51
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Fayad AI, Buamscha DG, Ciapponi A. Timing of kidney replacement therapy initiation for acute kidney injury. Cochrane Database Syst Rev 2022; 11:CD010612. [PMID: 36416787 PMCID: PMC9683115 DOI: 10.1002/14651858.cd010612.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common condition among patients in intensive care units (ICUs) and is associated with high numbers of deaths. Kidney replacement therapy (KRT) is a blood purification technique used to treat the most severe forms of AKI. The optimal time to initiate KRT so as to improve clinical outcomes remains uncertain. This is an update of a review first published in 2018. This review complements another Cochrane review by the same authors: Intensity of continuous renal replacement therapy for acute kidney injury. OBJECTIVES To assess the effects of different timing (early and standard) of KRT initiation on death and recovery of kidney function in critically ill patients with AKI. SEARCH METHODS We searched the Cochrane Kidney and Transplant's Specialised Register to 4 August 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Register, ClinicalTrials and LILACS to 1 August 2022. SELECTION CRITERIA We included all randomised controlled trials (RCTs). We included all patients with AKI in the ICU regardless of age, comparing early versus standard KRT initiation. For safety and cost outcomes, we planned to include cohort studies and non-RCTs. DATA COLLECTION AND ANALYSIS Data were extracted independently by two authors. The random-effects model was used, and results were reported as risk ratios(RR) for dichotomous outcomes and mean difference(MD) for continuous outcomes, with 95% confidence intervals (CI). MAIN RESULTS We included 12 studies enrolling 4880 participants. Overall, most domains were assessed as being at low or unclear risk of bias. Compared to standard treatment, early KRT initiation may have little to no difference on the risk of death at day 30 (12 studies, 4826 participants: RR 0.97,95% CI 0.87 to 1.09; I²= 29%; low certainty evidence), and death after 30 days (7 studies, 4534 participants: RR 0.99, 95% CI 0.92 to 1.07; I² = 6%; moderate certainty evidence). Early KRT initiation may make little or no difference to the risk of death or non-recovery of kidney function at 90 days (6 studies, 4011 participants: RR 0.91, 95% CI 0.74 to 1.11; I² = 66%; low certainty evidence); CIs included both benefits and harms. Low certainty evidence showed early KRT initiation may make little or no difference to the number of patients who were free from KRT (10 studies, 4717 participants: RR 1.07, 95% CI 0.94 to1.22; I² = 55%) and recovery of kidney function among survivors who were free from KRT after day 30 (10 studies, 2510 participants: RR 1.02, 95% CI 0.97 to 1.07; I² = 69%) compared to standard treatment. High certainty evidence showed early KRT initiation increased the risk of hypophosphataemia (1 study, 2927 participants: RR 1.80, 95% CI 1.33 to 2.44), hypotension (5 studies, 3864 participants: RR 1.54, 95% CI 1.29 to 1.85; I² = 0%), cardiac-rhythm disorder (6 studies, 4483 participants: RR 1.35, 95% CI 1.04 to 1.75; I² = 16%), and infection (5 studies, 4252 participants: RR 1.33, 95% CI 1.00 to 1.77; I² = 0%); however, it is uncertain whether early KRT initiation increases or reduces the number of patients who experienced any adverse events (5 studies, 3983 participants: RR 1.23, 95% CI 0.90 to 1.68; I² = 91%; very low certainty evidence). Moderate certainty evidence showed early KRT initiation probably reduces the number of days in hospital (7 studies, 4589 participants: MD-2.45 days, 95% CI -4.75 to -0.14; I² = 10%) and length of stay in ICU (5 studies, 4240 participants: MD -1.01 days, 95% CI -1.60 to -0.42; I² = 0%). AUTHORS' CONCLUSIONS Based on mainly low to moderate certainty of the evidence, early KRT has no beneficial effect on death and may increase the recovery of kidney function. Earlier KRT probably reduces the length of ICU and hospital stay but increases the risk of adverse events. Further adequate-powered RCTs using robust and validated tools that complement clinical judgement are needed to define the optimal time of KRT in critical patients with AKI in order to improve their outcomes. The surgical AKI population should be considered in future research.
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Affiliation(s)
- Alicia Isabel Fayad
- Pediatric Nephrology, Ricardo Gutierrez Children's Hospital, Buenos Aires, Argentina
| | - Daniel G Buamscha
- Pediatric Critical Care Unit, Juan Garrahan Children's Hospital, Buenos Aires, Argentina
| | - Agustín Ciapponi
- Argentine Cochrane Centre, Institute for Clinical Effectiveness and Health Policy (IECS-CONICET), Buenos Aires, Argentina
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Gomes RADS, Azevedo LF, Simões BPC, Detomi LS, Rodrigues KEDS, Rodrigues AT, Melo MDCBD, Fonseca JGD. Fluid overload: clinical outcomes in pediatric intensive care unit. J Pediatr (Rio J) 2022; 99:241-246. [PMID: 36370749 DOI: 10.1016/j.jped.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 10/15/2022] [Accepted: 10/17/2022] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE The aim of this study was to analyze the effects of fluid overload related to mechanical ventilation, renal replacement therapy, and evolution to discharge or death in critically ill children. METHODS A retrospective study in a Pediatric Intensive Care Unit for two years. Patients who required invasive ventilatory support and vasopressor and/or inotropic medications were considered critically ill. RESULTS 70 patients were included. The mean age was 6.8 ± 6 years. There was a tolerable increase in fluid overload during hospitalization, with a median of 2.45% on the first day, 5.10% on the third day, and 8.39% on the tenth day. The median fluid overload on the third day among those patients in pressure support ventilation mode was 4.80% while the median of those who remained on controlled ventilation was 8.45% (p = 0.039). Statistical significance was observed in the correlations between fluid overload measurements on the first, third, and tenth days of hospitalization and the beginning of renal replacement therapy (p = 0.049) and between renal replacement therapy and death (p = 0.01). The median fluid overload was 7.50% in patients who died versus 4.90% in those who did not die on the third day of hospitalization (p = 0.064). There was no statistically significant association between death and the variables sex or age. CONCLUSIONS The fluid overload on the third day of hospitalization proved to be a determinant for the clinical outcomes of weaning from mechanical ventilation, initiation of renal replacement therapy, discharge from the intensive care unit, or death among these children.
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Affiliation(s)
| | - Lorena Ferreira Azevedo
- Hospital das Clínicas da Universidade Federal de Minas Gerais (UFMG)/EBSERH, Belo Horizonte, MG, Brazil
| | | | - Letícia Silva Detomi
- Hospital das Clínicas da Universidade Federal de Minas Gerais (UFMG)/EBSERH, Belo Horizonte, MG, Brazil
| | | | - Adriana Teixeira Rodrigues
- Pediatria, Faculdade de Medicina da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
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53
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Wei EY, Vuong KT, Lee E, Liu L, Ingulli E, Coufal NG. Predictors of successful discontinuation of continuous kidney replacement therapy in a pediatric cohort. Pediatr Nephrol 2022:10.1007/s00467-022-05782-0. [PMID: 36315275 DOI: 10.1007/s00467-022-05782-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 09/30/2022] [Accepted: 09/30/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Recognizing the optimal time to discontinue continuous kidney replacement therapy (CKRT) is necessary to advance patient recovery and mitigate complications. The aim of this study was to identify predictors of successful CKRT cessation in pediatric patients. METHODS All patients requiring CKRT between January 2010 and March 2021 were evaluated. Patients on peritoneal or hemodialysis, who transferred between institutions, or who did not trial off CKRT were excluded. Successful discontinuation was defined as remaining off CKRT for at least 7 days. Demographics, admission diagnoses, PRISM III scores, and reasons for CKRT initiation were obtained. Clinical and biochemical variables were evaluated at CKRT initiation and discontinuation and in the 12-h period following discontinuation. Comparisons were conducted using Wilcoxon rank sum and Fisher's exact tests for continuous and categorical variables, respectively. A logistic regression model was fitted to identify significant factors. RESULTS Ninety-nine patients underwent a trial off CKRT. Admission and initiation characteristics of the success and failure groups were similar. Patients who required re-initiation (n = 26) had longer ICU lengths of stay (27.2 vs. 44.5 days, p = 0.046) and higher in-hospital mortality (15.1% vs. 46.2%, p = 0.002). Urine output greater than 0.5 mL/kg/h irrespective of diuretic administration in the 6-h period before CKRT discontinuation was a significant predictor (AUC 0.72, 95% CI 0.60-0.84, p = 0.0009). CONCLUSIONS Determining the predictors of sustained CKRT discontinuation is critical. Urine output greater than 0.5 mL/kg/h in this pediatric cohort predicted successful discontinuation. Future studies are needed to validate this threshold in disease- and age-specific cohorts and evaluate additional biomarkers of kidney injury. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Elizabeth Y Wei
- Department of Pediatrics, Division of Critical Care, University of California San Diego, 3020 Children's Way, MC 5065, San Diego, CA, 92123, USA. .,Rady Children's Hospital, San Diego, CA, USA.
| | - Kim T Vuong
- Rady Children's Hospital, San Diego, CA, USA.,Department of Pediatrics, University of California San Diego, San Diego, CA, USA
| | - Euyhyun Lee
- Altman Clinical and Translational Research Institute, University of California San Diego, San Diego, CA, USA
| | - Lin Liu
- Altman Clinical and Translational Research Institute, University of California San Diego, San Diego, CA, USA.,Division of Biostatistics and Bioinformatics, Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, San Diego, CA, USA
| | - Elizabeth Ingulli
- Rady Children's Hospital, San Diego, CA, USA.,Department of Pediatrics, Division of Nephrology, University of California San Diego, San Diego, CA, USA
| | - Nicole G Coufal
- Department of Pediatrics, Division of Critical Care, University of California San Diego, 3020 Children's Way, MC 5065, San Diego, CA, 92123, USA.,Rady Children's Hospital, San Diego, CA, USA
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54
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Sallee CJ, Fitzgerald JC, Smith LS, Angelo JR, Daniel MC, Gertz SJ, Hsing DD, Mahadeo KM, McArthur JA, Rowan CM. Fluid Overload in Pediatric Acute Respiratory Distress Syndrome after Allogeneic Hematopoietic Cell Transplantation. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1757480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AbstractThe aim of the study is to examine the relationship between fluid overload (FO) and severity of respiratory dysfunction in children post-hematopoietic cell transplantation (HCT) with pediatric acute respiratory distress syndrome (PARDS). This investigation was a secondary analysis of a multicenter retrospective cohort of children (1month to 21 years) post-allogeneic HCT with PARDS receiving invasive mechanical ventilation (IMV) from 2009 to 2014. Daily FO % (FO%) and daily oxygenation index (OI) were calculated for each patient up to the first week of IMV (day 0 = intubation). Linear mixed-effect regression was employed to examine whether FO% and OI were associated on any day during the study period. In total, 158 patients were included. Severe PARDS represented 63% of the cohort and had higher mortality (78 vs. 42%, p <0.001), fewer ventilator free days at 28 (0 [IQR 0–0] vs. 14 [IQR 0–23], p <0.001), and 60 days (0 [IQR 0–27] v. 45 [IQR 0–55], p <0.001) relative to non-severe PARDS. Increasing FO% was strongly associated with higher OI (p <0.001). For children with 10% FO, OI was higher by nearly 5 points (adjusted β 4.6, 95% CI [2.9, 6.3]). In subgroup analyses, the association between FO% and OI was strongest among severe PARDS (p <0.001) and during the first 3 days elapsed from intubation (p <0.001). FO% was associated with lower PaO2/FiO2 (adjusted β −1.92, 95% CI [−3.11, −0.73], p = 0.002), but not mean airway pressure (p = 0.746). In a multicenter cohort of children post-HCT with PARDS, FO was independently associated with oxygenation impairment. The associations were strongest among children with severe PARDS and early in the course of IMV.
