Burden and Risk Factors of Contrast-Associated Acute Kidney Injury in Hospitalized Zambian Children: A Prospective Cohort Study at the University Teaching Hospitals.

Background: Contrast-associated acute kidney injury (CAAKI) is defined as acute kidney injury (AKI) occurring within 72 hours of administration of contrast media (CM) and is linked to adverse outcomes including longer hospital stay, increased hospital mortality, and a higher risk of chronic kidney disease in later life. Risk factors for the development of CAAKI in the Zambian pediatric population have not been well studied. Objectives: The objective of this study was to assess the burden of CAAKI, ascertain its risk factors, and describe short-term outcomes in hospitalized children at the University Teaching Hospitals (UTH) undergoing contrast-enhanced radiological investigations. Methods: This was a prospective observational study of in-patients undergoing contrast-enhanced radiological procedures, between September 2020 and September 2021. The participants were recruited from the Children's Hospital, the Cancer Diseases Hospital, and the Pediatric Surgical Ward at the University Teaching Hospital in Lusaka, Zambia. The primary outcome variable was occurrence of AKI at 48 hours post CM administration. We used 2 criteria to define CAAKI in our study-the European Society of Urogenital Radiology (ESUR) and the Kidney Disease Improving Global Outcomes (KDIGO) 2012 criteria. Multivariable logistic regression models were formulated to assess for risk factors of CAAKI. Results: Of the 201 enrolled participants, 123 (61.2%) were male and the median age of the participants was 5 years (interquartile range [IQR] = 3-10). The mean hemoglobin was 103 g/L (standard deviation [SD] = 26), median creatinine was 30.9 µmol/l (IQR = 22.6-43), and the glomerular filtration rate (GFR) was 102.5 mL/min/1.73 m2 (IQR = 76.2-129.4). Forty-six (22.9%) developed CAAKI using the ESUR compared with 4.5% (9/201) using the KDIGO criteria. Independent risk factors of CAAKI were receiving a higher dose of CM (adjusted odds ratio [aOR] = 2.54; 95% confidence interval [CI] = [1.12-5.74]), prematurity (aOR = 4.6; 95% CI = [1.05-16.7]), and a higher eGFR (aOR= 1.01; 95% CI = [1.01-1.02]). Females had higher odds of CAAKI (aOR = 2.48; 95% CI = [1.18-5.18]) when compared with males. One CAAKI participant (2.2%) died; none of the participants who developed CAAKI and survived required dialysis and most of them (90%) were discharged before day 7. Day 7 eGFR results had returned to or near baseline values for those whose creatinine results were available. Conclusions: Using the ESUR criteria, a significant proportion (22.9%) of children undergoing contrast-enhanced computed tomography (CT) scans at the UTH developed CAAKI. In contrast, using the KDIGO criteria only 4.5% had CAAKI. Being born as a preterm baby, being female, having a higher eGFR at baseline, and receiving a higher dose of CM were found to be independent risk factors for CAAKI development in Zambian children. Most of the cases of CAAKI in children were transient and of little clinical significance as only a minority of patients developing CAAKI required kidney replacement therapy and all resolved by day 7 post administration of CM.

