Background: Acute kidney injury (AKI) is a common complication following congenital heart disease (CHD) surgery in infants. We aimed to develop and internally validate a perioperative risk score to predict severe postoperative AKI on arrival to the cardiac intensive care unit (CICU). Methods: Single-center cohort study included all infants ( < 1 year) undergoing STAT 3–5 cardiac surgeries between January 2016 and December 2025. Preterm infants (<37 weeks gestation) and those requiring preoperative kidney replacement therapy were excluded. The primary outcome was Stage 2/3 AKI (creatinine-based KDIGO criteria). Multivariable logistic regression with best subset selection identified key pre-, intra-, and immediate post-operative predictors. Internal validation was performed using 500 bootstrap iterations. Weighted points were assigned from odds ratio generating a score ranging from -1 to 19. Tool performance was assessed using area under the curve (AUC). Results: Among 1,187 patients, 448 (37.7%) developed stage 2/3 AKI. Six independent predictors were identified: neonates ( < 30 days) (3 points), single-ventricle physiology (3 points), cardiopulmonary bypass time > 152.5 minutes (7), ultrafiltration use (-1 point), delayed sternal closure (3 points), and vasoactive-inotropic score on arrival to CICU > 7.26 (3 points). Risk categories were defined as low (–1 to 5), moderate (9–12), and high (13–19). Severe AKI rates were 21%, 41% and 71% respectively. The model demonstrated good discrimination (AUC 0.71). Conclusion: We developed a simple, perioperative variable-based risk score that accurately stratifies the risk of severe postoperative AKI in infants undergoing high-complexity CHD Surgery. External validation is needed to confirm generalizability.

Acute kidney injury (AKI) occurs commonly in critically ill children. The impact of AKI on pediatric growth outcomes has been sparsely described. To compare growth in children with a history of AKI compared to those without AKI. We hypothesized that children with AKI would have worse growth compared to those without AKI. A convenience sample of existing prospective and retrospective cohorts of children with AKI who had already collected or were able to collect data on growth parameters before and after an episode of AKI. There are < 5 studies in the published literature on growth in children with AKI. These investigators were contacted, and additional studies were added by contacting primary investigators of studies of childhood AKI in which data on growth parameters was able to be collected. Children from existing cohorts evaluating AKI (exposure) during childhood. Each included cohort had previously received local IRB approval per institutional guidelines. As our study was a meta-analysis and only used cohort-level data, no IRB approval was required for this report. Growth parameters (length and weight z-scores) before and after an episode of AKI were compared using a meta-means analysis. MOOSE guidelines were used. Data were pooled using a random-effects model. Hedges g was calculated, and Higgins I2 statistic was used to define variability due to between-cohort heterogeneity. We included 3,586 children from 17 existing cohorts of AKI in various populations, including infants, children with cardiac disease, solid organ transplant and critically ill children without cardiac disease with follow-up from 12 months to 11 years after AKI. At most distant follow-up, those with AKI had lower length z-score than those without AKI (mean difference -0.37 [95

BackgroundLongitudinal cohort studies have traditionally relied on clinic-based recruitment models, which limit cohort diversity and the generalizability of research outcomes. Digital research platforms can be used to increase participant access, improve study engagement, streamline data collection, and increase data quality; however, the efficacy and sustainability of digitally enabled studies rely heavily on the design, implementation, and management of the digital platform being used. ObjectiveWe sought to design and build a secure, privacy-preserving, validated, participant-centric digital health research platform (DHRP) to recruit and enroll participants, collect multimodal data, and engage participants from diverse backgrounds in the National Institutes of Health’s (NIH) All of Us Research Program (AOU). AOU is an ongoing national, multiyear study aimed to build a research cohort of 1 million participants that reflects the diversity of the United States, including minority, health-disparate, and other populations underrepresented in biomedical research (UBR). MethodsWe collaborated with community members, health care provider organizations (HPOs), and NIH leadership to design, build, and validate a secure, feature-rich digital platform to facilitate multisite, hybrid, and remote study participation and multimodal data collection in AOU. Participants were recruited by in-person, print, and online digital campaigns. Participants securely accessed the DHRP via web and mobile apps, either independently or with research staff support. The participant-facing tool facilitated electronic informed consent (eConsent), multisource data collection (eg, surveys, genomic results, wearables, and electronic health records [EHRs]), and ongoing participant engagement. We also built tools for research staff to conduct remote participant support, study workflow management, participant tracking, data analytics, data harmonization, and data management. ResultsWe built a secure, participant-centric DHRP with engaging functionality used to recruit, engage, and collect data from 705,719 diverse participants throughout the United States. As of April 2024, 87% (n=613,976) of the participants enrolled via the platform were from UBR groups, including racial and ethnic minorities (n=282,429, 46%), rural dwelling individuals (n=49,118, 8%), those over the age of 65 years (n=190,333, 31%), and individuals with low socioeconomic status (n=122,795, 20%). ConclusionsWe built a participant-centric digital platform with tools to enable engagement with individuals from different racial, ethnic, and socioeconomic backgrounds and other UBR groups. This DHRP demonstrated successful use among diverse participants. These findings could be used as best practices for the effective use of digital platforms to build and sustain cohorts of various study designs and increase engagement with diverse populations in health research.

