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Oliguria and Acute Kidney Injury in Critically Ill Children

Implications for Diagnosis and Outcomes*

Kaddourah, Ahmad, MD, MS1,2; Basu, Rajit K., MD2,3; Goldstein, Stuart L., MD2; Sutherland, Scott M., MD4 on behalf of the Assessment of Worldwide Acute Kidney Injury, Renal Angina, and Epidemiology (AWARE) Investigators

Pediatric Critical Care Medicine: April 2019 - Volume 20 - Issue 4 - p 332–339
doi: 10.1097/PCC.0000000000001866
Renal Critical Care
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Objectives: Consensus definitions for acute kidney injury are based on changes in serum creatinine and urine output. Although the creatinine criteria have been widely applied, the contribution of the urine output criteria remains poorly understood. We evaluated these criteria individually and collectively to determine their impact on the diagnosis and outcome of severe acute kidney injury.

Design and Setting: Post hoc analysis of Assessment of Worldwide Acute Kidney Injury, Renal Angina, and Epidemiology study—a prospective international observational multicenter study.

Patients: Critically ill children enrolled in Assessment of Worldwide Acute Kidney Injury, Renal Angina and, Epidemiology database.

Measurement: To assess the differential impact of creatinine and urine output criteria on severe acute kidney injury (Kidney Disease: Improving Global Outcomes stage ≥ 2). Patients were divided into four cohorts: no-severe acute kidney injury, severe acute kidney injury by creatinine criteria only, severe acute kidney injury by urine output criteria only, and severe acute kidney injury by both creatinine and urine output criteria.

Results: Severe acute kidney injury occurred in 496 of 3,318 children (14.9%); 343 (69.2%) were creatinine criteria only, 90 (18.1%) were urine output criteria only, and 63 (12.7%) were both creatinine and urine output criteria. Twenty-eight–day mortality for creatinine criteria only and urine output criteria only patients was similar (6.7% vs 7.8%) and higher than those without severe acute kidney injury (2.9%; p < 0.01). Both creatinine and urine output criteria patients had higher mortality than creatinine criteria only and urine output criteria only patients (38.1%; p < 0.001). Compared with patients without severe acute kidney injury, the relative risk of receiving dialysis increased from 9.1 (95% CI, 3.9–21.2) in creatinine criteria only, to 28.2 (95% CI, 11.8–67.7) in urine output criteria only, to 165.7 (95% CI, 86.3–318.2) in both creatinine and urine output criteria (p < 0.01).

Conclusions: Nearly one in five critically ill children with acute kidney injury do not experience increase in serum creatinine. These acute kidney injury events, which are only identified by urine output criteria, are associated with comparably poor outcomes as those diagnosed by changes in creatinine. Children meeting both criteria had worse outcomes than those meeting only one. We suggest oliguria represents a risk factor for poorer outcomes among children who develop acute kidney injury. Application of both the creatinine and urine output criteria leads to a more comprehensive epidemiologic assessment of acute kidney injury and identifies a subset of children with acute kidney injury who are at higher risk for morbidity and mortality.

1Nephrology and Hypertension Division, Department of Pediatrics, Sidra Medicine, Doha, Qatar.

2Center for Acute Care Nephrology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.

3Division of Critical Care Medicine, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA.

4Department of Pediatrics, Division of Nephrology, Stanford University, Stanford, CA.

*See also p. 381.

All authors edited and revised the final draft. Dr. Kaddourah conducted statistical analysis and wrote the first draft. Drs. Kaddourah, Basu, and Goldstein designed the original Assessment of Worldwide Acute Kidney Injury, Renal Angina, and Epidemiology (AWARE) study. Dr. Sutherland wrote the final draft. All AWARE investigators revised and approved the submitted article.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/pccmjournal).

Supported, in part, by a grant (NIH P50 DK096418, to Drs. Basu and Goldstein) to the Pediatric Nephrology Center of Excellence at Cincinnati Children’s Hospital Medical Center.

Dr. Kaddourah disclosed that this work was supported in part by a grant (NIH P50 DK096418, to Drs. Basu and Goldstein) to the Pediatric Nephrology Center of Excellence at Cincinnati Children’s Hospital Medical Center. Dr. Kaddourah’s Pediatric Acute Care Nephrology and Dialysis Fellowship at Cincinnati Children’s Hospital Medical Center was supported by an unrestricted educational grant from Gambro Renal Products. Dr. Basu received funding from BioPorto Diagnostics and Baxter Healthcare Solutions - Acute Therapies Institute. The remaining authors have disclosed that they do not have any potential conflicts of interest.

A complete list of Assessment of Worldwide Acute Kidney Injury, Renal Angina, and Epidemiology (AWARE) Investigators is provided in Supplementary File 1 (Supplemental Digital Content 1, http://links.lww.com/PCC/A873).

The data used in this article are exclusively acquired from the data set of the original Assessment of Worldwide Acute Kidney Injury, Renal Angina, and Epidemiology (AWARE) study. The date we used were unidentified. All participating centers in the original AWARE study obtained health research ethics board approval for a waiver of informed consent prior to commencement of the study.

The data used for this article are available and controlled by the Center of Acute Care Nephrology at Cincinnati Children’s Hospital Medical Center. Requests for sharing data should be raised to Stuart Goldstein, MD, at stuart.goldstein@cchmc.org

For information regarding this article, E-mail: akaddourah@sidra.org

©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies