We read with interest the research letter by Nasir, et al. [1],
describing the etiological profile of 100 children with acute renal
failure (ARF) from Kashmir. The study is of relevance considering the
significant mortality and morbidity associated with the condition,
especially in children. It should be noted however, that due to usage of
more than 30 definitions of ARF in the literature, leading to wide
variations in the reported incidence and outcome, the term ARF was
replaced recently by acute kidney injury (AKI), including a new
classification system [2, 3] with a view to provide a uniform definition,
standardize patient care, enhance the ability to design prospective
studies and evaluate potential prophylactic and treatment strategies.
Based on this, AKI is an abrupt (within 48 hours) reduction in kidney
function currently defined as absolute increase in serum creatinine of
either ≥0.3 mg/dL or a percentage
increase of ≥50% or a reduction in
urine output (documented oliguria of <0.5 mL/kg/hr for >6 hours). This new
definition is applicable across all ages [2, 3]. Three grades of severity
for AKI have been described.
The authors of this research letter, while
acknowledging the new term AKI in the introductory statement, have used an
outdated definition to diagnose the condition (ARF) in their study
subjects based on old references. The lack of usage of a standardized
definition for study of the clinical profile of AKI impedes rational
comparison of epidemiological studies on AKI, limits generalization of
data and prevents patient stratification based on AKI severity. Hence,
adherence to the new definition is essential. In recent years, a number of
studies have been conducted across the world, in adults as well as
children to study the incidence and etiological profile of AKI based on
the new terminology [4]. The new definition has been validated in these
studies.
Another notable feature in the etiological profile of
AKI in this study is the absence of cases with snake envenomation. Snake
envenomation is known to be an important cause of AKI in certain regions
of India. Cases of snakebite envenomation among Kashmiri children have
been reported earlier [5]; many of them being due to viper bites, which
are known to be associated with systemic manifestations such as AKI,
hypotension and coagulopathy. The authors also mention that drug induced
ARF comprised 5% of cases. If the drugs could be specified, it would be a
learning point for the readers.
References
1. Nasir SA, Bhat MA, Hijaz SW, Charoo BA, Sheikh BA.
Profile of acute renal failure in children in Kashmir. Indian Pediatr.
2011;48:491-2.
2. Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P,
the ADQI workgroup. 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:R204-12.
3. Mehta RL, Kellum JA, Shah SV, Molitoris BA, Ronco C,
Warnock DG, et al. The Acute Kidney Injury Network. Acute Kidney
Injury Network: report of an initiative to improve outcomes in acute
kidney injury. Crit Care. 2007;11:R31.
4. Ricci Z, Cruz D, Ronco C. The RIFLE criteria and
mortality in acute kidney injury: A systematic review. Kidney Int.
2008;73:538-46.
5. Ahmed SM, Qureshi UA, Rasool A, Charoo BA, Iqbal Q.
Snake bite envenomation in children in Kashmir. Indian Pediatr.
2011;48:66-7.