Nephrotoxic medication (NTMx) exposure is a common cause of hospital-acquired acute kidney injury (AKI) in non-critically ill, hospitalized children. NINJA (Nephrotoxic Injury Negated by Just-In-Time Action), an AKI screening and quality improvement tool, has successfully decreased exposure to NTMx and associated AKI at various US children’s hospitals. We explored NTMx exposure and AKI rates by admitting service to understand patient risk profiles further. AKI screening was performed by daily serum creatinine when high NTMx exposure criteria were met (≥ 3 NTMx or ≥ 3 days of intravenous aminoglycosides or vancomycin). Centers separately reported data from children admitted to hematology-oncology (heme), bone marrow transplant (BMT), and pulmonary services over 5 years (n = 11, 2016–2021). Rates for NTMx exposure and AKI were expressed as events per 1000 patient days. AKI intensity (#AKI days/100 exposure days) was assessed. Adherence to recommended serum creatinine monitoring was a surrogate for AKI event reliability (observed/expected × 100). Mean exposure rates were highest in BMT (26.92), then pulmonary (22.73), and heme (13.01). AKI rates were highest in BMT (6.27), then pulmonary (4.24), and heme (1.82). Heme and BMT had the highest AKI intensity (12.93 and 12.25 AKI days per 100 high-NTMx exposure days, respectively) compared to pulmonary (7.50 AKI days/100 high-NTMx exposure days). Serum creatinine monitoring compliance varied between institutions (62.5–100

Acute kidney injury (AKI) is a major global health problem, expensive to manage, and its associations with negative pediatric health outcomes have been clearly demonstrated. One of the most fundamental questions to consider as we use previous epidemiological information to advance research and care paradigms is the strength of the causal link between pediatric AKI and health outcomes. In this review, we apply the foundational framework of the Bradford Hill criteria to evaluate the extent to which a causal link exists between AKI and the associated adverse outcomes in children. Available data in children support a causal link between AKI and short-term outcomes including mortality, length of stay, and ventilation time. Clarifying the causal nature of longer term associations requires further high-quality observational studies in children, careful consideration of what defines the most meaningful and measurable longer term outcomes after pediatric AKI, and integration of evolving biological data related to mechanisms of disease. Preventing or mitigating AKI should lead to improved outcomes. Demonstrating such reversibility will solidify confidence in the causal relationship, improve child health, and highlight an aspect which is highly relevant to clinicians, scientists, and policy makers.

