Evaluating long-term renal outcomes after acute kidney injury in critically ill children using two approaches: administrative data and patient-oriented research

Background: Acute kidney injury (AKI) in the pediatric intensive care unit (PICU) is associated with poor hospital outcomes. In adults, AKI is associated with the development of chronic kidney disease (CKD) and hypertension in the long-term, both of which are cardiovascular risk factors. However, the late renal effects of child AKI are unclear. Objectives: 1. Use patient-oriented research to determine if PICU-AKI is associated with long-term hypertension and microalbuminuria. 2. Develop novel pediatric CKD and hypertension definitions using provincial administrative healthcare data to evaluate AKI-long-term renal outcomes associations. Methods: Two observational cohort studies: 1) Retrospective Database cohort: n=2499 from two Montreal PICUs; 2) Patient-oriented cohort: 101 patients in an ongoing longitudinal study, 7 years post-PICU admission. Database cohort: medical chart data was collected and merged with 5 years post-PICU provincial administrative healthcare data. Administrative health data CKD and hypertension definitions were derived iteratively (diagnostic, procedural, medication codes). Patient-oriented cohort: 24-hour ambulatory blood pressure monitoring (ABPM) and first morning urine collection were performed to ascertain hypertension and microalbuminuria. Blood samples were not collected at this study visit and therefore glomerular filtration rate was unavailable. Univariate analyses were performed to compare long-term outcomes in patients with vs. without AKI. ResultsDatabase cohort: n=2404; 24.2% (477/1973 with data available) developed AKI. Patients with AKI were younger, had a higher Pediatric Risk of Mortality (PRISM) score, were more likely to require mechanical ventilation and had a longer length of PICU stay. Within 5 years post-PICU, 8.6% had a CKD diagnosis (AKI: 15.7%, non-AKI: 6%, p<0.001); 3.9% had a hypertension diagnosis (AKI: 43/467 (9.2%) vs. non-AKI: 40/1467 (2.7%), p<0.001). Patent-oriented cohort: 32/101 (31.7%) had AKI in the PICU. Patients with AKI were more likely to be given vasopressors in the PICU and had a longer length of PICU stay. Of the 89 patients with ABPM data, 4 (4.5%) had prehypertension, 1 (1.1%) had white coat hypertension, 11 (12.4%) had hypertension (10 masked hypertension, 1 ambulatory hypertension), and 34/68 (50%) had inadequate nighttime dipping (<10% decrease from day to night). In the total population the prevalence of microalbuminuria was 9/100 (9%). There were no statistically significant differences in long-term outcomes between the AKI and non-AKI patients. However, patients with AKI had clinically significantly higher nighttime blood pressure z-scores and a higher proportion had masked hypertension. Conclusions: PICU-AKI is associated with late provincial administrative healthcare data defined CKD and hypertension in preliminary (unadjusted) analyses. The hypertension prevalence after PICU admission is about 2-8 times higher than in the general child population. Research should address measures to decrease post-PICU long-term renal and cardiovascular risk.

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