Acute Kidney Injury – An Underestimated Problem In Pediatric Intensive Care / Akûts Nieru Bojâjums — Nenovçrtçta Problçma Bçrnu Intensîvajâ Terapijâ

Open access


Acute kidney injury (AKI) frequently occurs in critically ill children and adults, with 5-20% of patients experiencing an episode during their stay in an intensive care unit. AKI rarely is an isolated event and is associated with a broader spectrum of diseases, including sepsis and respiratory insufficiency, and often progresses into multiorgan dysfunction syndrome. Despite recent advancements in renal replacement therapy (RRT), mortality among patients who sustain AKI complicated by multiorgan dysfunction appears to have remained unchanged and is estimated at approximately 50%. Recent clinical evidence suggests that AKI is not only an indicator for severity of illness, but that it also leads to earlier onset of multiorgan dysfunction with profound effects on mortality rates. The aim of this paper is to inform medical professionals involved in the paediatric intensive care of recent advances in AKI diagnosis and management. Studies were identified from MEDLINE (OVID), PubMed, and the Cochrane Library for topics relevant to AKI. There is limited evidence in paediatrics regarding effective therapy for acute kidney injury, a significant problem in the paediatric intensive care unit that extends length of stay, duration of mechanical ventilation, and overall mortality. Sublethal kidney injury may be contributing to overall morbidity. Prospective clinical trials are needed to evaluate specific diagnostic aids, such as biomarkers, and therapeutic strategies like early initiation of continuous RRT in children with fluid overload

If the inline PDF is not rendering correctly, you can download the PDF file here.

  • Akcan-Arikan A. Zappitelli M. Loftis L. L Washburn K. K. Jefferson L. S Goldstein S. L. (2007). Modified RIFLE criteria in critically ill children with acute kidney injury. Kidney Int. 71 1028-1035.

  • Akech S. Gwer S. Idro R. Fegan G. Eziefula A. C. Newton C. R. J. Levin M. Maitland K. (2006). Volume expansion with albumin compared to gelofusine in children with severe malaria: Results of a controlled trial. PLoSClin Trials 1 (5): e21.

  • Akech S. Ledermann H. Maitland K. (2010). Choice of fluids for resuscitation in children with severe infection and shock: Systematic review. BMJ (British Medical Journal) 341:c4416.

  • Andoni G. Zangrillo A. Cabrini L. Monti G. Turi S. Bignami E. Biondi-Zoccai G. L. Sheiban I. (2012). Continuous infusion versus bolus injection of furosemide in pediatric patients after cardiac surgery: A meta-analysis of randomized studies. Signa Vitae 7 (1) 17-22.

  • Andreoli S. P. (2002). Acute renal failure. Curr. Opin. Pediatr. 14 183-188.

  • Andreoli S. P. (2009). Acute kidney injury in children. Pediatr. Nephrol. 24 253-263.

  • Anonymous (2000). Pediatric Advanced Life Support. Circulation 102 I-291-I-342.Askenazi D. J. Feig D. I. Graham N. M. Hui-Stickle S. Goldstein S. (2006). 1-5 year longitudinal follow-up of pediatric patients after acute renal failure. Kidney Int. 69 184-189.

  • Anonymous (2012). KDIGO clinical practice guideline for acute kidney injury. Kidney Int. Suppl. 22 (1) 1-138.

  • Axelrod D. M. Anglemyer A. T. Sherman-Levine S. F. Zhu A. Grimm P. C. Roth S. J. Sutherland S. M. (2014). Initial experience using aminophylline to improve renal dysfunction in the pediatric cardiovascular ICU. Pediatr. Crit. Care Med. 15 21-27.

  • Bailey D. Phan V. Litalien C. Ducruet T. Mérouani A. Lacroix J. Gauvin F. (2007). Risk factors of acute renal failure in critically ill children: A prospective descriptive epidemiological study. Pediatr. Crit. Care Med. 8 29-35.

  • Bakr A. F. (2005). Prophylactic theophylline to prevent renal dysfunction in newborns exposed to perinatal asphyxia: A study in a developing country. Pediatr. Nephrol. 20 (9) 1249-1252.