Background Neonates with hypoxic ischemic encephalopathy receiving therapeutic hypothermia (HIE + TH) are at risk for acute kidney injury (AKI). The standardized Kidney Disease Improving Global Outcomes (KDIGO) criteria identifies AKI based on a rise in serum creatinine (SCr) or reduced urine output. This definition is challenging to apply in neonates given the physiologic decline in SCr during the first week of life. Gupta et al. proposed alternative neonatal criteria centered on rate of SCr decline. This study aimed to compare the rate of AKI based on KDIGO and Gupta in neonates with HIE and to examine associations with mortality and morbidity. Methods A retrospective review was performed of neonates with moderate to severe HIE + TH from 2008 to 2020 at a single center. AKI was assessed in the first 7 days after birth by KDIGO and Gupta criteria. Mortality, brain MRI severity of injury, length of stay, and duration of respiratory support were compared between AKI groups. Results Among 225 neonates, 64 (28%) met KDIGO, 69 (31%) neonates met Gupta but not KDIGO, and 92 (41%) did not meet either definition. Both KDIGO-AKI and GuptaOnly-AKI groups had an increased risk of the composite mortality and/or moderate/severe brain MRI injury along with longer length of stay and prolonged duration of respiratory support compared to those without AKI. Conclusions AKI in neonates with HIE + TH was common and varied by definition. The Gupta definition based on rate of SCr decline identified additional neonates not captured by KDIGO criteria who are at increased risk for adverse outcomes. Incorporating the rate of SCr decline into the neonatal AKI definition may increase identification of clinically relevant kidney injury in neonates with HIE + TH. Graphical abstract A higher resolution version of the Graphical abstract is available as Supplementary information

BACKGROUND:Kidneys are at risk from drug-induced toxicity, with a significant proportion of acute kidney injury (AKI) linked to medications, particularly cisplatin. Existing cytoprotective drugs for cisplatin-AKI carry side effects, prompting a search for better biological therapies. Mesenchymal Stem Cells (MSCs) are under consideration given their regenerative properties, yet their clinical application has not achieved their full potential, mainly due to variability in the source of MSC tested. In addition, translating treatments from rodent models to humans remains challenging due to a lack of standardized dosing and understanding potential differential responses to cisplatin between animal strains. METHOD:In the current study, we performed a time-course analysis of the effect of cisplatin across different mouse strains and evaluated gender related differences to create a robust preclinical model that could then be used to explore the therapeutic efficacy of different sources of MSCs for their ability to reverse AKI. RESULT:Our data indicated that different mouse strains produce differential responses to the same cisplatin dosing regimen. Despite this, we did not observe any gender-related bias towards cisplatin nephrotoxicity. Furthermore, our time-course analysis identified that cisplatin-induced inflammation was driven by a strong CXCL1 response, which was used as a putative biomarker to evaluate the comparative therapeutic efficacy of different MSC sources in reversing AKI. Our data indicates that UC-MSCs have a stronger anti-inflammatory effect compared to BM-MSCs and AD-MSCs, which helped to ameliorate cisplatin-AKI. CONCLUSION:Overall, our data underscores the importance of using an optimized preclinical model of cisplatin-AKI to test different therapies. We identified CXCL1 as a potential biomarker of cisplatin-AKI and identified the superior efficacy of UC-MSCs in mitigating cisplatin-AKI.

Context and implementation approaches can impede the spread of patient safety interventions. The objective of this article is to characterize factors associated with improved outcomes among 9 hospitals implementing a medication safety intervention. Nephrotoxic Injury Negated by Just-in-Time Action (NINJA) is a pharmacist-driven intervention that led to a sustained reduction in nephrotoxic medication-associated acute kidney injury (NTMx-AKI) at 1 hospital. Using qualitative comparative analysis, the team prospectively assessed the association between context and implementation factors and NTMx-AKI reduction during NINJA spread to 9 hospitals. Five hospitals reduced NTMx-AKI. These 5 had either (1) a pharmacist champion and >2 pharmacists working on NINJA (Scon 1.0, Scov 0.8) or (2) a nephrologist-implementing NINJA with minimal competing organizational priorities (Scon 1.0, Scov 0.2). Interviews identified ways NINJA team leaders obtained pharmacist support or successfully implemented without that support. In conclusion, these findings have implications for future spread of NINJA and suggest an approach to study spread of safety interventions more broadly.

