Advances in Pediatric Acute Kidney Injury

The development of AKI (acute kidney injury) in critically ill patients in pediatric intensive care units (PICUs) is one of the most important factors affecting mortality. There are scoring modalities used to predict mortality in PICUs. We compared the AKIN (Acute Kidney Injury Network) and pRIFLE (pediatric risk, injury, failure, loss, and end stage) AKI classifications and PICU scoring modalities in this study. Methods: A total of 716 children, whose serum creatinine levels were within the normal limits at the time of admission to the PICU between January 2018 and December 2020, were included. Along with the demographic and clinical variables, AKIN and pRIFLE classifications were recorded at the most advanced stage of AKI. Along with the PIM-2, PRISM III, and PELOD-2 scores, the highest value of the pSOFA score was recorded. Results: According to the pRIFLE and AKIN classifications, 62 (8.7%) patients developed kidney injury, which had a statistically significant effect on mortality. The occurrence of renal injury was found to be statistically strongly and significantly correlated with high PRISM III, PELOD-2, and pSOFA scores. When the stages of kidney injury according to the AKIN criteria were compared with the PRISM III, PELOD 2, and pSOFA scores, a significant difference was found between the patients who did not develop AKI and those who developed stage 1, stage 2, and stage 3 kidney injury. For the PRISM III, PELOD 2, and pSOFA scores, there were no significant differences between the stages according to the AKIN criteria. A substantial difference was discovered between the patients who did not develop AKI and those who were in the risk, injury, and failure plus loss stages according to the pRIFLE criteria. According to the PIM-2 ratio and pRIFLE criteria, there was a statistically significant difference between patients in the injury and failure plus loss stages and those who did not develop AKI. Conclusions: Our study is the first pediatric study to show a substantial correlation between the variables associated with the PICU scoring modalities in critically ill children with AKI. Identifying the risk factors for the development of AKI and planning antimicrobial regimens for patients with favorable prognoses at the time of PICU admission could lower mortality rates. Full article

Background and objectives: Very low birth weight (VLBW) infants are at high risk of developing acute kidney injury (AKI), presumably secondary to low kidney reserves, stressful postnatal events, and drug exposures. Our study aimed to identify the prevalence, risk factors, and outcomes associated with AKI in VLBW infants. Study design: Records of all VLBW infants admitted to two medical campuses between January 2019 and June 2020 were retrospectively reviewed. AKI was classified using the modified KDIGO definition to include only serum creatinine. Risk factors and composite outcomes were compared between infants with and without AKI. We evaluated the main predictors of AKI and death with forward stepwise regression analysis. Results: 152 VLBW infants were enrolled. 21% of them developed AKI. Based on the multivariable analysis, the most significant predictors of AKI were the use of vasopressors, patent ductus arteriosus, and bloodstream infection. AKI had a strong and independent association with neonatal mortality. Conclusions: AKI is common in VLBW infants and is a significant risk factor for mortality. Efforts to prevent AKI are necessary to prevent its harmful effects. Full article

Global COVID-19 vaccination programs for children and adolescents have been developed with international clinical trial data confirming COVID-19 mRNA vaccine safety and efficacy for the pediatric population. The impact of COVID-19 vaccination in the kidneys is thought to be explained by a complex immune-mediated relationship between the two, although the pathophysiological mechanisms of how COVID-19 vaccination potentially induces kidney pathology are not presently well known. Whilst intrinsic kidney pathologies following COVID-19 vaccination have been reported in adults, such cases are only being recently reported with greater frequency in children and adolescents. Conforming to the PRISMA checklist, we conducted a systematic review of the current literature to provide an overview on the range of intrinsic kidney pathologies that have been reported following COVID-19 vaccination in children and adolescents. All English language research articles published on or before 30 June 2022 reporting new-onset or relapsed intrinsic kidney pathology in children or adolescents (≤18 years) following COVID-19 vaccination were selected for qualitative analysis. Out of 18 cases from the 13 published articles selected, there were 10 cases of IgA nephropathy (1 case of rapidly progressive glomerulonephritis requiring acute hemodialysis), 5 cases of minimal change disease (MCD), 1 case of concurrent MCD/tubulointerstitial nephritis (TIN) and 2 cases of TIN. There is no indication currently to avoid vaccination, unless specific circumstances exist, as the benefits of COVID-19 vaccination far outweigh its risks. Concluding the findings from our systematic review based on preliminary evidence, potential adverse effects to the kidney from COVID-19 vaccination affects a small number of children and adolescents among the many who have been vaccinated. There remains good reason at present to support vaccination of children and adolescents with a greater morbidity status, such as those living with preexisting chronic kidney disease. Close observation of all children and adolescents receiving COVID-19 vaccination is recommended, particularly in those with preceding intrinsic kidney pathology to identify risks of relapsed disease. Full article