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Affiliation(s)
- Colin J. Sallee
- Department of Pediatrics, Division of Pediatric Critical Care, UCLA Mattel Children's Hospital, University of California Los Angeles, Los Angeles, California, United States
| | - Julie C. Fitzgerald
- Department of Anesthesiology and Critical Care, Division of Critical Care, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Lincoln S. Smith
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Seattle Children's Hospital, University of Washington, Seattle, Washington, United States
| | - Joseph R. Angelo
- Department of Pediatrics, Renal Section, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, United States
| | - Megan C. Daniel
- Department of Pediatrics, Division of Critical Care, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, United States
| | - Shira J. Gertz
- Department of Pediatrics, Division of Pediatric Critical Care, Saint Barnabas Medical Center, Livingston, New Jersey, United States
| | - Deyin D. Hsing
- Department of Pediatrics, Division of Critical Care, Weil Cornell Medical College, New York Presbyterian Hospital, New York City, New York, United States
| | - Kris M. Mahadeo
- Department of Pediatrics, Pediatric Stem Cell Transplantation and Cellular Therapy, Children's Cancer Hospital, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Jennifer A. McArthur
- Department of Pediatrics, Division of Critical Care, St Jude Children's Research Hospital, Memphis, Tennessee, United States
| | - Courtney M. Rowan
- Department of Pediatrics, Division of Critical Care, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, United States
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55
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Ong LT. Management and outcomes of acute post-streptococcal glomerulonephritis in children. World J Nephrol 2022; 11:139-145. [PMID: 36187464 PMCID: PMC9521512 DOI: 10.5527/wjn.v11.i5.139] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 04/23/2022] [Accepted: 07/25/2022] [Indexed: 02/05/2023] Open
Abstract
Acute post-streptococcal glomerulonephritis (APSGN) is the major cause of acute glomerulonephritis among children, especially in low- and middle-income countries. APSGN commonly occurs following pharyngitis due to the activation of antibodies and complements proteins against streptococcal antigens through the immune-complex-mediated mechanism. APSGN can be presented as acute nephritic syndrome, nephrotic syndrome, and rapidly progressive glomerulonephritis, or it may be subclinical. The management of APSGN is mainly supportive in nature with fluid restriction, anti-hypertensives, diuretics, and renal replacement therapy with dialysis, when necessary, as the disease is self-limiting. Congestive heart failure, pulmonary edema, and severe hypertension-induced encephalopathy might occur during the acute phase of APSGN due to hypervolemia. APSGN generally has a favorable prognosis with only a small percentage of patients with persistent urinary abnormalities, persistent hypertension, and chronic kidney disease after the acute episode of APSGN. Decreased complement levels, increased C-reactive protein, and hypoalbuminemia are associated with disease severity. Crescent formations on renal biopsy and renal insufficiency on presentation may be the predictors of disease severity and poor outcomes in APSGN in children.
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Affiliation(s)
- Leong Tung Ong
- Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
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56
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Goldstein SL, Akcan-Arikan A, Alobaidi R, Askenazi DJ, Bagshaw SM, Barhight M, Barreto E, Bayrakci B, Bignall ONR, Bjornstad E, Brophy PD, Chanchlani R, Charlton JR, Conroy AL, Deep A, Devarajan P, Dolan K, Fuhrman DY, Gist KM, Gorga SM, Greenberg JH, Hasson D, Ulrich EH, Iyengar A, Jetton JG, Krawczeski C, Meigs L, Menon S, Morgan J, Morgan CJ, Mottes T, Neumayr TM, Ricci Z, Selewski D, Soranno DE, Starr M, Stanski NL, Sutherland SM, Symons J, Tavares MS, Vega MW, Zappitelli M, Ronco C, Mehta RL, Kellum J, Ostermann M, Basu RK. Consensus-Based Recommendations on Priority Activities to Address Acute Kidney Injury in Children: A Modified Delphi Consensus Statement. JAMA Netw Open 2022; 5:e2229442. [PMID: 36178697 PMCID: PMC9756303 DOI: 10.1001/jamanetworkopen.2022.29442] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE Increasing evidence indicates that acute kidney injury (AKI) occurs frequently in children and young adults and is associated with poor short-term and long-term outcomes. Guidance is required to focus efforts related to expansion of pediatric AKI knowledge. OBJECTIVE To develop expert-driven pediatric specific recommendations on needed AKI research, education, practice, and advocacy. EVIDENCE REVIEW At the 26th Acute Disease Quality Initiative meeting conducted in November 2021 by 47 multiprofessional international experts in general pediatrics, nephrology, and critical care, the panel focused on 6 areas: (1) epidemiology; (2) diagnostics; (3) fluid overload; (4) kidney support therapies; (5) biology, pharmacology, and nutrition; and (6) education and advocacy. An objective scientific review and distillation of literature through September 2021 was performed of (1) epidemiology, (2) risk assessment and diagnosis, (3) fluid assessment, (4) kidney support and extracorporeal therapies, (5) pathobiology, nutrition, and pharmacology, and (6) education and advocacy. Using an established modified Delphi process based on existing data, workgroups derived consensus statements with recommendations. FINDINGS The meeting developed 12 consensus statements and 29 research recommendations. Principal suggestions were to address gaps of knowledge by including data from varying socioeconomic groups, broadening definition of AKI phenotypes, adjudicating fluid balance by disease severity, integrating biopathology of child growth and development, and partnering with families and communities in AKI advocacy. CONCLUSIONS AND RELEVANCE Existing evidence across observational study supports further efforts to increase knowledge related to AKI in childhood. Significant gaps of knowledge may be addressed by focused efforts.
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Affiliation(s)
- Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ayse Akcan-Arikan
- Division of Critical Care Medicine and Nephrology, Texas Children's Hospital, Baylor College of Medicine, Houston
| | - Rashid Alobaidi
- Alberta Health Sciences University, Edmonton, Alberta, Canada
| | | | - Sean M Bagshaw
- Alberta Health Sciences University, Edmonton, Alberta, Canada
| | - Matthew Barhight
- Ann & Robert Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | | | - Benan Bayrakci
- Department of Pediatric Intensive Care Medicine, Life Support Center, Hacettepe University, Ankara, Turkey
| | | | | | - Patrick D Brophy
- Golisano Children's Hospital, Rochester University Medical Center, Rochester, New York
| | | | | | | | - Akash Deep
- King's College London, London, United Kingdom
| | - Prasad Devarajan
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kristin Dolan
- Mercy Children's Hospital Kansas City, Kansas City, Missouri
| | - Dana Y Fuhrman
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Katja M Gist
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Stephen M Gorga
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor
| | | | - Denise Hasson
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Arpana Iyengar
- St John's Academy of Health Sciences, Bangalore, Karnataka, India
| | | | | | - Leslie Meigs
- Stead Family Children's Hospital, The University of Iowa, Iowa City
| | - Shina Menon
- Seattle Children's Hospital, Seattle, Washington
| | - Jolyn Morgan
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Theresa Mottes
- Ann & Robert Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | - Tara M Neumayr
- Washington University School of Medicine, St Louis, Missouri
| | | | | | | | - Michelle Starr
- Riley Children's Hospital, Indiana University, Bloomington
| | - Natalja L Stanski
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Scott M Sutherland
- Lucille Packard Children's Hospital, Stanford University, Stanford, California
| | | | | | - Molly Wong Vega
- Division of Nephrology, Texas Children's Hospital, Baylor College of Medicine, Houston
| | | | - Claudio Ronco
- Universiti di Padova, San Bartolo Hospital, Vicenza, Italy
| | | | - John Kellum
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Rajit K Basu
- Ann & Robert Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
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57
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Persson JN, Kim JS, Good RJ. Diagnostic Utility of Point-of-Care Ultrasound in the Pediatric Cardiac Intensive Care Unit. CURRENT TREATMENT OPTIONS IN PEDIATRICS 2022; 8:151-173. [PMID: 36277259 PMCID: PMC9264295 DOI: 10.1007/s40746-022-00250-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/08/2022] [Indexed: 12/26/2022]
Abstract
Purpose of Review Recent Findings Summary Supplementary Information
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Affiliation(s)
- Jessica N. Persson
- Division of Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Children’s Hospital Colorado, 13123 East 16th, Avenue, Box 100, Aurora, CO 80045 USA
- Division of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine, Children’s Hospital Colorado, 13123 East 16th, Avenue, Box 100, Aurora, CO 80045 USA
| | - John S. Kim
- Division of Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Children’s Hospital Colorado, 13123 East 16th, Avenue, Box 100, Aurora, CO 80045 USA
| | - Ryan J. Good
- Division of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine, Children’s Hospital Colorado, 13123 East 16th, Avenue, Box 100, Aurora, CO 80045 USA
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58
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Gist KM, Misfeldt A, Sahay RD, Gorga SM, Askenazi DJ, Bridges BC, Paden ML, Zappitelli M, Gien J, Basu RK, Jetton JG, Murphy HJ, King E, Fleming GM, Selewski DT, Cooper DS. Acute Kidney Injury and Fluid Overload in Pediatric Extracorporeal Cardio-Pulmonary Resuscitation: A Multicenter Retrospective Cohort Study. ASAIO J 2022; 68:956-963. [PMID: 34643574 DOI: 10.1097/mat.0000000000001601] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Acute kidney injury (AKI) and fluid overload (FO) are common complications of extracorporeal membrane oxygenation (ECMO). The purpose of this study was to characterize AKI and FO in children receiving extracorporeal cardiopulmonary resuscitation (eCPR). We performed a multicenter retrospective study of children who received eCPR. AKI was assessed during ECMO and FO defined as <10% [FO-] vs. ≥10% [FO+] evaluated at ECMO initiation and discontinuation. A composite exposure, defined by a four-group discrete phenotypic classification [FO-/AKI-, FO-/AKI+, FO+/AKI-, FO+/AKI+] was also evaluated. Primary outcome was mortality and hospital length of stay (LOS) among survivors. 131 patients (median age 29 days (IQR:9, 242 days); 51% men and 82% with underlying cardiac disease) were included. 45.8% survived hospital discharge. FO+ at ECMO discontinuation, but not AKI was associated with mortality [aOR=2.3; 95% CI: 1.07-4.91]. LOS for FO+ patients was twice as long as FO- patients, irrespective of AKI status [(FO+/AKI+ (60 days; IQR: 49-83) vs. FO-/AKI+ (30 days, IQR: 19-48 days); P = 0.01]. FO+ at ECMO initiation and discontinuation was associated with an adjusted 66% and 50% longer length of stay respectively. Prospective studies that target timing and strategy of fluid management, including its removal in children receiving ECPR are greatly needed.