OBJECTIVE:Retention to complete follow-up surveys in extensive longitudinal epidemiological cohort studies is vital yet challenging. All of Us developed pilot interventions to improve response rates for follow-up surveys. STUDY DESIGN AND SETTING:The pilot interventions occurred from April 27, 2020, to August 3, 2020. The three arms were: (1) telephone appointment [staff members calling participants offering appointments to complete surveys over phone] (2) postal [mail reminder to complete surveys through U.S. Postal Service], and (3) combination of telephone appointment and postal. Controls received digital-only reminders [program-level digital recontact via email or through the participant portal]. Study sites chose their study arm and participants were not randomized. RESULTS:A total of 50 sites piloted interventions with 17,593 participants, while 47,832 participants comprised controls during the same period. Of all participants, 6,828 (10.4%) completed any follow-up surveys (1448: telephone; 522: postal; 486: combination; 4372: controls). Follow-up survey completions were 24% higher in the telephone appointment arm than in controls in bivariate analyses. When controlling for confounders, telephone appointment and combination arms increased rates of completion similarly compared to controls, while the postal arm had no significant effect (odds ratio [95% Confidence Interval], telephone appointment:2.01[1.81-2.23]; combination:1.91[1.66-2.20]; postal:0.92[0.79-1.07]). Although the effects of the telephone appointment and combination arms were similar, differential effects were observed across sub-populations. CONCLUSION:Telephone appointments appeared to be the most successful intervention in our study. Lessons learned about retention interventions, and improvement in follow-up survey completion rates provide generalizable knowledge for similar cohort studies and demonstrate the potential value of precision reminders and engagement with sub-populations of a cohort.

In response to the rapidly evolving coronavirus disease 2019 (COVID-19) pandemic, the All of Us Research Program longitudinal cohort study developed the COVID-19 Participant Experience (COPE) survey to better understand the pandemic experiences and health impacts of COVID-19 on diverse populations within the United States. Six survey versions were deployed between May 2020 and March 2021, covering mental health, loneliness, activity, substance use, and discrimination, as well as COVID-19 symptoms, testing, treatment, and vaccination. A total of 104,910 All of Us Research Program participants, of whom over 73% were from communities traditionally underrepresented in biomedical research, completed 275,201 surveys; 9,693 completed all 6 surveys. Response rates varied widely among demographic groups and were lower among participants from certain racial and ethnic minority populations, participants with low income or educational attainment, and participants with a Spanish language preference. Survey modifications improved participant response rates between the first and last surveys (13.9% to 16.1%, P < 0.001). This paper describes a data set with longitudinal COVID-19 survey data in a large, diverse population that will enable researchers to address important questions related to the pandemic, a data set that is of additional scientific value when combined with the program's other data sources.

Acute kidney injury (AKI), which is a common complication of acute illnesses, affects the health of individuals in community, acute care and post-acute care settings. Although the recognition, prevention and management of AKI has advanced over the past decades, its incidence and related morbidity, mortality and health care burden remain overwhelming. The rapid growth of digital technologies has provided a new platform to improve patient care, and reports show demonstrable benefits in care processes and, in some instances, in patient outcomes. However, despite great progress, the potential benefits of using digital technology to manage AKI has not yet been fully explored or implemented in clinical practice. Digital health studies in AKI have shown variable evidence of benefits, and the digital divide means that access to digital technologies is not equitable. Upstream research and development costs, limited stakeholder participation and acceptance, and poor scalability of digital health solutions have hindered their widespread implementation and use. Here, we provide recommendations from the Acute Disease Quality Initiative consensus meeting, which involved experts in adult and paediatric nephrology, critical care, pharmacy and data science, at which the use of digital health for risk prediction, prevention, identification and management of AKI and its consequences was discussed.