  • Barrantes F. Tian J. Vazquez R. Amoateng-Adjepong Y. Manthous C. A. (2008). Acute kidney injury criteria predict outcomes of critically ill patients. Crit. Care Med. 36 1397-1403.

  • Basu R. K. Zapitelly M. Brunner L. Yu W. Wong H. R. Chawla L. S. Wheeler D. S. Goldstein S. L. (2014). Derivation and validation of the renal angina index to improve the prediction of acute kidney injury in children. Kidney Int. 85 659-667.

  • Bellomo R. Auriemma S. Fabbri A. D’Onofrio A. Katz N. McCullough P. A. Ricci Z. Shaw A. Ronco C. (2008). The pathophysiology of cardiac surgery-associated acute kidney injury (CSA-AKI). Int. J. Artif. Organs 31 166-178.

  • Bellomo R. Chapman M. Finfer S. Hickling K. Myburgh J. (2000). Low-dose dopamine in patients with early renal dysfunction: A placebo- controlled randomised trial. Australian and New Zealand Intensive Care Society (ANZICS) Clinical Trials Group. Lancet 356 2139-2143.

  • Bellomo R. Kellum J. A. Ronco C. (2007). Defining and classifying acute renal failure: From advocacy to consensus and validation of the RIFLE criteria. Intensive Care Med. 33 409-413.

  • Bellomo R. Ronco C. Kellum J. A. Mehta R. L Palevsky P. Acute Dialysis Quality Initiative workgroup (2004). Acute renal failure-definition outcome measures animal models fluid therapy and information technology needs: Crit. Care 8 R204-R212.

  • Bellomo R. Wan L. Langenberg C. May C. (2008). Septic acute kidney injury: New concepts. Nephron Exp. Nephrol. 109 e95-e100.

  • Bennett M. Dent C. L. Ma Q. Dastrala S. Grenier F. Workman R. Syed H. Ali S. Barasch J. Devarajan P. (2008). Urine NGAL predicts severity of acute kidney injury after cardiac surgery: A prospective study. Clin. J. Amer. Soc. Nephrol. 3 665-673.

  • Boldt J. Brenner T. Lehmann A. Suttner S. W. Kumle B. Isgro F. (2003). Is kidney function altered by the duration of cardiopulmonary bypass? Ann. Thorac. Surg. 75 906-912.

  • Bunchman T. E. (2008). Treatment of acute kidney injury in children: From conservative management to renal replacement therapy. Nat. Clin. Pract. Nephrol. 4 510-514.

  • Chertow G. M. Burdick E. Honour M. Bonventre J. V. Bates D. W. (2005). Acute kidney injury mortality length of stay and costs in hospitalized patients. J. Amer. Soc. Nephrol. 16 3365-3370.

  • Cooper D. S. Claes S. G. Goldstein S. G. Menon S. Bennett M. Ma Q. Krawczeski C. D. (2014). Novel urinary biomarkers remain elevated years after acute kidney injury following surgery in children. Pediatr. Crit. Care Med. 15 (Suppl.) Abstract No. 25.

  • De Mendona A. Vincent J. L. Suter P. Moreno M. Dearden N. M. Antonelli M. Takala J. Sprung C. Cantraine F. (2000). Acute renal failure in the ICU: Risk factors and outcome evaluated by the SOFA score. Intensive Care Med. 6 915-921

  • de Oliveira C. F. de Oliveira D. S. F. Gottschald A. F. C. Moura J. D. G. Costa G. A. Ventura A. C. Fernandes J. C. Vaz F. A. C. Carcillo J. A. Rivers E. P. Troster E. J. (2008). ACCM/PALS haemodynamic support guidelines for paediatric septic shock: An outcomes comparison with and without monitoring central venous oxygen saturation. Intensive Care Med. 34 1065-1075.

  • El-Husseini A. A. Foda M. A. Shokeir A. A. Shehab El-Din A. B. Sobh M. A. Ghoneim M. A. (2005). Determinants of graft survival in pediatric and adolescent live donor kidney transplant recipients: A single center experience. Pediatr. Transplant. 9 763-769.