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Affiliation(s)
- Katja M Gist
- From the Department of Pediatrics, Children's Hospital of Colorado University of Colorado Anschutz Medical Campus Aurora, Colorado
| | - Andrew Misfeldt
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Rashmi D Sahay
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Stephen M Gorga
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan
| | - David J Askenazi
- Department of Pediatrics, University of Alabama Birmingham, Birmingham, Alabama
| | - Brian C Bridges
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Matthew L Paden
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Michael Zappitelli
- Department of Pediatrics, Toronto Hospital for Sick Children, Toronto, Canada and McGill University Health Centre, Montreal, Canada
| | - Jason Gien
- From the Department of Pediatrics, Children's Hospital of Colorado University of Colorado Anschutz Medical Campus Aurora, Colorado
| | - Rajit K Basu
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jennifer G Jetton
- Division of Nephrology, Dialysis and Transplantation, Stead Family Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, Iowa
| | - Heidi J Murphy
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Eileen King
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Geoffrey M Fleming
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
- Deceased
| | - David T Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - David S Cooper
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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59
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Raina R, Abu-Arja R, Sethi S, Dua R, Chakraborty R, Dibb JT, Basu RK, Bissler J, Felix MB, Brophy P, Bunchman T, Alhasan K, Haffner D, Kim YH, Licht C, McCulloch M, Menon S, Onder AM, Khooblall P, Khooblall A, Polishchuk V, Rangarajan H, Sultana A, Kashtan C. Acute kidney injury in pediatric hematopoietic cell transplantation: critical appraisal and consensus. Pediatr Nephrol 2022; 37:1179-1203. [PMID: 35224659 DOI: 10.1007/s00467-022-05448-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 12/22/2021] [Accepted: 12/23/2021] [Indexed: 12/15/2022]
Abstract
Hematopoietic cell transplantation (HCT) is a common therapy for the treatment of neoplastic and metabolic disorders, hematological diseases, and fatal immunological deficiencies. HCT can be subcategorized as autologous or allogeneic, with each modality being associated with their own benefits, risks, and post-transplant complications. One of the most common complications includes acute kidney injury (AKI). However, diagnosing HCT patients with AKI early on remains quite difficult. Therefore, this evidence-based guideline, compiled by the Pediatric Continuous Renal Replacement Therapy (PCRRT) working group, presents the various factors that contribute to AKI and recommendations regarding optimization of therapy with minimal complications in HCT patients.
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Affiliation(s)
- Rupesh Raina
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA.
- Department of Nephrology, Akron Children's Hospital, Akron, OH, USA.
| | - Rolla Abu-Arja
- Division of Hematology, Oncology, Blood and Bone Marrow Transplant, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Sidharth Sethi
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity Hospital, Gurgaon, Haryana, India
| | - Richa Dua
- Monmouth Medical Center, Long Branch, NJ, USA
| | - Ronith Chakraborty
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - James T Dibb
- Department of Internal Medicine, Summa Health System - Akron Campus, Akron, OH, USA
| | - Rajit K Basu
- Children's Healthcare of Atlanta, Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - John Bissler
- Department of Pediatrics, University of Tennessee Health Science Center and Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Melvin Bonilla Felix
- Department of Pediatrics, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico
| | - Patrick Brophy
- Department of Pediatrics, University of Rochester School of Medicine, Rochester, NY, USA
| | - Timothy Bunchman
- Pediatric Nephrology & Transplantation, Children's Hospital of Richmond at VCU, Richmond, VA, USA
| | - Khalid Alhasan
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Yap Hui Kim
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, Singapore, Singapore
| | - Christopher Licht
- Division of Nephrology, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Mignon McCulloch
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Shina Menon
- Division of Pediatric Nephrology, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Ali Mirza Onder
- Division of Pediatric Nephrology, Le Bonheur Children's Hospital, University of Tennessee, School of Medicine, Memphis, TN, USA
- Division of Pediatric Nephrology, Batson Children's Hospital of Mississippi, University of Mississippi Medical Center, Jackson, MS, USA
| | - Prajit Khooblall
- Department of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Amrit Khooblall
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Veronika Polishchuk
- Division of Hematology, Oncology, Blood and Bone Marrow Transplant, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Hemalatha Rangarajan
- Division of Hematology, Oncology, Blood and Bone Marrow Transplant, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Azmeri Sultana
- Department of Pediatric Nephrology, MR Khan Hospital & Institute of Child Health, Mirpur-2, Dhaka, Bangladesh
| | - Clifford Kashtan
- Department of Pediatrics, Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis, MN, USA
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Bakoš M, Braovac D, Barić H, Belina D, Željko Đurić, Dilber D, Novak M, Matić T. Extracorporeal membrane oxygenation in children: An update of a single tertiary center 11-Year experience from Croatia. Perfusion 2022:2676591221093204. [PMID: 35543369 DOI: 10.1177/02676591221093204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO) is an important treatment option for organ support in respiratory insufficiency, cardiac failure, or as an advanced tool for cardiopulmonary resuscitation. Reports on pediatric ECMO use in our region are lacking. METHODS This study is a retrospective review of all pediatric cases that underwent a veno-arterial (VA) or veno-venous (VV) ECMO protocol between November 2009 and August 2020 at the Department of Pediatrics, University Hospital Center Zagreb, Croatia. RESULTS Fifty-two ECMO runs identified over the period; data were complete for 45 cases, of which 23 (51%) were female, and median age was 8 months. Thirty-eight (84%) patients were treated using the VA-and 7 (16%) using VV-ECMO. The overall survival rate was 51%. Circulatory failure was the most common indication for ECMO (N = 38, 84%), and in 17 patients ECMO was started after cardiopulmonary resuscitation (E-CPR). Among survivors, 74% had no or minor neurological sequelae. Variables associated with poor outcome were renal failure with renal replacement therapy (p < .001) and intracranial injury (p < .001). CONCLUSION Overall survival rate in our cohort is comparable to the data published in the literature. The use of hemodialysis was shown to be associated with higher mortality. High rates of full neurological recovery among survivors are a strong case for further ECMO program development in our institution.
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Affiliation(s)
- Matija Bakoš
- Department of Pediatrics, University Hospital Centre Zagreb,Zagreb, Croatia
| | - Duje Braovac
- Department of Pediatrics, University Hospital Centre Zagreb,Zagreb, Croatia
| | - Hrvoje Barić
- Department of Neurosurgery, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Dražen Belina
- Department of Cardiac Surgery, University Hospital Centre Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Željko Đurić
- Department of Cardiac Surgery, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Daniel Dilber
- Department of Pediatrics, University Hospital Centre Zagreb,Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Milivoj Novak
- Department of Pediatrics, University Hospital Centre Zagreb,Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Toni Matić
- Department of Pediatrics, University Hospital Centre Zagreb,Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
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Bridges BC, Dhar A, Ramanathan K, Steflik HJ, Schmidt M, Shekar K. Extracorporeal Life Support Organization Guidelines for Fluid Overload, Acute Kidney Injury, and Electrolyte Management. ASAIO J 2022; 68:611-618. [PMID: 35348527 DOI: 10.1097/mat.0000000000001702] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
DISCLAIMER This guideline for extracorporeal membrane oxygenation (ECMO) fluid and electrolyte management for all patient populations is intended for educational use to build the knowledge of physicians and other health professionals in assessing the conditions and managing the treatment of patients undergoing extracorporeal life support (ECLS)/ECMO and describe what are believed to be useful and safe practice for ECLS/ECMO, but these are not necessarily consensus recommendations. The aim of clinical guidelines is to help clinicians to make informed decisions about their patients. However, adherence to a guideline does not guarantee a successful outcome. Ultimately, healthcare professionals must make their own treatment decisions about care on a case-by-case basis, after consultation with their patients, using their clinical judgment, knowledge, and expertise. These guidelines do not take the place of physicians' and other health professionals' judgment in diagnosing and treatment of particular patients. These guidelines are not intended to and should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment must be made by the physician and other health professionals and the patient in light of all the circumstances presented by the individual patient, and the known variability and biologic behavior of the clinical condition. These guidelines reflect the data at the time the guidelines were prepared; the results of subsequent studies or other information may cause revisions to the recommendations in these guidelines to be prudent to reflect new data, but Extracorporeal Life Support Organization (ELSO) is under no obligation to provide updates. In no event will ELSO be liable for any decision made or action taken in reliance upon the information provided through these guidelines.
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Affiliation(s)
- Brian C Bridges
- From the Division of Pediatric Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Archana Dhar
- Department of Pediatrics, UT Southwestern Medical School, Dallas, Texas
| | - Kollengode Ramanathan
- Department of Cardiothoracic Intensive Care Unit, National University Hospital, Singapore
| | - Heidi J Steflik
- Division of Neonatal Perinatal Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Matthieu Schmidt
- Department of Intensive Care Medicine at Sorbonne University, Paris, France
- Medical Intensive Care Unit, Pitié-Salpêtrière Hospital, Paris, France
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia
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Creatinine correction to account for fluid overload in children with acute respiratory distress syndrome treated with extracorporeal membrane oxygenation: an initial exploratory report. Pediatr Nephrol 2022; 37:891-898. [PMID: 34545447 DOI: 10.1007/s00467-021-05257-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 07/15/2021] [Accepted: 07/16/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Creatinine is distributed between the intracellular and extracellular compartments, and as a result, the measurement of its concentration is strongly related to the fluid status of the patient. An interest has been shown in correcting measured serum creatinine levels according to the fluid balance in order to better specify the degree of acute kidney injury (AKI). METHODS We conducted a retrospective observational study of 33 children, aged 0 to 5 years, admitted to the pediatric intensive care unit for acute respiratory distress syndrome treated by extracorporeal membrane oxygenation. We compared measured and corrected creatinine and assessed the degree of agreement between these values using both Cohen's kappa and Krippendorff's alpha coefficient. RESULTS In our cohort, 37% of the classifications made according to measured creatinine levels were erroneous and, in the majority of cases, the degree of AKI was underestimated. CONCLUSION Correction of the measured creatinine value according to the degree of fluid overload may result in more accurate diagnosis of AKI. Graphical abstract A higher resolution version of the Graphical abstract is available as Supplementary information.