Acute kidney injury (AKI) is common among hospitalized children, especially those receiving intensive care. Diagnosed in the setting of rising serum creatinine levels or the development of oligoanuria, AKI has been associated with poor in-hospital outcomes; children with AKI are more likely to require mechanical ventilation, experience longer lengths of stay, and have higher mortality rates.1Kaddourah A. Basu R.K. Bagshaw S.M. Goldstein S.L. AWARE Investigators Epidemiology of acute kidney injury in critically ill children and young adults.N Engl J Med. 2017; 376: 11-20Crossref PubMed Scopus (639) Google Scholar,2Alkandari O. Eddington K.A. Hyder A. Gauvin F. Ducruet T. Gottesman R. et al.Acute kidney injury is an independent risk factor for pediatric intensive care unit mortality, longer length of stay and prolonged mechanical ventilation in critically ill children: a two-center retrospective cohort study.Crit Care. 2011; 15: R146Crossref PubMed Scopus (261) Google Scholar Although these short-term associations have been well-described across a myriad of studies and cohorts, the relationship between AKI and longer term outcomes is less established. Studies of various sizes employing disparate methodologies have identified an association between AKI and hypertension, proteinuria, decreased kidney function, higher resource utilization, and chronic kidney disease.3Robinson C.H. Klowak J.A. Jeyakumar N. Luo B. Wald R. Garg A.X. et al.Long-term Health care utilization and associated costs after dialysis-treated acute kidney injury in children.Am J Kidney Dis. 2022; (Online ahead of print)https://doi.org/10.1053/j.ajkd.2022.07.005Abstract Full Text Full Text PDF Scopus (4) Google Scholar, 4Robinson C.H. Jeyakumar N. Luo B. Wald R. Garg A.X. Nash D.M. et al.Long-term kidney outcomes following dialysis-treated childhood acute kidney injury: a population-based cohort study.J Am Soc Nephrol. 2021; 32: 2005-2019Crossref PubMed Scopus (20) Google Scholar, 5Menon S. Kirkendall E.S. Nguyen H. Goldstein S.L. Acute kidney injury associated with high nephrotoxic medication exposure leads to chronic kidney disease after 6 months.J Pediatr. 2014; 165: 522-527.e522Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar However, these findings are not universal, and the heterogeneous nature of the studies makes it challenging to draw strong conclusions. In this volume of The Journal, Van den Eynde et al report these long-term outcomes specifically in children who developed AKI after cardiac surgery.6Van den Eynde J. Schuermans A. Fatehi Hassanabad A. Gewillig M. Budts W. Kutty S. et al.Long-term consequences of acute kidney injury after pediatric cardiac surgery: a systematic review.J Pediatr. 2023; 252: 83-92Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar In this systematic review, the authors analyzed data from 14 studies, which included more than 6700 children, of which more than 20% experienced AKI. Four of 11 studies (36%) found an association between AKI and chronic kidney dysfunction. Three of 5 found an association between AKI and long-term mortality. One of 4 found an association between AKI and the subsequent development of hypertension. The authors summarize their findings as such: "Although there is a trend, evidence on the long-term consequences of cardiac surgery-associated AKI in the pediatric population is mixed." The authors are to be applauded for gathering such a large, relatively homogenous cohort of pediatric patients with AKI. Their findings are not inconsistent with recent studies examining the long-term ramifications of severe AKI in more general pediatric populations. For example, Robinson et al evaluated more than 1600 children with dialysis requiring AKI.4Robinson C.H. Jeyakumar N. Luo B. Wald R. Garg A.X. Nash D.M. et al.Long-term kidney outcomes following dialysis-treated childhood acute kidney injury: a population-based cohort study.J Am Soc Nephrol. 2021; 32: 2005-2019Crossref PubMed Scopus (20) Google Scholar Survivors experienced an increased risk for kidney failure and death during the nearly 10-year follow-up period; these children were at increased risk for developing de novo chronic kidney disease (adjusted hazard ratio, 8.7; 95% CI, 6.7-11.3) and hypertension (adjusted hazard ratio, 3.4; 95% CI, 2.6-4.3). Similarly, Benisty et al followed a general cohort of children with AKI and found that, 6 years after the injurious event, they experienced higher rates of decreased glomerular filtration rate, albuminuria, and/or hypertension; children with severe AKI (Kidney Disease: Improving Global Outcomes [KDIGO] Stage 2/3) had a 4.5-fold higher adjusted risk for signs of chronic kidney disease or elevated blood pressure.7Benisty K. Morgan C. Hessey E. Huynh L. Joffe A.R. Garros D. et al.Kidney and blood pressure abnormalities 6 years after acute kidney injury in critically ill children: a prospective cohort study.Pediatr Res. 2020; 88: 271-278Crossref PubMed Scopus (25) Google Scholar Although Van den Eynde et al did not find associations as strong as these, they did identify a trend in poorer long-term outcomes in AKI survivors and, equally important, they highlighted several important challenges surrounding our ability to accurately explore this relationship. First, they identified the fact that studies applied different AKI definitions, citing the use of the pediatric Risk Injury Failure Loss End-Stage Kidney Disease, Acute Kidney Injury Network, and KDIGO criteria. Although these definitions are related, when applied to a single cohort of patients, they identify different AKI epidemiologies.8Sutherland S.M. Byrnes J.J. Kothari M. Longhurst C.A. Dutta S. Garcia P. et al.AKI in hospitalized children: comparing the pRIFLE, AKIN, and KDIGO definitions.Clin J Am Soc Nephrol. 2015; 10: 554-561Crossref PubMed Scopus (332) Google Scholar Although studies have gravitated toward the use of KDIGO, decreasing the impact of this issue, the authors astutely recognize that heterogeneous definitions of chronic kidney dysfunction continue to be applied. The use of different definitions for long-term AKI-related outcomes remains an important barrier for epidemiologic studies. A second issue noted by the authors is that AKI has historically been treated as a homogenous disease. However, it is clear that different AKI phenotypes exist that are differentiated by underlying etiologies, demographics, and comorbidities; different AKI phenotypes are likely to have distinct impacts on outcomes.9Goldstein S.L. Akcan-Arikan A. Alobaidi R. Askenazi D.J. Bagshaw S.M. Barhight M. et al.Consensus-based recommendations on priority activities to address acute kidney injury in children: a modified Delphi consensus statement.JAMA Netw Open. 2022; 5: e2229442Crossref PubMed Scopus (44) Google Scholar The authors expand on this concept, noting that unique cohorts of children at risk for AKI may also have dissimilar underlying risk factors for the long-term morbidities being studied. Different underlying risks for long-term morbidity will alter the relationship AKI has with these outcomes. Indeed, the rates of chronic kidney disease seen in some of the cardiac cohorts included in this systematic review are notable and significantly higher than other at-risk populations; it is possible that children with congenital cardiac disease have underlying chronic kidney disease risk high enough to obscure the impact of an AKI event.10Cooper D.S. Claes D. Goldstein S.L. Bennett M.R. Ma Q. Devarajan P. et al.Follow-Up Renal Assessment of Injury Long-Term After Acute Kidney Injury (FRAIL-AKI).Clin J Am Soc Nephrol. 2016; 11: 21-29Crossref PubMed Scopus (101) Google Scholar, 11Greenberg J.H. Zappitelli M. Devarajan P. Thiessen-Philbrook H.R. Krawczeski C. Li S. et al.Kidney outcomes 5 years after pediatric cardiac surgery: the TRIBE-AKI study.JAMA Pediatr. 2016; 170: 1071-1078Crossref PubMed Scopus (102) Google Scholar, 12Zappitelli M. Parikh C.R. Kaufman J.S. Go A.S. Kimmel P.L. Hsu C.Y. et al.Acute kidney injury and risk of CKD and hypertension after pediatric cardiac surgery.Clin J Am Soc Nephrol. 2020; 15: 1403-1412Crossref PubMed Scopus (24) Google Scholar Finally, the authors highlight several studies that have non-AKI comparator groups. To be able to effectively analyze the impact of AKI on long-term outcomes, it is likely beneficial for us to be able to simultaneous evaluate patients who did not experience AKI. Unfortunately, these controlled, prospective studies are challenging and costly to perform, often leaving them underpowered to detect an effect of AKI on longitudinal outcomes. This systematic review by Van den Eynde et al effectively sheds light on the long term ramifications of AKI.6Van den Eynde J. Schuermans A. Fatehi Hassanabad A. Gewillig M. Budts W. Kutty S. et al.Long-term consequences of acute kidney injury after pediatric cardiac surgery: a systematic review.J Pediatr. 2023; 252: 83-92Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Although AKI is well-known to be associated with acute complications, it is imperative that we raise awareness of the chronic implications. Recognition of this relationship will inform future studies, change practice patterns, and help us to develop better chronic care models for AKI. Although this concept is widely discussed among nephrologists and the critical care community, I am ecstatic to see the publication of studies such as these in general pediatric journals, because they bring awareness to the broader community of providers who care for children. As pediatric AKI becomes a more common issue with global implications, we will need to rely on the entire pediatric medical community to care for these children adequately. Long-Term Consequences of Acute Kidney Injury After Pediatric Cardiac Surgery: A Systematic ReviewThe Journal of PediatricsVol. 252PreviewThe objective of this study was to evaluate the available data on long-term kidney dysfunction, hypertension, and mortality after cardiac surgery–associated acute kidney injury (AKI) in the pediatric population. Full-Text PDF

