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A New Criterion for Pediatric AKI Based on the Reference Change Value of Serum Creatinine
Xin Xu1, Sheng Nie2, Aihua Zhang3
1National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, China; xux007@163.com ffhouguangzhou@163.com.
Insights
A new method, pediatric reference change value optimized for AKI in children (pROCK), improves acute kidney injury (AKI) detection in pediatric patients. pROCK reclassifies many cases, reducing overdiagnosis and identifying true AKI with higher accuracy.
Area of Science:
- Pediatric Nephrology
- Critical Care Medicine
- Biomarker Discovery
Background:
- Current definitions of acute kidney injury (AKI) in children do not account for significant variability in serum creatinine levels.
- This limitation can lead to inaccurate diagnosis and overdiagnosis of AKI in pediatric populations.
- There is a need for improved diagnostic criteria tailored to the unique physiological characteristics of children.
Purpose of the Study:
- To develop and validate a novel model for detecting AKI in hospitalized children.
- To establish a new criterion, pediatric reference change value optimized for AKI in children (pROCK), based on creatinine variability.
- To compare the diagnostic performance of pROCK with existing AKI definitions (pRIFLE, KDIGO) in children.
Main Methods:
- Analysis of a large dataset of 156,075 hospitalized children with at least two creatinine tests within 30 days.
- Estimation of the reference change value (RCV) for creatinine based on age and initial creatinine levels in children without kidney disease or AKI risk.
- Development of the pROCK criterion: AKI defined as creatinine increase beyond RCV (greater of 20 μmol/L or 30% of initial creatinine).
Main Results:
- In a cohort of 102,817 children, pROCK identified AKI in 5.3% of cases, significantly lower than pRIFLE (15.2%) and KDIGO (10.2%).
- Children with pROCK-defined AKI showed a substantially increased risk of death (HR 3.56).
- pROCK reclassified a large proportion of patients diagnosed with AKI by pRIFLE (66%) and KDIGO (51%) as non-AKI, with comparable mortality risks to those without AKI by any definition.
Conclusions:
- The pROCK criterion enhances the detection of true AKI in children by accounting for creatinine variability.
- This new definition helps mitigate the overdiagnosis of AKI common with previous pediatric criteria.
- pROCK offers a more accurate approach to identifying pediatric AKI, potentially improving patient outcomes and resource allocation.
Background:
Current definitions of AKI do not take into account serum creatinine's high variability in children.
Methods:
We analyzed data from 156,075 hospitalized children with at least two creatinine tests within 30 days. We estimated reference change value (RCV) of creatinine on the basis of age and initial creatinine level in children without kidney disease or known AKI risk, and we used these data to develop a model for detecting pediatric AKI on the basis of RCV of creatinine. We defined pediatric AKI according to pediatric reference change value optimized for AKI in children (pROCK) as creatinine increase beyond RCV of creatinine, which was estimated as the greater of 20 μmol/L or 30% of the initial creatinine level.
Results:
Of 102,817 children with at least two serum creatinine tests within 7 days, 5432 (5.3%) had AKI as defined by pROCK compared with 15,647 (15.2%) and 10,446 (10.2%) as defined by pediatric RIFLE (pRIFLE) and Kidney Disease Improving Global Outcomes (KDIGO), respectively. Children with pROCK-defined AKI had significantly increased risk of death (hazard ratio, 3.56; 95% confidence interval, 3.15 to 4.04) compared with those without AKI. About 66% of patients with pRIFLE-defined AKI and 51% of patients with KDIGO-defined AKI, mostly children with initial creatinine level of <30 μmol/L, were reclassified as non-AKI by pROCK, and mortality risk in these children was comparable with risk in those without AKI by all definitions.
Conclusions:
pROCK criterion improves detection of "true" AKI in children compared with earlier definitions that may lead to pediatric AKI overdiagnosis.
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