood, urine, or tissue tests or imaging studies, present for <3 months” during the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI). The AKIN classification recognizes three stages of AKI based on the change in serum creatinine and urine output [Table 1]. The ADQI group in 2004 created the risk of kidney dysfunction, injury to the kidney, failure of kidney function, loss of kidney function, and end-stage kidney disease criteria (RIFLE), using a multidimensional, staged definition to provide standardized criteria for defining AKI. In 2007, Akcan-Arikan et al., in their study on 150 critically ill children, modified the RIFLE criteria for pediatric patients and termed it pediatric RIFLE (pRIFLE) [Table 2]. Most recently, the 2012 clinical practice guidelines of the Kidney Disease Improving Global Outcomes (KDIGO) for AKI provide criteria for AKI, modified from the AKIN criteria, applicable to both adult and pediatric patients [Table 1].
|Table 1: The Acute Kidney Injury Network and Kidney Disease Improving Global Outcomes staging of AKI|
Click here to view
|Table 2: Pediatric modified risk, injury, failure, loss, and end-stage renal disease criteria|
Click here to view
All three definitions are reported to demonstrate an excellent discrimination between stages, and each definition offers certain advantages. However, application of the three definitions leads to differences in AKI incidence and staging.
| Epidemiology of Pediatric Acute Kidney Injury in the Kingdom of Saudi Arabia|| |
Studies assessing the epidemiology of pediatric AKI vary in their use of standardized definitions. AKI was observed in 37.4% of critically ill children in a recent multicenter prospective cohort study from KSA using the KDIGO definition for AKI. While this incidence is higher than in the AWARE study, it is comparable to a single-center retrospective study from north India that reported AKI in 36.3% of children admitted to PICU, and lower than in recent studies from India reporting AKI in 42.9% critically ill patients using pRIFLE criteria and in 53.2% cases using AKIN definition. The incidence of AKI is higher after cardiac surgery in children receiving extracorporeal membrane oxygenation (ECMO), with a study from King Faisal Specialist Hospital reporting AKI in 90% of 59 children initiated on ECMO. Most children were in failure stage of pRIFLE staging, in contrast to previous studies that have usually reported mild stages of AKI, namely the risk stage of pRIFLE and Stage I of KDIGO criteria.,,,
| Etiology of Acute Kidney Injury|| |
Sepsis and infections remain the most important underlying etiology of AKI, as was reported previously., There has been a recent expansion of the reports of AKI following cardiac surgery with an expansion of the number of pediatric cardiac surgical centers across the country.,, AKI has also been attributed to other causes, including hemolytic uremic syndrome, vancomycin toxicity, or congenital chloride diarrhea.
| Risk Factors for Acute Kidney Injury|| |
Patients with high Pediatric Risk of Mortality (PRISM) score, an index that is known to predict mortality, are at higher risk of AKI., Similarly, the incidence of AKI is higher in pediatric patients who require ventilatory support than those who do not.,
| Mortality and Acute Kidney Injury|| |
AKI is associated with increased risk of mortality.,,, Advanced stages of AKI are associated with higher likelihood of death.,, Oliguric children are at increased risk of dying as compared to those with nonoliguric AKI., Other predictors of mortality include volume overload, need for mechanical ventilation, and the requirement of renal replacement therapy (RRT). Hypotension as the etiology of AKI was reported to increase the risk of death 10-fold compared to patients without hypotension. The AWARE study showed that the need for vasoactive support was the strongest predictor of mortality by day 28 after admission, followed by requirement of RRT.
| Renal Replacement Therapy|| |
Safder et al. showed that RRT was required in 11.4% of pediatric patients with AKI. In contrast, RRT was required by only 1.5% of children with AKI in the AWARE study. The proportion of pediatric patients requiring RRT was 2.9% (0%–8.6%) of 129,809 admissions to PICU at 30 of 33 centers in the United Kingdom. Peritoneal dialysis (PD), used in 70.7% of the children, and was the most common modality of RRT, followed by continuous RRT (CRRT) which was used in 17.2% patients. Hemodialysis (HD) was used in 8.6% patients, while 3% cases underwent both PD and HD. CRRT was reported to be associated with mortality of 50% in a single-center Saudi study, which is higher than reported elsewhere.
