HASIL PENELITIAN

Acute Kidney Injury in Critically Ill Children at

Pediatric Intensive Care Unit
Husein Albar
Department of Child Health, Faculty of Medicine, Hasanuddin University/
Wahidin Sudirohusodo Hospital, Makassar, South Sulawesi, Indonesia

ABSTRACT
Background: Recognition of acute kidney injury (AKI) requires use and selection of easily measured criteria that can be applied widely across
age groups and clinical situations. Modified pediatric RIFLE (pRIFLE) has been used for diagnosis and grading of AKI (acute kidney injury) in
children. Objective: To investigate AKI in children aged 1-14 years hospitalized at PICU (pediatric intensive care unit), Wahidin Sudirohusodo
Hospital, Makassar. Methods: A cross-sectional study was done based on medical records from 2009 until 2011. The records were screened
for demographic data, serum creatinine level and estimated creatinine clearance by Schwartz formula. AKI was grouped according to pRIFLE
formula. Results: There were 77 patients, 58.4% boys and 41.6% girls. Majority were above 5 year-old (76.6%), have increased serum creatinine
level (80.05%) and decreased eCC/estimated creatinine clearance (80.05%). Underlying diseases as the cause of AKI consists of AGN/acute
glomerulonephritis (41.6%), NS/nephrotic syndrome (9.1%), UTI/urinary tract infections (9.1%), and others (40.3%) including DSS (dengue shock
syndrome), dehydration due to diarrhea, and septic shock. pRIFLE-R was more frequent in patients above five years old (33.8%), in boys (27.3%),
well-nourished patients (13.0%), and in patients with increased creatinine serum level or decreased eCC (49.9%) compared to pRIFLE-I and
pRIFLE-F groups. No significant difference of pRIFLE grading in different groups of underlying diseases (p=0.126), age (p=0.075), sex (p=0.817),
and nutritional status (p=0.102). The difference of creatinine serum level and eCC was significant (p <0.001) among different pRIFLE grading.
Conclusion: Early diagnosis of AKI should be based on pRIFLE grading and adequate preventive measures should be instituted as early as
possible to reduce the morbidity and mortality rates at PICU.

Key words: children, acute kidney injury, pRIFLE

ABSTRAK
Latar belakang: Diagnosis gangguan ginjal akut memerlukan kriteria diagnostik yang mudah diterapkan pada semua kelompok umur pasien
dengan risiko gangguan ginjal akut (acute kidney injury, AKI). Modifikasi pRIFLE telah digunakan untuk diagnosis dan penentuan gangguan ginjal
akut pada anak. Tujuan: Mengevaluasi gangguan ginjal akut pada anak yang dirawat di Unit Rawat Intensif Anak RS Wahidin Sudirohusodo
Makassar. Metode: Telah dilakukan penelitian retrospektif potong-silang dari catatan medik pasien anak 1-14 tahun yang dirawat di RS Wahidin
Sudirohusodo Makassar periode 2009 - 2011. Analisis data demografi, kadar kreatinin serum dan estimasi kliren kreatinin dengan rumus
Schwartz dari catatan medik pasien. Gangguan ginjal akut dikelompokkan dalam derajat pRIFLE-R, pRIFLE-I, pRIFLE-F, pRIFLE-L, dan pRIFLE-E.
Hasil: Dari tujuh puluh tujuh pasien yang dianalisis didapatkan 58,4% laki-laki dan 41,6% perempuan. Rerata usia 8,483 tahun, dari usia 1
tahun 10 bulan 14 tahun. Kebanyakan pasien berusia di atas lima tahun (76,6%), status gizi kurang (53,2%), kadar kreatinin serum tinggi dan
estimasi bersihan kreatinin rendah (80,05%). Penyebab gangguan ginjal akut pada penelitian ini adalah glomerulonefritis akut (41,6%), sindrom
nefrotik (9,1%), infeksi saluran kemih (9,1%), dan penyakit lain (40,3%) meliputi demam berdarah renjatan, diare dehidrasi, dan renjatan septik.
pRIFLE-R lebih sering ditemukan pada pasien umur di atas lima tahun (33,8%), pada anak lelaki (27,3%), pasien gizi baik (13,0%), dan pasien
dengan kadar kreatinin serum tinggi dan estimasi bersihan kreatinin rendah (49,9%) dibandingkan dengan kelompok pRIFLE-I dan pRIFLE-F.
Tidak ditemukan perbedaan bermakna di antara derajat pRIFLE dan penyakit penyebab gangguan ginjal akut (p=0,126) dan di antara derajat
pRIFLE dan distribusi umur (p=0,075), jenis kelamin (p=0,817), dan status gizi (p=0,102). Perbedaan bermakna ditemukan di antara derajat
pRIFLE dan distribusi kadar kreatinin serum (p <0,001) dan estimasi bersihan kreatinin (p <0,001). Simpulan: Diagnosis dini gangguan ginjal
akut berdasarkan derajat pRIFLE seyogyanya dilakukan pada semua pasien di Unit Rawat Intensif Anak sehingga pencegahan adekuat dapat
segera diberikan untuk mengurangi angka morbiditas dan mortalitas akibat gangguan ginjal akut. Husein Albar.Gangguan Ginjal Akut pada
Anak Sakit Kritis yang Dirawat di Unit Rawat Intensif.