  • Finfer S. Bellomo R. Boyce N. French J. Myburgh J. Norton R.; SAFE Study Investigators (2004). A comparison of albumin and saline for fluid resuscitation in the Intensive care unit. New Engl. J. Med. 350 2247-2256.

  • Flores F. X. Brophy P. D. Symons J. M. Flores F. X. Brophy P. D. Jordan M. Symons J. M. Fortenberry J. D. Chua A. N. Steven R. A. Mahan J. D. Bunchman T. E. Blowey D. Michael J. G. Somers M. B. Hackbarth R. Chand D. McBryde K. Benfield M. Goldstein S. L. (2008). Continuous renal replacement therapy (CRRT) after stem cell transplantation. A report from the prospective pediatric CRRT Registry Group. Pediatr. Nephrol. 23 625-630.

  • Foland J. A. Fortenberry J. D. Warshaw B. L. Pettignano R. Merritt R. K. Heard M. L. Rogers K. Reid C. Tanner A. J. Easley K. A. (2004). Fluid overload before continuous hemofiltration and survival in critically ill children: A retrospective analysis. Crit. Care Med. 32 1771-1776.

  • Gallego N. Perez-Caballero C. Gallego A. Estepaa R. Liañoa F. Ortuñoa J. (2001). Prognosis of patients with acute renal failure without cardiopathy. Arch. Dis. Child. 84 258-260.

  • Gillespie R. S. Seidel K. Symons J. M. (2004). Effect of fluid overload and dose of replacement fluid on survival in hemofiltration. Pediatr Nephrol. 19 1394-1399.

  • Goldstein S. L Chawla L. S. (2010). Renal angina. Clin. J. Amer. Soc. Nephrol. 5 943-949.

  • Goldstein S. L Currier H. Graf C. Cosio C. C. Brewer E. D. Sachdeva R. (2001). Outcome in children receiving continuous veno-venous hemofiltration. Pediatrics 107 1309-1312.

  • Goldstein S. L. Somers M. J. Baum M. A. Symons J. M. Brophy P. D. Blowey D Bunchman T. E. Baker C. Mottes T. McAfee N. Barnett J. Morrison G. Rogers K. Fortenberry J. D. (2005). Pediatric patients with multi-organ dysfunction syndrome receiving continuous renal replacement therapy. Kidney Int. 67 653-658.

  • Haase M. Bellomo R. Devarajan P. Schlattmann P. Haase-Fielitz A.; NGAL Meta-analysis Investigator Group. (2009). Accuracy of neutrophil gelatinase-associated lipocalin (NGAL) in diagnosis and prognosis in acute kidney injury: A systematic review and meta-analysis. Amer. J. Kidney Dis. 54 1012-1024.

  • Han F. Xiao W. Xu Y. Wu J. Wang Q. Wang H. Zhang M. Chen J. (2008). The significance of bold MRI in differentiation between renal transplant rejection and acute tubular necrosis. Nephrol. Dial Transplant. 23 2666-2672.

  • Harman P. Kron I. McLachlan H. D. Freedlender A. E. Nolan S. P. (1982). Elevated intra-abdominal pressure and renal function. Ann. Surg. 196 594-597.

  • Hui-Stickle S. Brewer E. D. Goldstein S. L. (2005). Pediatric ARF epidemiology at a tertiary care center from 1999 to 2001. Amer. J. Kidney Dis. 45 96-101.

  • Jenik A. G. Ceriani Cernadas J. M. Gorenstein A. Ramirez J. A. Vain N. Armadans M. Ferraris J. R. (2000). A randomized double blind placebo controlled trial of the effects of prophylactic theophylline on renal function in term neonates with perinatal asphyxia. Pediatrics 105 849-853.

  • Jones D. R Lee H.T. (2008). Perioperative renal protection. Best Pract. Res. Clin. Anaesthesiol. 22 193-208.

  • Just A. (2007). Mechanisms of renal blood flow autoregulation: Dynamics and contributions. Amer. J. Physiol. Regul. Integr. Comp. Physiol. 292 R1-R17.