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赖 志, 杨 文, 马 可. Effect of fluid load on the prognosis of children with sepsis-associated acute kidney injury undergoing continuous renal replacement therapy. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2022; 24:279-284. [PMID: 35351258 PMCID: PMC8974647 DOI: 10.7499/j.issn.1008-8830.2111001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 02/03/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES To evaluate the effect of fluid load on the prognosis of children with sepsis-associated acute kidney injury (AKI) undergoing continuous renal replacement therapy (CRRT). METHODS A total of 121 children who underwent CRRT for sepsis-associated AKI from August 2018 to March 2021 were enrolled in the retrospective study. According to the fluid load from admission or disease progression to CRRT, they were divided into three groups: low fluid load (fluid load: <5%; n=35), high fluid load (fluid load: 5% - <10%; n=35), and fluid overload (fluid load: ≥10%; n=51). Baseline data and clinical biochemical data before CRRT were collected for comparison and analysis. The Kaplan-Meier survival curve analysis was used for comparison of 28-day survival between groups. The multivariate logistic regression model was used to identify the influencing factors for the prognosis of the children. RESULTS The survival analysis showed that the fluid overload group had a significantly higher 28-day mortality rate than the low fluid load and high fluid load groups (P<0.05). The multivariate logistic regression analysis showed that an increase in fluid overload volume was a risk factor for increased 28-day mortality in the fluid overload group, while earlier initiation of CRRT was a protective factor (P<0.05). CONCLUSIONS Fluid overload before CRRT may increase the mortality in children with sepsis-associated AKI, and CRRT should be performed for these children as early as possible.
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Rameshkumar R, Chidambaram M, Bhanudeep S, Krishnamurthy K, Sheriff A, Selvan T, Mahadevan S. Prospective Cohort Study on Cumulative Fluid Balance and Outcome in Critically Ill Children Using a Restrictive Fluid Protocol. Indian J Pediatr 2022; 89:226-232. [PMID: 34106444 DOI: 10.1007/s12098-021-03788-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To study the association of cumulative fluid balance and clinical outcomes in a pediatric intensive care unit (PICU) practicing restrictive fluid protocol. METHODS In this prospective cohort study, children aged less than 13 y admitted for more than 48 h were screened. Children with unstable hemodynamics throughout the stay were excluded. Fluid balance was calculated by percentage fluid overload (%FO) for the first 7 d. Patients were divided into positive fluid and negative fluid balance groups. The primary outcome was all-cause 28-d mortality. RESULTS A total of 888 patients (positive fluid balance group = 531, negative fluid balance group = 357) were analyzed. Mean (SD) cumulative %FO was 1.52 (0.67) vs. -1.18 (0.71), p = < 0.001, and minimum and maximum cumulative %FO were -3.0% and 3.1%, respectively. There was no significant difference in all-cause 28-d mortality between the two groups (n = 104/531, 19.6% vs. n = 60/357, 16.8%, RR = 1.17, 95% CI 0.87 to 1.55; p = 0.29). There was no difference in organ dysfunction [mean (SD) sequential organ failure assessment (SOFA) score 3.3 (0.7) vs. 3.3 (0.6)], acute kidney injury (65% vs. 63.6%), need for renal replacement therapy (14% vs. 13%), and duration of ventilation (median, IQR 4, 2-6 vs. 4, 2-6 d). Longer stay in PICU (5, 3-9 vs. 4, 3-7 d; p = 0.014) and in hospital (8, 5-11 vs. 7, 4-10 d; p = 0.007) were noted in the positive fluid balance group. CONCLUSION Cumulative fluid balance within 3% using restrictive fluid protocol was not associated with a significant difference in PICU mortality and morbidity.
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Affiliation(s)
- Ramachandran Rameshkumar
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006, India.
| | - Muthu Chidambaram
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006, India
| | - Singanamalla Bhanudeep
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006, India
| | | | - Abraar Sheriff
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006, India
| | - Tamil Selvan
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Subramanian Mahadevan
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006, India
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Slagle C, Gist KM, Starr MC, Hemmelgarn TS, Goldstein SL, Kent AL. Fluid Homeostasis and Diuretic Therapy in the Neonate. Neoreviews 2022; 23:e189-e204. [PMID: 35229135 DOI: 10.1542/neo.23-3-e189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Understanding physiologic water balance and homeostasis mechanisms in the neonate is critical for clinicians in the NICU as pathologic fluid accumulation increases the risk for morbidity and mortality. In addition, once this process occurs, treatment is limited. In this review, we will cover fluid homeostasis in the neonate, explain the implications of prematurity on this process, discuss the complexity of fluid accumulation and the development of fluid overload, identify mitigation strategies, and review treatment options.
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Affiliation(s)
- Cara Slagle
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center and the University of Cincinnati, College of Medicine, Cincinnati, OH
| | - Katja M Gist
- Division of Cardiology, Cincinnati Children's Hospital Medical Center and the University of Cincinnati, College of Medicine, Cincinnati, OH
| | - Michelle C Starr
- Division of Pediatric Nephrology, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children, Indianapolis, IN
| | - Trina S Hemmelgarn
- Division of Pharmacology, Cincinnati Children's Hospital Medical Center and the University of Cincinnati, College of Pharmacy, Cincinnati, OH
| | - Stuart L Goldstein
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center and the University of Cincinnati, College of Medicine, Cincinnati, OH
| | - Alison L Kent
- Department of Pediatrics, University of Rochester, NY, and Australian National University Medical School, Canberra, ACT, Australia
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Duyu M, Turkozkan C. Clinical features and risk factors associated with mortality in critically ill children requiring continuous renal replacement therapy. Ther Apher Dial 2022; 26:1121-1130. [PMID: 35129292 DOI: 10.1111/1744-9987.13811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 12/07/2021] [Accepted: 02/05/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The aims of this study were to describe the demographic characteristics of critically ill children requiring continuous renal replacement therapy (CRRT) at our pediatric intensive care unit (PICU) and to explore risk factors associated with mortality. METHODS A retrospective cohort of 121 critically ill children who received CRRT from May 2015 to May 2020 in the PICU of a tertiary healthcare institution was evaluated. RESULTS Overall mortality was 29.8%. In patients diagnosed with sepsis, time until CRRT initiation was significantly shorter in survivors compared to non-survivors (p = 0.036). Based on multivariate logistic regression, presence of comorbidity (OR: 5.71), diagnoses of pneumonia/respiratory failure at admission (OR:16.16), and high lactate level at CRRT initiation (OR:1.43) were independently associated with mortality. CONCLUSION In the context of the population studied, mortality rate was lower than previously reported. Despite having a large series, heterogenous characteristics and limitations in subgroups may have influenced results and survival. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Muhterem Duyu
- Department of Pediatrics, Pediatric Intensive Care Unit, Istanbul Medeniyet University Prof. Dr. Suleyman Yalcin City Hospital, Istanbul, Turkey
| | - Ceren Turkozkan
- Department of Pediatrics, Istanbul Medeniyet University Prof. Dr. Suleyman Yalcin City Hospital, Istanbul, Turkey
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Fitzgerald JC, Basu RK, Fuhrman D, Gorga SM, Hassinger AB, Sanchez-Pinto LN, Selewski DT, Sutherland SM, Arikan AA. Renal Dysfunction Criteria in Critically Ill Children: The PODIUM Consensus Conference. Pediatrics 2022; 149:S66-S73. [PMID: 34970682 PMCID: PMC9722270 DOI: 10.1542/peds.2021-052888j] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/24/2021] [Indexed: 01/03/2023] Open
Abstract
CONTEXT Renal dysfunction is associated with poor outcomes in critically ill children. OBJECTIVE To evaluate the current evidence for criteria defining renal dysfunction in critically ill children and association with adverse outcomes. To develop contemporary consensus criteria for renal dysfunction in critically ill children. DATA SOURCES PubMed and Embase were searched from January 1992 to January 2020. STUDY SELECTION Included studies evaluated critically ill children with renal dysfunction, performance characteristics of assessment tools for renal dysfunction, and outcomes related to mortality, functional status, or organ-specific or other patient-centered outcomes. Studies with adults or premature infants (≤36 weeks' gestational age), animal studies, reviews, case series, and studies not published in English with inability to determine eligibility criteria were excluded. DATA EXTRACTION Data were extracted from included studies into a standard data extraction form by task force members. RESULTS The systematic review supported the following criteria for renal dysfunction: (1) urine output <0.5 mL/kg per hour for ≥6 hours and serum creatinine increase of 1.5 to 1.9 times baseline or ≥0.3 mg/dL, or (2) urine output <0.5 mL/kg per hour for ≥12 hours, or (3) serum creatinine increase ≥2 times baseline, or (4) estimated glomerular filtration rate <35 mL/minute/1.73 m2, or (5) initiation of renal replacement therapy, or (6) fluid overload ≥20%. Data also support criteria for persistent renal dysfunction and for high risk of renal dysfunction. LIMITATIONS All included studies were observational and many were retrospective. CONCLUSIONS We present consensus criteria for renal dysfunction in critically ill children.