Background: The development of acute kidney injury (AKI) has been associated with worse outcomes in children after heart transplantation. Our study compares the application of a cumulative six -point Kidney Diseases Improving Global Outcomes (KDIGO) AKI scoring system, utilizing both creatinine and urine output criteria that we term as the AKI- 6 criteria, to traditional AKI staging as a predictor for clinical and renal outcomes in the pediatric heart transplant recipients.Methods: We conducted a retrospective single-center chart review on 155 pediatric patients who underwent heart transplantation from May 2014 to December 2021. The primary independent variable was the presence of severe AKI. Severe AKI by KDIGO was defined as Stage =2, whereas severe AKI by AKI-6 was defined as cumulative scores =4 or Stage 3 AKI based on either KDIGO criterion alone. Primary outcomes included actuarial survival and renal dysfunction by 1 -year post-transplant, defined as an estimated glomerular filtration rate <60 mL/min/1.73 m(2).Results: In total, 140 (90%) patients developed AKI; 98 (63%) patients developed severe AKI by KDIGO, and 60 (39%) by AKI- 6. Severe AKI by AKI- 6 was associated with worse actuarial survival following heart transplantation compared with KDIGO (p = 0.01). Of the 143 patients with 1-year creatinine data, 6 (11%) patients out of 54 with severe AKI by AKI- 6 had evidence of renal dysfunction (p = 0.01), compared with 6 (7%) patients out of 88 by KDIGO (p = 0.3).Conclusions: AKI- 6 scoring provides greater prognostic utility for actuarial survival and renal dysfunction by 1 -year post -heart transplantation in pediatric patients than traditional KDIGO staging.