We hypothesized that—as in other common pediatric conditions—acute appendicitis (AA) could be complicated by acute kidney injury (AKI). We aimed to investigate the prevalence of, and the factors associated with AKI in a cohort of patients with AA. We retrospectively collected data of 122 children (63.9% of male gender; mean age 8.6 ± 2.9 years; range: 2.2–13.9 years) hospitalized for AA. AKI was defined according to the Kidney Disease/Improving Global Outcomes creatinine criteria. We considered a basal serum creatinine value as the value of creatinine estimated with the Hoste (age) equation, assuming that the basal estimated glomerular filtration rate (eGFR) was 120 mL/min/1.73 m². Explorative univariate logistic regression analysis was used to explore the associations with AKI. Out of 122 patients, nine (7.4%) presented with AKI. One patient had stage two AKI and the remaining had stage one AKI. The maximum AKI stage was found at admission. The patients with AKI showed a higher prevalence of fever ≥ 38.5 °C (p = 0.02), vomiting (p = 0.03), ≥5% dehydration (p = 0.03), and higher levels of both C-reactive protein (CRP) (p = 0.002) and neutrophils (p = 0.03) compared with patients without AKI. Because all patients with AKI also presented with vomiting, an Odds Ratio (OR) for the vomiting was not calculable. The exploratory univariate logistic regression analysis confirmed that fever ≥ 38.5 °C (OR = 5.0; 95% CI: 1.2/21.5; p = 0.03), ≥5% dehydration (OR = 8.4; 95% CI: 1.1/69.6; p = 0.04), CRP (OR = 1.1; 95% CI: 1.05/1.2; p = 0.01), and neutrophil levels (OR = 1.1; 95% CI: 1.01/1.3; p = 0.04) were all predictive factors of AKI. AKI can occur in 7.4% of patients with AA. Particular attention should be paid to the kidney health of patients with AA especially in the presence of vomiting, ≥5% dehydration, fever ≥ 38.5 °C, and high CRP and neutrophils levels. Full article

Introduction: COVID-19 infections resulting in pathological kidney manifestations have frequently been reported in adults since the onset of the global COVID-19 pandemic in December 2019. Gradually, there have been an increased number of COVID-19-associated intrinsic kidney pathologies in children and adolescents reported as well. The pathophysiological mechanisms between COVID-19 and the onset of kidney pathology are not fully known in children; it remains a challenge to distinguish between intrinsic kidney pathologies that were caused directly by COVID-19 viral invasion, and cases which occurred as a result of multisystem inflammatory syndrome due to the infection. This challenge is made more difficult in children, due to the ethical limitations of performing kidney biopsies to reach a biopsy-proven diagnosis. Although previous systematic reviews have summarized the various pathological kidney manifestations that have occurred in adults following acute COVID-19 infection, such reviews have not yet been published for children and adolescents. We describe the results of a systematic review for intrinsic kidney pathology following COVID-19 infection in children and adolescents. Methods: A systematic literature search of published data up until 31 October was completed through the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines. Research articles reporting new-onset or relapsed intrinsic kidney pathology in children or adolescents (≤18 years) following acute COVID-19 infection were included for qualitative review. COVID-19 infection status was defined by a positive result from a RT-PCR, or nuclear antibody testing. Only full-text articles published in the English language were selected for review. Results: Twenty-nine cases from fifteen articles were included in the qualitative synthesis of this systematic review. Nephrotic syndrome, as an umbrella condition, appeared as the most frequently observed presentation (20 cases) with disease remission noted in all cases with steroid treatment. Other cases included numerous glomerulonephritides, such as acute necrotizing glomerulonephritis, MPO vasculitis and collapsing glomerulopathy, and thrombotic microangiopathies, such as aHUS. For patients with transplanted kidneys, T-cell-mediated rejection and mild tubular interstitial infiltration were noted following testing positive for COVID-19. There were no mortalities reported in any of the included cases, although two patients remained dialysis dependent at hospital discharge. Conclusion: This systematic review highlights the various intrinsic pathological kidney manifestations in children and adolescents as a result of acute COVID-19 infection. The clinical timeline and presentation of these cases support the mechanistic hypothesis between COVID-19 infection and the onset of intrinsic kidney pathologies within this context. The progressive introduction of vaccination programs for children and adolescents may hopefully reduce the severity of COVID-19-associated illnesses, and pathological kidney manifestations in this population. Full article