Blood Transfusion in Pediatric Sepsis-Associated Acute Kidney Injury: A Nationwide Study of Risk Factors and Outcomes

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Methods Data from the Nationwide Inpatient Sample (NIS) database were retrospectively reviewed to examine pediatric patients diagnosed with sepsis-associated acute kidney injury (SA-AKI) from 2010 to 2019. Patients were divided into two cohorts: those who received blood transfusions and those who did not. Demographic, hospital, comorbidity, and complication data were compared between the two cohorts. Subsequently, univariate and multivariate logistic regression analyses were performed to identify factors associated with blood transfusion in children with SA-AKI. Results The study encompassed a total of 7,521 pediatric patients diagnosed with SA-AKI. Of these, 2,269 patients received blood transfusions, constituting 30.17% of the total cohort. The median age of patients in the transfusion group was 4 years (range: 0–12 years), while the median age in the non-transfusion group was 8 years (range: 1–15 years). Patients requiring blood transfusions exhibited significantly longer hospital stays, higher overall medical costs, and elevated in-hospital death rates ( p < 0.05). Multivariate regression analysis revealed several independent predictors of blood transfusion, including acute respiratory failure, continuous mechanical ventilation, septic shock, anemia, coagulopathy, disseminated intravascular coagulation, lymphoma, thrombocytopenia, gastrointestinal bleeding, and hepatic insufficiency ( p < 0.05). Conclusion Pediatric patients with SA-AKI who require blood transfusions experience heightened clinical complexity, increased resource utilization, and impose a greater economic burden on both families and society. A comprehensive understanding of the risk factors associated with transfusion enables healthcare providers to implement proactive measures and early interventions to mitigate the need for blood transfusions. Sepsis-related acute kidney injury Blood transfusions Risk factors Risk stratification Child intensive care National database analysis Figures Figure 1 Figure 2 Figure 3 1. Introduction Sepsis, a life-threatening condition characterized by a dysregulated host response to infection, results in organ dysfunction and immune system impairment [ 1 ]. This global health crisis[ 2 ] necessitates urgent medical attention and effective management strategies. As a multi-systemic disease, sepsis frequently involves multiple organs, including the kidneys[ 3 ]. It is now understood that sepsis-associated acute kidney injury (SA-AKI) occurs in approximately 16% of pediatric patients in pediatric intensive care units[ 4 ]. Current evidence suggests hypoxic/ischemic injury is essential in the development of SA-AKI[ 5 ]. Blood transfusion therapy has been shown to significantly enhance renal oxygenation, blood flow, and function in pediatric patients with this condition[ 6 , 7 ]. While blood transfusions offer therapeutic benefits, they are associated with several potential risks and complications. These include fever, allergic reactions, acute and delayed hemolytic events, allogeneic immunization, and pathogen transmission[ 8 ]. Additionally, serious adverse effects such as transfusion-related acute lung injury, circulatory overload, and immune dysregulation may occur[ 9 ]. In addition, transfusion-related errors can contribute to the wastage of blood products and place additional strain on healthcare resources [ 10 ]. Determining the ideal red blood cell transfusion threshold for pediatric patients experiencing severe sepsis or septic shock remains a challenge. Research focused on children with SA-AKI is scarce, though some investigations have explored this issue in hemodynamically stable septic children[ 11 , 12 ]. Consequently, it is crucial to accurately identify the clinical indicators that necessitate blood transfusion in pediatric patients with SA-AKI, to understand the underlying factors contributing to these indications, and to implement strategies aimed at reducing the frequency of blood transfusion therapy. In recent years, studies have reported the positive outcomes of transfusion therapy in cases of SA-AKI [ 6 , 7 , 13 ]. However, our understanding of the risk factors associated with transfusion remains limited. To date, no comprehensive multicenter study has addressed these aspects. The primary aims of this study were: 1) to determine the incidence of transfusion therapy in children with SA-AKI over the decade spanning 2010–2019, and 2) to evaluate temporal trends and factors associated with transfusion practices in this population. 2. Material and Methods 2.1. Ethical Approval Statements and Data Sources Data for this investigation were sourced from the United States' Nationwide Inpatient Sample (NIS) database. Cases of SA-AKI were determined using the International Classification of Diseases Clinical Modification (ICD-9-CM and ICD-10-CM) codes over a ten-year period, from January 1, 2010, to December 31, 2019. The NIS offers comprehensive details on pediatric patients and participating hospitals, encompassing essential clinical information like hospital length of stay (LOS), healthcare costs, documented adverse events, mortality rates, and the presence of comorbidities and complications in hospitalized children. As this study utilized de-identified, publicly available data, an ethical committee review was not necessary. 2.2. Data acquisition Pediatric patients with a diagnosis of SA-AKI were identified within discharge records spanning 2010–2019 using ICD-9-CM and ICD-10-CM codes. Inclusion: (1) Age < 18 years with SA-AKI diagnosis (ICD codes); (2) NIS database records (2010–2019).Exclusion: (1) Chronic/end-stage kidney disease; (2) Congenital coagulopathy/non-sepsis AKI.Transfusion criteria: Anemia (Hb < 7 g/dL), active bleeding (e.g., gastrointestinal), or coagulopathy [ 11 , 12 ].The initial cohort comprised 7,856 patients. Following exclusion of cases with incomplete data regarding hospital characteristics and patient demographics—specifically age, LOS, total charges, insurance type, hospital size, admission type (elective or non-elective), and mortality status—a final sample of 7,521 patients was derived from the NIS database (Fig. 1 ). 2.3. Statistical analysis Statistical analysis was conducted using IBM SPSS Statistics (version 25). Continuous variables were compared using independent samples t-tests, while categorical variables were assessed using chi-square tests to examine the relationship between blood transfusion rates and various demographic and hospital-related factors. To identify potential risk factors for blood transfusion, a multivariate logistic regression model was employed. This model incorporated demographic characteristics, hospital characteristics, comorbidities, and complications experienced by the children (Table 1 ). Odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were calculated from the logistic regression output. Statistical significance was defined as a p -value below 0.05. Table 1 Variables used in binary logistic regression analysis Variables Categories Specific Variables Patient demographics Age (˂18 years), sex (male and female), race (White, Black, Hispanic, Asian or Pacific Islander, Native American and Other) Hospital characteristics Type of admission (non-elective, elective), bed size of hospital (small, medium, large), teaching status of hospital (nonteaching, teaching), location of hospital (rural, urban), type of insurance (Medicare, Medicaid, private insurance, self-pay, no charge, other), location of the hospital (northeast, Midwest or north central, south, west) Comorbidities AIDS, Deficiency anemia, Rheumatoid arthritis/collagen vascular diseases, Congestive heart failure, Chronic pulmonary disease, Coagulopathy, Diffuse intravascular coagulation, Diabetes(uncomplicated), Diabetes(with chronic complications), hypothyroidism, Lymphoma, Fluid and electrolyte disorders, Metastatic cancer, Other neurological disorders, obesity, paralysis, Paralysis, Renal failure, Solid tumor without metastasis, Peptic ulcer disease excluding bleeding, Valvular disease, Severe malnutrition, Infectious diarrhea, Intestinal avascular necrosis AIDS: Acquired immunodeficiency syndrome 3. Results 3.1. Incidence of blood transfusion in children with sepsis-related acute kidney injury From 2010 to 2019, the NIS database yielded 7,521 qualifying patients with SA-AKI. Among these, 2,269 received transfusions, while 5,252 did not. Blood transfusions were administered to 30.17% of the SA-AKI patient cohort (Table 2 ). A notable reduction in the annual blood transfusion rate was observed, with a decline from 45.6% in 2010 to 21.6% in 2019. The most significant decrease was evident between the years 2011 and 2012, with a reduction from 42.3–33.9%, respectively. However, this downward trend was not consistently maintained. A slight increase in the annual rate was observed between 2012 and 2013, rising from 33.9–38.2% (Fig. 2 ). 3.2. Demographic characteristics between transfusion and non-transfusion groups Transfused children had a median age of 4 years (interquartile range: 0–12), while the non-transfused group’s median age was 8 years (interquartile range: 1–15). This four-year age difference between the groups was statistically significant ( p < 0.05), indicating distinct age profiles. Specifically, a greater percentage of children aged 0–3 years received transfusions (47.6%) compared to the non-transfused cohort (34.1%) ( P < 0.05) (Table 2 , Fig. 3 A and B). Analysis of ethnicity revealed significantly elevated transfusion rates among Black (19.3%), Hispanic (22.5%), and Asian/Pacific Islander (4.0%) children compared to their non-transfused counterparts ( p 0.05). 3.3. Hospital characteristics between transfusion group and non-transfusion group Significant variations in transfusion rates were observed based on hospital characteristics (Table 2 , Fig. 3 E and F). Larger hospitals exhibited a statistically significant elevation in transfusion rates compared to smaller and medium-sized facilities ( p < 0.05). This trend was also evident in teaching and city hospitals, which demonstrated notably higher transfusion rates (97.4% and 99.9%, respectively; p < 0.05) when contrasted with cases not involving transfusions (Table 2 ). Elective admissions were associated with a greater likelihood of receiving transfusions ( p < 0.05). Furthermore, regional disparities were apparent, with southern hospitals reporting higher transfusion rates than those located in the northeast, midwest, north-central, and western regions ( p < 0.05) (Table 2 ). 3.4. Adverse outcomes of blood transfusion in children with sepsis-related acute kidney injury A positive correlation was observed between the number of comorbidities and the likelihood of receiving a blood transfusion. Children with three or more coexisting conditions experienced a transfusion rate of 34.3% ( p < 0.05) (Table 2 ). Furthermore, mortality among SA-AKI patients who underwent transfusion therapy (32.3%) was substantially higher than the 14.5% observed in those who did not receive transfusions (17.8%) ( p < 0.05) (Table 2 ). Hospital stays were also notably longer in the transfusion group, with a median duration of 23 days (IQR: 11–45) compared to 13 days (IQR: 5–35) in the non-transfusion group ( p < 0.05) (Table 2 ). This extended hospitalization translated into significantly higher total costs for the transfusion group, exceeding the non-transfusion group's expenses by nearly $ 200,000 ( $ 363,119 vs. $ 163,646.50, respectively) ( p < 0.05) (Table 2 ). Finally, analysis by insurance type revealed that the transfusion group had lower proportions of patients with medical insurance (0.6% vs. 0.9%) and private insurance (33.8% vs. 36.3%) compared to the non-transfusion group ( p < 0.05) (Table 2 ). 