PODIUM renal dysfunction criteria identify children with higher severity of illness than KDIGO acute kidney injury criteria in an observational cohort study

Background KDIGO acute kidney injury (AKI) criteria are not specific to children. Pediatric Organ Dysfunction Information Update Mandate (PODIUM) renal dysfunction criteria were developed for children but have not been adopted. PODIUM defines renal dysfunction more strictly than KDIGO and adds fluid overload (FO) as an independent criterion. The impact of these changes on AKI diagnosis has not been evaluated. Methods Retrospective analysis of pediatric intensive care unit (PICU) admissions at an academic children’s hospital from 06/2022–05/2025. Creatinine, urine output, fluid balance, and weight were extracted in 6-h intervals. Patients were classified by maximum KDIGO AKI stage and PODIUM AKI. Outcomes were mortality, PICU length of stay (LOS), and major adverse kidney events at 30 days (MAKE-30). Results In 10,454 patients, 2,602 (25%) met KDIGO AKI criteria: 1,124 (11%) KDIGO 1, 579 (5%) KDIGO 2, and 899 (9%) KDIGO 3. By PODIUM, 1,599 (15%) met criteria. 105 (9%) KDIGO 1 patients and 16 (0.2%) patients without KDIGO AKI met PODIUM criteria; all KDIGO 2/3 met PODIUM. 110/1,599 (7%) of patients with PODIUM AKI met only FO criterion. Outcomes were similar between KDIGO 2/3 and PODIUM AKI (mortality 6–7%, median LOS 7–8.5 days, MAKE-30 12%). Patients meeting PODIUM by FO alone had worse outcomes than KDIGO Stage 1 or No AKI (mortality 4% vs. 1–2%, median LOS 13.8 vs. 1.5–5.5 days), but not different MAKE-30. Conclusions PODIUM criteria capture all KDIGO 2/3 patients while excluding most KDIGO 1 patients. PODIUM criteria appear useful for identifying critically ill children with clinically significant AKI resulting in greater short-term illness severity, while KDIGO criteria capture a larger spectrum of AKI severity. Graphical abstract A higher resolution version of the Graphical Abstract is available as Supplementary information.