AKI associated with increased mortality among critically ill children and young adults: The AWARE trial

1. The study demonstrated that acute kidney injury (AKI) is common in critically ill children and young adults, and is associated with increased mortality.

2. The majority of patients meeting the definition of AKI were missed when only the plasma creatinine criteria was used to make a diagnosis.

Evidence Rating: 2 (Good)

Study Rundown: In adults, AKI is associated with prolonged mechanical ventilation, longer length of stay in the ICU, and increased mortality in critically ill patients. However, studies in children are limited. The Assessment of Worldwide Acute Kidney Injury, Renal Angina, and Epidemiology (AWARE) study was conducted to define the epidemiology of AKI and the risk factors AKI and associated morbidity in a multinational cohort of critically ill children and young adults. The primary outcome was 28-day mortality. Secondary outcomes were length of stay in the ICU, receipt and duration of mechanical ventilation, receipt of extracorporeal membrane oxygenation, and receipt of renal-replacement therapy. The study demonstrated that AKI occurred in 25% of patients during the first 7 days after ICU admission. A significantly higher risk of death was observed in patients with severe AKI. There was significantly higher 28-day mortality in patients with the most severe AKI. For the majority of patients with an AKI diagnosis meeting the low urine-output criteria, the diagnosis would have been missed if only the plasma creatinine criteria had been used.

Click to read the study, published today in NEJM

Relevant Reading: AKI in hospitalized children: epidemiology and clinical associations in a national cohort.

In-Depth [observational study]: The AWARE trial was a multicenter, prospective, multinational, observational study that included 32 pediatric ICUs. Patients aged between 3 months to 25 years with a predicted ICU stay of at least 48 hours were eligible. Patients were excluded if the eGFR was less than 15 ml/min/1.73 m2 of body-surface area, maintenance dialysis or receipt of a kidney transplant in the preceding 90 days. A total of 5237 of the 6821 patients screened were eligible for the study. Data for 28-day outcomes were available for a total of 4984 patients.

After adjusting for 16 covariates, severe AKI was associated with an increased risk of death (OR 1.77; 95%CI, 1.17-2.68). Death was significantly higher in patients with severe AKI compared with non-severe AKI patients (11.0% vs. 2.5%, p < 0.001). An incremental increased risk of death at 28-days was observed with a stepwise increase in the maximum stage of AKI (p < 0.001). In 67.2% of patient who met the urine-output criteria for AKI, the diagnosis would have been missed if only the plasma creatinine criteria had been used.

Image: PD

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