Nephrology and Hypertension Division, Department of Pediatrics, Sidra Medicine, Doha, Qatar.
Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
Pediatr Crit Care Med. 2019 Apr;20(4):332-339. doi: 10.1097/PCC.0000000000001866.
Consensus definitions for acute kidney injury are based on changes in serum creatinine and urine output. Although the creatinine criteria have been widely applied, the contribution of the urine output criteria remains poorly understood. We evaluated these criteria individually and collectively to determine their impact on the diagnosis and outcome of severe acute kidney injury.
Post hoc analysis of Assessment of Worldwide Acute Kidney Injury, Renal Angina, and Epidemiology study-a prospective international observational multicenter study.
Critically ill children enrolled in Assessment of Worldwide Acute Kidney Injury, Renal Angina and, Epidemiology database.
To assess the differential impact of creatinine and urine output criteria on severe acute kidney injury (Kidney Disease: Improving Global Outcomes stage ≥ 2). Patients were divided into four cohorts: no-severe acute kidney injury, severe acute kidney injury by creatinine criteria only, severe acute kidney injury by urine output criteria only, and severe acute kidney injury by both creatinine and urine output criteria.
Severe acute kidney injury occurred in 496 of 3,318 children (14.9%); 343 (69.2%) were creatinine criteria only, 90 (18.1%) were urine output criteria only, and 63 (12.7%) were both creatinine and urine output criteria. Twenty-eight-day mortality for creatinine criteria only and urine output criteria only patients was similar (6.7% vs 7.8%) and higher than those without severe acute kidney injury (2.9%; p < 0.01). Both creatinine and urine output criteria patients had higher mortality than creatinine criteria only and urine output criteria only patients (38.1%; p < 0.001). Compared with patients without severe acute kidney injury, the relative risk of receiving dialysis increased from 9.1 (95% CI, 3.9-21.2) in creatinine criteria only, to 28.2 (95% CI, 11.8-67.7) in urine output criteria only, to 165.7 (95% CI, 86.3-318.2) in both creatinine and urine output criteria (p < 0.01).
Nearly one in five critically ill children with acute kidney injury do not experience increase in serum creatinine. These acute kidney injury events, which are only identified by urine output criteria, are associated with comparably poor outcomes as those diagnosed by changes in creatinine. Children meeting both criteria had worse outcomes than those meeting only one. We suggest oliguria represents a risk factor for poorer outcomes among children who develop acute kidney injury. Application of both the creatinine and urine output criteria leads to a more comprehensive epidemiologic assessment of acute kidney injury and identifies a subset of children with acute kidney injury who are at higher risk for morbidity and mortality.
急性肾损伤的共识定义基于血清肌酐和尿量的变化。尽管肌酐标准已被广泛应用，但尿量标准的贡献仍知之甚少。我们单独和集体评估这些标准，以确定它们对严重急性肾损伤的诊断和结果的影响。
对全球急性肾损伤、肾绞痛和流行病学研究的事后分析-一项前瞻性国际观察性多中心研究。
严重程度不同的急性肾损伤患儿，纳入全球急性肾损伤、肾绞痛和流行病学数据库。
评估肌酐和尿量标准对严重急性肾损伤（肾脏病：改善全球结局标准≥2 期）的差异影响。将患者分为四组：无严重急性肾损伤、仅肌酐标准的严重急性肾损伤、仅尿量标准的严重急性肾损伤、以及肌酐和尿量标准均有的严重急性肾损伤。
3318 例患儿中，496 例（14.9%）发生严重急性肾损伤；343 例（69.2%）为仅肌酐标准，90 例（18.1%）为仅尿量标准，63 例（12.7%）为肌酐和尿量标准均有。仅肌酐标准和仅尿量标准患者的 28 天死亡率相似（6.7% vs 7.8%），高于无严重急性肾损伤患者（2.9%；p < 0.01）。肌酐和尿量标准患者的死亡率均高于仅肌酐标准和仅尿量标准患者（38.1%；p < 0.001）。与无严重急性肾损伤患者相比，仅肌酐标准患者接受透析的相对风险从 9.1（95%CI，3.9-21.2）增加至仅尿量标准患者的 28.2（95%CI，11.8-67.7），再增加至肌酐和尿量标准均有的患者的 165.7（95%CI，86.3-318.2）（p < 0.01）。
近五分之一的急性肾损伤危重症患儿的血清肌酐没有升高。这些仅通过尿量标准确定的急性肾损伤事件，与因肌酐变化而诊断的急性肾损伤事件的预后相似较差。同时符合两种标准的患儿的预后比仅符合一种标准的患儿更差。我们建议少尿是急性肾损伤患儿预后较差的危险因素。肌酐和尿量标准的应用可以更全面地评估急性肾损伤，并确定一组急性肾损伤患儿的发病率和死亡率更高。
