Given the potential progression of AKI in critically ill children, early identification is crucial.5,23 An increase in SCr is currently the gold-standard biomarker of AKI, as a rise in SCr is associated with a decreased GFR. However, SCr has shortcomings as a biomarker, particularly in the pediatric population in which baseline creatinine may be unknown or may be low enough such that a rise in value may remain within the normal range for age. Additionally, creatinine testing is not sensitive in the early phase of AKI; creatinine may not rise for up to 48 hours after initial insult or until up to 50% of kidney function has been lost,64 as kidney reserve function must first be overwhelmed before a rise in SCr occurs. Creatinine is also sensitive to differences in muscle mass, gender, hydration status, and age.65 (See Table 4.) Moreover, as a spot value in the acute setting, SCr measurement may provide false reassurance, as there may not be a baseline value for comparison. For example, if a 3-year-old boy has an undocumented baseline SCr level of 0.3 mg/dL, then an acute rise by 100% would remain within the reference range for age.
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