|Year : 2019 | Volume
| Issue : 1 | Page : 51-54
Causes, management practices, and outcomes of pediatric acute kidney injury: A cross-sectional survey
Mritunjay Kumar1, Suprita Kalra2, Amit Sood2, Ragini Singh1, Madhuri Kanitkar2
1 Department of Pediatrics and Pediatric Nephrology, SGRR Institute of Medical and Health Sciences, Dehradun, Uttrakhand, India
2 Department of Pediatrics and Pediatric Nephrology, Command Hospital, AFMC, Pune, Maharashtra, India
|Date of Submission||25-Jun-2018|
|Date of Acceptance||29-Nov-2018|
|Date of Web Publication||19-Jun-2019|
Lt Col Suprita Kalra
Department of Pediatrics and Pediatric Nephrology, Command Hospital, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: AKI in critically ill children has multiple etiologies. The primary objective was to study the, causes, management practices and outcomes of AKI in critically ill children as seen by Pediatricians and Pediatric residents in two cities in different parts of India. Methodology: A cross sectional survey using Questionnaire based module with 12 questions was distributed to all participants during a CME at two centers. Results: 50/59 (response rate 84.7%) responded. Only 40% had trained pediatric nephrologist at their centers. 35 (70%) said they saw 1 case of AKI per month. 19/20 at center A believed sepsis with MODS as commonest cause while at center B 14, 21/30 (69.3%) participants selected prerenal causes such as dehydration. Renal causes (14/20, 70%) were commonest indication for dialysis at center A while at center B it was sepsis with AKI. Acute Peritoneal dialysis with stiff catheter was chosen as commonest modality. Complete recovery, persistence of kidney injury, and mortality contributed equally to outcome at center A whereas 56% at center B chose complete recovery. Conclusions: Intrinsic renal causes like HUS are the most common causes of AKI in critically ill children requiring RRT (renal replacement therapy). Despite some advances in infrastructure and training most residents and pediatricians felt that peritoneal dialysis was the commonest modality.
Keywords: AKI, dialysis, pediatric, practices, RRT
|How to cite this article:|
Kumar M, Kalra S, Sood A, Singh R, Kanitkar M. Causes, management practices, and outcomes of pediatric acute kidney injury: A cross-sectional survey. J Mar Med Soc 2019;21:51-4
| Introduction|| |
Staging of pediatric acute kidney injury (AKI) has been redefined by kidney disease improving global outcome for the sake of uniformity. Studies have shown that AKI in critically ill children may have multiple etiologies with various precipitating and aggravating factors. Approximately, a third of these children require renal replacement therapy (RRT). The modalities of RRT may vary depending on the availability of resources, technical expertise, and patient-related factors including the underlying disease, age, and severity of illness. Studies from the developed world have shown more frequent use of continuous RRT (CRRT) along with increasing use of hybrid techniques such as sustained low-efficiency daily dialysis (SLEDD). However, hardly any studies exist reviewing the dialysis practices in the developing world including India. We, therefore, designed this cross-sectional study to review the frequency of AKI, its causes, management practices, and its outcomes seen in general pediatric practice by the primary caregivers of critically ill children, that is, pediatricians and pediatric residents in two cities in different parts of India.
| Materials and Methods|| |
We designed a questionnaire-based workshop module with 12 questions on incidence, etiologies of AKI, and dialysis practices at their centers [Module 1] and distributed it to all the pediatric residents and faculties/consultants during a Continuing Medical Education (CME) conducted at two centers one each in Northern India and Southern India. This was a pilot survey and the questionnaire comprised simple questions requiring factual answers although it was not validated in any earlier studies.
The center in Southern India located in Maharashtra has five full-time pediatric nephrologists with pediatric nephrology being reasonably well established (hereafter referred to as center A) while the center in Northern India at Uttarakhand has so far only one full-time pediatric nephrologist with the subspecialty at a more developing stage (hereafter referred to as center B). The patient population at center A is mostly urban and suburban with a mix of children from upper-middle class, lower-middle class, and upper-lower class as defined by the modified Kuppuswamy scale. Center B caters mostly to patients from the neighboring villages and hills from lower-middle class, upper-lower class, and lower class. The residents at both the centers were from medical colleges and institutes both with and without the services of full-time pediatric nephrologists. The residents at center A were from three medical colleges and two corporate hospitals, whereas at center B, participants were residents from four medical colleges and pediatricians working at private hospitals. We collected responses from all the participants on the frequency of AKI, its causes, treatment practices, and its outcomes at their centers using a predesigned workshop module with 12 questions [Module 1]. The participants had the option of being anonymous if they so desired and were allowed to choose more than one answer believed to be correct by them. The results were then tabulated on Microsoft Excel sheet based on their responses [Table 1].