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Affiliation(s)
- Julie C. Fitzgerald
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Rajit K. Basu
- Department of Pediatrics, Emory School of Medicine, Atlanta, GA
| | - Dana Fuhrman
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Stephen M. Gorga
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI
| | - Amanda B. Hassinger
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, John R. Oishei Children’s Hospital, Buffalo, NY
| | - L. Nelson Sanchez-Pinto
- Department of Pediatrics, Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - David T. Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Scott M. Sutherland
- Department of Pediatrics, Division of Nephrology, Stanford University School of Medicine, Stanford, CA
| | - Ayse Akcan Arikan
- Department of Pediatrics, Sections of Critical Care and Renal, Baylor College of Medicine, Houston, TX
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Goldstein SL, Vidal E, Ricci Z, Paglialonga F, Peruzzi L, Giordano M, Laforgia N, Ronco C. Survival of infants treated with CKRT: comparing adapted adult platforms with the Carpediem™. Pediatr Nephrol 2022; 37:667-675. [PMID: 34414499 PMCID: PMC8376293 DOI: 10.1007/s00467-021-05180-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 06/07/2021] [Accepted: 06/08/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The most severely ill neonates and infants with AKI who need kidney replacement therapy have had to rely upon peritoneal dialysis, or adaptations of veno-venous continuous kidney replacement therapy (CKRT) devices for adults. Data from the Prospective Pediatric CRRT (ppCRRT) registry observed children < 10 kg had a lower survival rate than children > 10 kg (44% vs. 64%, p < 0.001). A CKRT device designed specifically for small children could improve outcomes. The Cardio-Renal Pediatric Dialysis Emergency Machine (CARPEDIEM™) is specifically dedicated to providing CKRT for newborns and small infants. METHODS We performed a retrospective cohort analysis comparing patient severity of illness and outcomes between the ppCRRT and CARPEDIEM registries, involving 6 Italian pediatric intensive care units. Thirty-eight subjects from the CARPEDIEM registry and 84 subjects from the ppCRRT registry < 10 kg were screened for comparison. We compared patient outcomes with a weight-matched cohort (< 5 kg) of 34 patients from the CARPEDIEM registry and 48 patients from the ppCRRT registry. RESULTS The ppCRRT subjects had higher rates of vasoactive medication at CKRT initiation. Survival to CKRT termination was higher for CARPEDIEM subjects (33/34 vs. 21/48, p < 0.0001). Multivariable logistic regression showed that CARPEDIEM registry cohort was the only variable to retain an association with survival to CKRT discontinuation. CONCLUSIONS We suggest children receiving CKRT using CARPEDIEM have excellent survival. Our data should be interpreted with caution given the retrospective comparison across two eras more than a decade apart.
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Affiliation(s)
- Stuart L. Goldstein
- Cincinnati Children’s Hospital, 3333 Burnet Avenue, MLC 7022, Cincinnati, OH 45229 USA
| | - Enrico Vidal
- University Hospital of Padova, Via Nicolò Giustiniani, 2, 35128 Padova, PD Italy
| | - Zaccaria Ricci
- Azienda Ospedaliero, Universitaria Meyer, Viale Gaetano Pieraccini, 24, 50139 Firenze, FI Italy
| | - Fabio Paglialonga
- Fondazione IRCSS Ca’ Grande Ospedale Maggiore Policlinico, Via della Commenda, 10, 20122 Milano, MI Italy
| | - Licia Peruzzi
- Regina Margherita Children’s Hospital, Piazza Polonia, 94, 10126 Torino, TO Italy
| | - Mario Giordano
- Giovanni XXIII Children’s Hospital, Via Giovanni Amendola, 207, 70126 Bari, BA Italy
| | - Nicola Laforgia
- Giovanni XXIII Children’s Hospital, Via Giovanni Amendola, 207, 70126 Bari, BA Italy
| | - Claudio Ronco
- San Bortolo Hospital, Viale Ferdinando Rodolfi, 37, 36100 Vicenza, VI Italy
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Yenjabog P, Kanchongkittiphon W, Chutipongtanate S, Lertbunrian R, Ungprasert P. Dynamic parameters for fluid responsiveness in mechanically ventilated children: A systematic review. Front Pediatr 2022; 10:1010600. [PMID: 36353262 PMCID: PMC9638161 DOI: 10.3389/fped.2022.1010600] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 09/28/2022] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE Fluid administration is the initial step of treatment of unstable pediatric patients. Evaluation of fluid responsiveness is crucial in mechanically ventilated children to avoid fluid overload, which increases mortality. We aim to review and compare the diagnostic performance of dynamically hemodynamic parameters for predicting fluid responsiveness in mechanically ventilated children. DESIGN A systematic review was performed using four electronic databases, including PubMed, EMBASE, Scopus, and Central, for published articles from 1 January 2010 to 31 December 2020. Studies were included if they described diagnostic performance of dynamic parameters after fluid challenge was performed in mechanically ventilated children. SETTINGS Pediatric intensive and cardiac intensive care unit, and operative room. PATIENTS Children aged 1 month to 18 years old who were under mechanical ventilation and required an intravenous fluid challenge. MEASUREMENTS AND MAIN RESULTS Twenty-seven studies were included in the systematic review, which included 1,005 participants and 1,138 fluid challenges. Respiratory variation in aortic peak velocity was reliable among dynamic parameters for predicting fluid responsiveness in mechanically ventilated children. All studies of respiratory variation in aortic peak velocity showed that the area under the receiver operating characteristic curve ranged from 0.71 to 1.00, and the cutoff value for determining fluid responsiveness ranged from 7% to 20%. Dynamic parameters based on arterial blood pressure (pulse pressure variation and stroke volume variation) were also used in children undergoing congenital heart surgery. The plethysmography variability index was used in children undergoing neurological and general surgery, including the pediatric intensive care patients. CONCLUSIONS The respiratory variation in aortic peak velocity exhibited a promising diagnostic performance across all populations in predicting fluid responsiveness in mechanically ventilated children. High sensitivity is advantageous in non-cardiac surgical patients and the pediatric intensive care unit because early fluid resuscitation improves survival in these patients. Furthermore, high specificity is beneficial in congenital heart surgery because fluid overload is particularly detrimental in this group of patients. SYSTEMATIC REVIEW REGISTRATION https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=206400.
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Affiliation(s)
- Patcha Yenjabog
- Division of Pediatric Critical Care, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Wacharoot Kanchongkittiphon
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Somchai Chutipongtanate
- Pediatric Translational Research Unit, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Department of Clinical Epidemiology and Biostatistics, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan, Thailand
| | - Rojjanee Lertbunrian
- Division of Pediatric Critical Care, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Patompong Ungprasert
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, United States
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Barhight MF, Nelson D, Chong G, Basu RK, Sanchez-Pinto LN. Non-resuscitation fluid in excess of hydration requirements is associated with higher mortality in critically ill children. Pediatr Res 2022; 91:235-240. [PMID: 33731814 PMCID: PMC7968408 DOI: 10.1038/s41390-021-01456-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/28/2021] [Accepted: 02/17/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Large volumes of non-resuscitation fluids are often administered to critically ill children. We hypothesize that excess maintenance fluid is a significant contributor to non-resuscitation fluid and that non-resuscitation fluid administered beyond hydration requirements is associated with worse clinical outcomes in critically ill children. METHODS We evaluated all patients admitted to two large urban pediatric intensive care units (PICU) between January 2010-August 2016 and January 2010-August 2018, respectively, who survived and remained in the hospital for at least 3 days following PICU admission. The primary outcome was in-hospital mortality. Association of excess fluid with outcomes was adjusted for confounders (age, Pediatric Risk of Mortality III score, study site, day 3 acute kidney injury, PICU era, resuscitation volume, and volume output) using multivariable regression. RESULTS We evaluated 14,483 patients; 52% received non-resuscitation fluid in excess of hydration requirements. Non-resuscitation fluid in excess of hydration requirements was associated with higher in-hospital mortality after adjustment for confounders (adjusted odds ratio 1.01 per 10 mL/kg in excess fluid, 95% confidence interval: 1.002-1.02). CONCLUSIONS Non-resuscitation fluid in excess of hydration requirements is associated with increased mortality in critically ill children. Excess maintenance fluid is a modifiable contributor to this fluid volume. Strategies to reduce excess maintenance fluids warrant further study. IMPACT Critically ill children frequently receive non-resuscitation fluid in excess of their estimated hydration requirements. Non-resuscitation fluid volume in excess of estimated hydration requirements is associated with higher morbidity and mortality in critically ill children. Critically ill children receive a large volume burden from maintenance fluid. Maintenance fluid represents a modifiable contributor of non-resuscitation fluid in excess of hydration requirements. Strategies focused on limitation of maintenance fluid warrant further study.
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Affiliation(s)
- Matthew F. Barhight
- grid.413808.60000 0004 0388 2248Division of Critical Care, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL USA ,grid.16753.360000 0001 2299 3507Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL USA
| | - Delphine Nelson
- grid.413808.60000 0004 0388 2248Division of Kidney Diseases, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL USA
| | - Grace Chong
- grid.428125.80000 0004 0383 0499The University of Chicago Comer Children’s Hospital, Chicago, IL USA
| | - Rajit K. Basu
- grid.189967.80000 0001 0941 6502Department of Pediatrics, Division of Critical Care Medicine, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA USA
| | - L. Nelson Sanchez-Pinto
- grid.413808.60000 0004 0388 2248Division of Critical Care, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL USA ,grid.16753.360000 0001 2299 3507Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL USA
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71
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Gelbart B, Masterson K, Serratore A, Zampetti M, Veysey A, Longstaff S, Bellomo R, Butt W, Duke T. Precision of weight measurement in critically ill infants: a technical report. CRIT CARE RESUSC 2021; 23:414-417. [PMID: 38046691 PMCID: PMC10692624 DOI: 10.51893/2021.4.tn] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: To investigate the precision of weight measurements in critically ill infants in a paediatric intensive care unit (PICU). Design: Prospective cohort study. Setting: Royal Children's Hospital PICU. Participants: Mechanically ventilated infants admitted to the Royal Children's Hospital PICU between September 2020 and February 2021. Main outcome measures: Mean percentage difference and agreement of consecutive weight measurements. Results: Thirty infants were enrolled, of which 17 were receiving post-surgical care for congenital heart disease and four were receiving extracorporeal membrane oxygenation (ECMO). The median age was 13 days (interquartile range [IQR], 3.1-52.4 days). The mean difference in weight was 1.3% (standard deviation [SD], 1.0%), and the test-retest agreement intraclass correlation was 0.99 (95% CI, 0.99-0.99; P < 0.01). The percentage difference between measurements was ≤ 2.5% in 26/30 (87%) children, and the range was < 0.1% to 3.6%. In 26 children not receiving ECMO, the mean difference in weight was 1.1% (SD, 1.0%). There were no complications. Conclusions: Weighing mechanically ventilated, critically ill infants in intensive care can be performed safely, with a mean difference between consecutive weights of 1.3%, making it a potentially useful additional measure of fluid accumulation.