BACKGROUND:Acute kidney injury (AKI) is independently associated with increased morbidity and mortality across the life course, yet care for AKI remains mostly supportive. Raising awareness of this life-threatening clinical syndrome through education and advocacy efforts is the key to improving patient outcomes. Here, we describe the unique roles education and advocacy play in the care of children with AKI, discuss the importance of customizing educational outreach efforts to individual groups and contexts, and highlight the opportunities created through innovations and partnerships to optimize lifelong health outcomes. METHODS:During the 26th Acute Disease Quality Initiative (ADQI) consensus conference, a multidisciplinary group of experts discussed the evidence and used a modified Delphi process to achieve consensus on recommendations on AKI research, education, practice, and advocacy in children. RESULTS:The consensus statements developed in response to three critical questions about the role of education and advocacy in pediatric AKI care are presented here along with a summary of available evidence and recommendations for both clinical care and research. CONCLUSIONS:These consensus statements emphasize that high-quality care for patients with AKI begins in the community with education and awareness campaigns to identify those at risk for AKI. Education is the key across all healthcare and non-healthcare settings to enhance early diagnosis and develop mitigation strategies, thereby improving outcomes for children with AKI. Strong advocacy efforts are essential for implementing these programs and building critical collaborations across all stakeholders and settings.

Fluid overload is common among pediatric cardiac patients receiving extracorporeal membrane oxygenation (ECMO) and is often treated with in-line ultrafiltration (UF) or continuous renal replacement therapy (CRRT). We assessed whether CRRT was associated with poor outcomes versus UF alone. Additionally, we identified characteristics associated with progression from UF to CRRT. Retrospective chart review of 131 patients age ≤18 years treated with ECMO at a single quaternary center. Data were collected to compare patient demographics, characteristics, and outcomes. A receiver operator curve (ROC) was used to create a tool predictive of the need for CRRT at the time of UF initiation. Patients who required CRRT had a higher creatinine and blood urea nitrogen at time of UF initiation ( p = 0.03 and p < 0.01), longer total ECMO duration ( p < 0.01), lower renal recovery incidence ( p = 0.02), and higher mortality ( p ≤ 0.01). Using ROC analysis, presence of ≤3 of 7 risk variables had a positive predictive value of 87.5% and negative predictive value of 50.0% for use of UF alone (area under the curve 0.801; 95% CI: 0.638-0.965, p = 0.002). Pediatric cardiac patients treated with ECMO and UF who require CRRT demonstrate worse outcomes versus UF alone. A novel clinical tool may assist in stratifying patients at UF initiation.

