Panel of experts address pediatric AKI needs in consensus statements
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Since 2000, the Acute Disease Quality Initiative has met to discuss kidney disease in adults, but in 2021, Rajit K. Basu, MD, coordinated the first meeting to focus solely on pediatric AKI critical care in nephrology.
“In the past 20 years, we have seen an increasing amount of evidence that AKI occurs in one in four critically ill neonates at some point through childhood,” Basu, the division head of critical care medicine at Ann & Robert H. Lurie Children’s Hospital, told Healio. “For the past couple of years, myself and other pediatricians attending the Acute Disease Quality Initiative have pitched to the adult-focused doctors that we need one just focused on kids. Finally, we got it approved.”
In November 2021, a total of 46 global experts gathered with the mission to develop pediatric-specific recommendations on AKI research, education, practice and advocacy. The group included physicians, nurses, pharmacists, nutritionists, a pediatric patient survivor of AKI and an expert in equity and care delivery.
“We need to hear what the experience of dialysis is from a patient,” Basu said. “Especially with the way things work and how we study disease now, we have to integrate patients to get the patient’s perspective as well.”
Creation of the statements
In six gender-balanced groups, the panel used the Delphi process based on existing data to determine key questions and drafted consensus statements with recommendations and suggestions. The group met for two follow-up meetings to finalize and approve the statements. The statements consist of epidemiology; risk assessment and diagnosis; fluid assessment; kidney support and extracorporeal therapies; pathobiology, nutrition and pharmacology; and education and advocacy.
The finalized statements are as follows:
- “AKI epidemiology related to short-term outcomes is well-described in critically ill neonates and children from high-income countries; however, further study is needed in other health care contexts, such as low-middle income countries and in non-ICU and ambulatory settings and for socioeconomic and long-term outcome;
- Validated tools which incorporate patient characteristics and exposure and also interface with the local health care environment should be utilized to estimate AKI risk in children, including assessment of objective measures of kidney fitness in at-risk children prior to a predictable or planned intervention;
- Fluid balance is the difference between total input and output that can be expressed as ‘daily’ and/or ‘cumulative’ over a defined duration of time;
- A dedicated multidisciplinary team made up of kidney health care workers, patients and families along with institutional investments of personnel, time, materials and quality assurance/ improvement systems are essential to a pediatric acute kidney support therapy (paKST) program;
- Successful pediatric translational AKI research programs include diverse teams using reverse translational approaches in partnership with clinical and epidemiological findings that prioritize development as a biologic variable. Sufficient support including pediatric specific government and industry funding along with meaningful partnerships among health professionals is necessary to understand and leverage the unique aspects of pediatric AKI to address kidney health and disease across the life course; and
- Given the adverse immediate and lifelong outcomes for children with AKI, education and advocacy are essential, starting with the patient and family and expanding across health care teams, systems and communities.”
These statements, along with the corresponding suggestions, can be accessed in JAMA Network Open.
“It’s in a worldwide journal that is open access, which is intentional, so that anyone in the world can access this. You don't need a membership fee,” Basu said. “We did all this intentionally with the idea that this is the roadmap.”
Moving forward
The 2021 Acute Disease Quality Initiative demonstrated that while knowledge gaps still exist in pediatric AKI, there are steps that can be taken to close these.
“One crucial element which will be a focus is to align neonatal, pediatric, and adult providers, researchers, and educators in the AKI space. This is a life-long syndrome and has a continuum of illness which only together can we properly understand, manage, and protect our patients from. A unified approach with help of our partners in industry, the public, patients and families will allow us to make progress,” Basu said.
Basu emphasized that to move the recommendations forward, pediatricians and patients need to be included in the story. Not only does the public need to be educated about pediatric AKI on the same level that it is educated about more well-known diseases like cancer, but the public needs to get involved in the effort. Additionally, research projects should be funded and prioritized, he said.
“We have to think in new ways of how to get our research agenda forward, and part of it is organizing. Right now, we have six or seven groups just in the U.S. that are involved in the space, but how do you organize all these groups to be aligned in what we're trying to do?” Basu said. “We can celebrate this as much as we want, but I’m done celebrating it. Now we need to move it forward.”
References:
- Ever in pediatrics: World experts set agenda to improve care of acute kidney injury in kids.
- https://www.newswise.com/articles/first-ever-in-pediatrics-world-experts-set-agenda-to-improve-care-of-acute-kidney-injury-in-kids?sc=dwhr&xy=10007438/?ad2f=1&aid=779223. Published Sept. 28, 2022. Accessed Oct. 03, 2022.
- Consensus-based recommendations for acute kidney injury in children.
- https://www.bcm.edu/news/consensus-based-recommendations-for-acute-kidney-injury-in-children. Published Sept. 30, 2022. Accessed Oct. 03, 2022.
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