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Affiliation(s)
- Ben Gelbart
- Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
| | - Kate Masterson
- Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Alyssa Serratore
- Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Michael Zampetti
- Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Andrea Veysey
- Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Stacey Longstaff
- Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation (DARE) Centre, University of Melbourne and Austin Hospital, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Warwick Butt
- Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
| | - Trevor Duke
- Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
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72
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Chen Z, Wang H, Wu Z, Jin M, Chen Y, Li J, Wei Q, Tao S, Zeng Q. Continuous Renal-Replacement Therapy in Critically Ill Children: Practice Changes and Association With Outcome. Pediatr Crit Care Med 2021; 22:e605-e612. [PMID: 33965990 DOI: 10.1097/pcc.0000000000002751] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES This study was designed to evaluate practice changes and outcomes over a 10-year period in a large single-center PICU cohort that received continuous renal-replacement therapy. DESIGN Retrospective study design. SETTING A multidisciplinary tertiary PICU of a university-affiliated hospital in Guangzhou, China. PATIENTS All critically ill children who were admitted to our PICU from January 2010 to December 2019 and received continuous renal-replacement therapy were included in this study. MEASUREMENTS AND MAIN RESULTS A total of 289 patients were included in the study. Of the two study periods, 2010-2014 and 2015-2019, the proportion of continuous renal-replacement therapy initiation time greater than 24 hours was significantly reduced ([73/223] 32.73% vs. [40/66] 60.60%, p < 0.001), the percentage of fluid overload at continuous renal-replacement therapy initiation was lower (3.8% [1.6-7.2%] vs. 12.1% [6.6-23.3%], p < 0.001), the percentage of regional citrate anticoagulation protocol was increased ([223/223] 100% vs. [15/66] 22.7%, p < 0.001), and the ICU survival rate was significantly improved ([24/66] 36.4% vs. [131/223] 58.7%, p = 0.001) in the latter period compared with the former. In addition, subgroup analysis found that survival were higher in patients with continuous renal-replacement therapy initiation time less than 24 hours, regional citrate anticoagulation protocol, and fluid overload less than 10%. CONCLUSIONS The survival rate of patients received continuous renal-replacement therapy treatment in our center has improved over past 10 years, and some changes have taken place during these periods. Among them, early initiation of continuous renal-replacement therapy, lower fluid overload, and regional citrate anticoagulation method seems to be related to the improvement of outcome. Ongoing evaluation of the practice changes and quality improvement of continuous renal-replacement therapy for critically ill pediatric patients still need attention.
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Affiliation(s)
- ZhiJiang Chen
- Department of Pediatrics, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - HuiLi Wang
- Department of Laboratory, Guangdong Women and Children Hospital, Guangzhou, China
| | - Zhu Wu
- Department of Pediatrics, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Ming Jin
- Department of Pediatrics, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - YiTing Chen
- Department of Pediatrics, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Jun Li
- Department of Pediatrics, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - QiuJu Wei
- Department of Pediatrics, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - ShaoHua Tao
- Department of Pediatrics, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Qiyi Zeng
- Department of Pediatrics, Zhujiang Hospital, Southern Medical University, Guangzhou, China
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73
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Controversies in paediatric acute kidney injury and continuous renal replacement therapy: can paediatric care lead the way to precision acute kidney injury medicine? Curr Opin Crit Care 2021; 27:604-610. [PMID: 34561357 DOI: 10.1097/mcc.0000000000000888] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Paediatric patients represent a unique challenge for providers managing acute kidney injury (AKI). Critical care for these children requires a precise approach to assessment, diagnostics and management. RECENT FINDINGS Primarily based on observational data, large epidemiologic datasets have demonstrated a strong association between AKI prevalence (one in four critically ill children) and poor patient outcome. Drivers of AKI itself are multifactorial and the causal links between AKI and host injury remain incompletely defined, creating a management paradigm primarily supportive in nature. The previous decades of research have focused primarily on elucidating the population-level epidemiologic signal of AKI and use of renal replacement therapy (RRT), but in order to reverse the course of the AKI 'epidemic', future decades will require more attention to the individual patient. A patient-level approach to AKI in children will require sophisticated approaches to risk stratification, diagnostics and targeted utilization of therapies (both supportive and targeted towards drivers of injury). SUMMARY In this review, we will summarize the past, present and future of AKI care in children, discussing the ongoing work and future goals of a personalized approach to AKI medicine.
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74
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Lessons Learned from a Small Pediatric Continuous Renal Replacement Therapy Program. Crit Care Res Pract 2021; 2021:6481559. [PMID: 34840825 PMCID: PMC8612790 DOI: 10.1155/2021/6481559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 10/04/2021] [Accepted: 11/06/2021] [Indexed: 11/18/2022] Open
Abstract
Continuous renal replacement therapy (CRRT) has become a pillar of care in pediatric intensive care units (PICUs) over the past few decades. Quality indicators (QIs) have been evaluated that reflect safe and accountable CRRT. However, there is a paucity of data on outcomes and QIs in smaller-volume CRRT programming. The purpose of this retrospective study was to evaluate the efficiencies, effectiveness, and outcomes of a small-volume CRRT program. Eighty-two patients received CRRT over a 13-year period, and 79% survived to discharge. Sepsis or nonseptic shock (n = 11 (22%) versus n = 6 (50%); p value = 0.004) and time to CRRT initiation after PICU admission (1.1 versus 5.0 days; p value = 0.005) were independent predictors for mortality. The program also had positive outcomes for QIs related to CRRT efficiency and time of initiation, dosing delivery, and rate of adverse events. This study is important as it illustrates the opportunity that smaller centers have to initiate CRRT programming and provide safe and effective care.
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75
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Starr MC, Charlton JR, Guillet R, Reidy K, Tipple TE, Jetton JG, Kent AL, Abitbol CL, Ambalavanan N, Mhanna MJ, Askenazi DJ, Selewski DT, Harer MW. Advances in Neonatal Acute Kidney Injury. Pediatrics 2021; 148:peds.2021-051220. [PMID: 34599008 DOI: 10.1542/peds.2021-051220] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/13/2021] [Indexed: 01/14/2023] Open
Abstract
In this state-of-the-art review, we highlight the major advances over the last 5 years in neonatal acute kidney injury (AKI). Large multicenter studies reveal that neonatal AKI is common and independently associated with increased morbidity and mortality. The natural course of neonatal AKI, along with the risk factors, mitigation strategies, and the role of AKI on short- and long-term outcomes, is becoming clearer. Specific progress has been made in identifying potential preventive strategies for AKI, such as the use of caffeine in premature neonates, theophylline in neonates with hypoxic-ischemic encephalopathy, and nephrotoxic medication monitoring programs. New evidence highlights the importance of the kidney in "crosstalk" between other organs and how AKI likely plays a critical role in other organ development and injury, such as intraventricular hemorrhage and lung disease. New technology has resulted in advancement in prevention and improvements in the current management in neonates with severe AKI. With specific continuous renal replacement therapy machines designed for neonates, this therapy is now available and is being used with increasing frequency in NICUs. Moving forward, biomarkers, such as urinary neutrophil gelatinase-associated lipocalin, and other new technologies, such as monitoring of renal tissue oxygenation and nephron counting, will likely play an increased role in identification of AKI and those most vulnerable for chronic kidney disease. Future research needs to be focused on determining the optimal follow-up strategy for neonates with a history of AKI to detect chronic kidney disease.
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Affiliation(s)
- Michelle C Starr
- Division of Pediatric Nephrology, Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, Indiana
| | - Jennifer R Charlton
- Division of Nephrology, Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Ronnie Guillet
- Division of Neonatology, Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, New York
| | - Kimberly Reidy
- Division of Pediatric Nephrology, Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
| | - Trent E Tipple
- Section of Neonatal-Perinatal Medicine, Department of Pediatrics, College of Medicine, The University of Oklahoma, Oklahoma City, Oklahoma
| | - Jennifer G Jetton
- Division of Nephrology, Dialysis, and Transplantation, Stead Family Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, Iowa
| | - Alison L Kent
- Division of Neonatology, Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, New York.,College of Health and Medicine, The Australian National University, Canberra, Australia Capitol Territory, Australia
| | - Carolyn L Abitbol
- Division of Pediatric Nephrology, Department of Pediatrics, Miller School of Medicine, University of Miami and Holtz Children's Hospital, Miami, Florida
| | | | - Maroun J Mhanna
- Department of Pediatrics, Louisiana State University Shreveport, Shreveport, Louisiana
| | - David J Askenazi
- Nephrology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - David T Selewski
- Division of Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
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76
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Starr MC, Menon S. Neonatal acute kidney injury: a case-based approach. Pediatr Nephrol 2021; 36:3607-3619. [PMID: 33594463 DOI: 10.1007/s00467-021-04977-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 01/19/2021] [Accepted: 02/01/2021] [Indexed: 12/19/2022]
Abstract
Neonatal acute kidney injury (AKI) is increasingly recognized as a common complication in critically ill neonates. Over the last 5-10 years, there have been significant advancements which have improved our understanding and ability to care for neonates with kidney disease. A variety of factors contribute to an increased risk of AKI in neonates, including decreased nephron mass and immature tubular function. Multiple factors complicate the diagnosis of AKI including low glomerular filtration rate at birth and challenges with serum creatinine as a marker of kidney function in newborns. AKI in neonates is often multifactorial, but the cause can be identified with careful diagnostic evaluation. The best approach to treatment in such patients may include diuretic therapies or kidney support therapy. Data for long-term outcomes are limited but suggest an increased risk of chronic kidney disease (CKD) and hypertension in these infants. We use a case-based approach throughout this review to illustrate these concepts and highlight important evidence gaps in the diagnosis and management of neonatal AKI.
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Affiliation(s)
- Michelle C Starr
- Division of Nephrology, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Shina Menon
- Department of Pediatrics, University of Washington, Seattle, WA, USA
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77
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Kong X, Zhu Y, Zhu X. Association between early fluid overload and mortality in critically-ill mechanically ventilated children: a single-center retrospective cohort study. BMC Pediatr 2021; 21:474. [PMID: 34702226 PMCID: PMC8549157 DOI: 10.1186/s12887-021-02949-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 10/14/2021] [Indexed: 02/08/2023] Open
Abstract
Background Positive fluid overload (FO) may cause adverse effect. This study retrospectively analyzed the relationship between early FO and in-hospital mortality in children with mechanical ventilation (MV) in pediatric intensive care unit (PICU). Methods This study retrospectively enrolled 309 children (ages 28 days to 16 years) receiving invasive MV admitted to the PICU of Xinhua Hospital from March 2014 to March 2019. Children receiving MV for less than 48 h were excluded. The FO in the first 3 days of MV was considered to the early FO. Patients were divided into groups according to early FO and survival to evaluate the associations of early FO, percentage FO(%FO) > 10%, and %FO > 20% with in-hospital mortality. Results A total of 309 patients were included. The mean early FO was 8.83 ± 8.81%, and the mortality in hospital was 26.2% (81/309). There were no significant differences in mortality among different FO groups (P = 0.053) or in early FO between survivors and non-survivors (P = 0.992). Regression analysis demonstrated that use of more vasoactive drugs, the presence of multiple organ dysfunction syndrome, longer duration of MV, and a non-operative reason for PICU admission were related to increased mortality (P < 0.05). Although early FO and %FO > 10% were not associated with in-hospital mortality (β = 0.030, P = 0.090, 95% CI = 0.995–1.067; β = 0.479, P = 0.153, 95% CI = 0.837–3.117), %FO > 20% was positively correlated with mortality (β = 1.057, OR = 2.878, P = 0.029, 95% CI = 1.116–7.418). Conclusions The correlation between early FO and mortality was affected by interventions and the severity of the disease, but %FO > 20% was an independent risk factor for in-hospital mortality in critically ill MV-treated children.
