In low and middle-income countries, reliable data on the epidemiology of Childhood acute kidney injury (AKI) is lacking. The Global Snapshot, conducted by the ISN “0by25” AKI initiative, was a world-wide cross-sectional, observational study to evaluate AKI in hospitalized patients

The “0by25” initiative of the International Society of Nephrology (ISN) has the ambitious goal of reaching zero preventable deaths from AKI across the world by 2025.

The AKI Global Snapshot (GSN) was an initial attempt to understand the incidence, causes, treatment and outcomes of AKI around the world, focusing on lower and lower-middle income group countries, which are underrepresented in the majority of AKI studies. In this report, we hypothesize that the causes and outcomes of pediatric AKI are dissimilar in diverse geographic and economic regions of the world.

Researchers collected data on children who met the Kidney Disease Improving Global Outcomes AKI criteria during a 10-week window in late 2014. AKI risk factors, etiological factors, management and outcomes were recorded using standardized forms and protocols.

Countries were classified according to their 2014 gross national income (GNI) per person into high-income countries (HIC), upper-middle income countries (UMIC) and low and low-middle income countries (LLMIC). Need for renal replacement therapy, mortality, and renal recovery was assessed seven days after AKI diagnosis or at hospital discharge, whichever came first.

92 centres from 41 countries collected data on 354 pediatric AKI patients; 53% of the children developed AKI while hospitalized and 47% in the community. The most common etiological factors for AKI differed across GNI categories as well as between patients with community-acquired vs hospital-acquired AKI.

Children from HIC were younger, and larger proportion of AKI in this group was due to post-surgical complications vs other etiologies when compared to other income categories. In patients with hypotension as the cause of AKI, the adjusted risk of death was almost 10-fold higher compared to patients without hypotension as an etiological factor for AKI development.

Mortality was similar within AKI stages in HIC and UMIC. In LLMIC, patients with the highest AKI level of severity had higher mortality than patients in higher income categories. Patients from LLMIC and UMIC had a 57-fold and 11 fold higher adjusted risk of death, respectively, compared to patients from HIC.

In resource-limited countries, pediatric AKI-associated mortality is disproportionately higher when compared to high-resource areas, especially among patients with more severe AKI.

Limitations

The GSN pediatric snapshot is a survey of a convenience sample that may over-represent certain demographic and socioeconomic factors. Firstly, more than 50% of the patients reported were from North America or South Asia.

Secondly, urban areas were more likely to report AKI cases than rural areas. Thirdly, heterogeneous age ranges in different country income categories limit our understanding of the overall picture of AKI in these settings.

Given that most of the data in GSN was reported by nephrologists, and the actual scarcity or absence of nephrologists in LLMIC, it is very likely that less severe cases of AKI, seen in the community and treated by non-specialists, were not included in the sample.