In this issue of Pediatrics, Meena et al demonstrate not only the notable incidence of acute kidney injury (AKI) among hospitalized pediatric patients worldwide but also the concerning discrepancy in AKI-related mortality as a function of a country’s income.1 With improvement in provider education and the implementation of tools to identify AKI early, incidence and associated mortality can be reduced. Through sustained efforts and policy implementation on the local, national, and global scale, we can work to eliminate mortality discrepancies.
As described in the authors’ meta-analysis, one-quarter of hospitalized pediatric patients worldwide are diagnosed with AKI. The adoption of the 2012 Kidney Disease Improving Global Outcomes AKI definition has helped to standardize the diagnostic criteria.2 However, the use of serum creatinine and urine output-based classification system detects AKI once it is already established, leaving little window for preventive strategies.3 Thus, there is a need for tools to allow for earlier detection of AKI, as well as identification of those patients at the highest risk. Substantial progress has been made in the use of novel biomarkers that would allow providers to detect AKI before any overt clinical manifestation.2,3 The clinical application of these biomarkers and the widespread availability of their assays continue to be elucidated.
For example, the Renal Angina Index has been used in pediatric patients on admission to the ICU to predict those at risk for the development of severe AKI.2,3 Prediction models have been used to develop electronic medical record alerts, which notify providers of patients at increased risk for AKI.3 Although these tools are beneficial, the intervention that is likely to have the greatest impact on AKI incidence is increased provider awareness and education.
The majority of AKI is present on hospital admission, indicating that the injury commonly originates in the community setting. Kidney injury is often seen as an unavoidable consequence of acute illness. However, several interventions can be implemented to attenuate the development or worsening of kidney injury, including ensuring adequate intravascular fluid volume, minimizing exposure to nephrotoxic agents, and maintaining normotension. Development and provision of AKI mitigation guidance to all providers regardless of specialty is crucial, with a focus on patient risk assessment, timely AKI diagnosis, appropriate referral and intervention, and close monitoring that continues after the resolution of an AKI episode.4
AKI is associated with increased morbidity and mortality in all pediatric patients, but, as demonstrated in this study, mortality risk is increased disproportionately in patients residing in low- and low-middle-income countries. The etiologies of kidney injury differ between lower-income and higher-income countries, and low-income countries also face specific difficulties related to a lack of resources. Despite the widespread use of the Kidney Disease Improving Global Outcomes AKI classification, many low- and middle-income countries lack comprehensive data registries describing the prevalence of kidney disease, making it more difficult to determine epidemiologic trends and identify areas in need of additional support.5,6 Low- and middle-income countries have a greater prevalence of certain microbes, poor sanitation, and lack of supply of safe drinking water, all of which contribute to increased risk of infection, dehydration, and subsequent development of AKI.5
With respect to AKI treatment, there is often inadequate infrastructure and reduced means available for travel to a major medical center to receive appropriate care. Even within the major medical centers in low- and middle-income countries, access to the standard of care treatment is often limited because of inadequate resources. Continuous kidney replacement therapy is the treatment of choice for severe AKI; however, it is costly and requires significant training and support staff. Many developing countries report preferential use of peritoneal dialysis because of ease of use, staffing support, and cost constraints.7
Increased education and guidance surrounding preventive measures can help decrease the overall incidence of pediatric AKI worldwide, and early detection and prompt intervention will help mitigate associated morbidity and mortality. Clinical and policy-based strategies to ensure provider training, improved infrastructure, and increased funding are needed to improve equity in AKI outcomes.
Dr Brummer drafted the initial commentary and critically reviewed and revised the manuscript; Dr Brophy critically reviewed and revised the manuscript for important intellectual content; and both authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2022-058823.
CONFLICT OF INTEREST DISCLOSURES: Dr Brummer has no conflicts of interest relevant to this article to disclose. Dr Brophy currently receives royalties for the UpToDate section on Pediatric Acute Kidney Injury.
acute kidney injury