| Long-Term Outcome of Acute Kidney Injury|| |
AKI is associated with increased mortality after discharge from the hospital. The 2-year mortality was reported to be more than 40% in children admitted to the PICU of King Abdulaziz University. The chief predictors of mortality were the severity of AKI and the PRISM score, which increased the risk of mortality by 6% per unit increment in PRISM score. A significant proportion of the survivors had evidence of chronic kidney disease, in the form of reduced estimated glomerular filtration rate, proteinuria, or hypertension., This is similar to findings in reports from other parts of the world.,
| Acute Kidney Injury in Neonates|| |
AKI is common in neonates admitted to the neonatal intensive care unit (NICU). AKI is associated with increased morbidity and mortality and a high long-term risk of chronic kidney disease. A recent study from King Abdulaziz University reported AKI in 56% in NICU admissions. This is much higher than in a previous report from King Khalid University around three decades ago of 3.6%. AKI is more common among low-birth-weight babies and in those born premature., Perinatal asphyxia is a major risk factor for AKI in neonates. A high clinical risk index for babies II score predicts AKI in infants with gestational age <32 weeks. Neonatal AKI is shown to be associated with increased mortality., However, the rates of mortality in neonates with AKI have decreased to 28.5% compared to 77% around three decades ago.,
| New Acute Kidney Injury Biomarkers|| |
Serum creatinine is a suboptimal biomarker of kidney function, as the rise in serum creatinine is significantly delayed to 48–72 h after an insult and requires loss of function to about 50% before it is reflected in a rise in serum creatinine. Various plasma and urinary biomarkers such as kidney injury molecule-1, neutrophil gelatinase-associated lipocalin (NGAL), interleukin-18, and cystatin C have been proposed and investigated for their role in enabling early detection of kidney injury. There are few Saudi studies to investigate these biomarkers in critically ill pediatric patients. Serum cystatin C was identified as a sensitive, but not a specific, marker for the diagnosis of AKI in critically ill children. Similarly, urinary NGAL (uNGAL) was shown to predict AKI early in critically ill children.
| Conclusion|| |
AKI is common in critically ill children and neonates. It is associated with increased mortality and length of hospital stay. The severity of AKI is associated with increased inhospital mortality as well as high mortality after discharge, particularly in the early months after admission to PICU. Considerable proportion of survivors develops evidence of chronic kidney disease. Cystatin C and uNGAL are useful in enabling early diagnosis of AKI in critically ill children.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kaddourah A, Basu RK, Bagshaw SM, Goldstein SL; AWARE Investigators. Epidemiology of acute kidney injury in critically ill children and young adults. N Engl J Med 2017;376:11-20.
Mehta RL, Cerdá J, Burdmann EA, Tonelli M, García-García G, Jha V, et al.
International Society of Nephrology's 0by25 initiative for acute kidney injury (zero preventable deaths by 2025): A human rights case for Nephrology. Lancet 2015;385:2616-43.
Macedo E, Cerdá J, Hingorani S, Hou J, Bagga A, Burdmann EA, et al.
Recognition and management of acute kidney injury in children: The ISN 0by25 global snapshot study. PLoS One 2018;13:e0196586.
Mehta RL, Kellum JA, Shah SV, Molitoris BA, Ronco C, Warnock DG, et al.
Acute kidney injury network: Report of an initiative to improve outcomes in acute kidney injury. Crit Care 2007;11:R31.
Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P; Acute Dialysis Quality Initiative Workgroup, et al.
Acute renal failure – Definition, outcome measures, animal models, fluid therapy and information technology needs: The Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care 2004;8:R204-12.
Akcan-Arikan A, Zappitelli M, Loftis LL, Washburn KK, Jefferson LS, Goldstein SL, et al.
Modified RIFLE criteria in critically ill children with acute kidney injury. Kidney Int 2007;71:1028-35.
Khwaja A. KDIGO clinical practice guidelines for acute kidney injury. Nephron Clin Pract 2012;120:c179-84.
Sutherland SM, Byrnes JJ, Kothari M, Longhurst CA, Dutta S, Garcia P, et al.
AKI in hospitalized children: Comparing the pRIFLE, AKIN, and KDIGO definitions. Clin J Am Soc Nephrol 2015;10:554-61.
Kari JA, Alhasan KA, Shalaby MA, Khathlan N, Safdar OY, Al Rezgan SA, et al.
Outcome of pediatric acute kidney injury: A multicenter prospective cohort study. Pediatr Nephrol 2018;33:335-40.
Shalaby M, Khathlan N, Safder O, Fadel F, Farag YM, Singh AK, et al.
Outcome of acute kidney injury in pediatric patients admitted to the intensive care unit. Clin Nephrol 2014;82:379-86.
Gupta S, Sengar GS, Meti PK, Lahoti A, Beniwal M, Kumawat M, et al.
Acute kidney injury in pediatric intensive care unit: Incidence, risk factors, and outcome. Indian J Crit Care Med 2016;20:526-9.