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Affiliation(s)
- Xiangmei Kong
- Department of Pediatric Intensive Care Unit, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, 200092, China
| | - Yueniu Zhu
- Department of Pediatric Intensive Care Unit, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, 200092, China
| | - Xiaodong Zhu
- Department of Pediatric Intensive Care Unit, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, 200092, China.
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Boeken U, Assmann A, Beckmann A, Schmid C, Werdan K, Michels G, Miera O, Schmidt F, Klotz S, Starck C, Pilarczyk K, Rastan A, Burckhardt M, Nothacker M, Muellenbach R, Zausig Y, Haake N, Groesdonk H, Ferrari M, Buerke M, Hennersdorf M, Rosenberg M, Schaible T, Köditz H, Kluge S, Janssens U, Lubnow M, Flemmer A, Herber-Jonat S, Wessel L, Buchwald D, Maier S, Krüger L, Fründ A, Jaksties R, Fischer S, Wiebe K, Hartog CS, Dzemali O, Zimpfer D, Ruttmann-Ulmer E, Schlensak C, Kelm M, Ensminger S. S3 Guideline of Extracorporeal Circulation (ECLS/ECMO) for Cardiocirculatory Failure. Thorac Cardiovasc Surg 2021; 69:S121-S212. [PMID: 34655070 DOI: 10.1055/s-0041-1735490] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Udo Boeken
- Department of Cardiac Surgery, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Alexander Assmann
- Department of Cardiac Surgery, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Andreas Beckmann
- German Society for Thoracic and Cardiovascular Surgery, Langenbeck-Virchow-Haus, Berlin, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Karl Werdan
- Clinic for Internal Medicine III, University Hospital Halle (Saale), Martin-Luther University Halle-Wittenberg, Germany
| | - Guido Michels
- Department of Acute and Emergency Care, St Antonius Hospital Eschweiler, Eschweiler, Germany
| | - Oliver Miera
- Department of Congenital Heart Disease-Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Florian Schmidt
- Department of Pediatric Cardiology and Intensive Care Medicine, Medical School Hannover, Hannover, Germany
| | - Stefan Klotz
- Department of Cardiac Surgery, Segeberger Kliniken, Bad Segeberg, Germany
| | - Christoph Starck
- Department of Cardiothoracic and Vascular Surgery, German Heart Centre, Berlin, German
| | - Kevin Pilarczyk
- Department for Intensive Care Medicine, Imland Hospital Rendsburg, Rendsburg, Schleswig-Holstein, Germany
| | - Ardawan Rastan
- Department of Cardiac and Vascular Thoracic Surgery, Philipps-University Hospital Marburg, Marburg, Germany
| | - Marion Burckhardt
- Department of Health Sciences and Management; Baden-Wuerttemberg Cooperative State University (DHBW), Stuttgart, Germany
| | - Monika Nothacker
- Institute for Medical Knowledge Management, Association of the Scientific Medical Societies (AWMF), Universität Marburg, Marburg, Germany
| | - Ralf Muellenbach
- Department of Anaesthesiology and Critical Care Medicine, Campus Kassel of the University of Southampton, Kassel, Germany
| | - York Zausig
- Department of Anesthesiology and Operative Intensive Care Medicine, Aschaffenburg-Alzenau Hospital, Aschaffenburg, Bavaria, Germany
| | - Nils Haake
- Department for Intensive Care Medicine, Imland Hospital Rendsburg, Rendsburg, Schleswig-Holstein, Germany
| | - Heinrich Groesdonk
- Department of Intensive Care Medicine, Helios Clinic Erfurt, Erfurt, Germany
| | - Markus Ferrari
- HSK, Clinic of Internal Medicine I, Helios-Kliniken, Wiesbaden, Germany
| | - Michael Buerke
- Department of Cardiology, Angiology and Intensive Care Medicine, St. Marienkrankenhaus Siegen, Siegen, Germany
| | - Marcus Hennersdorf
- Department of Cardiology, Pneumology, Angiology and Internal Intensive Care Medicine, SLK-Kliniken Heilbronn, Heilbronn, Germany
| | - Mark Rosenberg
- Klinikum Aschaffenburg-Alzenau, Medizinische Klinik 1, Aschaffenburg, Germany
| | - Thomas Schaible
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Harald Köditz
- Medical University Children's Hospital, Hannover, Germany
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Uwe Janssens
- Medical Clinic and Medical Intensive Care Medicine, St Antonius Hospital, Eschweiler, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Andreas Flemmer
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich - Grosshadern, LMU Munich, Munich, Germany
| | - Susanne Herber-Jonat
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich - Grosshadern, LMU Munich, Germany
| | - Lucas Wessel
- Department of Pediatric Surgery, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Dirk Buchwald
- Department of Pediatric Surgery, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Sven Maier
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany
| | - Lars Krüger
- Division of Thoracic and Cardiovascular Surgery, Heart- and Diabetescentre NRW, Ruhr-University, Bochum, Germany
| | - Andreas Fründ
- Department of Physiotherapy, Heart- and Diabetescentre NRW, Ruhr-University, Bochum, Germany
| | | | - Stefan Fischer
- Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Germany
| | - Karsten Wiebe
- Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Germany
| | - Christiane S Hartog
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, and Klinik Bavaria, Kreischa
| | - Omer Dzemali
- Department of Cardiac Surgery, Triemli City hospital Zurich, Zurich, Switzerland
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Christian Schlensak
- Department of Cardio-Thoracic and Vascular Surgery, University of Tübingen, Tübingen, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Stephan Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital of Schleswig-Holstein, Lübeck, Germany
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Wu NL, Hingorani S. Outcomes of kidney injury including dialysis and kidney transplantation in pediatric oncology and hematopoietic cell transplant patients. Pediatr Nephrol 2021; 36:2675-2686. [PMID: 33411070 PMCID: PMC11198913 DOI: 10.1007/s00467-020-04842-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/10/2020] [Accepted: 10/22/2020] [Indexed: 01/26/2023]
Abstract
Pediatric oncology and hematopoietic cell transplant (HCT) patients are susceptible to both acute kidney injury (AKI) and chronic kidney disease (CKD). The etiologies of AKI vary but include tumor infiltration, radiation, drug-induced toxicity, and fluid and electrolyte abnormalities including tumor lysis syndrome. HCT patients can also have additional complications such as sinusoidal obstructive syndrome, graft-versus-host disease, or thrombotic microangiopathy. For patients with severe AKI requiring dialysis, multiple modalities can be used successfully, although continuous kidney replacement therapy (CKRT) is often the principal modality for critically ill patients. While increasing numbers of pediatric cancer and HCT patients are now surviving long term, they remain at risk for a number of chronic medical conditions, including CKD. Certain high-risk patients, due to underlying risk factors or treatment-related complications, eventually develop kidney failure and may require kidney replacement therapies. Management of co-morbidities and complications associated with kidney failure, including use of erythropoietin for anemia and potential need for ongoing cancer-related treatment while on dialysis, is an additional consideration in this patient population. Kidney transplantation can be successfully performed in pediatric cancer survivors, although additional features such as specific cancer diagnosis and duration of remission should be considered.
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Affiliation(s)
- Natalie L Wu
- Department of Pediatrics, Division of Hematology/Oncology, Fred Hutchinson Cancer Research Center, Seattle Children's Hospital, University of Washington School of Medicine, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
| | - Sangeeta Hingorani
- Department of Pediatrics, Division of Nephrology, Fred Hutchinson Cancer Research Center, Seattle Children's Hospital, University of Washington School of Medicine, 4800 Sand Point Way NE, Seattle, WA, 98105, USA.
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80
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Impact of Downtime on Clinical Outcomes in Critically Ill Patients with Acute Kidney Injury Receiving Continuous Renal Replacement Therapy. ASAIO J 2021; 68:744-752. [PMID: 34506331 DOI: 10.1097/mat.0000000000001549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Continuous renal replacement therapy (CRRT) downtime is considered a quality indicator; however, it remains uncertain whether downtime affects outcomes. This study retrospectively investigated the impact of downtime on clinical outcomes. Patients were classified as downtime <20% or ≥20% of potential operative time over 4 days from CRRT initiation. Patients with ≥20% downtime were matched to those with <20% downtime using 1:2 propensity score matching. There were 88 patients with <20% downtime and 44 patients with ≥20% downtime. The cumulative effluent volume was lower in patients with ≥20% downtime (p < 0.001). The difference in levels of urea and creatinine widened over time (p = 0.004 and <0.001). At days 2 and 3, daily fluid balance differed (p = 0.046 and 0.031), and the levels of total carbon dioxide were lower in those with ≥20% downtime (p = 0.038 and 0.020). Based on our results, ≥20% downtime was not associated with increased 28 day mortality; however, a subgroup analysis showed the interaction between downtime and daily fluid balance (p = 0.004). In conclusion, increased downtime could impair fluid and uremic control and acidosis management. Moreover, the adverse effect of downtime on fluid control may increase mortality rate. Further studies are needed to verify the value of downtime in critically ill patients requiring CRRT.
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81
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Mishra OP, Verma AK, Abhinay A, Singh A, Singh A, Prasad R. Risk factors for mortality in critically ill infants with acute kidney injury: A resource-limited setting experience. Ther Apher Dial 2021; 26:297-305. [PMID: 34296516 DOI: 10.1111/1744-9987.13712] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/08/2021] [Accepted: 07/19/2021] [Indexed: 11/28/2022]
Abstract
Infants with acute kidney injury (AKI) who are critically ill often will have multiorgan dysfunctions. Objective of the present study was to find out mortality, recovery of kidney function at discharge and at 3 months, and to determine risk factors for mortality. Fifty-two infants (24 newborns and 28 postneonatal) with AKI were included. Staging was done as per Kidney Disease Improving Global Outcomes classification. Patients were subjected to medical treatment and peritoneal dialysis (PD), wherever indicated. Kidney function tests were performed at admission, discharge, and at 3 months follow-up. Median age of neonates was 8 days and postneonatal infants were 4.5 months. Stage 1, 2, and 3 AKI were present in 14 (26.9%), 16 (30.7%), and 22 (42.3%) cases, respectively. PD was required in 22 (42.3%) infants, and significantly higher in postneonatal than in neonates (57.1% vs. 25%, p < 0.05). Significant recovery of kidney function occurred at discharge and cases had normal parameters at 3 months. Mortality was 17.3%. Patients had significantly higher risk of mortality, if they had metabolic acidosis (OR 13.22, CI 2.33-74.94, p = 0.002) and needed ventilation (OR 14.93, 95% CI 1.7-130.97, p = 0.006) and PD (OR 6.53, 95% CI 1.20-35.48, p = 0.026). In logistic regression analysis, fluid overload (p < 001), hypotension (p < 0.01), and higher PRISM-III score (p < 0.05) were found as significant risk factors for mortality. Medical management including PD led to good recovery of kidney function. Presence of fluid overload, hypotension, and higher PRISM-III score adversely affected the outcome.
