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Pediatric Postoperative Acute Kidney Injury After Noncardiac Surgery: A Systematic Review and Meta-Analysis
Arash Emami1, Ebba Sivertsson1, Johan Westerbergh2
1Anesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
Insights
Estimates for pediatric postoperative acute kidney injury (AKI) are uncertain. Incidence is high in neonates and liver transplant recipients, increasing with higher American Society of Anesthesiologists (ASA) class and younger age.
Area of Science:
- Pediatric Nephrology
- Surgical Outcomes Research
- Systematic Review and Meta-Analysis
Background:
- Postoperative acute kidney injury (AKI) significantly increases morbidity and mortality in children.
- Current estimates of AKI incidence following pediatric noncardiac surgery are limited and lack reliability.
- A systematic review was conducted to synthesize existing evidence on pediatric AKI post-noncardiac surgery.
Purpose of the Study:
- To determine the incidence of acute kidney injury (AKI) in children undergoing noncardiac surgery.
- To synthesize available evidence on pediatric AKI using standardized criteria.
- To identify factors associated with AKI in this population.
Main Methods:
- A comprehensive literature search was performed across PubMed, Cochrane, and Web of Science.
- Studies reporting AKI incidence based on Kidney Disease: Improving Global Outcomes (KDIGO) criteria within 7 days post-surgery were included.
- The review adhered to PRISMA guidelines, with evidence certainty assessed by GRADE.
Main Results:
- Twenty-seven studies encompassing 21,908 pediatric patients were analyzed.
- High heterogeneity (I²=98.7%) and overrepresentation of high-risk groups limited pooled estimates.
- Incidence varied: 22.3% in neonates, 30.1% in liver transplant recipients, and 9.2% in mixed populations. AKI increased with higher ASA class and younger age.
Conclusions:
- The incidence of postoperative AKI in pediatric noncardiac surgery remains uncertain due to study heterogeneity and focus on high-risk populations.
- AKI incidence was notably high in neonates and liver transplant recipients.
- Further prospective studies in diverse pediatric surgical groups are essential for accurate risk assessment.
Background:
Postoperative acute kidney injury (AKI) is associated with substantial morbidity and mortality. Reliable estimates of AKI after surgery in children are lacking. To address this gap, we aimed to synthesize the available evidence on the incidence of AKI after pediatric noncardiac surgery.
Methods:
We searched PubMed, Cochrane and Web of Science for studies reporting the incidence of AKI, defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria, within 7 postoperative days. Observational studies and clinical trials including patients aged < 18 years were eligible. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.
Results:
Twenty-seven studies (n = 21 908) were included. Considerable heterogeneity (I2 = 98.7%) and likely overrepresentation of clinically distinct high-risk populations limited the interpretability of a single overall pooled incidence estimate. The incidence was 22.3% (95% CI, 11.2-39.3) after neonatal surgery, 30.1% (95% CI, 21.4-40.6) after pediatric liver transplantation, and 9.2% (95% CI, 3.3-23.6) in mixed pediatric surgical populations. The certainty of evidence was rated low to very low. In mixed pediatric surgical populations, AKI incidence increased from 2.4% in American Society of Anesthesiologists (ASA) class 1-2 to 7.5% in ASA 3 (p < 0.001) and 18.9% in ASA 4-5 (p < 0.001), and decreased from 9.8% at 0-2 years to 4.0% at 12-18 years (p < 0.001).
Conclusion:
The reported incidence of postoperative AKI in children undergoing noncardiac surgery remains uncertain due to substantial heterogeneity and overrepresentation of high-risk populations. AKI incidence was high in neonates and liver transplant recipients and was associated with younger age and higher ASA class, although data were limited. Further prospective studies in broader pediatric surgical populations are needed to better assess the risk of postoperative AKI in children.
Trial Registration:
PROSPERO registration no.: CRD42024518832.
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