  • Kainuma M. Yamada M. Miyake T. (1996). Continuous urine oxygen tension monitoring in patients undergoing cardiac surgery. J. Cardiothorac. Vasc. Anesth. 10 603-608.

  • Kellum J. A. Angus D. C. (2002). Patients are dying of acute renal failure. Crit. Care Med. 30 2156-2157.

  • Kellum J. A. Pinsky M. R. (2002). Use of vasopressor agents in critically ill patients. Curr. Opin. Crit. Care 8 236-241.

  • Kist-van Holthe J. E. Van Zwet J. M. Brand R. van Weel M. H. Bredius R. G. van Oostayen J. A. Vossen J. M. van der Heijden B. J. (2002). Prospective study of renal insufficiency after bone marrow transplantation. Pediatr. Nephrol. 17 1032-1037.

  • Langenberg C. Bellomo R. May C. Wan L. Egi M. Morgera S. (2005). Renal blood flow in sepsis. Crit. Care 9 R363-R374.

  • Legrand M. Mik E. G. Johannes T. Payen D. Ince C. (2008). Renal hypoxia and dysoxia after reperfusion of the ischemic kidney. Mol. Med. 14 502-516.

  • Levy E. M. Viscoli C. M. Horwitz R. I. (1996). The effect of acute renal failure on mortality. A cohort analysis. JAMA (The Journal of the American Medical Association) 275 1489-1494.

  • Maitland K. Pamba A. English M. Peshu N. Marsh K. Newton C. Levin M. (2005). Randomized trial of volume expansion with albumin or saline in children with severe malaria: Preliminary evidence of albumin bene?t. Clin. Infect. Dis. 40 538-545.

  • Malbrain M. L. Chiumello D. Pelosi P. Bihari D. Innes R. Ranieri V. M. Del Turco M. Wilmer A. Brienza N. Malcangi V. Cohen J. Japiassu A. De Keulenaer B. L. Daelemans R. Jacquet L. Laterre P. F. Frank G. de Souza P. Cesana B. Gattinoni L. (2005). Incidence and prognosis of intraabdominal hypertension in a mixed population of critically ill patients: A multiple-center epidemiological study. Crit. Care Med. 33 315-322.

  • Mehta R. L. Kellum J. A. Shah S. V. Molitoris B. A. Ronco C. Warnock D. G. Levin A.; Acute Kidney Injury Network. (2007). Acute Kidney Injury Network. Acute Kidney Injury Network: Report of an initiative to improve outcomes in acute kidney injury. Crit. Care 11 R31.

  • Metnitz P. G. Krenn C. G. Steltzer H. Lang T. Ploder J. Lenz K. Le Gall J. R. Druml W. (2002). Effect of acute renal failure requiring renal replacement therapy on outcome in critically ill patients. Crit. Care Med. 30 2051-2058.

  • Michael M. Kuehnle I. Goldstein S. L. (2004). Fluid overload and acute renal failure in pediatric stem cell transplant patients. Pediatr. Nephrol. 19 91-95.

  • Moat N. E. Shore D. F. Evans T. W. (1993). Organ dysfunction and cardiopulmonary bypass: The role of complement and complement regulatory proteins. Eur. J. Cardiothorac. Surg. 7 563-573.

  • Moore A. F. Hargest R. Martin M. Delicata R. J. (2004). Intraabdominal hypertension and the abdominal compartment syndrome. Brit. J. Surg. 91 1102-1110.

  • Moreau R. Lebrec D. (2008). Acute kidney injury: New concepts. Hepatorenal syndrome: The role of vasopressors. Nephron Physiol. 109 73-79.

  • Naftiu O. O. Vopel-Levis T. Morris M. Voeppel-Lewis T. Morris M. ChimbraW. T. Malvyia S. Reynolds P. Tremper K. K. (2009). How do pediatric anesthesiologists define intraoperative hypotension? Pediatric Anesthesia 19 1048-1053.

  • Parikh C. R. Edelstein C. L. Devarajan P. Cantley L. (2007). Biomarkers of acute kidney injury: Early diagnosis pathogenesis and recovery. J. Investig. Med. 55 333-340.