3.5. Analysis of risk factors related to transfusion therapy in children with sepsis-related acute kidney injury from demographic and hospital characteristics Multivariable logistic regression (Table 3 ) was employed to assess factors associated with blood transfusions. Several characteristics emerged as risk factors ( p < 0.05), including racial background (Black: OR 1.33, 95% Table 2 Characteristics and outcomes of acute kidney injury associated with sepsis in children Characteristics Transfusion No Transfusion P Elective admission (%) 10.1 7.2 < 0.001 Type of hospital (teaching %) 97.4 94.4 < 0.001 Region of hospital (%) Northeast 16.1 12.4 < 0.001 Midwest or North Central 22.1 23.0 South 41.3 40.8 West 20.6 23.8 Died (%) 32.3 17.8 < 0.001 LOS: Length of stay, TOTCHE: Total charge CI 1.15–1.55; Hispanic: OR 1.37, 95% CI 1.81–1.58; Asian/Pacific Islander: OR 1.48, 95% CI 1.21–1.96; other: OR 1.54, 95% CI 1.32–1.80), admission to a teaching hospital (OR 1.54, 95% CI 1.14–2.10), treatment at an urban hospital (OR 4.93, 95% CI 1.47–16.53), and elective admission status (OR 1.34, 95% CI 1.12–1.61). Conversely, hospital location appeared to have a protective effect ( p < 0.05), with lower odds of transfusion observed in the Midwest/North Central (OR 0.73, 95% CI 0.62–0.87), South (OR 0.75, 95% CI 0.65–0.89), and West (OR 0.60, 95% CI 0.50–0.71). No significant association was found between blood transfusion and patient age, comorbidity burden, payment source, or hospital bed size ( p > 0.05). Table 3 Risk factors associated with sepsis-related acute kidney injury and blood transfusion in children Variable Multivariate Logistic Regression OR 95% CI P Age group 0–3 Ref —— —— 4–6 0.923 0.34–2.51 0.875 7–10 1.055 0.44–2.56 0.905 11–18 1.526 0.84–2.78 0.166 Race White Ref —— —— Black 1.33 1.15–1.55 <0.001 Hispanic 1.37 1.81–1.58 <0.001 Asian or Pacific Islander 1.48 1.21–1.96 0.006 Native American 0.86 0.48–1.56 0.625 Other 1.54 1.32–1.80 <0.001 Number of Comorbidity 0 Ref —— —— 1 1.21 0.94–1.56 0.132 2 1.25 0.94–1.67 0.126 ≥ 3 1.42 0.97–2.08 0.069 Type of insurance Medicare Ref —— —— Medicaid 1.16 0.62–2.20 0.640 Private insurance 1.12 0.59–2.12 0.733 Self-pay 1.15 0.56–2.40 0.701 No charge 0.00 0.00 0.999 Other 1.75 0.90–3.42 0.101 Bed size of hospital Small Ref —— —— Medium 1.18 1.00-1.41 0.068 Large 1.04 0.89–1.21 0.644 Elective admission 1.34 1.12–1.61 0.001 Teaching hospital 1.54 1.14–2.10 0.006 Urban hospital 4.93 1.47–16.53 0.010 Region of hospital Northeast Ref —— —— Midwest or North Central 0.73 0.62–0.87 <0.001 South 0.76 0.65–0.89 <0.001 West 0.60 0.50–0.71 <0.001 OR: Odds ratio, CI: Confidence interval 3.6. Relationship between comorbidities and blood transfusion in children with sepsis-related acute kidney injury Univariate analysis revealed significant associations between specific comorbidities and transfusion requirements. Deficiency anemia (39.6% vs. 60.4%, p < 0.001), coagulopathy (39.6% vs. 60.4%, p < 0.001), diffuse intravascular coagulation (DIC) (44.0% vs. 56.0%, p < 0.001), lymphoma (47.9% vs. 52.1%, p = 0.001), and solid tumors without metastasis (45.2% vs. 54.8%, p < 0.001) were strongly associated with higher transfusion rates. Conversely, chronic pulmonary disease (22.3% vs. 77.7%, p < 0.001), uncomplicated diabetes (19.3% vs. 80.7%, p = 0.005), and hypothyroidism (24.3% vs. 75.7%, p = 0.031) correlated with reduced transfusion needs. Multivariate analysis identified coagulopathy (OR = 1.67, 95% CI 1.44–1.93, p < 0.001), DIC (OR = 1.45, 95% CI 1.25–1.70, p < 0.001), deficiency anemia (OR = 1.24, 95% CI 1.05–1.48, p = 0.013), and lymphoma (OR = 1.79, 95% CI 1.10–2.90, p = 0.018) as Independent Predictors of transfusion. A number of protective factors were also identified, included chronic pulmonary disease (OR = 0.64, 95% CI 0.52–0.78, p < 0.001), uncomplicated diabetes (OR = 0.59, 95% CI 0.38–0.93, p = 0.022), hypothyroidism (OR = 0.72, 95% CI 0.53–0.96, p = 0.028), paralysis (OR = 0.72, 95% CI 0.59–0.88, p = 0.002), and Intestinal avascular necrosis(OR = 0.83, 95% CI 0.69–1.00, p = 0.048).(Table 4). 3.7. Relationship between complications of sepsis-related acute kidney injury and blood transfusion Chi-square analysis revealed significant associations between blood transfusion and specific complications in children with sepsis-associated acute kidney injury (SA-AKI). Complications with statistically significant positive associations ( p < 0.05) included continuous mechanical ventilation (46.8% vs. 53.2%, p < 0.001), acute respiratory (36.6% vs. 63.4%, p < 0.001), gastrointestinal bleeding (46.3% vs. 53.7%, p < 0.001), thrombocytopenia (39.5% vs. 60.5%, p < 0.001), septic shock (35.2% vs. 64.8%, p < 0.001), and hepatic insufficiency (45.1% vs. 54.9%, p < 0.001). Negative associations were observed for urinary tract infection (26.1% vs. 73.9%, p = 0.006), acute respiratory distress syndrome (38.7% vs. 61.3%, p < 0.001), and uremia (24.2% vs. 75.8%, p < 0.001).After adjusting for confounders, multivariate regression identified continuous mechanical ventilation (OR 2.45, 95% CI 2.15–2.81, p < 0.001), acute respiratory (OR 1.22, 95% CI 1.06–1.41, p = 0.006), gastrointestinal bleeding (OR 1.73, 95% CI 1.32–2.28, p < 0.001), thrombocytopenia (OR 1.40, 95% CI 1.23–1.60, p < 0.001), septic shock (OR 1.62, 95% CI 1.44–1.83, p < 0.001), and hepatic insufficiency (OR 1.65, 95% CI 1.19–2.29, p = 0.003) as independent positive predictors of transfusion. Conversely, urinary tract infection (OR 0.81, 95% CI 0.68–0.96, p = 0.016), acute cerebrovascular disease (OR 0.76, 95% CI 0.58–0.98, p = 0.037), acute respiratory distress syndrome (OR 0.80, 95% CI 0.68–0.94, p = 0.008), and uremia (OR 0.82, 95% CI 0.72–0.94, p = 0.004) emerged as protective factors.(Table 5). Table 5 Relationship between blood transfusion and complications Complications Univariate Analysis Multivariate Logistic Regression transfusion No Transfusion P OR 95% CI P Urinary tract infection 221 (26.1%) 626(73.9%) 0.006 0.81 0.68–0.96 0.016 Deep vein thrombosis 159 (35.7%) 286 (64.3%) 0.008 1.18 0.95–1.46 0.132 Peripheral vascular disease 110 (36.3%) 193 (63.7%) 0.018 1.21 0.93–1.56 0.152 Gastrointestinal complication 39 (25.7%) 113 (74.3%) 0.221 1.03 0.71–1.52 0.866 Urinary retention 55(34.6%) 104 (65.4%) 0.219 1.30 0.92–1.84 0.144 Continuous trauma ventilation 1062 (46.8%) 1208 (53.2%) <0.001 2.45 2.15–2.81 <0.001 Arrhythmia 26(41.3%) 37 (58.7%) 0.054 1.33 0.78–2.26 0.298 Pneumonia 645 (32.1%) 1362 (67.9%) 0.025 0.90 0.80–1.01 0.076 Acute respiratory failure 1071 (36.6%) 1854 (63.4%) <0.001 1.22 1.06–1.41 0.006 Heart failure 187 (35.4%) 341 (64.6%) 0.006 1.02 0.84–1.25 0.833 Acute cerebrovascular disease 96 (31.5%) 209 (68.5%) 0.612 0.76 0.58–0.98 0.037 GI bleeding 113 (46.3%) 131 (53.7%) <0.001 1.73 1.32–2.28 <0.001 Thrombocytopenia 531 (39.5%) 813 (60.5%) <0.001 1.40 1.23–1.60 <0.001 Acute respiratory distress syndrome 871 (38.7%) 1380 (61.3%) <0.001 0.80 0.68–0.94 0.008 Septic shock 1757 (35.2%) 3237 (64.8%) <0.001 1.62 1.44–1.83 <0.001 Ileus 157 (30.0%) 367 (70.0%) 0.915 0.87 0.71–1.07 0.173 Hepatic insufficiency 74 (45.1%) 90 (54.9%) <0.001 1.65 1.19–2.29 0.003 Myocardial ischemia 2 (15.4%) 11 (84.6%) 0.390 0.42 0.09–1.95 0.268 Acute lung injury 86 (33.3%) 172 (66.7%) 0.260 1.23 0.92–1.65 0.165 Uremia 1037 (24.2%) 3256 (75.8%) <0.001 0.82 0.72–0.94 0.004 Inflammatory diseases of the central nervous system 103 (32.8%) 211 (67.2%) 0.299 1.05 0.82–1.36 0.687 Thrombotic thrombocytopenic purpura 22 (42.3%) 30 (57.7%) 0.056 1.62 0.90–2.90 0.107 OR: Odds ratio, CI: Confidence interval 4. Discussion AKI poses a significant threat to children with sepsis, with high morbidity and mortality[ 2 ]. Contemporary studies have elucidated a strong association between SA-AKI and microcirculatory dysfunction, cellular metabolic remodeling, and dysregulation of the inflammatory response[ 13 ]. Blood transfusions can significantly improve oxygenation and microvascular perfusion in children with sepsis[ 6 ]. However, blood transfusions may also increase the potential risk of organ damage. In this study, 30.17% of children with SA-AKI received blood transfusions. In contrast, nearly half (49%) of the children in North American pediatric intensive care units (PICUs) received blood transfusion therapy [ 14 ]. This indicates that anemia and blood transfusion are common issues in critically ill children, especially those with combined AKI. This study demonstrated a decline in the annual incidence of blood transfusion from 45.6–21.6% between 2010 and 2019, aligning with the literature [ 15 ]. Meybohm Patrick et al.[ 16 ] achieved a significant reduction in red blood cell transfusion rates through optimized blood management practices in hospitalized children. The present study indicated that, although younger patients (median age 4 years) received transfusions more frequently [ 14 , 15 , 17 ], further statistical analysis revealed that age itself was not an independent predictor of transfusion necessity. This may be attributed to the wide age range and significant physiological changes in pediatric populations, as well as the diverse factors influencing the need for blood transfusion. Currently, data on blood transfusion thresholds for this vulnerable age group remain limited[ 9 , 18 ]. We observed disparities across racial groups, with Black and Hispanic children experiencing higher transfusion rates compared to White and Indian children. This disparity may be linked to the lower average hemoglobin and serum transferrin saturation in the Black population, suggesting that ethnic or genetic factors may contribute to the increased demand for blood transfusions[ 19 ]. A greater incidence of blood transfusions is typically observed in major medical centers, including teaching and urban hospitals. This investigation, mirroring findings from a nationwide U.S. study[ 18 ], found a correlation between planned hospitalizations and elevated probabilities of RBC transfusions. Geographical analysis revealed more frequent transfusions in hospitals located in the South; the precise underlying causes remain unclear, likely stemming from a confluence of contributing elements. Other studies have also indicated that blood transfusion is closely associated with a higher number of comorbidities, prolonged hospitalization, increased medical costs, and elevated mortality rates [ 14 , 20 , 21 ], and the findings of this study align with these observations (Table 2 ). Nevertheless, logistic regression analysis suggests that these associations may primarily reflect the severity of the underlying disease rather than a direct causal relationship. Our study further reveals that most children receiving blood transfusions were enrolled in Medicaid, while those not receiving transfusions primarily relied on private insurance. A survey of blood transfusion trends in the United States indicated that most patients receiving blood transfusions were covered by Medicare[ 15 ]. Notably, this study was based on the NIS database, and it may be subject to statistical limitations associated with ICD coding and other factors. This study identifies several independent predictors of blood transfusion in SA-AKI patients, including deficiency anemia, coagulopathy, diffuse intravascular coagulation, lymphoma, thrombocytopenia, gastrointestinal bleeding, continuous trauma ventilation, acute respiratory failure, and septic shock. In pediatric intensive care units, managing anemia usually involves transfusions to raise tissue oxygen levels, primarily determined by low hemoglobin concentration [ 11 ]. Sepsis triggers a systemic inflammatory response that activates the coagulation cascade, this process leads to platelet consumption and worsens bleeding tendencies. Additionally, the pathological process of DIC further increases the risk of microvascular bleeding, especially when acute kidney injury is present [ 22 , 23 ]. In children with SA-AKI, thrombocytopenia is a significant driving factor for transfusion, possibly related to sepsis-associated thrombocytopenia and the consumption effects of DIC. There is a significant synergistic effect between thrombocytopenia and coagulopathy as well as DIC, with studies indicating that children with both thrombocytopenia and coagulopathy have a higher risk of transfusion than those with only one of the factors[ 24 ]。