Community-acquired Acute Kidney Injury Among Children Seen in the Pediatric Emergency Department

Acad Emerg Med. 2018 Jul;25(7):758-768. doi: 10.1111/acem.13421. Epub 2018 May 1.


Objectives: Acute kidney injury (AKI) is a significant risk factor for morbidity and mortality in children. Little is known about community-acquired AKI (CA-AKI) in the pediatric emergency department (PED). Early recognition of AKI allows for nephroprotective measures. The goal of this investigation was to determine the incidence of CA-AKI and the frequency of clinician identified CA-AKI to better inform future nephroprotective interventions.

Methods: This was a retrospective cross-sectional study in the PED of a children's hospital. Children 1 month to 18 years of age seen in the PED from January 1 to December 31, 2015, and in whom at least one creatinine level was obtained were included. Patients with chronic kidney disease or end-stage renal disease or who died in the PED were excluded. Patients had CA-AKI based on modified Kidney Disease-Improving Global Outcomes criteria using the creatinine obtained in the PED compared to age-specific norms. Patients were considered identified if the PED clinician diagnosed AKI. The primary outcome was the incidence of CA-AKI. Secondary outcomes included frequency of AKI identification, nephrotoxic medication use, hospital length of stay, renal replacement therapy, and death. Fisher exact test or Pearson's chi-square test was used to calculate odds ratio (OR) with 95% confidence intervals (CIs); multivariable analyses were performed using logistic regression.

Results: In 2015 there were 119,151 PED visits; 15,486 met inclusion criteria. CA-AKI was present in 239 of 15,486 (1.5%) encounters. AKI was identified by PED clinicians in 46 of 239 (19%) of encounters and by the inpatient team in 123 of 199 (62%) of the encounters admitted. AKI was never recognized by a PED or inpatient clinician in 74 of 199 (37%) encounters. Encounters with AKI correctly diagnosed were older (13 years old vs. 10 years old, p = 0.0114), had more severe (stage 2 or 3) AKI (OR = 5.5, 95% CI = 2.6-11.8), and were more likely to be admitted (OR = 10.3, 95% CI = 1.38-77.4) than encounters with missed AKI.

Conclusions: CA-AKI remains an underrecognized entity in the PED. Better tools for early recognition of AKI in the busy PED environment are needed.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Acute Kidney Injury / diagnosis
  • Acute Kidney Injury / epidemiology*
  • Adolescent
  • Chi-Square Distribution
  • Child
  • Child, Preschool
  • Community-Acquired Infections / diagnosis
  • Community-Acquired Infections / epidemiology
  • Creatinine / analysis
  • Cross-Sectional Studies
  • Emergency Service, Hospital / statistics & numerical data*
  • Female
  • Hospital Mortality
  • Hospitals, Pediatric / statistics & numerical data
  • Humans
  • Incidence
  • Infant
  • Length of Stay / statistics & numerical data
  • Logistic Models
  • Male
  • Odds Ratio
  • Retrospective Studies
  • Risk Factors


  • Creatinine