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Epidemiology of Pediatric Acute Kidney Injury
Objectives
This chapter will:
- 1.
Review the major causes of acute kidney injury in critically ill pediatric patients.
- 2.
Describe pediatric acute kidney injury seen in different subpopulations, including infants in the postoperative period after corrective congenital heart surgery, stem cell transplant recipients, and patients with multiple organ dysfunction syndrome.
- 3.
Review new diagnostic measures for pediatric acute kidney injury with a focus on classification systems.
Until the last decade, interpretation and extrapolation of findings reported in the epidemiology literature on pediatric acute kidney injury (AKI) was hampered by numerous factors, including lack of a consistent definition of AKI, increased survival of critically ill children with multiorgan dysfunction and AKI because of advances in care, the wide range of patient size distribution in pediatrics, and limited access to renal replacement therapies (RRT) and tertiary care in developing countries. Although multicenter epidemiologic pediatric AKI data are lacking, single-center studies from the 1980s and early 1990s report hemolytic uremic syndrome, other primary renal causes, sepsis, and burns as the most prevalent causes of pediatric AKI. Many pediatric AKI studies from the 1990s and early 2000s, with the exception of those in infants who received peritoneal dialysis after corrective congenital heart surgery, were composed solely of literature reviews. Recent epidemiology of pediatric AKI has been studied mainly in acutely ill hospitalized patients, because nonoliguric forms of AKI may be self-limited and go undetected in the outpatient setting. In developing countries with limited or no access to intensive care resources, published reports detail experiences with trauma-associated AKI induced by rhabdomyolysis or with AKI secondary to epidemic disease such as hemolytic uremic syndrome or poisonings.
In the last decade, however, major advancements in the AKI field, including standardization of the AKI definition with multidimensional criteria, development of RRT devices designed specifically for children, and multicenter pediatric AKI collaboratives, have led to a more robust understanding of pediatric AKI. This chapter is focused primarily on the epidemiology of AKI in the critically ill child using the most up-to-date definitions. Although emerging AKI definition concepts using novel biomarkers will no doubt change pediatric AKI epidemiologic assessment in the near future, the subject of structural AKI biomarkers is covered elsewhere. In addition, because AKI of a severity necessitating RRT provision often is viewed as an outcome measure, changes in the incidence of need for and in the modalities of RRT used in pediatric patients with AKI are discussed in a subsequent chapter ( Chapter 201 ).
Pediatric Acute Kidney Injury Epidemiology: Current State of Knowledge
Recent single-center data detail the underlying causes of pediatric AKI in large cohorts of children and demonstrate an epidemiologic shift wherein AKI more often is now a concomitant of another underlying disease or systemic process, or its treatment, instead of a primary renal disease. This shift was concurrent with technologic improvements in pediatric, neonatal, and cardiovascular intensive care. Accordingly, critically ill children who require RRT have been the most-studied pediatric AKI cohort in the past decade. Bunchman reported data for 226 children with AKI treated with RRT; the most common causes of AKI were congenital heart disease, acute tubular necrosis (ATN), and sepsis. Hui-Stickle et al. performed a retrospective review of 248 patients aged birth to 21 years with a diagnosis of AKI on discharge or death summary and found ATN and nephrotoxic medicines to be the most common primary causes of AKI for all age groups and patient sizes, whereas primary kidney disease was cited in only 7% of the cases. Many single-center studies report data on the experience with pediatric AKI for 10 years or longer and compare different periods at the same institution or geographic region. All studies demonstrate a slight male predominance in pediatric AKI.
Vachvanichsanong et al. assessed pediatric AKI epidemiology in 311 children (318 episodes) from 1983 through 2004 at a Thailand tertiary referral center. These investigators reported an incidence of AKI of 0.5 to 0.9 case per 1000 pediatric patients younger than 18 years of age who were admitted to their institution. This report also divided AKI epidemiology into three different eras: 1983 to 1995, 1995 to 2000, and 2000 to 2004. In each era, sepsis was the most common underlying cause of AKI, whereas hypovolemic ATN decreased from 16.1% of cases in the early era to 8.3% in the latter era. This study reports a high incidence of other infections, including leptospirosis and dengue hemorrhagic shock syndrome. Poststreptococcal glomerulonephritis and systemic lupus erythematosus accounted for a majority of primary renal AKI causes, with combined incidence increasing from 19.3% of cases in the early era to 24.8% of cases in the latter era.
Williams et al. evaluated 228 consecutive pediatric AKI cases in critically ill children from Richmond, Virginia, between 1979 and 1998. These investigators divided their epidemiologic assessment into the earlier and latter decades studied and compared underlying causes leading to AKI in survivors and in nonsurvivors. In the earlier era, hemolytic uremic syndrome, sepsis, and burns were cited as the most common causes leading to AKI, whereas hematologic-oncologic and pulmonary causes replaced burns as a common cause of AKI in the second era. Higher mortality rates were observed in the latter era in patients after cardiac surgery or with pulmonary or hematologic-oncologic comorbid conditions.
The Prospective Pediatric Continuous Renal Replacement Therapy (ppCRRT) Registry Group has reported epidemiology and outcome for 344 patients who received CRRT in the United States. Patients with sepsis (23.5%), stem cell transplantation (15.9%), and underlying cardiac disease (11.9%) composed half of the ppCRRT cohort. Once again, patients with primary renal disease represented a minority of patients (9.3%).
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