Children with malignant tumors often need transfusions due to bone marrow suppression from chemotherapy, tumor infiltration, and anemia related to sepsis[ 25 , 26 ]. Particularly in children with lymphoma, splenomegaly and portal hypertension are often present, further increasing the risk of gastrointestinal bleeding. Gastrointestinal bleeding directly leads to blood loss, while liver dysfunction may impair the synthesis of coagulation factors, increasing the risk of bleeding, which is consistent with research findings related to coagulopathy and mucosal ischemia in SA-AKI[ 23 , 26 ]. Children with acute respiratory failure often present with hypoxemia and anemia, and pediatricians improve oxygen-carrying capacity through transfusions. Prolonged mechanical ventilation time typically reflects the severity of the disease, with studies showing that red blood cell transfusions in critically ill children are associated with extended mechanical ventilation time[ 20 , 27 ]. Children with severe infections, especially those with septic shock, often require transfusions, which may be related to microcirculatory dysfunction and adrenal insufficiency exacerbating anemia[ 28 , 29 ]. Relatively speaking, chronic pulmonary disease, uncomplicated diabetes, hypothyroidism, acute respiratory distress syndrome, and uremia serve as protective factors. Children with chronic pulmonary disease are often observed among those born prematurely, they adapt to chronic hypoxia over time, leading to higher baseline hemoglobin levels and reduced transfusion needs[ 30 ]. The transfusion risk in children with uncomplicated diabetes is lower, possibly related to strict blood glucose control[ 31 ]. Children with hypothyroidism can increase red blood cell counts and hemoglobin levels by supplementing thyroid hormones, which accelerate enhances intracellular metabolism[ 32 ]. While acute respiratory distress syndrome (ARDS) is typically linked with hypoxemia, recent studies advocate for restrictive transfusion strategies because excessive transfusion may worsen pulmonary edema and oxidative stress[ 11 , 33 ]. Early antibiotic treatment for urinary tract infections can control inflammation and prevent systemic coagulation activation[ 34 ]. Although uremia can lead to platelet dysfunction, this study identified a negative correlation with transfusion needs. This may be due to disease progression, which allows for compensatory erythropoiesis, and the earlier initiation of renal replacement therapy (CRRT)[ 35 ]. The reduced transfusion needs in children with SA-AKI and paralysis may be related to their clinical management strategies. Intestinal ischemic necrosis is usually viewed as a high-risk complication in critical illness; however, this study found a negative correlation with transfusion needs, likely due to early intervention and conservative transfusion strategies[ 36 ].Acute cerebrovascular events, as protective factors, may be related to anticoagulation management strategies and transfusion thresholds to avoid fluctuations in blood volume that could worsen cerebral edema[ 37 ]。 Our study had limitations inherent to its retrospective design, including the inability to track post-discharge outcomes and limited access to detailed clinical metrics within the NIS database. These constraints affected our ability to evaluate certain established transfusion risk factors and long-term patient outcomes. Despite these limitations, this study retains important clinical significance. Future research employing a prospective design would overcome the limitations of existing studies and allow for a more accurate assessment of SA-AKI risk factors related to blood transfusion. 5. Summary In summary, the proportion of children with SA-AKI receiving blood transfusions decreased between 2010 and 2019. The coexistence of independent predictive and protective factors underscores the complexity involved in making transfusion decisions for SA-AKI. Positive indicators, like coagulopathy and ongoing trauma ventilation, indicate the need to closely monitor for bleeding and anemia. In contrast, protective factors, such as chronic pulmonary disease, imply that transfusion may be unnecessary. Therefore, this study aimed to ascertain factors associated with blood transfusion and to reduce transfusion needs through early recognition and intervention of these factors, ultimately leading to improved clinical outcomes. Abbreviations Nationwide Inpatient Sample (NIS) Sepsis-associated acute kidney injury (SA-AKI) International classification of diseases (ICD) Length of stay (LOS) Odds ratios (ORs) Confidence intervals (CIs) Figure (Fig) Odds ratios （OR ） Confidence intervals （CI） Acquired immunodeficiency syndrome (AIDS) Disseminated intravascular coagulation (DIC) Red blood cell（RBC） Pediatric intensive care units (PICUs) Acute respiratory distress syndrome (ARDS) Declarations Acknowledgements None. Fundings Zhuhai Municipal Bureau of Science and Technology Innovation.2024 Annual Zhuhai Science and Technology Plan Project in Social Development Sector.2420004000180. Author contributions J.Y. Gao：Writing – original draft, Formal analysis, Data curation，Methodology, Conceptualization; Y.F. Zhang and L. Chen：Writing – original draft, Data curation; W.X. Song ：Project administration, Methodology, Conceptualization; H. Hou and C.W. Yi ：Formal analysis, Data curation； Y.X. He and B. Huang：Writing – review & editing, Project administration, Methodology, Conceptualization. All authors have read and approved the final version of the manuscript and agree to be accountable for all aspects of the work. Date availability The datasets are available at https://www.ahrq.gov/data/hcup/index.html. Ethics approval and consent to participate This research study did not require approval from an ethics board since it used anonymous date that is publicly accessible. Competing interests The authors declare no competing interests. References Schlapbach, L.J., et al., International Consensus Criteria for Pediatric Sepsis and Septic Shock. JAMA, 2024. 331 (8): p. 665-674.https://doi.org/10.1001/jama.2024.0179. Rudd, K.E., et al., Global, regional, and national sepsis incidence and mortality, 1990-2017: analysis for the Global Burden of Disease Study. Lancet (London, England), 2020. 395 (10219): p. 200-211.https://doi.org/10.1016/S0140-6736(19)32989-7. Khatana, J., et al., Increasing incidence of acute kidney injury in pediatric severe sepsis and related adverse hospital outcomes. Pediatr Nephrol, 2023. 38 (8): p. 2809-2815.https://doi.org/10.1007/s00467-022-05866-x. Fitzgerald, J.C., et al., Acute Kidney Injury in Pediatric Severe Sepsis: An Independent Risk Factor for Death and New Disability. Crit Care Med, 2016. 44 (12): p. 2241-2250.https://doi.org/10.1097/ccm.0000000000002007. Duzova, A., et al., Etiology and outcome of acute kidney injury in children. Pediatr Nephrol, 2010. 25 (8): p. 1453-61.https://doi.org/10.1007/s00467-010-1541-y. Harer, M.W. and V.Y. Chock, Renal Tissue Oxygenation Monitoring-An Opportunity to Improve Kidney Outcomes in the Vulnerable Neonatal Population. Front Pediatr, 2020. 8 : p. 241.https://doi.org/10.3389/fped.2020.00241. Scott, H.F., et al., Evaluating Pediatric Sepsis Definitions Designed for Electronic Health Record Extraction and Multicenter Quality Improvement. Crit Care Med, 2020. 48 (10): p. e916-e926.https://doi.org/10.1097/ccm.0000000000004505. Gauvin, F., et al., Acute transfusion reactions in the pediatric intensive care unit. Transfusion, 2006. 46 (11): p. 1899-1908.https://doi.org/10.1111/j.1537-2995.2006.00995.x. Goel, R., M.M. Cushing, and A.A.R. Tobian, Pediatric Patient Blood Management Programs: Not Just Transfusing Little Adults. Transfusion Medicine Reviews, 2016. 30 (4): p. 235-241.https://doi.org/10.1016/j.tmrv.2016.07.004. Chavez Ortiz, J.L., et al., Transfusion-related errors and associated adverse reactions and blood product wastage as reported to the National Healthcare Safety Network Hemovigilance Module, 2014-2022. Transfusion, 2024. 64 (4): p. 627-637.https://doi.org/10.1111/trf.17775. Lacroix, J., P. Demaret, and M. Tucci, Red blood cell transfusion: decision making in pediatric intensive care units. Seminars In Perinatology, 2012. 36 (4): p. 225-231.https://doi.org/10.1053/j.semperi.2012.04.002. Weiss, S.L., et al., Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Medicine, 2020. 46 (Suppl 1): p. 10-67.https://doi.org/10.1007/s00134-019-05878-6. Peerapornratana, S., et al., Acute kidney injury from sepsis: current concepts, epidemiology, pathophysiology, prevention and treatment. Kidney International, 2019. 96 (5): p. 1083-1099.https://doi.org/10.1016/j.kint.2019.05.026. Bateman, S.T., et al., Anemia, blood loss, and blood transfusions in North American children in the intensive care unit. American Journal of Respiratory and Critical Care Medicine, 2008. 178 (1): p. 26-33.https://doi.org/10.1164/rccm.200711-1637OC. Goel, R., et al., Blood transfusion trends in the United States: national inpatient sample, 2015 to 2018. Blood Advances, 2021. 5 (20): p. 4179-4184.https://doi.org/10.1182/bloodadvances.2021005361. Meybohm, P., et al., Patient Blood Management is Associated With a Substantial Reduction of Red Blood Cell Utilization and Safe for Patient's Outcome: A Prospective, Multicenter Cohort Study With a Noninferiority Design. Annals of Surgery, 2016. 264 (2): p. 203-211.https://doi.org/10.1097/SLA.0000000000001747. Karam, O., et al., Red blood cell transfusion thresholds in pediatric patients with sepsis. Pediatric Critical Care Medicine : a Journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 2011. 12 (5): p. 512-518.https://doi.org/10.1097/PCC.0b013e3181fe344b. Goel, R., et al., Individual- and hospital-level correlates of red blood cell, platelet, and plasma transfusions among hospitalized children and neonates: a nationally representative study in the United States. Transfusion, 2020. 60 (8): p. 1700-1712.https://doi.org/10.1111/trf.15855. Hassan, N.E., et al., Hemoglobin Levels Across the Pediatric Critical Care Spectrum: A Point Prevalence Study. Pediatric Critical Care Medicine : a Journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 2018. 19 (5): p. e227-e234.https://doi.org/10.1097/PCC.0000000000001467. Demaret, P., et al., Clinical Outcomes Associated With RBC Transfusions in Critically Ill Children: A 1-Year Prospective Study. Pediatric Critical Care Medicine : a Journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 2015. 16 (6): p. 505-514.https://doi.org/10.1097/PCC.0000000000000423. Kneyber, M.C., et al., Red blood cell transfusion in critically ill children is independently associated with increased mortality. Intensive Care Med, 2007. 33 (8): p. 1414-22.https://doi.org/10.1007/s00134-007-0741-9. Ruan, X., et al., Assessing the impact of transfusion thresholds in patients with septic acute kidney injury: a retrospective study. Frontiers In Medicine, 2023. 10 : p. 1308275.https://doi.org/10.3389/fmed.2023.1308275. Xiang, L., et al., Clinical value of pediatric sepsis-induced coagulopathy score in diagnosis of sepsis-induced coagulopathy and prognosis in children. J Thromb Haemost, 2021. 19 (12): p. 2930-2937.https://doi.org/10.1111/jth.15500. Aziz, K.B., et al., The frequency and timing of sepsis-associated coagulopathy in the neonatal intensive care unit. Front Pediatr, 2024. 12 : p. 1364725.https://doi.org/10.3389/fped.2024.1364725. Ishihara, T., et al., Fibrinolytic abnormality associated with progression of pediatric solid tumor. Pediatrics International : Official Journal of the Japan Pediatric Society, 2018. 60 (6): p. 540-546.https://doi.org/10.1111/ped.13546. Lieberman, L., et al., Plasma and Platelet Transfusion Strategies in Critically Ill Children With Malignancy, Acute Liver Failure and/or Liver Transplantation, or Sepsis: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. Pediatr Crit Care Med, 2022. 23 (13 Suppl 1 1S): p. e37-e49.https://doi.org/10.1097/pcc.0000000000002857. Kneyber, M.C.J., et al., Red blood cell transfusion in critically ill children is independently associated with increased mortality. Intensive Care Medicine, 2007. 33 (8): p. 1414-1422.https://doi.org/10.1007/s00134-007-0741-9. Dallman, M.D., et al., Changes in transfusion practice over time in the PICU. Pediatric Critical Care Medicine : a Journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 2013. 