Contexte: L'insuffisance rénale aiguë associée aux produits de contraste (IRA par produits de contraste) est définie comme une IRA survenant dans les 72 heures suivant l'administration d'un produit de contraste. L'IRA par produits de contraste est associée à des résultats de santé indésirables comme un séjour prolongé à l'hôpital, une mortalité hospitalière accrue et un risque plus élevé de souffrir d'insuffisance rénale chronique plus tard dans la vie. Les facteurs de risque de l'IRA par produits de contraste dans la population pédiatrique zambienne n'avaient pas fait l'objet d'études approfondies. Objectifs: Évaluer le fardeau de l'IRA par produits de contraste, déterminer ses facteurs de risque et décrire les résultats de santé à court terme chez les enfants hospitalisés dans des hôpitaux universitaires et subissant des examens radiologiques avec produit de contraste. Méthodologie: Il s'agit d'une étude observationnelle prospective examinant des patients hospitalisés ayant subi des procédures radiologiques avec rehaussement de contraste entre septembre 2020 et septembre 2021. Les participants ont été recrutés dans trois hôpitaux de Lusaka en Zambie : l'Hôpital pour enfants, le Cancer Diseases Hospital et le University Teaching Hospital (service de chirurgie pédiatrique). Le principal critère d'évaluation était la survenue d'une IRA dans les 48 heures suivant l'administration du produit de contraste. Nous avons défini l'IRAPC à l'aide de deux critères, soit celui de la Société européenne de radiologie urologique et celui de KDIGO (Kidney Disease Improving Global Outcomes) de 2012. Des modèles de régression logistique multivariés ont été formulés afin d'évaluer les facteurs de risque de l'IRA par produits de contraste. Résultats: Des 201 participants inscrits, dont l'âge médian était de 5 ans (ÉIQ : 3 - 10), 123 (61,2%) étaient des garçons. Le taux d'hémoglobine moyen s'établissait à 103 g/L (écart-type : 26), le taux de créatinine médian à 30,9 umol/L (IQR : 22,6 ­ 43) et le DFGe à 102,5 ml/min/1,73 m2 (ÉIQ: 76,2 ­ 129,4). Le taux d'IRA par produits de contraste était de 22,9% (46 patients) selon le critère de la Société européenne de radiologie urologique, et de 4,5% (9/201) avec le critère KDIGO. Les facteurs de risque indépendants de développer une IRAPC étaient : l'administration d'une dose plus élevée de produit de contraste (rapport de cote ajusté [RCc] = 2,54; IC 95% : 1,12 ­ 5,74), une naissance prématurée (RCc = 4,6; IC 95% : 1,05 ­ 16,7) et un DFGe plus élevé (RCc = 1,01; IC 95% :1,01 ­ 1,02). Les filles étaient plus susceptibles de développer une IRA par produits de contraste (RCc = 2,48; IC 95% : 1,18 ­ 5,18) que les garçons. Un patient qui avait développé une IRA par produits de contraste (2,2%) est décédé; aucun des survivants à une IRA par produits de contraste n'a eu besoin de dialyse, et la plupart des patients (90%) avaient reçu leur congé de l'hôpital avant le septième jour. Chez les patients dont les résultats de créatinine étaient disponibles, les valeurs de DFGe au septième jour étaient de retour aux valeurs initiales, ou proches de celles-ci. Conclusion: Selon le critère de la Société européenne de radiologie urologique, une proportion significative des enfants (22,9%) avait développé une IRA associée aux produits de contraste à la suite d'une tomodensitométrie avec rehaussement de contraste à l'University Teaching Hospital. Cette proportion s'établissait à 4,5% avec les critères de KDIGO. Dans cette population pédiatrique de Zambie, le fait d'être né prématurément, d'être de sexe féminin, d'avoir un DFGe initial plus élevé et de recevoir une dose plus élevée de produit de contraste se sont avérés des facteurs de risque indépendants de développer une IRA par produits de contraste. La plupart des cas d'IRA par produits de contraste étaient transitoires et peu significatifs sur le plan clinique puisque seuls quelques patients ont eu besoin d'une thérapie de remplacement rénal et que tous les cas se sont résolus dans les sept jours suivant l'administration du produit de contraste.

Malaria is the leading cause of acute kidney injury among a Zambian paediatric renal service cohort retrospectively evaluated for aetiologies, predictors of the need for dialysis, and outcomes.

