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Early prediction of pediatric acute kidney injury from the emergency department: A pilot study

  • Author Footnotes
    1 Division of Pediatric Emergency Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, 2200 Children's Way, VCH-B-319, Nashville, TN 37232.
    Holly R. Hanson
    Correspondence
    Corresponding author at: Division of Pediatric Emergency Medicine, Monroe Carell Jr Children's Hospital at Vanderbilt, 2200 Children's Way, VCH B-319, Nashville, TN 37232-9001, United States of America.
    Footnotes
    1 Division of Pediatric Emergency Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, 2200 Children's Way, VCH-B-319, Nashville, TN 37232.
    Affiliations
    Division of Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2008, Cincinnati, OH 45229, United States of America
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  • Author Footnotes
    2 Division of Pediatric Critical Care Medicine, Children's Hospital Colorado, 13,123 East 16th Ave, Aurura, CO 80045.
    Michael A. Carlisle
    Footnotes
    2 Division of Pediatric Critical Care Medicine, Children's Hospital Colorado, 13,123 East 16th Ave, Aurura, CO 80045.
    Affiliations
    Department of General Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, United States of America
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  • Rachel S. Bensman
    Affiliations
    Division of Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2008, Cincinnati, OH 45229, United States of America

    Department of General Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, United States of America
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  • Terri Byczkowski
    Affiliations
    Division of Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2008, Cincinnati, OH 45229, United States of America
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  • Holly Depinet
    Affiliations
    Division of Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2008, Cincinnati, OH 45229, United States of America

    Department of General Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, United States of America
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  • Tara C. Terrell
    Affiliations
    Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, United States of America
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  • Hilary Pitner
    Affiliations
    Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, United States of America
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  • Ryan Knox
    Affiliations
    Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, United States of America
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  • Stuart L. Goldstein
    Affiliations
    Department of General Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, United States of America

    Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, United States of America
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  • Author Footnotes
    3 Division of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta, Emory School of Medicine, 1405 Clifton Rd NE, Atlanta, GA 30322.
    Rajit K. Basu
    Footnotes
    3 Division of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta, Emory School of Medicine, 1405 Clifton Rd NE, Atlanta, GA 30322.
    Affiliations
    Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, United States of America
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  • Author Footnotes
    1 Division of Pediatric Emergency Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, 2200 Children's Way, VCH-B-319, Nashville, TN 37232.
    2 Division of Pediatric Critical Care Medicine, Children's Hospital Colorado, 13,123 East 16th Ave, Aurura, CO 80045.
    3 Division of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta, Emory School of Medicine, 1405 Clifton Rd NE, Atlanta, GA 30322.
Published:January 27, 2020DOI:https://doi.org/10.1016/j.ajem.2020.01.046

      Abstract

      Background

      Identifying acute kidney injury (AKI) early can inform medical decisions key to mitigation of injury. An AKI risk stratification tool, the renal angina index (RAI), has proven better than creatinine changes alone at predicting AKI in critically ill children.

      Objective

      To derive and test performance of an “acute” RAI (aRAI) in the Emergency Department (ED) for prediction of inpatient AKI and to evaluate the added yield of urinary AKI biomarkers.

      Methods

      Study of pediatric ED patients with sepsis admitted and followed for 72 h. The primary outcome was inpatient AKI defined by a creatinine >1.5× baseline, 24–72 h after admission. Patients were denoted renal angina positive (RA+) for an aRAI score above a population derived cut-off. Test characteristics evaluated predictive performance of the aRAI compared to changes in creatinine and incorporation of 4 urinary biomarkers in the context of renal angina were assessed.

      Results

      118 eligible subjects were enrolled. Mean age was 7.8 ± 6.4 years, 16% required intensive care admission. In the ED, 27% had a +RAI (22% had a >50% creatinine increase). The aRAI had an AUC of 0.92 (0.86–0.98) for prediction of inpatient AKI. For AKI prediction, RA+ demonstrated a sensitivity of 94% (69–99) and a negative predictive value of 99% (92–100) (versus sensitivity 59% (33–82) and NPV 93% (89–96) for creatinine ≥2× baseline). Biomarker analysis revealed a higher AUC for aRAI alone than any individual biomarker.

      Conclusions

      This pilot study finds the aRAI to be a sensitive ED-based tool for ruling out the development of in-hospital AKI.

      Abbreviations:

      AKI (Acute Kidney Injury), aRAI (acute Renal Angina Index), ED (Emergency Department), IL-18 (Interleukin 18), KDIGO (Kidney Disease Improving Global Outcomes), KIM-1 (kidney injury molecule-1), L-FABP (liver fatty acid binding protein), NGAL (neutrophil gelatinase-associated lipocalin), RA (Renal Angina), RAI (Renal Angina Index), SCr (serum creatinine)

      Keywords

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