14 (9): p. 843-850.https://doi.org/10.1097/PCC.0b013e31829b1bce. Mink, R.B. and M.M. Pollack, Effect of blood transfusion on oxygen consumption in pediatric septic shock. Crit Care Med, 1990. 18 (10): p. 1087-91.https://doi.org/10.1097/00003246-199010000-00007. Zhang, Z., X. Huang, and H. Lu, Association between red blood cell transfusion and bronchopulmonary dysplasia in preterm infants. Sci Rep, 2014. 4 : p. 4340.https://doi.org/10.1038/srep04340. Deák, B., et al., HbA1c levels and erythrocyte transport functions in complication-free type 1 diabetic children and adolescents. Acta Diabetol, 2003. 40 (1): p. 9-13.https://doi.org/10.1007/s005920300002. Butenandt, O., Erythrocytic enzyme activities in hypothyroid children. Acta Haematol, 1972. 47 (6): p. 335-43.https://doi.org/10.1159/000208546. Emeriaud, G., et al., Executive Summary of the Second International Guidelines for the Diagnosis and Management of Pediatric Acute Respiratory Distress Syndrome (PALICC-2). Pediatr Crit Care Med, 2023. 24 (2): p. 143-168.https://doi.org/10.1097/pcc.0000000000003147. Mattoo, T.K., N. Shaikh, and C.P. Nelson, Contemporary Management of Urinary Tract Infection in Children. Pediatrics, 2021. 147 (2).https://doi.org/10.1542/peds.2020-012138. Buccione, E., et al., Continuous Renal Replacement Therapy in Critically Ill Children in the Pediatric Intensive Care Unit: A Retrospective Analysis of Real-Life Prescriptions, Complications, and Outcomes. Front Pediatr, 2021. 9 : p. 696798.https://doi.org/10.3389/fped.2021.696798. Numanoglu, A. and A.J. Millar, Necrotizing enterocolitis: early conventional and fluorescein laparoscopic assessment. J Pediatr Surg, 2011. 46 (2): p. 348-51.https://doi.org/10.1016/j.jpedsurg.2010.11.021. Tasker, R.C., A.F. Turgeon, and P.C. Spinella, Recommendations on RBC Transfusion in Critically Ill Children With Acute Brain Injury From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Pediatr Crit Care Med, 2018. 19 (9S Suppl 1): p. S133-s136.https://doi.org/10.1097/pcc.0000000000001589. Table 4 Table 4 is available in the Supplementary Files section. Supplementary Files Table4Relationshipbetweenbloodtransfusionandcomorbidities.docx Cite Share Download PDF Status: Published Journal Publication published 24 Mar, 2026 Read the published version in Pediatric Nephrology → Version 1 posted Editorial decision: Major Revisions Needed 12 Jun, 2025 Reviewers agreed at journal 07 May, 2025 Reviewers invited by journal 05 May, 2025 Editor assigned by journal 05 May, 2025 First submitted to journal 03 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6376778","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":452293019,"identity":"86bf62fa-2e7f-4fd3-bf21-fdad3091ecd3","order_by":0,"name":"Jiaying Gao","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0klEQVRIiWNgGAWjYBACNvbmAwc+VPzjYWxvPkCcFj6eY4kPZ5w5IMPccyyBOC1yEjnGxrxtB2zYZ/gYEOkwibQ0yRlsd3h4Z/B8vPGGwU5Ot4GQFp7HxyQ+8DzjkZzdu9lyDkOysdkBQlrYQbZIMPMYzjm7TZqH4UDiNoJaGHLMpHkMmHnsb+Q8I1ILB9D7PAmHeRhn5LARqQUcyAfSeBh7jhlbzjEgwi/ywBg88PGfjT0wKh/eeFNhJ0dQCwqQ4CEyapC1kKpjFIyCUTAKRgQAAEZsRP2GEntyAAAAAElFTkSuQmCC","orcid":"","institution":"Fifth Affiliated Hospital of Zunyi Medical University","correspondingAuthor":true,"prefix":"","firstName":"Jiaying","middleName":"","lastName":"Gao","suffix":""},{"id":452293020,"identity":"acc5dc63-4f36-450c-b5e8-901e94bd2dcc","order_by":1,"name":"Youfang Zhang","email":"","orcid":"","institution":"Zunyi Medical University - Zhuhai Campus","correspondingAuthor":false,"prefix":"","firstName":"Youfang","middleName":"","lastName":"Zhang","suffix":""},{"id":452293021,"identity":"3f3820b4-6ef4-4f39-a03f-152e127649ce","order_by":2,"name":"Lu Chen","email":"","orcid":"","institution":"Zunyi Medical University - Zhuhai Campus","correspondingAuthor":false,"prefix":"","firstName":"Lu","middleName":"","lastName":"Chen","suffix":""},{"id":452293022,"identity":"077cf1e6-2284-4650-97de-60f9b75357f8","order_by":3,"name":"Wenxiu Song","email":"","orcid":"","institution":"Fifth Affiliated Hospital of Zunyi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Wenxiu","middleName":"","lastName":"Song","suffix":""},{"id":452293023,"identity":"a5a2138b-8d6f-4b45-a2a4-4de25a7fd6d8","order_by":4,"name":"Huan Hou","email":"","orcid":"","institution":"Fifth Affiliated Hospital of Zunyi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Huan","middleName":"","lastName":"Hou","suffix":""},{"id":452293024,"identity":"50f83cb0-3ae3-4cdf-8c7c-a4cb53d5dec9","order_by":5,"name":"Changwei Yi","email":"","orcid":"","institution":"Fifth Affiliated Hospital of Zunyi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Changwei","middleName":"","lastName":"Yi","suffix":""},{"id":452293025,"identity":"6dff4228-a92c-4290-99b1-ccfc50efc0b0","order_by":6,"name":"Yuexian He","email":"","orcid":"https://orcid.org/0009-0002-6387-092X","institution":"Fifth Affiliated Hospital of Zunyi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yuexian","middleName":"","lastName":"He","suffix":""},{"id":452293026,"identity":"4f097b56-b5ec-49df-9e70-70d7e6d94d22","order_by":7,"name":"Bo Huang","email":"","orcid":"","institution":"Fifth Affiliated Hospital of Zunyi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Bo","middleName":"","lastName":"Huang","suffix":""}],"badges":[],"createdAt":"2025-04-04 14:04:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6376778/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6376778/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00467-026-07165-1","type":"published","date":"2026-03-24T16:09:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":82359195,"identity":"895573c5-17bd-4d8d-866c-258ba7a30f35","added_by":"auto","created_at":"2025-05-09 11:28:02","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":252343,"visible":true,"origin":"","legend":"\u003cp\u003eExclusion process for children receiving blood transfusions associated with sepsis-related acute kidney injury\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6376778/v1/b8db84e7d2841defed2b8e6e.png"},{"id":82356886,"identity":"557ed98d-87b6-48d4-b3bc-00d130998ed5","added_by":"auto","created_at":"2025-05-09 11:20:02","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":151493,"visible":true,"origin":"","legend":"\u003cp\u003eAnnual incidence of blood transfusion associated with sepsis-related acute kidney injury\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6376778/v1/dbd0e5882ceb27cef051e15f.png"},{"id":82359198,"identity":"b7b24ee1-0660-4642-bdef-ba904c497b76","added_by":"auto","created_at":"2025-05-09 11:28:02","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":203580,"visible":true,"origin":"","legend":"\u003cp\u003ePatient demographics and hospital characteristics between the two groups.\u003c/p\u003e\n\u003cp\u003eA : Age distribution analysis of blood transfusion patients. B: Analysis of age distribution of patients without blood transfusion. C: Racial distribution analysis of blood transfusion patients. D: Racial distribution analysis of patients without blood transfusion. E: Analysis of the number of hospital beds for blood transfusion patients. F: Analysis of the number of hospital beds for patients without blood transfusion.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-6376778/v1/defb5763aee805d702a837f8.png"},{"id":105755879,"identity":"31e04312-1810-467d-8380-a131f99e4735","added_by":"auto","created_at":"2026-03-30 16:32:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1942243,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6376778/v1/ced11b35-05de-470a-8ce8-1d18666beb5a.pdf"},{"id":82356877,"identity":"82b0ff41-32c4-4459-bb61-ccb14a5d66c8","added_by":"auto","created_at":"2025-05-09 11:20:02","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":21175,"visible":true,"origin":"","legend":"","description":"","filename":"Table4Relationshipbetweenbloodtransfusionandcomorbidities.docx","url":"https://assets-eu.researchsquare.com/files/rs-6376778/v1/737ecb85e665f8f4820f68f1.docx"}],"financialInterests":"","formattedTitle":"Blood Transfusion in Pediatric Sepsis-Associated Acute Kidney Injury: A Nationwide Study of Risk Factors and Outcomes","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eSepsis, a life-threatening condition characterized by a dysregulated host response to infection, results in organ dysfunction and immune system impairment [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This global health crisis[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] necessitates urgent medical attention and effective management strategies. As a multi-systemic disease, sepsis frequently involves multiple organs, including the kidneys[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. It is now understood that sepsis-associated acute kidney injury (SA-AKI) occurs in approximately 16% of pediatric patients in pediatric intensive care units[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Current evidence suggests hypoxic/ischemic injury is essential in the development of SA-AKI[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Blood transfusion therapy has been shown to significantly enhance renal oxygenation, blood flow, and function in pediatric patients with this condition[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile blood transfusions offer therapeutic benefits, they are associated with several potential risks and complications. These include fever, allergic reactions, acute and delayed hemolytic events, allogeneic immunization, and pathogen transmission[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Additionally, serious adverse effects such as transfusion-related acute lung injury, circulatory overload, and immune dysregulation may occur[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In addition, transfusion-related errors can contribute to the wastage of blood products and place additional strain on healthcare resources [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Determining the ideal red blood cell transfusion threshold for pediatric patients experiencing severe sepsis or septic shock remains a challenge. Research focused on children with SA-AKI is scarce, though some investigations have explored this issue in hemodynamically stable septic children[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Consequently, it is crucial to accurately identify the clinical indicators that necessitate blood transfusion in pediatric patients with SA-AKI, to understand the underlying factors contributing to these indications, and to implement strategies aimed at reducing the frequency of blood transfusion therapy.\u003c/p\u003e \u003cp\u003eIn recent years, studies have reported the positive outcomes of transfusion therapy in cases of SA-AKI [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, our understanding of the risk factors associated with transfusion remains limited. To date, no comprehensive multicenter study has addressed these aspects. The primary aims of this study were: 1) to determine the incidence of transfusion therapy in children with SA-AKI over the decade spanning 2010\u0026ndash;2019, and 2) to evaluate temporal trends and factors associated with transfusion practices in this population.\u003c/p\u003e"},{"header":"2. Material and Methods","content":"\u003cp\u003e \u003cb\u003e2.1. Ethical Approval Statements and Data Sources\u003c/b\u003e \u003c/p\u003e \u003cp\u003eData for this investigation were sourced from the United States' Nationwide Inpatient Sample (NIS) database. Cases of SA-AKI were determined using the International Classification of Diseases Clinical Modification (ICD-9-CM and ICD-10-CM) codes over a ten-year period, from January 1, 2010, to December 31, 2019. The NIS offers comprehensive details on pediatric patients and participating hospitals, encompassing essential clinical information like hospital length of stay (LOS), healthcare costs, documented adverse events, mortality rates, and the presence of comorbidities and complications in hospitalized children. As this study utilized de-identified, publicly available data, an ethical committee review was not necessary.