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Methods to estimate baseline creatinine and define acute kidney injury in lean Ugandan children with severe malaria:
Anthony Batte1, Michelle C Starr2, Andrew L Schwaderer2
1Child Health and Development Center, Makerere University College of Health Sciences, Kampala, Uganda.
Insights
Estimating baseline creatinine (bSCr) in children with severe malaria is crucial for diagnosing acute kidney injury (AKI). Age-based methods, like the Pottel equation, are recommended for accuracy in low-income settings.
Area of Science:
- Pediatric Nephrology
- Infectious Diseases
- Global Health
Background:
- Acute kidney injury (AKI) is a significant complication in children with severe malaria.
- Standardized methods for estimating baseline creatinine (bSCr) are lacking in pediatric populations, especially in low-income countries.
Purpose of the Study:
- To evaluate and compare six different methods for estimating bSCr in Ugandan children.
- To assess the prevalence of AKI and its association with mortality in children with severe malaria using various bSCr estimation techniques.
Main Methods:
- Six bSCr estimation methods were evaluated in two cohorts: children with severe malaria (n=1078) and healthy community children (n=289).
- Methods included height-dependent and height-independent equations, and population-specific norms, compared against isotope dilution mass spectrometry (IDMS)-traceable creatinine measures.
Main Results:
- The Pottel-age based equation demonstrated higher accuracy and minimal bias compared to the Schwartz height-based equation.
- AKI prevalence in severe malaria cases ranged from 15.6% to 43.4% depending on the bSCr estimation method.
- AKI was strongly associated with increased mortality, with the Pottel-age based estimation showing the strongest link (RR 5.13).
Conclusions:
- Height-independent, age-based methods are recommended for estimating bSCr in hospitalized children in sub-Saharan Africa due to measurement challenges and undernutrition.
- The Pottel-age based GFR estimating equation provides comparable bSCr estimates to population-based methods in healthy children.
Background:
Acute kidney injury (AKI) is increasingly recognized as a consequential clinical complication in children with severe malaria. However, approaches to estimate baseline creatinine (bSCr) are not standardized in this unique patient population. Prior to wide-spread utilization, bSCr estimation methods need to be evaluated in many populations, particularly in children from low-income countries.
Methods:
We evaluated six methods to estimate bSCr in Ugandan children aged 6 months to 12 years of age in two cohorts of children with severe malaria (n = 1078) and healthy community children (n = 289). Using isotope dilution mass spectrometry (IDMS)-traceable creatinine measures from community children, we evaluated the bias, accuracy and precision of estimating bSCr using height-dependent and height-independent estimated glomerular filtration (eGFR) equations to back-calculate bSCr or estimating bSCr directly using published or population-specific norms.
Results:
We compared methods to estimate bSCr in healthy community children against the IDMS-traceable SCr measure. The Pottel-age based equation, assuming a normal GFR of 120 mL/min per 1.73m2, was the more accurate method with minimal bias when compared to the Schwartz height-based equation. Using the different bSCr estimates, we demonstrated the prevalence of KDIGO-defined AKI in children with severe malaria ranged from 15.6-43.4%. The lowest estimate was derived using population upper levels of normal and the highest estimate was derived using the mean GFR of the community children (137 mL/min per 1.73m2) to back-calculate the bSCr. Irrespective of approach, AKI was strongly associated with mortality with a step-wise increase in mortality across AKI stages (p < 0.0001 for all). AKI defined using the Pottel-age based equation to estimate bSCr showed the strongest relationship with mortality with a risk ratio of 5.13 (95% CI 3.03-8.68) adjusting for child age and sex.
Conclusions:
We recommend using height-independent age-based approaches to estimate bSCr in hospitalized children in sub-Saharan Africa due to challenges in accurate height measurements and undernutrition which may impact bSCr estimates. In this population the Pottel-age based GFR estimating equation obtained comparable bSCr estimates to population-based estimates in healthy children.
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