[Comparison of diagnostic criteria for acute kidney injury in critically ill children].

Objective: The kidney disease: improving global outcome (KDIGO) and pediatric reference change value optimized for acute kidney injury (pROCK) criteria were used to evaluate the incidence, stages and mortality of acute kidney injury (AKI). The differences between the 2 criteria were compared for exploring the value of pROCK criteria in diagnosing pediatric AKI and predicting adverse outcomes. Methods: In the multicenter prospective clinical cohort study, we collected general data and clinical data such as serum creatinine values from 1 120 children admitted to 4 PICUs of Children's Hospital of Soochow University, Children's Hospital of Fudan University, Anhui Provincial Children's Hospital, and Xuzhou Children's Hospital from September 2019 to February 2021. AKI was defined and staged according to the KDIGO and pROCK criteria. The incidence of AKI, the consistency of AKI definite diagnosis and stages, and the mortality in PICU were compared between the 2 groups. The chi-square test or Fisher's exact test was applied for comparison between 2 groups. The Cohen's Kappa and Weighted Kappa analyses were used for evaluating diagnostic consistency. The Cox regression analysis was used to evaluate the correlation between AKI and mortality. Results: A total of 1 120 critically ill children were included, with an age of 33 (10, 84) months. There are 668 boys and 452 girls. The incidence of AKI defined by the KDIGO guideline was higher than that defined by pROCK criteria (27.2%(305/1 120), 14.7%(165/1 120), χ2=52.78, P<0.001). The concordance rates of the 2 criteria for the diagnosis of AKI and AKI staging were 87.0% (κ=0.62) and 79.7% (κ=0.58), respectively. Totally 63 infants with AKI stage 1 defined by the KDIGO guideline were redefined as non-AKI by following the pROCK criteria. The PICU mortality rate of these infants was similar to patients without AKI defined by KDIGO guideline(P=0.761). After adjusting for confounders, AKI defined by KDIGO or pROCK criteria was an independent risk factor of death in PICU (AHR=2.04, 2.73,95%CI 1.27-3.29, 1.74-4.28, both P<0.01), and the risk of death was higher when using the pROCK compared with the KDIGO criteria. As for the KDIGO criteria, mild AKI was not associated with the mortality in PICU (P=0.702), while severe AKI was associated with increased mortality (P<0.001). As for the pROCK criteria, both mild and severe AKI were risk factors of PICU death in children (HR=3.51, 6.70, 95%CI 1.94-6.34, 4.30-10.44, both P<0.001). In addition, The AKI severity was positively associated with the mortality. Conclusions: The AKI incidence and staging varied depending on the used diagnostic criteria. The KDIGO definition is more sensitive, while the pROCK-defined AKI is more strongly associated with high mortality rate.目的： 采用改善全球肾脏病预后组织（KDIGO）和儿童基线肌酐参考值（pROCK）标准评估儿童急性肾损伤（AKI）发生率、分期及病死率，探索pROCK标准对儿童AKI诊断及预后判断的价值。 方法： 前瞻性多中心队列研究。收集2019年9月至2021年2月4家儿童医疗中心（苏州大学附属儿童医院、复旦大学附属儿童医院、安徽省儿童医院、徐州儿童医院）儿童重症监护病房（PICU）收治的1 120例重症患儿的一般资料及肌酐值等临床资料。分别采用KDIGO和pROCK标准对其进行AKI诊断和分期，比较两组间AKI的发生率、AKI诊断及分期的一致率、患儿的PICU病死率。组间比较采用χ2检验或Fisher确切概率法；诊断一致性采用Cohen′s Kappa和Weighted Kappa分析；采用Cox回归分析评估AKI与病死率的相关性。 结果： 1 120例重症患儿中男668例，女452例，年龄33（10，84）月龄，依据KDIGO诊断标准的AKI发生率显著高于依据pROCK标准［27.2%（305/1 120）比14.7%（165/1 120），χ2=52.78，P<0.001］。两种标准诊断AKI及AKI分期的一致率分别为87.0%（k=0.62）和79.7%（k=0.58）。其中63例KDIGO标准诊断为AKI 1期的婴儿被pROCK重新定义为非AKI，这些婴儿的PICU病死率与KDIGO标准诊断的非AKI患儿的病死率差异无统计学意义（P=0.761）。校正混杂因素后，KDIGO及pROCK标准诊断的AKI均为患儿住PICU期间死亡的独立危险因素（AHR=2.04、2.73，95%CI 1.27~3.29、1.74~4.28，均P<0.01），与KDIGO标准相比，pROCK诊断的AKI患儿发生PICU死亡的风险更高。采用KDIGO标准，轻度AKI与PICU死亡的相关性差异无统计学意义（P=0.702），严重AKI为患儿PICU死亡的危险因素（P<0.001）。采用pROCK标准，轻度和严重AKI均为患儿PICU死亡的危险因素（HR=3.51、6.70，95%CI 1.94~6.34、4.30~10.44，均P<0.001），随着AKI严重程度增加，PICU死亡风险上升。 结论： 重症儿童AKI的发生率和分期因诊断标准不同而变异。采用KDIGO标准诊断儿童AKI的灵敏度高；采用pROCK标准诊断的AKI患儿发生PICU死亡的风险更高。.