  • Parikh C. R. Lu J. C. Coca S. G. Devarajan P. (2010). Tubular proteinuria in acute kidney injury: A critical evaluation of current status and future promise. Ann. Clin. Biochem. 47 301-312.

  • Patzer L. (2008). Nephrotoxicity as a cause of acute kidney injury in children. Pediatr. Nephrol. 23 2159-2173.

  • Pedersen K. R. Hjortdal V. E. Christensen S. Pedersen J. Hjortholm K. Larsen S. H. Povlsen J. V. (2008). Clinical outcome in children with acute renal failure treated with peritoneal dialysis after surgery for congenital heart disease. Kidney Int. Suppl. S81-86.

  • Plotz F. B. Bouma A. B. van Wijk J. A. Kneyber M. C. J. Bökenkamp A. (2008). Pediatric acute kidney injury in the ICU: An independent evaluation of pRIFLE criteria. Intensive Care Med. 34 1713-1717.

  • Polito C. Papale M. R. La Manna A. L. (1998). Long term prognosis of acute renal failure in the full term newborn. Clin. Pediatr. (Phila) 37 381-386.

  • Price J. F. Goldstein S. L. (2009). Cardiorenal syndrome in children with heart failure. Curr. Heart Fail. Rep. 6 191-198.

  • Price J. F. Mott A. R. Dickerson H. A. Jefferies J. L. Nelson D. P. Chang A. C. O'Brian Smith E. Towbin J. A. Dreyer W. J. Denfield S. W. Goldstein S. L. (2008). Worsening renal function in children hospitalized with decompensated heart failure: Evidence for a pediatric cardiorenal syndrome? Pediatr. Crit. Care Med. 9 279-284.

  • Ricci Z. Stazi G. V. Di Chiara L. Morelli S. Vitale V. Giorni C. Ronco C. Picardo S. (2008). Fenoldopam in newborn patients undergoing cardiopulmonary bypass: Controlled clinical trial. Interact. Cardiovasc. Thorac. Surg. 7 1049-1053.

  • Rodriguez M. M. Gomez A. Abitbol C. Chandar J. Montane B. Zilleruelo G. (2005). Comparative renal histomorphometry: A case study of oliogonephropathy of prematurity. Pediatr. Nephrol. 20 945-949.

  • Rosner M. H. Okusa M. D. (2006). Acute kidney injury associated with cardiac surgery. Clin. J. Amer. Soc. Nephrol. 1 19-32.

  • Rudnick M. R. Aaron K. Stainly G. (2006). Contrast-induced nephropathy: How it develops how to prevent it. Cleveland Clin. J. Med. 73 (1) 75-87.

  • Sakr Y. Reinhart K. Vincent J. L. Sprung C. L. Moreno R. Ranieri V. M. De Backer D. Payen D. (2006). Does dopamine administration in shock influence outcome? Results of the Sepsis Occurrence in Acutely Ill Patients (SOAP) Study. Crit. Care Med. 34 589-597.

  • Schwartz G. J. Muñoz A. Schneider M. F. Mak R. H. Kaskel F. Warady B. A. Furth S. L. (2009). New equations to estimate GFR in children with CKD. J. Amer. Soc. Nephrol. 20 629-637.

  • Shear W. Rosner M. (2006). Acute kidney dysfunction secondary to the abdominal compartment syndrome. J. Nephrol. 19 556-565.

  • Simmons E. M. Himmelfarb J. Sezer M. T. Chertow G. M. Mehta R. L. Paganini E. P. Soroko S. Freedman S. Becker K. Spratt D. Shyr Y. Ikizler T. (2004). Plasma cytokine levels predict mortality in patients with acute renal failure. Kidney Int. 65 1357-1365.

  • Sutherland S. M. Zappitelli M. Alexander S. R. Chua A. N. Brophy P. D. Bunchman T. E. Hackbarth R. Somers M. J. Baum M. Symons J. M. Flores F. X. Benfield M. Askenazi D. Chand D. Fortenberry J. D. Mahan J. D. McBryde K. Blowey D. Goldstein S. L. (2010). Fluid overload and mortality in children receiving continuous renal replacement therapy: The prospective pediatric continuous renal replacement therapy registry. Amer. J. Kidney Dis. 55 316-325.

