Sepsis criteria and kidney function: eliminating sex, age and economic status biases

The kidney is a target organ for the dysregulated host response to infection that defines sepsis, and acute kidney injury (AKI) is often an early manifestation of this response. Current sepsis criteria for adults (Sepsis-3) continue to include outmoded measures of kidney health, such as absolute creatinine values, which are used in organ failure scoring independently of baseline kidney function or treatment with dialysis. This approach perpetuates disparities, as older female patients require much larger decreases in kidney function compared with young male patients to achieve the same ‘renal domain’ points, exacerbating sex- and age-based inequities in health assessment and response. Furthermore, the latest data-driven machine learning-assisted paediatric sepsis criteria (the Phoenix Sepsis Score) have excluded kidney function entirely from sepsis diagnosis. Consequently, these criteria will exclude a child with pneumonia and associated AKI, even if receiving dialysis, from a sepsis diagnosis unless other organs fail. This inconsistency, given the extensive refinement and validation of AKI diagnostic criteria over the past three decades, is unacceptable. Current criteria for diagnosis of sepsis in both adults and children fail to incorporate crucial advances in the diagnosis of kidney disease. We maintain that it is imperative that kidney injury is quantified accurately in sepsis scoring systems free of sex, race and other biases.