Kuai Y X, Li M, Jiang Z, Chen J, Bai Z J, Li X Z, Lu G P, Li Y H
Department of Nephrology and Immunology, Children's Hospital of Soochow University, Suzhou 215000, China.
Pediatric Intensive Care Unit, Anhui Provincial Children's Hospital, Hefei 230002, China.
Zhonghua Er Ke Za Zhi. 2023 Nov 2;61(11):1011-1017. doi: 10.3760/cma.j.cn112140-20230623-00418.
The kidney disease: improving global outcome (KDIGO) and pediatric reference change value optimized for acute kidney injury (pROCK) criteria were used to evaluate the incidence, stages and mortality of acute kidney injury (AKI). The differences between the 2 criteria were compared for exploring the value of pROCK criteria in diagnosing pediatric AKI and predicting adverse outcomes. In the multicenter prospective clinical cohort study, we collected general data and clinical data such as serum creatinine values from 1 120 children admitted to 4 PICUs of Children's Hospital of Soochow University, Children's Hospital of Fudan University, Anhui Provincial Children's Hospital, and Xuzhou Children's Hospital from September 2019 to February 2021. AKI was defined and staged according to the KDIGO and pROCK criteria. The incidence of AKI, the consistency of AKI definite diagnosis and stages, and the mortality in PICU were compared between the 2 groups. The chi-square test or Fisher's exact test was applied for comparison between 2 groups. The Cohen's Kappa and Weighted Kappa analyses were used for evaluating diagnostic consistency. The Cox regression analysis was used to evaluate the correlation between AKI and mortality. A total of 1 120 critically ill children were included, with an age of 33 (10, 84) months. There are 668 boys and 452 girls. The incidence of AKI defined by the KDIGO guideline was higher than that defined by pROCK criteria (27.2%(305/1 120), 14.7%(165/1 120), =52.78, <0.001). The concordance rates of the 2 criteria for the diagnosis of AKI and AKI staging were 87.0% (0.62) and 79.7% (0.58), respectively. Totally 63 infants with AKI stage 1 defined by the KDIGO guideline were redefined as non-AKI by following the pROCK criteria. The PICU mortality rate of these infants was similar to patients without AKI defined by KDIGO guideline(=0.761). After adjusting for confounders, AKI defined by KDIGO or pROCK criteria was an independent risk factor of death in PICU (2.04, 2.73,95% 1.27-3.29, 1.74-4.28, both <0.01), and the risk of death was higher when using the pROCK compared with the KDIGO criteria. As for the KDIGO criteria, mild AKI was not associated with the mortality in PICU (0.702), while severe AKI was associated with increased mortality (<0.001). As for the pROCK criteria, both mild and severe AKI were risk factors of PICU death in children (3.51, 6.70, 95% 1.94-6.34, 4.30-10.44, both 0.001). In addition, The AKI severity was positively associated with the mortality. The AKI incidence and staging varied depending on the used diagnostic criteria. The KDIGO definition is more sensitive, while the pROCK-defined AKI is more strongly associated with high mortality rate.
采用改善全球肾脏病预后（KDIGO）标准和针对急性肾损伤优化的儿科参考变化值（pROCK）标准来评估急性肾损伤（AKI）的发病率、分期及死亡率。比较这两种标准之间的差异，以探究pROCK标准在诊断儿童AKI及预测不良结局方面的价值。在这项多中心前瞻性临床队列研究中，我们收集了2019年9月至2021年2月期间苏州大学附属儿童医院、复旦大学附属儿童医院、安徽省儿童医院及徐州市儿童医院4个儿科重症监护病房（PICU）收治的1120例儿童的一般资料和临床资料，如血清肌酐值等。根据KDIGO标准和pROCK标准对AKI进行定义和分期。比较两组之间AKI的发病率、AKI确诊及分期的一致性以及PICU的死亡率。两组之间的比较采用卡方检验或Fisher精确检验。采用Cohen's Kappa分析和加权Kappa分析评估诊断一致性。采用Cox回归分析评估AKI与死亡率之间的相关性。共纳入1120例危重症儿童，年龄为33（10，84）个月。其中男668例，女452例。KDIGO指南定义的AKI发病率高于pROCK标准定义的发病率（27.2%（305/1120），14.7%（165/1120），χ² = 52.78，P < 0.001）。两种标准对AKI诊断及AKI分期的一致性率分别为87.0%（κ = 0.62）和79.7%（κ = 0.58）。按照KDIGO指南定义为1期AKI的63例婴儿，按照pROCK标准重新定义为非AKI。这些婴儿的PICU死亡率与KDIGO指南定义的非AKI患者相似（P = 0.761）。校正混杂因素后，KDIGO或pROCK标准定义的AKI均是PICU死亡的独立危险因素（HR分别为2.04、2.73，95%CI分别为1.27 - 3.29、1.74 - 4.28，均P < 0.01），且与KDIGO标准相比，采用pROCK标准时死亡风险更高。对于KDIGO标准，轻度AKI与PICU死亡率无关（P = 0.702），而重度AKI与死亡率增加有关（P < 0.001）。对于pROCK标准，轻度和重度AKI均是儿童PICU死亡的危险因素（HR分别为3.51、6.70，95%CI分别为1.94 - 6.34、4.30 - 10.44，均P < 0.001）。此外，AKI严重程度与死亡率呈正相关。AKI的发病率和分期因所采用的诊断标准而异。KDIGO定义更敏感，而pROCK定义的AKI与高死亡率的关联更强。