  • Symons J. M. Brophy P. D. Gregory M. J. McAfee N. Somers M. J. Bunchman T. E. Goldstein S. L. (2003). Continuous renal replacement therapy in children up to 10 kg. Amer. J. Kidney Dis. 41 984-989.

  • Symons J. M. Chua A. N. Somers M. J. Baum M. A. Bunchman T. E. Benfield M. R. Brophy P. D. Blowey D. Fortenberry J. D. Chand D. Flores F. X. Hackbarth R. Alexander S. R. Mahan J. McBryde K. D. Goldstein S. L. (2007). Demographic characteristics of pediatric continuous renal replacement therapy: A report of the prospective pediatric continuous renal replacement therapy registry. Clin. J. Amer. Soc. Nephrol. 2 732-738.

  • Uchino S. Gordon D. Bellomo R. Morimatsu H. Morgera S. Miet S. Ian T. Bouman C. Macedo E. Noel G. Ashita T. Ronco C. Kellum J. A.; Beginning and Ending Supportive Therapy for the Kidney (B.E.S.T. Kidney) Investigators (2004). Diuretics and mortality in acute renal failure. Crit. Care Med. 32 1669-1677.

  • Vachvanichsanong P. Dissaneewate P. Lim A. McNeil E. (2006). Childhood acute renal failure: 22-year experience in a university hospital in southern Thailand. Pediatrics 118 e786-791.

  • Vandijck D. M. Reynvoet E. Blot S. I. Vandecasteele E. Hoste E. A. (2007). Severe infection sepsis and acute kidney injury. Acta Clin. Belg. Suppl 332-336.

  • Vlasselaers D. Milants I. Desmet L. et al. (2009). Intensive insulin therapy for patients in paediatric intensive care: A prospective randomised controlled study. Lancet 373 547-556.

  • Warady B. A. Bunchman T. (2000). Dialysis therapy for children with acute renal failure: survey results. Pediatr. Nephrol. 15 11-13.

  • Wheeler D. S Devarajan P. Ma Q. Harmon K. Monaco M. Cvijanovich N. Wong H. R. (2008). Serum neutrophil gelatinase-associated lipocalin (NGAL) as a marker of acute kidney injury in critically ill children with septic shock. Crit. Care Med. 36 1297-1303.

  • Williams D. M. Sreedhar S. S. Mickell J. J. Chan J. C. (2002). Acute kidney failure: A pediatric experience over 20 years. Arch. Pediatr. Adolesc. Med. 156 893-900.

  • Ympa Y. P. Sakr Y. Reinhart K. Vincent J. L. (2005). Has mortality from acute renal failure decreased? A systematic review of the literature. Amer. J. Med. 118 827-832.

  • Zager R. A. (1996). Rhabdomyolysis and myohemoglobinuric acute renal failure. Kidney Int. 49 314-326.

  • Zappitelli M. Parikh C. R Akcan-Arikan A.Washburn K. K. Moffett B. S. Goldstein S. L. (2008). Ascertainment and epidemiology of acute kidney injury varies with definition interpretation. Clin. J. Amer. Soc. Nephrol. 3 948-954.

  • Zappitelli M. Washburn K. K. Arikan A. A. Loftis L. Ma Q. Devarajan P. Parikh C. R. Goldstein S. L. (2007). Urine neutrophil gelatinase-associated lipocalin is an early marker of acute kidney injury in critically ill child: A prospective cohort study. Crit. Care 11 R84

  • Zappitelli M. (2008). Epidemiology and diagnosis of acute kidney injury. Semin. Nephrol. 28 436-446.

Journal information
Impact Factor

CiteScore 2018: 0.3

SCImago Journal Rank (SJR) 2018: 0.137
Source Normalized Impact per Paper (SNIP) 2018: 0.192

All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 238 121 3
PDF Downloads 96 55 2