Kata kunci: anak, gangguan ginjal akut, pRIFLE

INTRODUCTION resulting in disturbance of physiological water and electrolyte regulation and loss of
Acute renal failure (ARF) is defined as a rapid renal functions including impairment of acid-base regulation. Although the incidence
decline in glomerular filtration rate (GFR), nitrogenous waste product excretion, loss of of ARF varies with geographical localization

Alamat korespondensi email: hexin_01@yahoo.com

890 CDK-211/ vol. 40 no. 12, th. 2013


Table 1 pRIFLE grading4-6
and countries, it has been reported in 2-5%
of hospitalized children and in 4.5-30% of
children in pediatric intensive care units (
PICU). Mortality rates of 35 to 80% have been
reported in patients developing ARF.1-3 An
acute decline of kidney function is secondary
to tubular (or more extensive) injury that
leads to functional or structural damage in
the kidney. ARF actually includes a spectrum
of conditions, the term acute kidney injury
(AKI) has been recently proposed to reflect
the entire spectrum of the syndrome.4-6
The exact incidence and causes of AKI in
children is unknown; recent studies suggest
that incidence of AKI in hospitalized children
is increasing. Previous studies in Nigeria
and North India showed 11.7 and 20 AKI
cases admitted per year per 1000 pediatric
admissions, respectively7 and in New Zealand
children, 4.0 per 100 000 total population
under 15 year of age.8 No study reported
incidence of AKI in Indonesia.
This study retrospectively investigated AKI
in children hospitalized at PICU in Wahidin
Sudirohusodo Hospital, Makassar.
METHOD
This survey was a retrospective cross-sectional
CDK-211/ vol. 40 no. 12, th. 2013
study to investigate AKI in hospitalized children
at Wahidin Sudirohusodo Hospital Makassar.
Data were based on a review of standard
medical records of all patients aged 1-14 years
hospitalized at PICU of Wahidin Sudirohusodo
Hospital, Makassar from 2009 until 2011.
Study approval was obtained from the Ethical
Committee of Wahidin Sudirohusodo Hospital,
Makassar.
We enrolled all patients who had been
hospitalized at PICU of the hospital with
complete medical records. Patient records
were retrospectively analyzed for age, sex,
nutritional status, underlying diseases, whole
blood count, urinary analysis, duration of renal
failure, blood ureum, serum creatinine, and
estimated creatinine clearance (eCC). Systolic
and/or diastolic blood pressure levels equal
or greater than 95 percentile was defined
as hypertension whereas systolic blood
pressure <70 mmHg + 2 x Age(yr) defined
as hypotension.8 Patients with a history of
chronic renal failure and incomplete medical
records were excluded from the study. The
medical records were screened for creatinine
serum level and estimated GFR, and patients
with GFR of 75 ml/min/1.73 m2 or less were
selected for additional analysis. GFR was
assessed by Schwartz formula.9 AKI was
HASIL PENELITIAN
defined according to the modifed pediatric
