Epidemiology, Risk Factors, and Clinical Outcomes of AKI in Pediatric Hematopoietic Stem Cell Transplant Patients

Abstract

Key Points The cumulative incidence of AKI diagnosis post–hematopoietic stem cell transplantation was 12.9%. Calcineurin inhibitor use was associated with the highest cumulative incidence, 21.6%, after hematopoietic stem cell transplantation.Patients with AKI with hypertension/hypertensive disease had a 30-day survival probability of 63.9% (hazard ratio, 4.86, 95% confidence interval, 3.58 to 6.60).Patients with AKI were 2.5 times more likely to experience composite hospitalization and/or mortality at 30 days. Of patients who developed AKI, dialysis dependence has nearly tripled since 2014. Background AKI is a common complication in pediatric patients undergoing hematopoietic stem cell transplantation (HSCT), with a reported prevalence ranging from 68% to 84%. Few multicenter pediatric studies comprehensively assess the epidemiologic associations and clinical outcomes associated with AKI development. Methods An observational, retrospective analysis was conducted using an aggregated electronic health record data platform. The study population consisted of pediatric patients (age <18 years) who underwent HSCT over a 20-year period. The study groups consisted of patients with an encounter diagnosis of AKI (n=713) and those without AKI (n=4455). Both groups were propensity matched for age, sex, race, prior cancer diagnosis, and other comorbidities. End points were incidence, mortality risk, clinical outcomes, and prevalence of dialysis dependence. Competing risks analysis, Cox proportional hazard analyses, Kaplan–Meier survival curves, and incidence/prevalence rates were calculated. Results After matching, 688 patients were identified. Cumulative incidence of AKI diagnosis post-HSCT was 13.7%. Hypertensive disease, calcineurin inhibitors, and vancomycin were the most prevalent risk factors for AKI, with calcineurin inhibitors showing the highest cumulative incidence (21.6%). Patients with AKI with hypertensive disease had a survival probability of 63.9% at 30 days, followed by calcineurin inhibitors (64.4%) and vancomycin (65.9%). Patients with AKI were 1.7 times more likely to experience composite hospitalization and/or mortality at 30 days. At 365 days post-HSCT, patients with AKI had higher rates of all-cause emergency department visits, intensive care unit admissions, and mechanical ventilation compared with non-AKI. Of patients who developed AKI, the prevalence of dialysis dependence has nearly tripled since 2014. Conclusions The findings highlight a strong association between specific risk factors, such as hypertension, calcineurin inhibitor use, and vancomycin use, with increased mortality and adverse clinical outcomes in patients with AKI after HSCT. These results emphasize the need for preventative actions such as 24-hour BP monitoring and discontinuation of potential nephrotoxic medications.