BACKGROUND: Whilst malaria is a prominent aetiology associated with acute kidney injury (AKI) in many parts of Africa, a shift in the traditional AKI aetiologies has been witnessed in sections of the continent. Additionally, limited access to dialysis worsens patient outcomes in these low-resource settings. This retrospective cross-sectional study aimed to determine the associated aetiologies, predictors of need for dialysis and malaria-associated AKI (MAKI), and outcomes of AKI and dialysis among children evaluated by the renal service in Lusaka, Zambia. METHODS: The study sampled all children aged 16 years or below, diagnosed with AKI between 2017 and 2021, by the renal unit at the University Teaching Hospitals- Children's Hospital (UTH-CH), and retrospectively abstracted their records for exposures and outcomes. AKI was defined using the Kidney Disease Improving Global Outcomes (KDIGO) 2012 criteria. Frequency and percentage distributions were used to describe the occurrence of AKI aetiologies and treatment outcomes. Predictors of the need for dialysis, MAKI, and poor treatment outcome were identified by using multivariable logistic regression models. RESULTS: A total of 126 children diagnosed with AKI were included in this study. Malaria was the most frequent aetiology of AKI(61.1% (77/126, 95% Confidence Interval (CI): 52.0%-69.7%)). Of the 126 children with AKI, 74.6% (94) underwent dialysis. Predictors of the need for dialysis were oliguria (p = 0.0024; Odds ratio (OR) = 7.5, 95% CI: 2.1-27.7) and anuria (p = 0.0211; OR = 6.4, 95% CI = 1.3, 30.7). A fifth (18.3%, 23/126) of the children developed chronic kidney disease (CKD), 5.6% (7/126) died and, a year later, 77% (97/126) were lost to follow-up. CONCLUSION: At UTH-CH, malaria is the most frequent aetiology among children with AKI undergoing dialysis and children from low-medium malaria incidence areas are at risk; a considerable proportion of children with AKI need dialysis and Tenchoff catheter use in AKI is advocated.

The renal angina index accurately predicts low risk of developing severe acute kidney injury among children admitted to a low-resource pediatric intensive care unit.

BACKGROUND: Acute kidney injury (AKI) increases the risk of adverse outcomes. The renal angina index (RAI) has previously been used to predict patients at risk of developing severe AKI (sAKI). METHOD: This single-centre prospective observational study aimed to assess the prevalence of sAKI in PICU as the primary outcome and the duration of mechanical ventilation and PICU stay, RRT need, and mortality as secondary outcomes. The utility of the RAI in predicting day 3 sAKI was also assessed. We enrolled 122 patients aged 1 month to 16 years whose baseline characteristics were collected via questionnaire. RAI was calculated on day 0 with a score of ≥8 being considered positive. sAKI was defined as KDIGO stages 2 and 3. RESULTS: sAKI prevalence was 14.8% and its development was associated with longer duration of mechanical ventilation (p = 0.001) and higher mortality (p = 0.011). A positive Day 0 RAI predicted day 3 sAKI with sensitivity 55.6%, specificity 85.6%, PPV 40.0%, NPV 91.8%, and AUC of 0.77. Exclusion of children older than 5 years improved RAI performance (sensitivity 72.7%, specificity 88.0%, PPV 57.1%, NPV 93.6%, AUC 0.80). A modified RAI based on local AKI risk factors had equivalent performance to RAI (Z - score 0.78 (CI -0.077-0.033), p = 0.435) with sensitivity 72.2%, specificity 80.8%, PPV 39.4%, NPV 94.4% and AUC 0.80. CONCLUSION: The RAI can be an effective tool in ruling out sAKI in patients and a modification of RAI based on population-based risk factors improves the test's sensitivity and NPV.

Risk factors for acute kidney injury at presentation among children with CNS malaria: a case control study.