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Data acquisition\u003c/h2\u003e \u003cp\u003ePediatric patients with a diagnosis of SA-AKI were identified within discharge records spanning 2010\u0026ndash;2019 using ICD-9-CM and ICD-10-CM codes. Inclusion: (1) Age\u0026thinsp;\u0026lt;\u0026thinsp;18 years with SA-AKI diagnosis (ICD codes); (2) NIS database records (2010\u0026ndash;2019).Exclusion: (1) Chronic/end-stage kidney disease; (2) Congenital coagulopathy/non-sepsis AKI.Transfusion criteria: Anemia (Hb\u0026thinsp;\u0026lt;\u0026thinsp;7 g/dL), active bleeding (e.g., gastrointestinal), or coagulopathy [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].The initial cohort comprised 7,856 patients. Following exclusion of cases with incomplete data regarding hospital characteristics and patient demographics\u0026mdash;specifically age, LOS, total charges, insurance type, hospital size, admission type (elective or non-elective), and mortality status\u0026mdash;a final sample of 7,521 patients was derived from the NIS database (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Statistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was conducted using IBM SPSS Statistics (version 25). Continuous variables were compared using independent samples t-tests, while categorical variables were assessed using chi-square tests to examine the relationship between blood transfusion rates and various demographic and hospital-related factors. To identify potential risk factors for blood transfusion, a multivariate logistic regression model was employed. This model incorporated demographic characteristics, hospital characteristics, comorbidities, and complications experienced by the children (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were calculated from the logistic regression output. Statistical significance was defined as a \u003cem\u003ep\u003c/em\u003e-value below 0.05.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eVariables used in binary logistic regression analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables Categories\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSpecific Variables\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient demographics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge (˂18 years), sex (male and female), race (White, Black, Hispanic, Asian or Pacific Islander, Native American and Other)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital characteristics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eType of admission (non-elective, elective), bed size of hospital (small, medium, large), teaching status of hospital (nonteaching, teaching), location of hospital (rural, urban), type of insurance (Medicare, Medicaid, private insurance, self-pay, no charge, other), location of the hospital (northeast, Midwest or north central, south, west)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComorbidities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAIDS, Deficiency anemia, Rheumatoid arthritis/collagen vascular diseases, Congestive heart failure, Chronic pulmonary disease, Coagulopathy, Diffuse intravascular coagulation, Diabetes(uncomplicated), Diabetes(with chronic complications), hypothyroidism, Lymphoma, Fluid and electrolyte disorders, Metastatic cancer, Other neurological disorders, obesity, paralysis, Paralysis, Renal failure, Solid tumor without metastasis, Peptic ulcer disease excluding bleeding, Valvular disease, Severe malnutrition, Infectious diarrhea, Intestinal avascular necrosis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eAIDS: Acquired immunodeficiency syndrome\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Incidence of blood transfusion in children with sepsis-related acute kidney injury\u003c/h2\u003e \u003cp\u003eFrom 2010 to 2019, the NIS database yielded 7,521 qualifying patients with SA-AKI. Among these, 2,269 received transfusions, while 5,252 did not. Blood transfusions were administered to 30.17% of the SA-AKI patient cohort (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). A notable reduction in the annual blood transfusion rate was observed, with a decline from 45.6% in 2010 to 21.6% in 2019. The most significant decrease was evident between the years 2011 and 2012, with a reduction from 42.3\u0026ndash;33.9%, respectively. However, this downward trend was not consistently maintained. A slight increase in the annual rate was observed between 2012 and 2013, rising from 33.9\u0026ndash;38.2% (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Demographic characteristics between transfusion and non-transfusion groups\u003c/h2\u003e \u003cp\u003eTransfused children had a median age of 4 years (interquartile range: 0\u0026ndash;12), while the non-transfused group\u0026rsquo;s median age was 8 years (interquartile range: 1\u0026ndash;15). This four-year age difference between the groups was statistically significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), indicating distinct age profiles. Specifically, a greater percentage of children aged 0\u0026ndash;3 years received transfusions (47.6%) compared to the non-transfused cohort (34.1%) (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA and B). Analysis of ethnicity revealed significantly elevated transfusion rates among Black (19.3%), Hispanic (22.5%), and Asian/Pacific Islander (4.0%) children compared to their non-transfused counterparts (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eC and D). No significant difference in transfusion rates was observed based on gender (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Hospital characteristics between transfusion group and non-transfusion group\u003c/h2\u003e \u003cp\u003eSignificant variations in transfusion rates were observed based on hospital characteristics (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eE and F). Larger hospitals exhibited a statistically significant elevation in transfusion rates compared to smaller and medium-sized facilities (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). This trend was also evident in teaching and city hospitals, which demonstrated notably higher transfusion rates (97.4% and 99.9%, respectively; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) when contrasted with cases not involving transfusions (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Elective admissions were associated with a greater likelihood of receiving transfusions (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Furthermore, regional disparities were apparent, with southern hospitals reporting higher transfusion rates than those located in the northeast, midwest, north-central, and western regions (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.4. Adverse outcomes of blood transfusion in children with sepsis-related acute kidney injury\u003c/h2\u003e \u003cp\u003eA positive correlation was observed between the number of comorbidities and the likelihood of receiving a blood transfusion. Children with three or more coexisting conditions experienced a transfusion rate of 34.3% (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Furthermore, mortality among SA-AKI patients who underwent transfusion therapy (32.3%) was substantially higher than the 14.5% observed in those who did not receive transfusions (17.8%) (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Hospital stays were also notably longer in the transfusion group, with a median duration of 23 days (IQR: 11\u0026ndash;45) compared to 13 days (IQR: 5\u0026ndash;35) in the non-transfusion group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). This extended hospitalization translated into significantly higher total costs for the transfusion group, exceeding the non-transfusion group's expenses by nearly \u003cspan\u003e$\u003c/span\u003e200,000 (\u003cspan\u003e$\u003c/span\u003e363,119 vs. \u003cspan\u003e$\u003c/span\u003e163,646.50, respectively) (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Finally, analysis by insurance type revealed that the transfusion group had lower proportions of patients with medical insurance (0.6% vs. 0.9%) and private insurance (33.8% vs. 36.3%) compared to the non-transfusion group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e3.5. Analysis of risk factors related to transfusion therapy in children with sepsis-related acute kidney injury from demographic and hospital characteristics\u003c/p\u003e \u003cp\u003eMultivariable logistic regression (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) was employed to assess factors associated with blood transfusions. Several characteristics emerged as risk factors (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), including racial background (Black: OR 1.33, 95%\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eTable 2\u0026nbsp;\u003c/strong\u003eCharacteristics and outcomes of acute kidney injury associated with sepsis in children\u0026nbsp;\u003c/p\u003e\n\u003ctable id=\"Taba\" border=\"1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTransfusion\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo Transfusion\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eElective admission (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eType of hospital (teaching %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e97.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e94.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRegion of hospital (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNortheast\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMidwest or North Central\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSouth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eDied (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003eLOS: Length of stay, TOTCHE: Total charge\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cp\u003eCI 1.15–1.55; Hispanic: OR 1.37, 95% CI 1.81–1.58; Asian/Pacific Islander: OR 1.48, 95% CI 1.21–1.96; other: OR 1.54, 95% CI 1.32–1.80), admission to a teaching hospital (OR 1.54, 95% CI 1.14–2.10), treatment at an urban hospital (OR 4.93, 95% CI 1.47–16.53), and elective admission status (OR 1.34, 95% CI 1.12–1.61). Conversely, hospital location appeared to have a protective effect (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05), with lower odds of transfusion observed in the Midwest/North Central (OR 0.73, 95% CI 0.62–0.87), South (OR 0.75, 95% CI 0.65–0.89), and West (OR 0.60, 95% CI 0.50–0.71). No significant association was found between blood transfusion and patient age, comorbidity burden, payment source, or hospital bed size (\u003cem\u003ep\u003c/em\u003e \u0026gt; 0.05).\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 3\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eRisk factors associated with sepsis-related acute kidney injury and blood transfusion in children\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\" rowspan=\"2\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eMultivariate Logistic Regression\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eAge group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0–3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e——\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e——\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e4–6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.923\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.34–2.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.875\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e7–10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.055\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.44–2.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.905\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e11–18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.526\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.84–2.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.166\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRace\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWhite\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e——\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e——\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBlack\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.15–1.