co m m e nta r y
see original article on page 1028
Pediatric acute kidney injury: The
use of the RIFLE criteria
DJ Askenazi1 and TE Bunchman2
Outcome in pediatric acute kidney injury (AKI) is in part related to
diagnosis and intervention. Standard markers of severity of illness
do not identify AKI. Modified RIFLE criteria are shown to identify
patients who develop AKI, potentially allowing for early intervention.
Kidney International (2007) 71, 963–964. doi:10.1038/sj.ki.5002238
Based on urine output volume and
changes in glomerular filtration rate,
the RIFLE criteria (risk, injury, failure,
loss, and end-stage renal disease) to
classify acute kidney injury (AKI) were
proposed by the Acute Dialysis Quality
Initiative Group in 2001 and have been
adopted by most intensive care units and
nephrology societies as a way to define
AKI. 1 The RIFLE criteria have been
shown to independently predict length
of stay, costs, morbidity, and mortality
in adults, and RIFLE predicts renal mor-
bidity and mortality better than acute
physiological assessment and chronic
health evaluation (APACHE) in the
adult population.
Pediatric studies to date are limited,
as they were performed in single centers
and the patients selected had high mor-
bidities and mortalities and AKI that was
severe enough to require renal replace-
ment therapy. 2–4 Some multicenter
studies using retrospective databases
have shown improvement of survival in
patients with AKI on renal replacement
therapy, yet no adequate predictors of
AKI outcomes have been found.5 Simi-
lar to the APACHE score in adults, the
1Children’s Hospital of Alabama, Department
of Pediatric Nephrology, University of Alabama,
Birmingham, Alabama, USA; and 2Helen DeVos
Children’s Hospital, Pediatric Nephrology,
Dialysis and Transplantation, Grand Rapids,
Michigan, USA
Correspondence: TE Bunchman, Helen DeVos
Children’s Hospital, Pediatric Nephrology, Dialysis
and Transplantation, 221 Michigan Street NE,
Suite 406, Grand Rapids, Michigan 49503, USA.
E-mail: timothy.bunchman@devoschildrens.org
Kidney International (2007) 71
pediatric RIFLE in children with multi-
organ dysfunction.
This work by the Texas Children’s Hos-
pital group at Baylor College of Medicine
looks at a prospective series of children
admitted to their intensive care unit over a
year’s period. They found that AKI is very
common, as 113 of 150 pediatric patients
requiring ventilation (82%) developed
AKI.7 In addition, this group has shown
for the first time that AKI as judged by
a modified pediatric RIFLE predicts
increased cost, length of stay, mortality,
and need for renal replacement therapy.
pediatric risk of mortality (PRISM) score They validate its use in those pediatric
in pediatrics does not adequately predict patients with neuromuscular disease and
renal and hospital survival.6 The article show that RIFLE is as good as or better
by Akcan-Arikan et al.7 (this issue) is the than PRISM scores at predicting outcomes
first of its kind, as it explores a modified in pediatric patients with AKI.
Understand natural history of AKI
Understand association
Identify children at between
high risk of AKI AKI and poor outcome
• Underlying chronic • Improve severity of ilness
kidney disease scoring in pediatric ICU
• Undergoing coronary • Identify risk factors leading
bypass surgery to poor outcome in those
• Those requiring contrast with AKI
for imaging • Identify factors that
influence renal recovery
Strategies to improve pediatric AKI outcomes
Strategies to prevent AKI in those at risk for AKI
NaHCO
Fluid resuscitation
Pharmacy
Avoid Nephrotoxic medications
NSAIDS
aminoglycosides
Strategies to alter the natural course of AKI
Early identification of AKI
IL-18
NGAL
KIM-1
Blood pressure support
Drugs to provide adequate renal perfusion
Methods to assess intravascular volume and perfusion
Pharmacologic interventions
Goal-oriented strategies to support children with AKI
Fluid management strategies
Blood pressure support
Ventilator support
Renal replacement therapies
Figure 1 | Strategies to improve outcome in children with acute kidney injury (AKI): where
we are, and where we are going. NGAL; neutrophil gelatinase-associated lipocalin. KIM-1; kidney
injury molecule 1.
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Further, these authors hope this new
model will now be implemented at other
programs in pediatric intensive care and
nephrology units to help look at early
markers and measurement of AKI (Fig-
ure 1).8 This work in combination with
urinary markers such as neutrophil gela-
tinase-associated lipocalin (NGAL) and
interleukin-18 may be used to predict who
is at risk for developing short-term and
long-term renal damage9,10 and to iden-
tify early interventions that may improve
morbidity, mortality, and length of stay by
improving the quality of care of children.
ACKNOWLEDGMENTS
Timothy E Bunchman, MD, receives financial
964
grants from Gambro, Dialysis Solutions Inc.,
and Baxter Healthcare.
REFERENCES
1. Bellomo R, Ronco C, Kellum JA et al. Acute
renal failure: definition, outcome measures,
animal models, fluid therapy and information
technology needs. The Second International
Consensus Conference of the Acute Dialysis
Quality Initiative (ADQI) Group. Crit Care 2004; 8:
R204–R212.
2. Bunchman TE, McBryde KD, Mottes TE et al.
Pediatric acute renal failure: outcome by
modality and disease. Pediatr Nephrol 2001; 16:
1067–1071.
3. Goldstein SL, Currier H, Graf CD et al. Outcome
in children receiving continuous venovenous
hemofiltration. Pediatrics 2001; 107: 1309–1312.
4. Foland JA, Fortenberry JD, Warshaw BL et al. Fluid
overload before continuous hemofiltration and
survival in critically ill children: a retrospective
analysis. Crit Care Med 2004; 32: 1771–1776.
5. Goldstein SL, Somers MJ, Baum MA et al. Pediatric
patients with multi-organ dysfunction syndrome
receiving continuous renal replacement therapy.
Kidney Int 2005; 67: 653–658.
6. Pollack MM, Patel KM, Ruttimann UE. PRISM III:
an updated Pediatric Risk of Mortality score. Crit
Care Med 1996; 24: 743–752.
7. Akcan-Arikan A, Zappitelli L, Loftis LL et al.
Modified RIFLE criteria in critically ill children
with acute kidney injury. Kidney Int 2007; 71:
1028–1035.
8. Goldstein SL. Pediatric acute kidney injury: it’s
time for real progress. Pediatr Nephrol 2006; 21:
891–895.
9. Parikh CR, Mishra J, Thiessen-Philbrook H et al.
Urinary IL-18 is an early predictive biomarker of
acute kidney injury after cardiac surgery. Kidney
Int 2006; 70: 199–203.
10. Mishra J, Dent C, Tarabishi R et al. Neutrophil
gelatinase-associated lipocalin (NGAL) as a
biomarker for acute renal injury after cardiac
surgery. Lancet 2005; 365: 1231–1238.
Kidney International (2007) 71