Clinical assessment and risk stratification
History Taking – Risk Stratification
In assessing children with acute illness or a history of decreased urine output, you must assess whether they are at increased risk of AKI. Guidelines from the British Association of Paediatric Nephrologists (BAPN) identify two groups who are at increased risk of AKI:
- Children with pre-existing diseases or risk factors – high risk groups (table 1)
- Children presenting with acute high-risk scenarios (table 2)
Children in high-risk groups OR high-risk scenarios are at risk of AKI and should have a serum creatinine according to BAPN guidelines.
Table 1: High risk groups for Paediatric AKI
| High risk groups | Examples |
| Nephro-urological, cardiac or liver disease | Henoch-Schönlein Purpura (HSP) with renal involvement, Nephritic Syndrome, Polycystic Kidneys, Heart failure, Kidney/Liver Transplant |
| Malignancy and/ or a bone marrow transplant | Acute Lymphoblastic Leukaemia (ALL) |
| Dependence on others for access to fluids | Neonates, infants, children with severe neurodisability |
| History of taking medication that may adversely affect renal function | ● ACE Inhibitors/Angiotensin 2 receptor blockers – e.g. enalapril, captopril, losartan
● NSAIDs – e.g. ibuprofen ● Aminoglycoside antibiotics – e.g. gentamicin ● calcineurin inhibitors – e.g. tacrolimus for children post transplantation |
Table 2: High risk scenarios for Paediatric AKI
| High risk scenarios |
| History of reduced urine output**(<0.5 ml/kg/hour for 8 hours) |
| Sepsis |
| Hypoperfusion or dehydration |
| History of exposure to drugs or toxin that may adversely affect renal function |
| Renal disease or urinary tract obstruction |
| Major surgery |
AKI Risk Stratification and clinical judgement
For a child identified as being at increased risk of AKI using the BAPN guidelines, clinical judgement can be used to determine whether serum creatinine testing is needed. In particular:
- Children in high-risk groups who do not have a history of reduced urine output and are not acutely unwell, e.g. a child with cardiac disease who has a simple fracture do not need creatinine blood testing.
- In children with suspected gastroenteritis and a history of reduced urine output or mild to moderate dehydration, a trial of oral rehydration can be performed and the child reassessed before considering blood testing. This approach is consistent with NICE guidance on gastroenteritis for children under 5 years of age. [8]
Pitfalls
- NICE guidance on AKI advises that acutely unwell children with severe diarrhoea (children with bloody diarrhoea are at particular risk) should have a serum creatinine measured. [6] This requires clinical judgement, as a definition of severe diarrhoea is not provided.
- Be aware that NICE guidance on children with gastroenteritis [8] identifies children who have passed more than five diarrhoeal stools in the previous 24 hours as at increased risk of dehydration; these children require careful evaluation.