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHispanic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.81–1.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAsian or Pacific Islander\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.21–1.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNative American\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.48–1.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.625\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.32–1.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eNumber of Comorbidity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e——\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e——\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.94–1.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.132\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.94–1.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.126\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e≥ 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.97–2.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.069\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eType of insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedicare\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e——\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e——\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedicaid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.62–2.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.640\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrivate insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.59–2.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.733\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSelf-pay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.56–2.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.701\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo charge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.999\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.90–3.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.101\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eBed size of hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSmall\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e——\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e——\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00-1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.068\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLarge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.89–1.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.644\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eElective admission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.12–1.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eTeaching hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.14–2.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eUrban hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.47–16.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.010\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRegion of hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNortheast\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e——\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e——\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMidwest or North Central\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.62–0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSouth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.65–0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.50–0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003eOR: Odds ratio, CI: Confidence interval\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\"\u003e\n \u003ch2\u003e3.6. Relationship between comorbidities and blood transfusion in children with sepsis-related acute kidney injury\u003c/h2\u003e\n \u003cp\u003eUnivariate analysis revealed significant associations between specific comorbidities and transfusion requirements. Deficiency anemia (39.6% vs. 60.4%, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), coagulopathy (39.6% vs. 60.4%, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), diffuse intravascular coagulation (DIC) (44.0% vs. 56.0%, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), lymphoma (47.9% vs. 52.1%, \u003cem\u003ep\u003c/em\u003e = 0.001), and solid tumors without metastasis (45.2% vs. 54.8%, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001) were strongly associated with higher transfusion rates. Conversely, chronic pulmonary disease (22.3% vs. 77.7%, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), uncomplicated diabetes (19.3% vs. 80.7%, \u003cem\u003ep\u003c/em\u003e = 0.005), and hypothyroidism (24.3% vs. 75.7%, \u003cem\u003ep\u003c/em\u003e = 0.031) correlated with reduced transfusion needs. Multivariate analysis identified coagulopathy (OR = 1.67, 95% CI 1.44–1.93, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), DIC (OR = 1.45, 95% CI 1.25–1.70, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), deficiency anemia (OR = 1.24, 95% CI 1.05–1.48, \u003cem\u003ep\u003c/em\u003e = 0.013), and lymphoma (OR = 1.79, 95% CI 1.10–2.90, \u003cem\u003ep\u003c/em\u003e = 0.018) as Independent Predictors of transfusion. A number of protective factors were also identified, included chronic pulmonary disease (OR = 0.64, 95% CI 0.52–0.78, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), uncomplicated diabetes (OR = 0.59, 95% CI 0.38–0.93, \u003cem\u003ep\u003c/em\u003e = 0.022), hypothyroidism (OR = 0.72, 95% CI 0.53–0.96, \u003cem\u003ep\u003c/em\u003e = 0.028), paralysis (OR = 0.72, 95% CI 0.59–0.88, \u003cem\u003ep\u003c/em\u003e = 0.002), and Intestinal avascular necrosis(OR = 0.83, 95% CI 0.69–1.00, \u003cem\u003ep\u003c/em\u003e = 0.048).(Table 4).\u003c/p\u003e\n \u003cdiv\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\"\u003e\n \u003ch2\u003e3.7. Relationship between complications of sepsis-related acute kidney injury and blood transfusion\u003c/h2\u003e\n \u003cp\u003eChi-square analysis revealed significant associations between blood transfusion and specific complications in children with sepsis-associated acute kidney injury (SA-AKI). Complications with statistically significant positive associations (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05) included continuous mechanical ventilation (46.8% vs. 53.2%, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), acute respiratory (36.6% vs. 63.4%, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), gastrointestinal bleeding (46.3% vs. 53.7%, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), thrombocytopenia (39.5% vs. 60.5%, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), septic shock (35.2% vs. 64.8%, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), and hepatic insufficiency (45.1% vs. 54.9%, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001). Negative associations were observed for urinary tract infection (26.1% vs. 73.9%, \u003cem\u003ep\u003c/em\u003e = 0.006), acute respiratory distress syndrome (38.7% vs. 61.3%, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), and uremia (24.2% vs. 75.8%, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001).After adjusting for confounders, multivariate regression identified continuous mechanical ventilation (OR 2.45, 95% CI 2.15–2.81, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), acute respiratory (OR 1.22, 95% CI 1.06–1.41, \u003cem\u003ep\u003c/em\u003e = 0.006), gastrointestinal bleeding (OR 1.73, 95% CI 1.32–2.28, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), thrombocytopenia (OR 1.40, 95% CI 1.23–1.60, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), septic shock (OR 1.62, 95% CI 1.44–1.83, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), and hepatic insufficiency (OR 1.65, 95% CI 1.19–2.29, \u003cem\u003ep\u003c/em\u003e = 0.003) as independent positive predictors of transfusion. Conversely, urinary tract infection (OR 0.81, 95% CI 0.68–0.96, \u003cem\u003ep\u003c/em\u003e = 0.016), acute cerebrovascular disease (OR 0.76, 95% CI 0.58–0.98, \u003cem\u003ep\u003c/em\u003e = 0.037), acute respiratory distress syndrome (OR 0.80, 95% CI 0.68–0.94, \u003cem\u003ep\u003c/em\u003e = 0.008), and uremia (OR 0.82, 95% CI 0.72–0.94, \u003cem\u003ep\u003c/em\u003e = 0.004) emerged as protective factors.(Table 5).\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 5\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eRelationship between blood transfusion and complications\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"8\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\" rowspan=\"2\"\u003e\n \u003cp\u003eComplications\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eUnivariate Analysis\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eMultivariate Logistic Regression\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003etransfusion\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo Transfusion\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eUrinary tract infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e221 (26.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e626(73.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.68–0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.016\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDeep vein thrombosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e159 (35.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e286 (64.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.95–1.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.132\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePeripheral vascular disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e110 (36.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e193 (63.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.93–1.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.152\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGastrointestinal complication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39 (25.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e113 (74.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.221\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.71–1.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.866\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUrinary retention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55(34.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e104 (65.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.219\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.92–1.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.144\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eContinuous trauma ventilation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1062 (46.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1208 (53.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.15–2.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eArrhythmia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26(41.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37 (58.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.054\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.78–2.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.298\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePneumonia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e645 (32.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1362 (67.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.025\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.80–1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.076\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAcute respiratory failure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1071 (36.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1854 (63.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.06–1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eHeart failure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e187 (35.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e341 (64.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.84–1.