RIFLE (pRIFLE) and graded into pRIFLE-R
(risk for reduced kidney function) ,pRIFLE-I
(injury of kidney function), pRIFLE-F (failure
of kidney), pRIFLE-L(loss of kidney function),
and pRIFLE-E (End Stage Renal Disease).
pRIFLE-L and pRIFLE-E define the outcome of
AKI. pRIFLE grading uses estimated creatinine
clearance estimation (eCC) to assess renal
function based on Schwartz formulas (0.55 x
height (cm) / serum creatinine (mg/dL) in mL/
minute/1.73 m2)5,6 (Tabel 1).
Baseline of normal eCC used in this study was
120 mL/min/1.73 m2.6 Underlying diseases
as the cause of AKI were grouped into
acute glomerulonephritis (AGN), nephrotic
syndrome (NS), urinary tract infection (UTI), and
others including any shock conditions such as
dengue shock syndrome (DSS), dehydration
caused by diarrhea, and any cause of septic
shock. Data were analyzed using SPSS v.15.00
(SPSS, Inc, Chicago). Pearson chi-square was
used to compare characteristic data and p
<0.05 was considered as significant.
RESULTS
There were 77 patients enrolled in this study,
consisting of 58.4% boys and 41.6% girls
with a boy to girl ratio of 1.4:1. Mean age of
subjects was 8.483 years ranging from 1.10 to
13.50 years. Majority of subjects was above
5 years (76.6%) and undernourished (53.2%).
Increased serum creatinine level or decreased
eCC occured in 80.05 % cases (Table 2).
Tabel 2 Characteristics of subjects
Parameters n (77) / (100%)
Age (mean: 8.483 [1.83 - 13.5])
< 5 yr 18/23.4%
> 5 yr 59/76.6%
Sex
Boy 45/58.4%
Girl 32/41.6%
Nutritional status
Well-nourished 36/46.8%
Undernourished 41/53.2%
Serum creatinine (mean: 1.553
[0.410-6.861])
Normal 15/19.05 %
High 62/80.05 %
eCC (mean: 40.920 [0.45-127.00])
Normal 15/19.05 %
Low 62/80.05 %
Table 3 shows that underlying diseases as the
cause of AKI consist of AGN (41.6%), NS (9.1%),
UTI ( 9.1%), or others (40.3%) including DSS,
dehydration due to diarrhea, and septic shock.
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Table 3 Distribution of pRIFLE grading according to underlying diseases There was no significant difference of pRIFLE
pRIFLE ETIOLOGY Total grading among different underlying diseases
(p=0.126). pRIFLE-R was more frequent in
AGN (n/%) NS (n/%) UTI (n/%) Others (n/%)
patients aged under and above five years old
Normal 6/7.8% 1/1.3% 0/0.02% 8/10.4% 15/19.5%
(9.1%/33.8%), in boys (27.3%), well-nourished
Risk 18/23.4% 3/3.9% 5/6.5% 7/9.1% 33/42.9% patients (13.0%), and patients with increased
Injury 6/7.8% 3/3.9% 2/2.6% 10/13.0% 21/27.3% creatinine serum level and decreased eCC
Failure 2/2.6% 0/0.02% 0/0.02% 6/7.8% 8/10.4% (49.9%) compared to those with pRIFLE-I and
Total 32/41.6% 7/9.1% 7/9.1% 31/40.3% 77/100.0%
pRIFLE-F (Table 4).

Pearson chi-square=13.896 df=9 p=0.126 Table 4 shows no significant differences of

pRIFLE grading among distribution of age
(p=0.075), sex (p=0.817), and nutritional status
20
(p=0.102) but very significant difference
among different pRIFLE grading, creatinine
serum level (p <0.001) and eCC (p <0.001).