] [Full text]
Nawaz S, Afzal K. Pediatric acute kidney injury in North India: A prospective hospital-based study. Saudi J Kidney Dis Transpl 2018;29:689-97.
] [Full text]
Elella RA, Habib E, Mokrusova P, Joseph P, Aldalaty H, Ahmadi MA, et al.
Incidence and outcome of acute kidney injury by the pRIFLE criteria for children receiving extracorporeal membrane oxygenation after heart surgery. Ann Saudi Med 2017;37:201-6.
Mahmoud AM, Al-Harbi MS, Al-Sowailem AM, Mattoo TK. Etiology, presentation and management of acute renal failure in Saudi children. Ann Saudi Med 1992;12:196-200.
Abou El-Ella RS, Najm HK, Godman M, Kabbani MS. Acute renal failure and outcome of children with solitary kidney undergoing cardiac surgery. Pediatr Cardiol 2008;29:614-8.
Elzouki AY, Mirza K, Mahmood A, Al-Sowailem AM. Hemolytic uremic syndrome-clinical aspects and outcome of an outbreak: Report of 28 cases. Ann Saudi Med 1995;15:113-6.
Abouelkheir M, Alsubaie S. Pediatric acute kidney injury induced by concomitant vancomycin and piperacillin-tazobactam. Pediatr Int 2018;60:136-41.
Al Makadma AS, Al-Akash SI, Al Dalaan I, Al Turaiki M, Shabib SM. Congenital sodium diarrhea in a neonate presenting as acute renal failure. Pediatr Nephrol 2004;19:905-7.
Safder O, Alhasan K, Shalaby M, Khathlan N, Al Rezgan S, Albanna AS, et al
. Short-term outcome associated with disease severity and electrolyte abnormalities among critically ill children with acute kidney injury. BMC Nephrol 2018. (in press).
Westrope CA, Fleming S, Kapetanstrataki M, Parslow RC, Morris KP. Renal replacement therapy in the critically ill child. Pediatr Crit Care Med 2018;19:210-7.
Al-Ayed T, Rahman NU, Alturki A, Aljofan F. Outcome of continuous renal replacement therapy in critically ill children: A retrospective cohort study. Ann Saudi Med 2018;38:260-8.
Cortina G, McRae R, Hoq M, Donath S, Chiletti R, Arvandi M, et al.
Mortality of critically ill children requiring continuous renal replacement therapy: Effect of fluid overload, underlying disease, and timing of initiation. Pediatr Crit Care Med 2018. PMID: 30431556 DOI: 10.1097/PCC.0000000000001806 (online).
Al-Otaibi NG, Zeinelabdin M, Shalaby MA, Khathlan N, Mashat GD, Zahrani AA, et al.
Impact of acute kidney injury on long-term mortality and progression to chronic kidney disease among critically ill children. Saudi Med J 2017;38:138-42.
Greenberg JH, Coca S, Parikh CR. Long-term risk of chronic kidney disease and mortality in children after acute kidney injury: A systematic review. BMC Nephrol 2014;15:184.
Mammen C, Al Abbas A, Skippen P, Nadel H, Levine D, Collet JP, et al.
Long-term risk of CKD in children surviving episodes of acute kidney injury in the intensive care unit: A prospective cohort study. Am J Kidney Dis 2012;59:523-30.
Jetton JG, Boohaker LJ, Sethi SK, Wazir S, Rohatgi S, Soranno DE, et al.
Incidence and outcomes of neonatal acute kidney injury (AWAKEN): A multicentre, multinational, observational cohort study. Lancet Child Adolesc Health 2017;1:184-94.
Al-Idressy HM, Abdel Basit OB, Haque KN, Abdurrahman MB. Acute renal failure in neonates: A prospective study. Ann Saudi Med 1991;11:297-301.
Chen LX, Koyner JL. Biomarkers in acute kidney injury. Crit Care Clin 2015;31:633-48.
Safdar OY, Shalaby M, Khathlan N, Elattal B, Bin Joubah M, Bukahri E, et al.
Serum cystatin is a useful marker for the diagnosis of acute kidney injury in critically ill children: Prospective cohort study. BMC Nephrol 2016;17:130.
Kari JA, Shalaby MA, Sofyani K, Sanad AS, Ossra AF, Halabi RS, et al.
Urinary neutrophil gelatinase-associated lipocalin (NGAL) and serum cystatin C measurements for early diagnosis of acute kidney injury in children admitted to PICU. World J Pediatr 2018;14:134-42.
[Table 1], [Table 2]