BACKGROUND AND OBJECTIVE: Nephrotoxic medication exposure represents a common cause of acute kidney injury (nephrotoxin-AKI) in hospitalized children. Systematic serum creatinine (SCr) screening has not been routinely performed in children receiving nephrotoxins, potentially leading to underestimating nephrotoxin-AKI rates. We aimed to accurately determine nephrotoxin exposure and nephrotoxin-AKI rates to drive appropriate interventions in non-critically ill hospitalized children. METHODS:We conducted a prospective quality improvement project implementing a systematic electronic health record (EHR) screening and decision support process (trigger) at a single quaternary pediatric hospital. Patients were all noncritically ill hospitalized children receiving an intravenous aminoglycoside for $3 days or $3 nephrotoxins simultaneously (exposure). Pharmacists recommended daily SCr monitoring in exposed patients. AKI was defined by the modified pediatric Risk, Injury, Failure, Loss and End-stage Renal Disease criteria ($25% decrease in estimated creatinine clearance). We developed 4 novel metrics: exposure rate per 1000 patient-days, AKI rate per 1000 patient-days, AKI rate (%) per high nephrotoxin admission, and AKI days per 100 exposure days (AKI intensity).RESULTS: This study included 21 807 patients accounting for 27 711 admissions. A total of 726 (3.3%) unique exposed patients accounted for 945 hospital admissions (6713 patient-days). AKI occurred in 25% of unique exposed patients and 31% of exposure admissions (1974 patient-days). Our EHR-driven SCr nephrotoxin-AKI surveillance process was associated with a 42% reduction in AKI intensity.CONCLUSIONS: Nephrotoxin-AKI rates are high in noncritically ill children; systematic screening for nephrotoxic medication exposure and AKI detection was accomplished reliably through an EHR based trigger tool. Pediatrics 2013;132:e756-e767 The changing disease distribution in tertiary and quaternary medical centers has led to therapies required to promote survival but that increasingly put patients at risk for iatrogenic injuries including kidney damage. [1][2][3][4] Nephrotoxic medication exposure and associated acute kidney injury (nephrotoxin-AKI) occur commonly in hospitalized children. Eighty-six percent of noncritically ill children at a large children' s hospital received at least 1 nephrotoxin. 5 Nephrotoxin-AKI was cited as the primary cause of 16% of pediatric AKI cases 3 and is associated with significant morbidity and increased length of stay and costs. 5,6 Noncritically ill children with AKI are 1.7 times more likely to have received a nephrotoxin, 5 and AKI rates increase from 16% to 45% with exposure to $3 nephrotoxins. 5 Intravenous aminoglycoside (IV AG) exposure for .5 days is associated with nephrotoxin-AKI rates of 19% to 31%. 6 Thus, nephrotoxin-AKI represents a significant health care burden for hospitalized children.Nephrotoxin-AKI is usually diagnosed by a serum creatinine (SCr) level increase, because nephrotoxin-AKI is generally nonoliguric in...
Objectives: Nephrotoxin exposure is a common cause of acute kidney injury (AKI) in hospitalized children. AKI detection relies on regular serum creatinine (SCr) screening among exposed patients. We sought to determine how well administrative data identify hospitalized noncritically ill children with nephrotoxic medication-associated AKI in the contexts of incomplete and complete screening. Methods: We conducted a single-center retrospective cohort study among noncritically ill hospitalized children. We compared administrative data sensitivity to that among a separate cohort for whom adequate screening was defined as daily SCr measurement. For the original cohort, nephrotoxin exposure was defined as exposure to ≥3 nephrotoxins at once or ≥3 days of aminoglycoside therapy. AKI was defined by the change in SCr (pediatric-modified Risk Injury Failure Loss End-Stage Renal Disease [pRIFLE] criteria) or discharge code. Adequate SCr screening was defined as 2 measurements obtained ≤96 hours apart. Administrative data and laboratory values were merged to compare AKI by discharge code and pRIFLE criteria. Results: 747 of 1472 (50.7%) nephrotoxin-exposed patients were adequately screened; 82 (11.0%) had AKI by pRIFLE criteria, 52 (7.0%) by discharge code. Sensitivity of nephrotoxin-associated AKI diagnosis by discharge code compared with pRIFLE criteria was 23.2% (95% confidence interval = 14.0–32.3). In the comparison cohort, 70 (26.8%) patients had AKI by pRIFLE criteria and 26 (10.0%) by discharge code; sensitivity was 21.4% (95% confidence interval = 11.8%–31.0%). Conclusions: pRIFLE criteria identified more patients than were identified by discharge code. Identifying patients with nephrotoxin-associated AKI by discharge code, even in the presence of complete AKI detection, underrepresents the true incidence of nephrotoxin-associated AKI in hospitalized children.
BACKGROUND The epidemiology of aminoglycoside-associated acute kidney injury (AG-AKI) has not been well-described in pediatric patients with cystic fibrosis (CF). We aimed to assess the impact of daily serum creatinine (SCr) measurement on detection of AG-AKI at our institution. METHODS We examined a cohort of hospitalized patients with CF who received an intravenous (IV) aminoglycoside for ≥3 days. We compared the rate, timing, and medical management surrounding detection of AG-AKI during 2 periods: January 2010 - May 2011 (Era 1, SCr measured at the discretion of the medical team, N=124) and June 2011 - June 2012 (Era 2, SCr measured daily, N=103). Our primary outcome was detection of AG-AKI defined as ≥50% increase in SCr from baseline (lowest value in prior 6 months), or ≥0.3 mg/dL rise within 48 hours, occurring after day 2. RESULTS The use of once daily tobramycin (p=.02) and IV fluids (p<.001) was higher during Era 2, while AG courses were shorter (p=.04) and fewer concomitant nephrotoxins (p=.04) were given; higher daily tobramycin doses (p<.001) were administered. Although the rate of AG-AKI was not significantly different (12% during Era 1 vs. 20% during Era 2, p=.09), the number of AG-AKI days detected increased (5.5 vs. 2.9 per 100 AG days, p=.003) and detection occurred earlier (median six vs. nine days, log rank test p=.02) during the daily SCr period. CONCLUSIONS Daily SCr measurement promoted earlier and increased detection of AG-AKI in patients with CF at our institution. We suggest systematic evaluation for AKI during aminoglycoside administration in patients with CF.
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