The Prognosis of Acute Kidney Disease With or Without Acute Kidney Injury in the PICU

Introduction: Acute kidney disease (AKD) includes abnormalities of kidney function present for < 90 days, and acute kidney injury (AKI) is defined as a subset of AKD, with onset within 7 days. Recent data in adult patients suggests that AKD not associated with AKI is common and is associated with death and progression to end stage kidney disease. There is scant data defining AKD in children and its association with outcomes. Our primary objective was to examine the rates of AKD with and without AKI and compare major adverse events (MAKE) in children in the pediatric intensive care unit (PICU).


Methods: This is a retrospective cohort study of children >60 days of age admitted to a quaternary care PICU between the years of 2009-2016 using a high-density pediatric database. Patients that were dialysis dependent at the time of admission, had an estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73m2, a history of kidney transplant, or did not have a baseline serum creatinine available were excluded. AKI and AKD were defined by Kidney Disease: Improving Global Outcomes (KDIGO) guideline definitions through 30 days. MAKE-90 was defined as a composite outcome of death, dialysis, or incomplete kidney recovery (>25% decline in eGFR from baseline) 90 days after PICU admission. Multivariable logistic regression was used to test the associations of MAKE-90 with AKD (with or without AKI).


Results: Of the 5922 patients (median (IQR) age of 8 (2-14) years, 43% female) included in this study, 386 (6.5%) had AKD with AKI and 107 (1.8%) had AKD without AKI. The overall incidence of MAKE-90 was 5.9% (352/5922). MAKE-90 occurred in 31% (152/493) of those with AKD. The incidence of MAKE-90 in those with AKD and AKI was 31% (120/386). The incidence of MAKE-90 in those with AKD without AKI was 34% (36/107). After adjusting for age, sex, and severity of illness (Pediatric Index of Mortality 2 Score), compared to patients that had no kidney disease, patients with AKD with AKI (aOR: 12.08, 95% CI: 9.18-15.89) and patients with AKD without AKI (aOR: 14.46, 95% CI: 9.25-22.61) had a greater odds of MAKE-90.


Conclusions: MAKE-90 is common in pediatric critically ill patients with AKD. Even in the absence of AKI, AKD appears to be strongly associated with poor clinical outcomes.