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Chapter 42: Acute Kidney Injury in Infants

Gia Oh; Paul Grimm

EPIDEMIOLOGY

Definition of Acute Kidney Injury

Acute kidney injury (AKI) is a condition defined by an acute decrease in the glomerular filtration rate (GFR), resulting in dysregulation of volume, electrolytes, acid-base balance and inability to excrete metabolic waste products. The term AKI has replaced the older term acute renal failure (ARF) to highlight the varying degrees of renal dysfunction, to enable clinicians to recognize renal dysfunction earlier in the patient’s course, and to allow researchers to apply a uniform definition of acute renal dysfunction.1 The Acute Dialysis Quality Initiative (ADQI) and Acute Kidney Injury Network (AKIN) groups standardized the definition of AKI in adult patients based on the increase in serum creatinine (Cr) or oligoanuria, and the pediatric community has adopted modified criteria based on the ADQI and AKIN definitions (Table 42-1).2

Table 42-1Acute Kidney Injury Definitions Using RIFLE, pRIFLE, and AKIN
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Table 42-1 Acute Kidney Injury Definitions Using RIFLE, pRIFLE, and AKIN
Stage Serum Creatinine/GFR Criteria Urine Output Criteria
RIFLEa R SCr increase 1.5 times or GFR decrease >25% <0.5 mL/kg/h for 6 h
I SCr increase 2 times or GFR decrease >50% <0.5 mL/kg/h for 12 h
F

SCr increase 3 times or SCr ≥ 4mg/dL or

GFR decrease >75%

 <0.3 mL/kg/h for 24 h or anuria for 12 h
L Persistent failure > 4 weeks
E Persistent failure >3 months
Pediatric RIFLEb R eCCld decrease > 25% <0.5 mL/kg/h for 8 h
I eCCl decrease > 50% <0.5 mL/kg/h for 16 h
F eCCl decrease > 75% or eCCl < 35 mL/min/1.73 m2 <0.3 mL/kg/h for 24 h or anuria for 12 h
L Persistent failure > 4 weeks
E Persistent failure > 3 months
AKINc 1 SCr increase > 0.3 mg/dL or > 1.5–2 times baseline <0.5 mL/kg/h for 6 h
2 SCr increase > 2–3 times baseline <0.5 mL/kg/h for 12 h
3 SCr increase > 3 times baseline or SCr ≥ 4.0 mg/dL with acute increase ≥ 0.5 mg/dL <0.3 mL/kg/h for 24 h or anuria for 12 h

Abbreviations: AKIN, Acute Kidney Injury Network; eCCl, estimated creatinine clearance; pRIFLE, pediatric RIFLE; RIFLE, risk injury failure loss end stage; SCr, serum creatinine

aBellomo et al.125

bAkcan-Arikan et al.120

cMehta et al.126

dSchwartz GJ et al.127

Definition of AKI in Neonates and Infants

There are additional important factors to consider in defining AKI in neonates using serum Cr and urine output criteria. First, neonatal serum Cr following birth reflects maternal Cr, and it decreases to a steady state over 1 to 2 weeks in term infants and over 3 to 4 weeks in preterm infants as the neonate’s GFR steadily improves.3, 4 Tables 42-2 and 42-3 show the increasing GFR in preterm and term neonates.5, 6 Second, unlike in ...

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