Epidemiology, Risk Factors, and Practice Points of Acute Kidney Injury in Pediatric Hematopoietic Stem Cell Transplant Patients


Omer S Ashruf BS, Zaid Ashruf, Zara Orozco BS, Matt Zinter MD, Rolla Abu-Arja MD, Keval Yerigeri MD, Imad U Haq BS, David C Kaelber MD PhD FACP, John Bissler MD, Rupesh Raina MD FACP


Acute kidney injury (AKI) is a common complication in pediatric patients undergoing hematopoietic stem cell transplantation (HSCT), with a reported prevalence ranging from 68-84% (1, 2). Many cases of post-operative AKI are preventable and stress the importance of preventative care, especially in this vulnerable patient population (3). Few multicenter pediatric studies comprehensively assess the epidemiologic associations and clinical outcomes associated with AKI development.


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 (2003-2023). The study groups consisted of patients with an encounter diagnosis of AKI (n=606) and those without AKI (n=4,097) within 1 month of HSCT. Both groups were propensity matched for age, sex, and race. Endpoints were incidence, mortality risk, clinical outcomes, and dialysis dependence. Measures of association, Competing Risks analysis, Cox proportional hazard analyses, Kaplan-Meier survival curves, and incidence/prevalence rates were calculated.


After matching, 604 patients were identified in both cohorts. Cumulative incidence of AKI diagnosis post-HSCT was 12.9%. Hypertensive disease, calcineurin inhibitors, and vancomycin were the most prevalent risk factors for AKI, with calcineurin inhibitors showing the highest cumulative incidence (21.6%). AKI patients with hypertensive disease had a survival probability of 63.9% at 30 days, followed by calcineurin inhibitors (64.4%) and vancomycin (65.9%). AKI patients were 2.5 times more likely to experience composite hospitalization and/or mortality at 30 days. At 90, 180, and 365 days post-HSCT, AKI patients had higher rates of all-cause emergency department visits, intensive care unit admissions, and mechanical ventilation/intubation compared to the control group. Of patients who developed AKI, dialysis dependence has nearly tripled since 2014.


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 AKI patients after HSCT. In order to minimize harms and provide high value care, our results emphasize the need for evidence-based practices such as 24-hour ambulatory blood pressure monitoring post-HSCT, replacement of immunosuppressants with alternatives that are less nephrotoxic such as carboplatin or tacrolimus if necessary or discontinuing immunosuppressants altogether in HSCT patients without graft-versus-host-disease, and implementing an antimicrobial stewardship program to reduce prolonged vancomycin use (greater than 72 hours) and thereby reducing the rate of AKI in this vulnerable patient population.


  1. Koh KN, Sunkara A, Kang G, et al. Acute kidney injury in pediatric patients receiving allogeneic hematopoietic cell transplantation: incidence, risk factors, and outcomes. Biol Blood Marrow Transplant. 2018;24:758-764. [PMID: 29196074] doi:10.1016/j.bbmt.2017.11.021
  2. Kizilbash SJ, Kashtan CE, Chavers BM, et al. Acute kidney injury and the risk of mortality in children undergoing hematopoietic stem cell transplantation. Biol Blood Marrow Transplant. 2016;22:1264-1270. [PMID: 27034153] doi:10.1016/j.bbmt.2016.03.014
  3. Hazar V, Gungor O, Guven AG, et al. Renal function after hematopoietic stem cell transplantation in children. Pediatr Blood Cancer. 2009;53:197-202. [PMID: 19353620] doi:10.1002/pbc.22030

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