| Results|| |
Fifty of the total 59 residents (response rate 84.7%) at the two centers (20 at center A and 30 at center B) where the study was conducted gave their feedback on pediatric dialysis practices for AKI. Twenty (40%) participants in all said that they had a trained pediatric nephrologist at their centers. Twenty-two of the 30 (75.9%) participants who did not have a pediatric nephrologist at their center said that the nephrology support to critically ill children was provided by the pediatricians looking after the patient, whereas others sought adult nephrologists' help for the same. Thirty-five residents (70%) responded that they came across approximately one case of AKI every month at their center and 15 (30%) of them encountered children with AKI less than once a month. 19/20 residents at the center A believed sepsis with multiorgan dysfunction (MODS) as the most common cause for AKI while only 1 chose prerenal cause such as dehydration. No residents chose infections such as malaria or renal causes such as glomerulonephritis (GN) and hemolytic uremic syndrome (HUS). At center B, 21/30 (69.3%) participants selected prerenal causes such as dehydration as the most common causative factor for AKI while 7/30 participants (23.3%) responded in favor of sepsis with MODS. Renal causes such as HUS and GN (14/20, 70%), followed by sepsis were the most common indication for dialysis at center A. At center B, 14/30 participants (46.6%) responded in favor of sepsis with AKI as the most common indication for dialysis while 7/30 participants (23.3%) believed prerenal cause such as dehydration were responsible for dialysis. Interestingly, only 4 (13.3) of them believed that intrinsic renal causes such as GN and HUS were the culprits for AKI requiring dialysis. Acute peritoneal dialysis (PD) with a stiff catheter was chosen as the most common modality (12/20, 60% in center A and 15/30, 50% in center B) for dialysis in AKI whereas PD with a soft catheter and hemodialysis was less commonly used modalities. Eleven (55%) residents at center A and 27 (90%) at center B did not have facility for CRRT at their centers. Sixteen (80%) residents in center A and 22 (73.33) in center B had no experience at all with SLEDD. Fourteen (70%) residents at center A and 24 (80%) at center B did not attend workshops/CMEs on critical care nephrology or RRT. Catheter block was believed to be the most common complication associated with PD. Complete recovery, persistence of kidney injury but not requiring dialysis, and mortality contributed equally to the outcome at center A. However, 56% participants at center B believed that complete recovery was the most common outcome.
| Discussion|| |
Pediatricians and pediatric residents are usually the first--contact doctors, and in many cases, the primary care providers for children with AKI. We reviewed the etiologies of AKI, its frequency, and treatment modalities as experienced by them. Participants from most centers reported that they encountered children with AKI at least once a month, but children with AKI requiring RRT were less frequent. Interestingly, our study shows that sepsis with or without shock and multiple organ dysfunction syndrome secondary to causes such as malignancies and forms the underlying etiology in children across centers as has been reported in the Western literature. The prerenal causes such as diarrhea and dehydration rarely cause AKI in at least the urban centers but in centers with large number of referrals from neighboring rural areas as in our center in Northern India, still contribute significantly to AKI and AKI requiring dialysis. This has been reported in the previous studies also., On the other hand, tropical infections such as malaria were rarely reported to be a cause of AKI in either center. This probably indicates that even if early stages of AKI were not recognized, at least AKI requiring RRT has become uncommon. This was in sharp contrast to the earlier studies where tropical infections were an important cause of AKI in children and even though referral bias may be contributory. However, as previous studies were also from referral centers, it perhaps reflects the changing epidemiology of AKI. Among the renal causes of AKI requiring dialysis, HUS was reported as the more common cause than GN. This is also in concordance with the recent reports of decline in cases of postinfectious GN which was the most frequently encountered earlier in developing countries.
As far as the use of dialysis modality in AKI is concerned, PD with a stiff PD catheter remains the most commonly employed modality. Vasudevan et al. reported that in India, even with the availability of PD, hemodialysis, CRRT, and SLED in 23 of 26 centers surveyed, acute intermittent PD with rigid catheter was the most commonly used modality due to low cost and simplicity. Despite further advances in infrastructure and training, since then, it has remained largely unchanged and was further highlighted in our study where 60% participants at center A and 50% at center B responded in favor of PD as the most common modality [Table 1]. Raina et al. in their international pediatric dialysis modality survey had similar observations in developing countries where 68.5% respondents reported PD as a first-line RRT for infants. It also brought out that although CRRT has been there for quite some time, the cost of procedure and disposables are still the major limiting factor for its use in acute settings. Another important consideration is the availability of expertise for CRRT, especially in younger children. Similarly, hybrid techniques such as SLEDD, which can be performed using the standard hemodialysis machines, are perhaps not used frequently due to technical difficulties of securing a vascular access in children, maintaining it and close monitoring that these children would require during the procedure., Hence, while the use of CRRT and SLEDD is well established in pediatric practice, its use is still limited to children from families who can afford them and to centers where technical expertise is available. Catheter block and peritonitis were commonly encountered complications by most of the participants. These have been reported to be the most frequent complications in earlier studies on PD also.
As far as outcomes at discharge were concerned, the residents at the center in Southern India believed that almost equal numbers had complete recovery, persistence of AKI but not requiring dialysis and mortality indicating essentially the varied degree of severity of AKI and etiologies seen by them. Participants at other center in Northern India where prerenal causes contributed more to AKI, complete recovery was observed as the most common outcome. Previous large-scale studies have shown the mortality in children requiring RRT for AKI for any reason to be nearly 30% as also brought out in our study.
Our study also brought out that more than two-thirds of the attending participants said that they did not attend workshops/CMEs on critical care nephrology or RRT. This is despite the fact that both the cities are having full-time pediatric nephrologists. This essentially points out the need to include the critical care nephrology including basics of RRT in the curriculum and to hold more focused hands-on training activities for postgraduate students and practicing pediatricians.
An obvious limitation of our study is that it is essentially a pilot survey conducted at two centers with the questionnaire comprising questions which have not been validated in any earlier studies. However, it brings to light important points about etiology, management, and outcomes of AKI in children in our country and also highlights the need for improvement in infrastructure as well as training.
| Conclusion|| |
We concluded that across centers sepsis along with intrinsic renal causes such as atypical HUS are the most common causes of AKI requiring RRT in children. Majority of patients with AKI requiring RRT are taken up for PD with a stiff catheter even when other modalities such as CRRT and SLEDD were available. The participants also felt that they did not attend enough training activities and it was reflected in their responses. These findings highlight the need for further improvement in infrastructure availability as well as for training of pediatricians and residents in the basics of RRT.
We acknowledge the support in the form of training material provided by the National Kidney Foundation for the workshop conducted at AFMC, Pune, and IAP Uttarakhand Chapter for the CME conducted at Dehradun.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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