BACKGROUND: Recent research has established that acute kidney injury (AKI) is a common problem in severe paediatric malaria. Limited access to kidney diagnostic studies in the low resources settings where malaria is common has constrained research on this important problem. METHODS: Enrolment data from an ongoing clinical trial of antipyretics in children with central nervous system (CNS) malaria, CNS malaria being malaria with seizures or coma, was used to identify risk factors for AKI at presentation. Children 2-11 years old with CNS malaria underwent screening and enrollment assessments which included demographic and anthropomorphic data, clinical details regarding the acute illness, and laboratory studies including creatinine (Cr), quantitative parasite count (qPC), quantitative histidine rich protein 2 (HRP2), lactate, and bilirubin levels. Children with a screening Cr > 106 µmol/l were excluded from the study due to the potential nephrotoxic effects of the study drug. To identify risk factors for AKI at the time of admission, children who were enrolled in the study were categorized as having AKI using estimates of their baseline (i.e. before this acute illness) kidney function and creatinine at enrollment applying the Kidney Disease: Improving Global Outcome (KDIGO) 2012 guidelines. Logistic regressions and a multivariate model were used to identify clinical and demographic risk factors for AKI at presentation among those children enrolled in the study. RESULTS: 465 children were screened, 377 were age-appropriate with CNS malaria, 22 (5.8%) were excluded due to Cr > 106 µmol/l, and 209 were enrolled. Among the 209, AKI using KDIGO criteria was observed in 134 (64.1%). One child required dialysis during recovery. Risk factors for AKI in both the logistic regression and multivariate models included: hyperpyrexia (OR 3.36; 95% CI 1.39-8.12) and age with older children being less likely to have AKI (OR 0.72; 95% CI 0.62-0.84). CONCLUSION: AKI is extremely common among children presenting with CNS malaria. Hyperpyrexia with associated dehydration may contribute to the AKI or may simply be a marker for a more inflammatory systemic response that is also affecting the kidney. Appropriate fluid management in children with CNS malaria and AKI may be challenging since generous hydration to support kidney recovery could worsen malaria-induced cerebral oedema in this critically ill population. Trial registration https://clinicaltrials.gov/ct2/show/NCT03399318.

Rapidly progressive glomerulonephritis in two Zambian children: a case report.

Rapidly progressive glomerulonephritis (RPGN) is a rare syndrome which is marked by a sudden rise in serum creatinine and the presence of crescents on renal biopsy. If appropriate and timely treatment is not instituted, as many as 90% of affected patients may develop End Stage Renal Disease (ESRD). There is only limited access to renal replacement therapy in many low resource countries, thus it is important that awareness of this entity is raised. We narrate the clinical course of two children who were admitted with rising serum creatinine, hypertension and haematuria and who were subsequently diagnosed with crescentic glomerulonephritis on biopsy. Despite having received immunosuppressive therapy, both children had a poor renal outcome, perhaps due to delays in institution of appropriate treatment. It is imperative that all clinicians who manage children are made aware of this clinical syndrome so that timely referrals to nephrology are done. This will help to improve renal outcomes.

Organophosphate insecticide poisoning with monocrotophos-induced fabricated illness in a 7-year-old girl with refractory seizures over a 4-year period.

Munchausen syndrome by proxy is a form of abuse in which an adult, usually the mother, deceives health workers by exaggerating, falsifying or directly inducing psychological or physical symptoms in the child victim for psychological gratification. In 2013, the American Academy of Pediatrics coined the term 'caregiver-fabricated illness in a child' to describe this form of child abuse. A 7-year-old girl had many encounters with health workers over a period of 4 years and presented with evolving clinical features including refractory seizures and red urine for which she was followed up as a case of acute intermittent porphyria. She was later discovered to be the victim of chronic monocrotophos organophosphate poisoning by her mother. If all medical staff who manage children are to avoid becoming inadvertent participants in medical child abuse, this case report is an important reminder that a high index of suspicion is warranted in cases which present a diagnostic dilemma and who respond unexpectedly to treatment.Abbreviations AIP: Acute intermittent porphyria; APSAC: American Professional Society on the Abuse of Children; ASM: anti-seizure medication; CFIC: caregiver-fabricated illness in a child; CT: computed tomography: DVT: deep vein thrombosis; EEG: electroencephalogram: ESR: erythrocyte sedimentation rate; HDW: high-dependency ward; ICU: intensive care unit; LFT: liver function test; MBP: Munchausen syndrome by proxy; NICU: neonatal intensive care unit; RFT: renal function test; TB: Tuberculosis; UTH-CH: University Teaching Hospitals Children's Hospital.