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.833\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAcute cerebrovascular disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e96 (31.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e209 (68.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.612\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.58–0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.037\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGI bleeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e113 (46.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e131 (53.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.32–2.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThrombocytopenia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e531 (39.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e813 (60.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.23–1.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAcute respiratory distress syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e871 (38.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1380 (61.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.68–0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSeptic shock\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1757 (35.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3237 (64.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.44–1.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIleus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e157 (30.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e367 (70.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.915\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.71–1.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.173\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHepatic insufficiency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e74 (45.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e90 (54.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.19–2.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMyocardial ischemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (15.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (84.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.390\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.09–1.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.268\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAcute lung injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e86 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e172 (66.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.260\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.92–1.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.165\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUremia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1037 (24.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3256 (75.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.72–0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInflammatory diseases of the central nervous system\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e103 (32.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e211 (67.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.299\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.82–1.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.687\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThrombotic thrombocytopenic purpura\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22 (42.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 (57.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.056\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.90–2.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.107\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\"\u003eOR: Odds ratio, CI: Confidence interval\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eAKI poses a significant threat to children with sepsis, with high morbidity and mortality[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Contemporary studies have elucidated a strong association between SA-AKI and microcirculatory dysfunction, cellular metabolic remodeling, and dysregulation of the inflammatory response[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Blood transfusions can significantly improve oxygenation and microvascular perfusion in children with sepsis[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, blood transfusions may also increase the potential risk of organ damage. In this study, 30.17% of children with SA-AKI received blood transfusions. In contrast, nearly half (49%) of the children in North American pediatric intensive care units (PICUs) received blood transfusion therapy [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This indicates that anemia and blood transfusion are common issues in critically ill children, especially those with combined AKI. This study demonstrated a decline in the annual incidence of blood transfusion from 45.6\u0026ndash;21.6% between 2010 and 2019, aligning with the literature [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Meybohm Patrick et al.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] achieved a significant reduction in red blood cell transfusion rates through optimized blood management practices in hospitalized children.\u003c/p\u003e \u003cp\u003eThe present study indicated that, although younger patients (median age 4 years) received transfusions more frequently [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], further statistical analysis revealed that age itself was not an independent predictor of transfusion necessity. This may be attributed to the wide age range and significant physiological changes in pediatric populations, as well as the diverse factors influencing the need for blood transfusion. Currently, data on blood transfusion thresholds for this vulnerable age group remain limited[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. We observed disparities across racial groups, with Black and Hispanic children experiencing higher transfusion rates compared to White and Indian children. This disparity may be linked to the lower average hemoglobin and serum transferrin saturation in the Black population, suggesting that ethnic or genetic factors may contribute to the increased demand for blood transfusions[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA greater incidence of blood transfusions is typically observed in major medical centers, including teaching and urban hospitals. This investigation, mirroring findings from a nationwide U.S. study[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], found a correlation between planned hospitalizations and elevated probabilities of RBC transfusions. Geographical analysis revealed more frequent transfusions in hospitals located in the South; the precise underlying causes remain unclear, likely stemming from a confluence of contributing elements.\u003c/p\u003e \u003cp\u003eOther studies have also indicated that blood transfusion is closely associated with a higher number of comorbidities, prolonged hospitalization, increased medical costs, and elevated mortality rates [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], and the findings of this study align with these observations (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Nevertheless, logistic regression analysis suggests that these associations may primarily reflect the severity of the underlying disease rather than a direct causal relationship. Our study further reveals that most children receiving blood transfusions were enrolled in Medicaid, while those not receiving transfusions primarily relied on private insurance. A survey of blood transfusion trends in the United States indicated that most patients receiving blood transfusions were covered by Medicare[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Notably, this study was based on the NIS database, and it may be subject to statistical limitations associated with ICD coding and other factors.\u003c/p\u003e \u003cp\u003eThis study identifies several independent predictors of blood transfusion in SA-AKI patients, including deficiency anemia, coagulopathy, diffuse intravascular coagulation, lymphoma, thrombocytopenia, gastrointestinal bleeding, continuous trauma ventilation, acute respiratory failure, and septic shock. In pediatric intensive care units, managing anemia usually involves transfusions to raise tissue oxygen levels, primarily determined by low hemoglobin concentration [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Sepsis triggers a systemic inflammatory response that activates the coagulation cascade, this process leads to platelet consumption and worsens bleeding tendencies. Additionally, the pathological process of DIC further increases the risk of microvascular bleeding, especially when acute kidney injury is present [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In children with SA-AKI, thrombocytopenia is a significant driving factor for transfusion, possibly related to sepsis-associated thrombocytopenia and the consumption effects of DIC. There is a significant synergistic effect between thrombocytopenia and coagulopathy as well as DIC, with studies indicating that children with both thrombocytopenia and coagulopathy have a higher risk of transfusion than those with only one of the factors[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]。Children with malignant tumors often need transfusions due to bone marrow suppression from chemotherapy, tumor infiltration, and anemia related to sepsis[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Particularly in children with lymphoma, splenomegaly and portal hypertension are often present, further increasing the risk of gastrointestinal bleeding. Gastrointestinal bleeding directly leads to blood loss, while liver dysfunction may impair the synthesis of coagulation factors, increasing the risk of bleeding, which is consistent with research findings related to coagulopathy and mucosal ischemia in SA-AKI[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Children with acute respiratory failure often present with hypoxemia and anemia, and pediatricians improve oxygen-carrying capacity through transfusions. Prolonged mechanical ventilation time typically reflects the severity of the disease, with studies showing that red blood cell transfusions in critically ill children are associated with extended mechanical ventilation time[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Children with severe infections, especially those with septic shock, often require transfusions, which may be related to microcirculatory dysfunction and adrenal insufficiency exacerbating anemia[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRelatively speaking, chronic pulmonary disease, uncomplicated diabetes, hypothyroidism, acute respiratory distress syndrome, and uremia serve as protective factors. Children with chronic pulmonary disease are often observed among those born prematurely, they adapt to chronic hypoxia over time, leading to higher baseline hemoglobin levels and reduced transfusion needs[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The transfusion risk in children with uncomplicated diabetes is lower, possibly related to strict blood glucose control[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Children with hypothyroidism can increase red blood cell counts and hemoglobin levels by supplementing thyroid hormones, which accelerate enhances intracellular metabolism[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. While acute respiratory distress syndrome (ARDS) is typically linked with hypoxemia, recent studies advocate for restrictive transfusion strategies because excessive transfusion may worsen pulmonary edema and oxidative stress[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Early antibiotic treatment for urinary tract infections can control inflammation and prevent systemic coagulation activation[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Although uremia can lead to platelet dysfunction, this study identified a negative correlation with transfusion needs. This may be due to disease progression, which allows for compensatory erythropoiesis, and the earlier initiation of renal replacement therapy (CRRT)[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. The reduced transfusion needs in children with SA-AKI and paralysis may be related to their clinical management strategies. Intestinal ischemic necrosis is usually viewed as a high-risk complication in critical illness; however, this study found a negative correlation with transfusion needs, likely due to early intervention and conservative transfusion strategies[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].Acute cerebrovascular events, as protective factors, may be related to anticoagulation management strategies and transfusion thresholds to avoid fluctuations in blood volume that could worsen cerebral edema[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]。