Chen Jiao, Jiang Zhen, Huang Hui, Li Min, Bai Zhenjiang, Kuai Yuxian, Wei Lin, Liu Ning, Li Xiaozhong, Lu Guoping, Li Yanhong
Department of Nephrology and Immunology, Children's Hospital of Soochow University, Suzhou, Jiangsu Province, China.
Pediatric Intensive Care Unit, Children's Hospital of Soochow University, Suzhou, Jiangsu Province, China.
Ann Intensive Care. 2023 Mar 28;13(1):23. doi: 10.1186/s13613-023-01119-8.
The concept of acute kidney injury (AKI) substages has been recommended to better phenotype AKI and identify high-risk patient groups and therefore improve the diagnostic accuracy of AKI. However, there remains a gap between the recommendation and the clinical application. The study aimed to explore the incidence of AKI substages based on a sensitive AKI biomarker of urinary cystatin C (uCysC), and to determine whether AKI substages were relevant with respect to outcome in critically ill children.
The multicenter cohort study enrolled 793 children in pediatric intensive care unit (PICU) of four tertiary hospitals in China. Children were classified as non-AKI, sub-AKI and AKI substages A and B according to uCysC level at PICU admission. Sub-AKI was defined by admission uCysC level ≥ 1.26 mg/g uCr in children not meeting the KDIGO criteria of AKI. In children who fulfilled KDIGO criteria, those with uCysC < 1.26 was defined as AKI substage A, and with ≥ 1.26 defined as AKI substage B. The associations of AKI substages with 30-day PICU mortality were assessed. 15.6% (124/793) of patients met the definition of sub-AKI. Of 180 (22.7%) patients with AKI, 90 (50%) had uCysC-positive AKI substage B and were more likely to have classical AKI stage 3, compared to substage A. Compared to non-AKI, sub-AKI and AKI substages A and B were risk factors significantly associated with mortality, and the association of sub-AKI (adjusted hazard ratio HR = 2.42) and AKI substage B (adjusted HR = 2.83) with mortality remained significant after adjustment for confounders. Moreover, AKI substage B had increased risks of death as compared with sub-AKI (HR = 3.10) and AKI substage A (HR = 3.19).
Sub-AKI defined/based on uCysC occurred in 20.2% of patients without AKI and was associated with a risk of death close to patients with AKI substage A. Urinary CysC-positive AKI substage B occurred in 50% of AKI patients and was more likely to have classical AKI stage 3 and was associated with the highest risk of mortality.
急性肾损伤（AKI）亚分期的概念已被推荐用于更好地表征AKI、识别高危患者群体，从而提高AKI的诊断准确性。然而，该推荐与临床应用之间仍存在差距。本研究旨在基于尿胱抑素C（uCysC）这一敏感的AKI生物标志物探讨AKI亚分期的发生率，并确定AKI亚分期与危重症儿童预后是否相关。
这项多中心队列研究纳入了中国四家三级医院儿科重症监护病房（PICU）的793名儿童。根据PICU入院时的uCysC水平，将儿童分为非AKI、亚AKI以及AKI亚分期A和B。亚AKI定义为未达到AKI的KDIGO标准的儿童入院时uCysC水平≥1.26 mg/g尿肌酐。在符合KDIGO标准的儿童中，uCysC＜1.26的定义为AKI亚分期A，≥1.26的定义为AKI亚分期B。评估AKI亚分期与PICU 30天死亡率的相关性。15.6%（124/793）的患者符合亚AKI的定义。在180例（22.7%）AKI患者中，90例（50%）uCysC阳性的AKI亚分期B患者比A期更有可能处于经典的AKI 3期。与非AKI相比，亚AKI以及AKI亚分期A和B是与死亡率显著相关的危险因素，在对混杂因素进行调整后，亚AKI（调整后风险比HR = 2.42）和AKI亚分期B（调整后HR = 2.83）与死亡率的相关性仍然显著。此外，与亚AKI（HR = 3.10）和AKI亚分期A（HR = 3.19）相比，AKI亚分期B的死亡风险增加。
基于uCysC定义的亚AKI发生在20.2%的非AKI患者中，其死亡风险与AKI亚分期A患者相近。尿CysC阳性的AKI亚分期B发生在50%的AKI患者中，更有可能处于经典的AKI 3期，且与最高的死亡风险相关。