DISCUSSION
AKI is defined as functional or structural
abnormalities or markers of kidney damage
including abnormalities in blood, urine or
tissue tests or imaging studies present for less
10 than three months. AKI is an abrupt or less
than 48 hours reduction in kidney function
ETIOLOGY confirmed by an absolute increase in serum
creatinine of either >0.3 mg/dL or a percentage
AGN increase of 50% or reduction in urine output
or documented oliguria of <0.5 mL/kg/hr
NS for >6 hr. The heterogenous cause of AKI has
been associated with increased morbidity and
Count

UTI mortality by increasing dialysis need as well as

further subsequent development of chronic
0 others kidney disease and its progression to dialysis
normal risk injyury failure dependency.3 Recognition of AKI requires
selection and use of easily measured criteria
that can be applied widely, across age groups
RIFLE and clinical situations. Modified pRIFLE has
Figure 1 Histogram of pRIFLE according to underlying diseases been used for diagnosis and grading of AKI in
JUDUL SUMBU Y: Number of patients children.4-6
JUDUL SUMBU X: RIFLE category (ada ralat juga: injyury injury)
The reported incidences of AKI in children and
Table 4 Distribution of age, sex, nutritional status, creatinine serum and eCC of subjects according to pRIFLE grading adolescents hospitalized at PICU ranged from
8% to 30%.10 The present study found that
RIFLE
Parameters Total pRIFLE-R, pRIFLE-I, and pRIFLE-F in children
P
Normal Risk Injury Failure hospitalized at PICU in Wahidin Sudirohusodo
Age <5 yr 7/9.1% 7/9.1% 2/2.6% 2/2.6% .075 18/23.4% Makassar was 49.9%, 27.3%, and 10.4%,
>5 yr 8/10.4% 26/33.8% 19/24.7% 6/7.8% 59/76.6% respectively. This result is similiar to other
Sex Boy 9/11.7% 21/27.3% 11/14.3% 4/5.2% .817 45/58.4% studies.
Girl 6/7.8% 12/15.6% 10/13.0% 4/5.2% 32/41.6%
The common cause of childhood AKI reported
Nutrition Wellnourished 7/9.1% 10/13.0% 13/16.9% 6/7.8% .102 36/46.8%
in New Zealand was post cardiac surgery
Undernourished 8/10.4% 23/29.9% 8/10.4% 2/2.6% 41/53.2%
(58%), HUS (17%), sepsis (13%), and AGN (4%).8
Serum creatinine Normal 15/19.5% 0/.0% 0/.0% .0001 15/19.5%
0/.0% In Houston Texas, the cause of AKI in children
High 0/.0% 33/42.9% 21/27.3% 8/10.4% 62/80.5% were renal ischemia (21%), nephrotoxic
eCC Normal 15/19.5% 0/.0% 0/.0% 0/.0% .0001 15/19.5% agents (16%), sepsis (11%), and primary renal
Low 0/.0% 33/42.9% 21/27.3% 8/10.4% 62/80.5% disease (7%).10 The present study showed that

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the cause of AKI in children was AGN (41.6%),
NS (9.1%), UTI (9.1%), and others (40.3%)
including any shock conditions such as
dengue shock syndrome (DSS), dehydration
caused by diarrhea, and any cause of septic
shock. This result was similar to a study from
Anatolia, Turkey that AGN caused more than
60% of AKI in children.7
A limitation of this study is that data analysis
based on a retropective and cross-sectional
design. A prospective cohort study should
be done further to confirm the results from
this study. Early diagnosis of AKI in all children
hospitalized at PICU should be established
based on the pRIFLE criteria using Schwartz
formula. Since children hospitalized in PICU
are at high risk of AKI, early diagnosis and
adequate preventive measures should be
instituted as early as possible to decrease
the need for RRT (renal replacement therapy)
and subsequently to reduce morbidity and
mortality rates.
CONCLUSION
Early diagnosis of AKI should be based on
pRIFLE grading and adequate preventive
measures should be instituted as early as
possible to reduce the morbidity and mortality
rates at PICU.

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2. Moghal NE, Brocklebank JT, Maedow RS. A review of acute renal failure in children: Incidence, etiology and outcome. Clin Nephrol. 1998;49:91-5.
3. Ozakar ZB, Yalinkaya F, Altas B, Ergn H, Kendirli T, Ate C, et al. Application of the new classification criteria of the acute kidney injury network: A pilot study in a pediatric population.
Pediatr Nephrol. 2009;24:1379-84.
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Nephrol. 2008;3:948-54.
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