Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
Deparment of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
Pediatr Res. 2023 Apr;93(5):1354-1360. doi: 10.1038/s41390-022-02233-2. Epub 2022 Aug 6.
The functional acute kidney injury (AKI) diagnostic tests serum creatinine (SCr) and urine output are imprecise and make management challenging. Combining tubular injury biomarkers with functional markers reveal AKI phenotypes that may facilitate personalized care. However, when and in whom to obtain injury biomarkers remains unclear.
This was a prospective, observational study of patients admitted to a pediatric intensive care unit (PICU). Using the Renal Angina Index (RAI), subjects were screened for the presence (RAI+) or absence (RAI-) of renal angina 12 h post-admission and assigned an AKI phenotype using urinary NGAL (NGAL+: ≥150 ng/ml) and SCr (SCr+: ≥KDIGO Stage 1). Outcomes for each AKI phenotype were assessed and compared by RAI status.
In all, 200/247 (81%) subjects were RAI+. RAI+ subjects who were NGAL+ had higher risk of Day 3 AKI, renal replacement therapy use, and mortality and fewer ventilator- and PICU-free days, compared to NGAL-, irrespective of Day 0 SCr. Similar findings were not demonstrated in RAI- subjects, though NGAL+/SCr+ was associated with fewer ventilator- and PICU-free days compared to NGAL-/SCr+.
NGAL- and SCr-based AKI phenotypes provide improved prognostic information in children with renal angina (RAI+) and/or with SCr elevation. These populations may be appropriate for targeted biomarker testing.
New consensus recommendations encourage the integration of kidney tubular injury biomarkers such as urinary NGAL with serum creatinine for diagnosis and staging of acute kidney injury; however, no structured testing framework exists guiding when to test and in whom. Urinary NGAL- and serum creatinine-based acute kidney injury phenotypes increase diagnostic precision in critically ill children experiencing renal angina (RAI+) or serum creatinine-defined acute kidney injury. These data provide preliminary evidence for a proposed framework for directed urinary NGAL assessment in the pediatric intensive care unit.
功能性急性肾损伤（AKI）的诊断检测血清肌酐（SCr）和尿量不精确，使得管理具有挑战性。将肾小管损伤生物标志物与功能标志物相结合，可揭示 AKI 表型，从而可能促进个体化治疗。然而，何时以及在哪些患者中获得损伤生物标志物仍不清楚。
这是一项前瞻性、观察性研究，纳入了入住儿科重症监护病房（PICU）的患者。使用肾绞痛指数（RAI），在入院后 12 小时筛选出存在（RAI+）或不存在（RAI-）肾绞痛的患者，并根据尿中性粒细胞明胶酶相关脂质运载蛋白（NGAL）（NGAL+：≥150ng/ml）和 SCr（SCr+：≥KDIGO 第 1 期）确定 AKI 表型。根据 RAI 状态评估和比较每种 AKI 表型的结局。
共纳入 247 例患者中的 200 例（81%）为 RAI+。与 NGAL-相比，无论入院时的 SCr 水平如何，NGAL+且 RAI+的患者第 3 天 AKI、肾脏替代治疗的使用率和死亡率更高，且呼吸机和 PICU 无使用天数更少。而在 RAI-患者中未观察到类似的结果，尽管与 NGAL-/SCr+相比，NGAL+/SCr+与更少的呼吸机和 PICU 无使用天数相关。
在有肾绞痛（RAI+）和/或 SCr 升高的患儿中，基于 NGAL 和 SCr 的 AKI 表型提供了更好的预后信息。这些人群可能适合进行靶向生物标志物检测。
新的共识建议鼓励将肾脏管状损伤生物标志物（如尿中性粒细胞明胶酶相关脂质运载蛋白）与血清肌酐结合，用于诊断和分期急性肾损伤；然而，目前尚无结构化的检测框架来指导何时进行检测以及检测哪些患者。在经历肾绞痛（RAI+）或血清肌酐定义的急性肾损伤的危重症患儿中，基于尿 NGAL 和 SCr 的急性肾损伤表型提高了诊断精度。这些数据为儿科重症监护病房中针对尿 NGAL 的定向评估提供了初步证据，提出了一个框架。
