Consensus-Based Recommendations on Priority Activities to Address Acute Kidney Injury in Children: A Modified Delphi Consensus Statement

Abstract

Importance: Increasing 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.

Objective: To develop expert-driven pediatric specific recommendations on needed AKI research, education, practice, and advocacy.

Evidence review: At 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.

Findings: The 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 relevance: Existing 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.

Figure 1.. Acute Kidney Injury (AKI) Risk Assessment and Dynamic Phenotyping

A, AKI risk assessment should occur in children with a potential kidney insult or any clinical changes to stratify patients into those at standard or high risk for AKI such that kidney-focused care can be implemented. B, Combined with individual susceptibility, multiple elements contribute to discernible AKI phenotypes in affected children that may have prognostic and therapeutic implications. Adapted from the 26th Acute Disease Quality Initiative with permission. These are open access images distributed under the terms of the Creative Commons Attribution License.

Figure 2.. Development as a Biologic Variable Related to Acute Kidney Injury

The left slope highlights important developmental stages critical to reach optimal kidney function. The right slope represents the normal age-related decrease of kidney function. Acute kidney injury (AKI) can occur at any phase along the developmental trajectory resulting in early kidney compromise and potentially accelerated nephron loss. The timing and degree of AKI likely affect the trajectory to recovery of normal kidney function or persistently decreased function. Research efforts must focus on uncovering and capitalizing on the ways to improve the outlook of an injured kidney. These efforts may include optimization of nutrition, limiting further injury, and novel therapeutics. There are factors that accelerate nephron loss and the trajectory toward kidney failure. The social determinants of health, the types or clusters of AKI, sex as a biologic variable, nutritional factors, and medication dosing are all components that affect the recovery or decrease of kidney function after AKI. Adapted from the 26th Acute Disease Quality Initiative with permission. These are open access images distributed under the terms of the Creative Commons Attribution License.

Figure 3.. The Role of Education and Advocacy in Pediatric Acute Kidney Injury (AKI)

Education to improve AKI awareness and recognition in children rests on the pillar of advocacy and must engage key stakeholders in developing multidisciplinary context-appropriate customized approaches to improve AKI care globally and across all resource settings. Effective AKI education programs center the child and family, and expand across health care teams, systems, and communities with champions embedded at every level, health care systems, science, and government. AKI education must be a core competency for health care clinicians to ensure that AKI risk mitigation measures are in place to reduce AKI in community and hospital settings, to facilitate early recognition of AKI through technological innovation, and to appropriately manage AKI using context-specific guidelines that recognize the need for continuity of care and clinical follow-up. Implementation of an effective AKI education and advocacy program assures equitable access to diagnostics, emphasizes integrated multidisciplinary collaborative care, and recognizes the unique long-term health outcomes of AKI in children across the life span. Adapted from the 26th Acute Disease Quality Initiative with permission. These are open access images distributed under the terms of the Creative Commons Attribution License.