Acute kidney injury (AKI) is a condition that affects about 15% of critically ill children. The prevalence of AKI among patients in pediatric intensive care
units is on the rise.
A study by University at Buffalo researchers has shown that
physicians in pediatric intensive care units (PICUs) are not using the newest
guidelines to diagnose acute kidney injury in critically ill
children, a practice that could affect their patients' long-term health.
‘Physicians in pediatric intensive care units are not using the newest guidelines to diagnose acute kidney injury in critically ill children, a practice that could affect their patients' long-term health.’
A pediatric critical care physician who focuses on acute kidney
injury, Amanda Hassinger surveyed colleagues in her field on practice
patterns related to the diagnosis and treatment of AKI.
The study was reported in a recent
paper in the journal Pediatric Critical Care Medicine
"What we found was pretty surprising. It was scarier than I thought
in terms of how aware other physicians in my field are to the new
guidelines for treatment of AKI and the new methods to diagnosis earlier
and more effectively," said Hassinger, lead author on the
paper, published in the journal's August issue.
She wrote it while working on her master's degree in
epidemiology/clinical research in UB's School of Public Health and
Health Professions. Hassinger has been an attending physician in the
Division of Critical Care at Women & Children's Hospital of Buffalo,
and is also an assistant professor of pediatrics in UB's Jacobs School
of Medicine and Biomedical Sciences and a member of UBMD Pediatrics.
Hassinger and her co-authors surveyed 170 pediatric critical care
physicians from academic centers, the Pediatric Acute Lung Injury and
Sepsis Investigators network and the pediatric branch of the Society of
Critical Care Medicine.
The survey consisted of more than two-dozen questions. Among them,
researchers asked what criteria the physicians frequently rely on to
diagnose acute kidney injury in young patients. Half of the respondents
reported not using recent AKI guidelines or diagnostic criteria in
clinical practice. Specifically, 74% of physicians said they
diagnose AKI using serum creatinine and urine output only, despite the
fact that newer, more reliable, tests are available.
The problem with serum creatinine as a test for renal function,
Hassinger says, is that it is not effective in children for detecting
AKI. It can be affected by several other factors, including nutrition
and muscle mass. Several new biomarkers have been discovered that aid in
the diagnosis of AKI.
Diagnosing AKI in children in clinical practice has also proven
difficult because there is not a consensus definition of AKI in
pediatric patients. Several guidelines and criteria are available, but
there is a lack of knowledge among pediatric intensive care physicians
about which ones to use, leading to variability in how children are
treated in the ICU, according to Hassinger.
"I wasn't surprised that the newer tests aren't being used, because
they do cost a lot of money and require special machinery," Hassinger
says. "But what really upset me was that physicians were happy with the
status quo and weren't looking for a better biomarker for this
critically important condition. The existing biomarkers are inadequate.
That was disappointing."
AKI occurs most frequently in patients who are already in the
hospital. It can be caused by a number of health conditions, including
sepsis, shock, trauma, exposure to medications that affect the kidneys,
or major surgery.
What's more, according to the National Kidney Foundation, one
episode of AKI increases a patient's chances of developing other health
problems - such as kidney disease, stroke or heart disease - later in
life. In fact, Hassinger said, data now show that children who
experience a single episode of AKI in the ICU have a 50% to 75% chance of having renal insufficiency for the rest of their life.
"It's an important but silent issue that needs more attention," she
says. "The kidneys are a very vulnerable set of organs and they're
important to overall balance in the body, so we should be paying more
attention to them than we do. Somebody has to fight for the little
"This study gives us an important picture of what practice looks
like in pediatric ICUs, so that we can understand what is missing," said
Jo Freudenheim, chair of epidemiology and environmental health in
UB's School of Public Health and Health Professions, and a co-author on
the paper. "We can now start to make renewed efforts to change practice
and to improve care."
Hassinger has an idea why AKI often goes underappreciated. "The
kidneys are extremely resilient, and children are resilient, so even if
you have the worst stage of acute kidney injury, despite the physician,
the kidneys and the patient get better. There's not as much urgency to
diagnose it and call it the right name because most of the time, no
matter what name you call it, kids will bounce back pretty well," she
Toward that point, the researchers' survey asked physicians if they
were aware that AKI independently has increased morbidity and mortality. 12% of the respondents - a particularly high number,
Hassinger says - said either no or that they were unsure.
Hassinger was also surprised to learn that just one-third of the
PICU physicians surveyed said they refer a child who has AKI to a kidney
specialist once the patient is discharged from the intensive care unit.
That means that two-thirds of the respondents reported either rarely or
never offering referrals.
"So these patients go unmonitored for periods of time until the
kidney issues manifest when they're teenagers and they get an infection
or another injury that knocks out the kidneys completely, and then
they're in renal failure at 18," Hassinger said.
Hassinger is partnering with a colleague at Cincinnati Children's
Hospital Medical Center for a second survey that will take a closer look
at the relationship between fluid overload and acute kidney injury in
ICU patients. Fluids, given through IVs, are used regularly in
hospitalized children. Fluid overload can cause organs to fail,
Hassinger said, explaining why that's another area of current medical
practice that needs better scrutiny.