Key performance indicators for acute kidney replacement therapy in critically ill children: a systematic review

Acute kidney injury is common among critically ill children and independently associated with morbidity and mortality, particularly in those receiving kidney replacement therapy (KRT). As KRT is not innocuous, standardizing its delivery is critical for accurate outcome tracking. Establishing key performance indicators (KPIs) is essential to guide quality improvement and support decision-making through ongoing monitoring of KRT processes.

This systematic review evaluated existing evidence on KPIs related to KRT delivery in critically ill pediatric populations.

A comprehensive search of Ovid MEDLINE, Ovid Embase, CINAHL, and the Cochrane Library was conducted for studies published from inception to February 2025.

Eligible studies reported KPIs related to dialysis processes in critically ill children receiving KRT.

Critically ill children receiving all KRT modalities were assessed for KPIs according to the Donabedian framework, with each KPI stratified based on whether it measured a process related to KRT care.

Six reviewers independently screened, selected, and appraised studies using the risk-of-bias tool appropriate for each study design. Data were summarized narratively.

Of 7,111 citations screened, 107 studies met inclusion criteria, comprising 57 retrospective cohorts, 27 case series, 16 prospective cohorts, 4 case reports, 2 randomized controlled trials, and 1 audit. Most studies (66.7%) were of moderate quality. Six KPIs were identified across 240 instances: solute clearance (n = 59), filter life (n = 52), downtime (n = 43), fluid management (n = 36), hypotension (n = 25), and prescription (n = 24). KPI definitions were heterogeneous. KPIs were categorized as important (n = 242, 52.1%), scientifically acceptable (n = 107, 23.1%), and feasible (n = 115, 24.8%).

This systematic review is limited by heterogeneity in study quality, with most evidence derived from observational or clinical studies rather than structured quality improvement initiatives. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS : Multiple potential KPIs for pediatric KRT were identified; however, definitions and validation were inconsistent. Standardizing and prioritizing a set of concise KPIs are needed to measure, benchmark, and improve KRT quality in critically ill children.

PROSPERO CRD42023474374 (October 30, 2023).