A proposed framework for advancing acute kidney injury risk stratification and diagnosis in children: a report from the 26th Acute Disease Quality Initiative (ADQI) conference

Pediatr Nephrol. 2023 Sep 5. doi: 10.1007/s00467-023-06133-3.

Dana Y Fuhrman, Natalja L Stanski, Catherine D Krawczeski, Jason H Greenberg, A Ayse Akcan Arikan, Raj K Basu, Stuart L Goldstein, Katja M Gist; ADQI 26 workgroup

Reviewed by: Elizabeth Isner


Acute kidney injury (AKI) is associated with increased morbidity and mortality, and care is largely supportive after it has been identified. Ideally, we can identify high-risk individuals prior to development of AKI; however, we need more precise tools to help with early recognition.


The ADQI reviewed our current knowledge of pediatric AKI, including use of currently available biomarkers (urine output and serum creatinine as in the KDIGO definition), novel biomarkers undergoing more study, and available validated tools to identify high risk populations as well as trend their function. The goal of this article was for a more comprehensive understanding of identification and prevention of AKI in children and where further research can be focused to further our knowledge. This includes structural and functional biomarkers and new integrative tools that look at various AKI phenotypes.

Study design:

This paper is a product of the ADQI conference, in which experts discussed and reviewed our current knowledge of markers of AKI, validated tools, and gaps in our knowledge.


Validated tools currently exist to identify high risk individuals and overall kidney fitness including the Renal Angina Index (RAI) and Fluid Overload Kidney Injury Score (FOKIS). Our electronic health records have shown promise in identifying nephrotoxic medication exposure, such as in the NINJA study; however these tools are not available to all providers around the world.

The ADQI proposes several AKI phenotypes which includes decreased urine output, fluid accumulation, responsiveness to loop diuretics, and those AKIs identified by novel biomarkers such as NGAL and cystatin-c. A single patient can have an overlapping phenotype, and use of them as a framework can help direct specific interventions and treatment goals for our unique patients.


Identifying AKI in a timely and precise manner is of utmost importance in the care of our patients. Traditional markers of urine output and serum creatinine are no longer enough to recognize this diagnosis, as they often only change after a severe injury has taken place. To further our goals of patient care, we need implementation of validated tools, recognition of AKI phenotypes, and further research and access to novel biomarkers.