Most PICU Physicians Use Older Test to Diagnose AKI, Study Shows

Amanda B. Hassinger, MD, assistant professor of pediatrics, found that nearly three-quarters of physicians are relying primarily on an older, less reliable test — a practice that could affect patients’ long-term health.

Hassinger reported her findings, which she describes as “disappointing,” in the August issue of Pediatric Critical Care Medicine.

“It was scarier than I thought in terms of how aware other physicians in my field are to the new guidelines for treatment of AKI and the new methods to diagnose earlier and more effectively,” she says.

Hassinger and her co-authors surveyed 170 pediatric critical care physicians from academic centers, the Pediatric Acute Lung Injury and Sepsis Investigators Network, and the pediatric branch of the Society of Critical Care Medicine.

Among the two-dozen survey questions, researchers asked which criteria the physicians frequently rely on to diagnose pediatric AKI.

Half of the respondents reported not using recent AKI guidelines or diagnostic criteria in clinical practice; 74 percent said they diagnose the condition using serum creatinine and urine output only, despite the availability of newer, more reliable tests.

Serum creatinine doesn’t effectively detect AKI in children, Hassinger says, because it can be affected by factors such as nutrition and muscle mass. Several new biomarkers have been discovered that aid in the diagnosis of AKI.

Diagnosing AKI in children has proven difficult because no consensus definition exists of the condition in the pediatric population. The lack of knowledge among pediatric intensive care physicians about which guidelines and criteria to use leads to variability in treatment, Hassinger says.

“I wasn’t surprised that the newer tests aren’t being used because they do cost a lot of money and require special machinery,” Hassinger says.

“But what really upset me was that physicians were happy with the status quo and weren’t looking for a better biomarker for this critically important condition. The existing biomarkers are inadequate.”

AKI among critically ill children is on the rise, Hassinger says, lending more urgency to gauging its management.

It occurs most frequently in critically ill children, the result of any number of causes, including sepsis, shock, trauma and exposure to medications that affect the kidneys.

According to the National Kidney Foundation and recent evidence, one episode of AKI significantly increases a patient’s chance of developing health problems — including chronic kidney disease, stroke and heart disease — later in life.

In addition, data now show that children who experience a single episode of AKI in an intensive care unit have a 50 to 75 percent chance of having renal insufficiency for the rest of their lives.

“It’s an important, but silent issue that needs more attention,” Hassinger says. 

“The kidneys are a very vulnerable set of organs, and they’re important to overall balance in the body, so we should be paying more attention to them than we do.”

Hassinger theorizes that clinicians underappreciate the impact of AKI on children because of the resilience of both kidneys and pediatrics patients.

“Even if you have the worst stage of acute kidney injury, despite the physician, the kidneys and the patient get better,” she says. “There’s not as much urgency to diagnose it and call it the right name because, most of the time, no matter what you call it, kids will bounce back pretty well.”

Toward that end, the survey asked physicians if they were aware that AKI independently increases morbidity and mortality. Twelve percent of respondents said they were not or they were unsure.

The survey also revealed that only one-third of the PICU physicians surveyed refer kids with AKI to a kidney specialist after they’ve been discharged from intensive care.

“These patients go unmonitored for periods of time until the kidney issues manifest when they’re teenagers and they get an infection or another injury that knocks out the kidneys completely,” Hassinger says.

“Then they’re in renal failure at 18.”

Hassinger is now partnering with a colleague at Cincinnati Children’s Hospital Medical Center for a second survey that will examine the relationship between IV fluid overload and acute kidney injury in PICU patients.

IV fluids are often given to hospitalized children, Hassinger says, but it’s another area of medical practice that warrants scrutiny because fluid overload can cause organ failure.

Hassinger conducted the original study — titled “The Current State of the Diagnosis and Management of Acute Kidney Injury by Pediatric Critical Care Physicians” — while completing her master’s degree in epidemiology/clinical research in UB’s School of Public Health and Health Professions.

“This study gives us an important picture of what practice looks like in pediatric ICUs so that we can understand what is missing,” says co-author Jo L. Freudenheim, PhD, chair of epidemiology and environment health.

“We can now start to make renewed efforts to change practice and improve care.”

Other co-authors are Sudha Garimella, MBBS, clinical assistant professor of pediatrics and a pediatric nephrologist, and Brian H. Wrotniak, a departmental instructional support technician.