\u003c/p\u003e \u003cp\u003eOur study had limitations inherent to its retrospective design, including the inability to track post-discharge outcomes and limited access to detailed clinical metrics within the NIS database. These constraints affected our ability to evaluate certain established transfusion risk factors and long-term patient outcomes. Despite these limitations, this study retains important clinical significance. Future research employing a prospective design would overcome the limitations of existing studies and allow for a more accurate assessment of SA-AKI risk factors related to blood transfusion.\u003c/p\u003e"},{"header":"5. Summary","content":"\u003cp\u003eIn summary, the proportion of children with SA-AKI receiving blood transfusions decreased between 2010 and 2019. The coexistence of independent predictive and protective factors underscores the complexity involved in making transfusion decisions for SA-AKI. Positive indicators, like coagulopathy and ongoing trauma ventilation, indicate the need to closely monitor for bleeding and anemia. In contrast, protective factors, such as chronic pulmonary disease, imply that transfusion may be unnecessary. Therefore, this study aimed to ascertain factors associated with blood transfusion and to reduce transfusion needs through early recognition and intervention of these factors, ultimately leading to improved clinical outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eNationwide Inpatient Sample (NIS)\u003c/p\u003e\n\u003cp\u003eSepsis-associated acute kidney injury (SA-AKI)\u003c/p\u003e\n\u003cp\u003eInternational classification of diseases (ICD)\u003c/p\u003e\n\u003cp\u003eLength of stay (LOS)\u003c/p\u003e\n\u003cp\u003eOdds ratios (ORs)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConfidence intervals (CIs)\u003c/p\u003e\n\u003cp\u003eFigure (Fig)\u003c/p\u003e\n\u003cp\u003eOdds ratios\u0026nbsp;（OR\u0026nbsp;）\u003c/p\u003e\n\u003cp\u003eConfidence intervals\u0026nbsp;（CI）\u003c/p\u003e\n\u003cp\u003eAcquired immunodeficiency syndrome (AIDS)\u003c/p\u003e\n\u003cp\u003eDisseminated intravascular coagulation (DIC)\u003c/p\u003e\n\u003cp\u003eRed blood cell（RBC）\u003c/p\u003e\n\u003cp\u003ePediatric intensive care units (PICUs)\u003c/p\u003e\n\u003cp\u003eAcute respiratory distress syndrome (ARDS)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFundings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZhuhai Municipal Bureau of Science and Technology Innovation.2024 Annual Zhuhai Science and Technology Plan Project in Social Development Sector.2420004000180.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJ.Y. Gao：Writing \u0026ndash; original draft, Formal analysis, Data curation，Methodology, Conceptualization;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eY.F. Zhang and L. Chen：Writing \u0026ndash; original draft, Data curation;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eW.X. Song\u0026nbsp;：Project administration, Methodology, Conceptualization;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eH. Hou and C.W. Yi\u0026nbsp;：Formal analysis, Data curation；\u003c/p\u003e\n\u003cp\u003eY.X. He and B. Huang：Writing \u0026ndash; review \u0026amp; editing, Project administration, Methodology, Conceptualization.\u003c/p\u003e\n\u003cp\u003eAll authors have read and approved the final version of the manuscript and agree to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDate availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets are available at https://www.ahrq.gov/data/hcup/index.html.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research study did not require approval from an ethics board since it used anonymous date that is publicly accessible.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSchlapbach, L.J., et al., \u003cem\u003eInternational Consensus Criteria for Pediatric Sepsis and Septic Shock.\u003c/em\u003e JAMA, 2024. \u003cstrong\u003e331\u003c/strong\u003e(8): p. 665-674.https://doi.org/10.1001/jama.2024.0179.\u003c/li\u003e\n\u003cli\u003eRudd, K.E., et al., \u003cem\u003eGlobal, regional, and national sepsis incidence and mortality, 1990-2017: analysis for the Global Burden of Disease Study.\u003c/em\u003e Lancet (London, England), 2020. \u003cstrong\u003e395\u003c/strong\u003e(10219): p. 200-211.https://doi.org/10.1016/S0140-6736(19)32989-7.\u003c/li\u003e\n\u003cli\u003eKhatana, J., et al., \u003cem\u003eIncreasing incidence of acute kidney injury in pediatric severe sepsis and related adverse hospital outcomes.\u003c/em\u003e Pediatr Nephrol, 2023. \u003cstrong\u003e38\u003c/strong\u003e(8): p. 2809-2815.https://doi.org/10.1007/s00467-022-05866-x.\u003c/li\u003e\n\u003cli\u003eFitzgerald, J.C., et al., \u003cem\u003eAcute Kidney Injury in Pediatric Severe Sepsis: An Independent Risk Factor for Death and New Disability.\u003c/em\u003e Crit Care Med, 2016. \u003cstrong\u003e44\u003c/strong\u003e(12): p. 2241-2250.https://doi.org/10.1097/ccm.0000000000002007.\u003c/li\u003e\n\u003cli\u003eDuzova, A., et al., \u003cem\u003eEtiology and outcome of acute kidney injury in children.\u003c/em\u003e Pediatr Nephrol, 2010. \u003cstrong\u003e25\u003c/strong\u003e(8): p. 1453-61.https://doi.org/10.1007/s00467-010-1541-y.\u003c/li\u003e\n\u003cli\u003eHarer, M.W. and V.Y. 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Shaikh, and C.P. Nelson, \u003cem\u003eContemporary Management of Urinary Tract Infection in Children.\u003c/em\u003e Pediatrics, 2021. \u003cstrong\u003e147\u003c/strong\u003e(2).https://doi.org/10.1542/peds.2020-012138.\u003c/li\u003e\n\u003cli\u003eBuccione, E., et al., \u003cem\u003eContinuous Renal Replacement Therapy in Critically Ill Children in the Pediatric Intensive Care Unit: A Retrospective Analysis of Real-Life Prescriptions, Complications, and Outcomes.\u003c/em\u003e Front Pediatr, 2021. \u003cstrong\u003e9\u003c/strong\u003e: p. 696798.https://doi.org/10.3389/fped.2021.696798.\u003c/li\u003e\n\u003cli\u003eNumanoglu, A. and A.J. Millar, \u003cem\u003eNecrotizing enterocolitis: early conventional and fluorescein laparoscopic assessment.\u003c/em\u003e J Pediatr Surg, 2011. \u003cstrong\u003e46\u003c/strong\u003e(2): p. 348-51.https://doi.org/10.1016/j.jpedsurg.2010.11.021.\u003c/li\u003e\n\u003cli\u003eTasker, R.C., A.F. Turgeon, and P.C. Spinella, \u003cem\u003eRecommendations on RBC Transfusion in Critically Ill Children With Acute Brain Injury From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative.\u003c/em\u003e Pediatr Crit Care Med, 2018. \u003cstrong\u003e19\u003c/strong\u003e(9S Suppl 1): p. S133-s136.https://doi.org/10.1097/pcc.0000000000001589.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table 4","content":"\u003cp\u003eTable 4 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"pediatric-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pnep","sideBox":"Learn more about [Pediatric Nephrology](http://link.springer.com/journal/467)","snPcode":"467","submissionUrl":"https://www.editorialmanager.com/pnep/default2.aspx","title":"Pediatric Nephrology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Sepsis-related acute kidney injury, Blood transfusions, Risk factors, Risk stratification, Child intensive care, National database analysis","lastPublishedDoi":"10.21203/rs.3.rs-6376778/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6376778/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo identify the predictors of blood transfusion in children with sepsis-related acute kidney injury through a nationwide database analysis.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eData from the Nationwide Inpatient Sample (NIS) database were retrospectively reviewed to examine pediatric patients diagnosed with sepsis-associated acute kidney injury (SA-AKI) from 2010 to 2019. Patients were divided into two cohorts: those who received blood transfusions and those who did not. Demographic, hospital, comorbidity, and complication data were compared between the two cohorts. Subsequently, univariate and multivariate logistic regression analyses were performed to identify factors associated with blood transfusion in children with SA-AKI.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe study encompassed a total of 7,521 pediatric patients diagnosed with SA-AKI. Of these, 2,269 patients received blood transfusions, constituting 30.17% of the total cohort. The median age of patients in the transfusion group was 4 years (range: 0\u0026ndash;12 years), while the median age in the non-transfusion group was 8 years (range: 1\u0026ndash;15 years). Patients requiring blood transfusions exhibited significantly longer hospital stays, higher overall medical costs, and elevated in-hospital death rates (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Multivariate regression analysis revealed several independent predictors of blood transfusion, including acute respiratory failure, continuous mechanical ventilation, septic shock, anemia, coagulopathy, disseminated intravascular coagulation, lymphoma, thrombocytopenia, gastrointestinal bleeding, and hepatic insufficiency (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ePediatric patients with SA-AKI who require blood transfusions experience heightened clinical complexity, increased resource utilization, and impose a greater economic burden on both families and society. A comprehensive understanding of the risk factors associated with transfusion enables healthcare providers to implement proactive measures and early interventions to mitigate the need for blood transfusions.\u003c/p\u003e","manuscriptTitle":"Blood Transfusion in Pediatric Sepsis-Associated Acute Kidney Injury: A Nationwide Study of Risk Factors and Outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-09 11:19:57","doi":"10.21203/rs.3.rs-6376778/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major Revisions Needed","date":"2025-06-12T12:30:22+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2025-05-07T14:16:26+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-05T21:59:30+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-05T18:02:34+00:00","index":"","fulltext":""},{"type":"submitted","content":"Pediatric Nephrology","date":"2025-05-04T02:02:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"pediatric-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pnep","sideBox":"Learn more about [Pediatric Nephrology](http://link.springer.com/journal/467)","snPcode":"467","submissionUrl":"https://www.editorialmanager.com/pnep/default2.aspx","title":"Pediatric Nephrology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"26bbc724-8669-4835-8eff-4b861c53b50d","owner":[],"postedDate":"May 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-30T16:26:39+00:00","versionOfRecord":{"articleIdentity":"rs-6376778","link":"https://doi.org/10.1007/s00467-026-07165-1","journal":{"identity":"pediatric-nephrology","isVorOnly":false,"title":"Pediatric Nephrology"},"publishedOn":"2026-03-24 16:09:00","publishedOnDateReadable":"March 24th, 2026"},"versionCreatedAt":"2025-05-09 11:19:57","video":"","vorDoi":"10.1007/s00467-026-07165-1","vorDoiUrl":"https://doi.org/10.1007/s00467-026-07165-1","workflowStages":[]},"version":"v1","identity":"rs-6376778","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6376778","identity":"rs-6376778","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}