OBJECTIVES: With the recognition that fluid overload (FO) has a detrimental impact on critically ill children, the critical care nephrology community has focused on identifying clinically meaningful targets for intervention. The current study aims to evaluate the epidemiology and outcomes associated with FO in an international multicenter cohort of critically ill children. The current study also aims to evaluate the association of FO at predetermined clinically relevant thresholds and time points (FO ≥ 5% and FO ≥ 10% at the end of ICU days 1 and 2) with outcomes. DESIGN: Prospective cohort study. SETTING: Multicenter, international collaborative of 32 pediatric ICUs. PATIENTS: A total of 5,079 children and young adults admitted consecutively to pediatric ICUs as part of the Assessment of the Worldwide Acute Kidney Injury, Renal Angina and Epidemiology Study. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The FO thresholds at the time points of interest occurred commonly in the cohort (FO ≥ 5%Day1 in 38.1% [ n = 1753], FO ≥ 10%Day1 in 11.7% [ n = 537], FO ≥ 5%Day2 in 53.3% [ n = 1,539], FO ≥ 10%Day2 in 25.1% [ n = 724]). On Day1, multivariable modeling demonstrated that FO ≥ 5% was associated with fewer ICU-free days, and FO ≥ 10% was associated with higher mortality and fewer ICU and ventilator-free days. On multivariable modeling, FO-peak, Day2 FO ≥ 5%, and Day2 FO ≥ 10% were associated with higher mortality and fewer ICU and ventilator-free days. CONCLUSIONS: This study found that mild-to-moderate FO as early as at the end of ICU Day1 is associated with adverse outcomes. The current study fills an important void in the literature by identifying critical combinations of FO timing and quantity associated with adverse outcomes (FO ≥ 5%Day1, FO ≥10%Day1, FO ≥ 5%Day2, and FO ≥ 10%Day2). Those novel findings will help guide the development of interventional strategies and trials targeting the treatment and prevention of clinically relevant FO.

Continuous-flow ventricular assist devices (CF-VADs) are used increasingly in pediatric end-stage heart failure (ESHF) patients. Alongside common risk factors like oxidant injury from hemolysis, non-pulsatile flow constitutes a unique circulatory stress on kidneys. Post-implantation recovery after acute kidney injury (AKI) is commonly reported, but long-term kidney outcomes or factors implicated in the evolution of chronic kidney disease (CKD) with prolonged CF-VAD support are unknown. We studied ESHF patients supported > 90 days on CF-VAD from 2008 to 2018. The primary outcome was CKD (per Kidney Disease Improving Global Outcomes (KDIGO) criteria). Secondary outcomes included AKI incidence post-implantation and CKD evolution in the 6–12 months of CF-VAD support. We enrolled 134 patients; 84/134 (63

ImportanceIncreasing evidence indicates that acute kidney injury (AKI) occurs frequently in children and young adults and is associated with poor short-term and long-term outcomes. Guidance is required to focus efforts related to expansion of pediatric AKI knowledge.ObjectiveTo develop expert-driven pediatric specific recommendations on needed AKI research, education, practice, and advocacy.Evidence ReviewAt the 26th Acute Disease Quality Initiative meeting conducted in November 2021 by 47 multiprofessional international experts in general pediatrics, nephrology, and critical care, the panel focused on 6 areas: (1) epidemiology; (2) diagnostics; (3) fluid overload; (4) kidney support therapies; (5) biology, pharmacology, and nutrition; and (6) education and advocacy. An objective scientific review and distillation of literature through September 2021 was performed of (1) epidemiology, (2) risk assessment and diagnosis, (3) fluid assessment, (4) kidney support and extracorporeal therapies, (5) pathobiology, nutrition, and pharmacology, and (6) education and advocacy. Using an established modified Delphi process based on existing data, workgroups derived consensus statements with recommendations.FindingsThe meeting developed 12 consensus statements and 29 research recommendations. Principal suggestions were to address gaps of knowledge by including data from varying socioeconomic groups, broadening definition of AKI phenotypes, adjudicating fluid balance by disease severity, integrating biopathology of child growth and development, and partnering with families and communities in AKI advocacy.Conclusions and RelevanceExisting evidence across observational study supports further efforts to increase knowledge related to AKI in childhood. Significant gaps of knowledge may be addressed by focused efforts.