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Affiliation(s)
- Om P Mishra
- Division of Pediatric Nephrology, Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Avdhesh Kumar Verma
- Division of Pediatric Nephrology, Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Abhishek Abhinay
- Division of Pediatric Nephrology, Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Akanksha Singh
- Division of Pediatric Nephrology, Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Ankur Singh
- Division of Pediatric Nephrology, Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Rajniti Prasad
- Division of Pediatric Nephrology, Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
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82
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Sallee CJ, Smith LS, Rowan CM, Heckbert SR, Angelo JR, Daniel MC, Gertz SJ, Hsing DD, Mahadeo KM, McArthur JA, Fitzgerald JC. Early Cumulative Fluid Balance and Outcomes in Pediatric Allogeneic Hematopoietic Cell Transplant Recipients With Acute Respiratory Failure: A Multicenter Study. Front Oncol 2021; 11:705602. [PMID: 34354951 PMCID: PMC8329703 DOI: 10.3389/fonc.2021.705602] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 06/21/2021] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES To evaluate the associations between early cumulative fluid balance (CFB) and outcomes among critically ill pediatric allogeneic hematopoietic cell transplant (HCT) recipients with acute respiratory failure, and determine if these associations vary by treatment with renal replacement therapy (RRT). METHODS We performed a secondary analysis of a multicenter retrospective cohort of patients (1mo - 21yrs) post-allogeneic HCT with acute respiratory failure treated with invasive mechanical ventilation (IMV) from 2009 to 2014. Fluid intake and output were measured daily for the first week of IMV (day 0 = day of intubation). The exposure, day 3 CFB (CFB from day 0 through day 3 of IMV), was calculated using the equation [Fluid in - Fluid out] (liters)/[PICU admission weight](kg)*100. We measured the association between day 3 CFB and PICU mortality with logistic regression, and the rate of extubation at 28 and 60 days with competing risk regression (PICU mortality = competing risk). RESULTS 198 patients were included in the study. Mean % CFB for the cohort was positive on day 0 of IMV, and increased further on days 1-7 of IMV. For each 1% increase in day 3 CFB, the odds of PICU mortality were 3% higher (adjusted odds ratio (aOR) 1.03, 95% CI 1.00-1.07), and the rate of extubation was 3% lower at 28 days (adjusted subdistribution hazard ratio (aSHR) 0.97, 95% CI 0.95-0.98) and 3% lower at 60 days (aSHR 0.97, 95% CI 0.95-0.98). When day 3 CFB was dichotomized, 161 (81%) had positive and 37 (19%) had negative day 3 CFB. Positive day 3 CFB was associated with higher PICU mortality (aOR 3.42, 95% CI 1.48-7.87) and a lower rate of extubation at 28 days (aSHR 0.30, 95% CI 0.18-0.48) and 60 days (aSHR 0.30, 95% 0.19-0.48). On stratified analysis, the association between positive day 3 CFB and PICU mortality was significantly stronger in those not treated with RRT (no RRT: aOR 9.11, 95% CI 2.29-36.22; RRT: aOR 1.40, 95% CI 0.42-4.74). CONCLUSIONS Among critically ill pediatric allogeneic HCT recipients with acute respiratory failure, positive and increasing early CFB were independently associated with adverse outcomes.
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Affiliation(s)
- Colin J. Sallee
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle, WA, United States
| | - Lincoln S. Smith
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle, WA, United States
| | - Courtney M. Rowan
- Division of Critical Care, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Susan R. Heckbert
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, United States
| | - Joseph R. Angelo
- Renal Section, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, United States
| | - Megan C. Daniel
- Division of Critical Care, Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, Columbus, OH, United States
| | - Shira J. Gertz
- Division of Pediatric Critical Care, Department of Pediatrics, Saint Barnabas Medical Center, Livingston, NJ, United States
| | - Deyin D. Hsing
- Division of Critical Care, Department of Pediatrics, Weil Cornell Medical College, New York Presbyterian Hospital, New York City, NY, United States
| | - Kris M. Mahadeo
- Stem Cell Transplantation and Cellular Therapy, Children’s Cancer Hospital, University of Texas at MD Anderson Cancer Center, Houston, TX, United States
| | - Jennifer A. McArthur
- Division of Critical Care, Department of Pediatrics, St Jude Children’s Research Hospital, Memphis, TN, United States
| | - Julie C. Fitzgerald
- Division of Critical Care, Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
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83
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Hemodynamic disturbances and oliguria during continuous kidney replacement therapy in critically ill children. Pediatr Nephrol 2021; 36:1889-1899. [PMID: 33433709 DOI: 10.1007/s00467-020-04804-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/15/2020] [Accepted: 09/29/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND About 1.5% of patients admitted to the Pediatric Intensive Care Unit (PICU) will require continuous kidney replacement therapy (CKRT)/renal replacement therapy (CRRT). Mortality of these patients ranges from 30 to 60%. CKRT-related hypotension (CKRT-RHI) can occur in 19-45% of patients. Oliguria after onset of CKRT is also common, but to date has not been addressed directly in the scientific literature. METHODS A prospective observational study was conducted to define factors involved in the hemodynamic changes that take place during the first hours of CKRT, and their relationship with urinary output. RESULTS Twenty-five patients who were admitted to a single-center PICU requiring CKRT between January 1, 2014, and December 31, 2018, were included, of whom 56.3% developed CKRT-RHI. This drop in blood pressure was transient and rapidly restored to baseline, and significantly improved after the third hour of CKRT, as core temperature and heart rate decreased. Urine output significantly decreased after starting CKRT, and 72% of patients were oliguric after 6 h of therapy. Duration of CKRT was significantly longer in patients presenting with oliguria than in non-oliguric patients (28.7 vs. 7.9 days, p = 0.013). CONCLUSIONS The initiation of CKRT caused hemodynamic instability immediately after initial connection in most patients, but had a beneficial effect on the patient's hemodynamic status after 3 h of therapy, presumably owing to decreases in body temperature and heart rate. Urine output significantly decreased in all patients and was not related to negative fluid balance, patient's hemodynamic status, CKRT settings, or kidney function parameters.
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84
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Tan WW, Watt KM, Boakye-Agyeman F, Cohen-Wolkowiez M, Mok YH, Yung CF, Chan YH. Optimal Dosing of Meropenem in a Small Cohort of Critically Ill Children Receiving Continuous Renal Replacement Therapy. J Clin Pharmacol 2021; 61:744-754. [PMID: 33314163 PMCID: PMC8089047 DOI: 10.1002/jcph.1798] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 12/07/2020] [Indexed: 11/10/2022]
Abstract
Severe sepsis is an important cause of mortality and morbidity in critically ill children. Meropenem is a broad-spectrum antibiotic commonly used to treat sepsis. Current meropenem dosage recommendations for children on continuous renal replacement therapy are extrapolated from pharmacokinetic (PK) studies done in adults. Our study aims to determine the optimal dosing in critically ill septic children receiving continuous renal replacement therapy. A prospective single-center PK study was performed in 9 children in the intensive care unit on continuous renal replacement therapy. Meropenem concentrations were measured from blood and effluent fluid samples. A population PK model was developed using nonlinear mixed-effects modeling software (NONMEM, AstraZeneca UK Ltd, Cheshire, UK). Monte Carlo simulations were performed. The PK/pharmacodynamic target aimed for plasma concentrations above minimum inhibitory concentration of 4 mg/L for 100% of dosing interval (100%ƒT>MIC ). A 2-compartment model best characterized meropenem PK. Mean (range) clearance and elimination half-life was 0.091 L/h/kg (0.04-0.157) and 3.9 hours (2.1-7.5), respectively. Dosing of 40 mg/kg/dose every 12 hours over 30 minutes achieved PK/PD target in only 32% while 20 mg/kg every 8 hours over 4 hours or 40 mg/kg every 8 hours over 2 hours achieved 100% ƒT>MIC target for at least 90% of simulated patients.
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Affiliation(s)
- Wei Wei Tan
- Department of Pharmacy, KK Women's and Children's Hospital, Singapore, Singapore
| | - Kevin M Watt
- Pharmacometrics Center, Duke Clinical Research Institute (DCRI), Durham, North Carolina, USA
| | - Felix Boakye-Agyeman
- Integrated Drug Development, Certara Strategic Consulting, Certara USA, Inc. 100 Overlook Center, Princeton, New Jersey, USA
| | - Michael Cohen-Wolkowiez
- Pharmacometrics Center, Duke Clinical Research Institute (DCRI), Durham, North Carolina, USA
| | - Yee Hui Mok
- Department of Paediatric Subspecialties, Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore
| | - Chee Fu Yung
- Department of Paediatric Medicine, Infectious Disease Service, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yoke Hwee Chan
- Department of Paediatric Subspecialties, Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore
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85
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Coccia PA, Ramírez FB, Suárez ADC, Alconcher LF, Balestracci A, García Chervo LA, Principi I, Vázquez A, Ratto VM, Planells MC, Montero J, Saurit M, Gutiérrez MGPY, Puga MC, Isern EM, Bettendorff MC, Boscardin MV, Bazán M, Polischuk MA, De Sarrasqueta A, Aralde A, Ripeau DB, Leroy DC, Quijada NE, Escalante RS, Giordano MI, Sánchez C, Selva VS, Caminiti A, Ojeda JM, Bonany P, Morales SE, Allende D, Arias MA, Exeni AM, Geuna JD, Arrúa L. Acute peritoneal dialysis, complications and outcomes in 389 children with STEC-HUS: a multicenter experience. Pediatr Nephrol 2021; 36:1597-1606. [PMID: 33394193 DOI: 10.1007/s00467-020-04876-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/30/2020] [Accepted: 11/25/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Management of acute kidney injury (AKI) in children with hemolytic uremic syndrome induced by a Shiga toxin-producing Escherichia coli infection (STEC-HUS) is supportive; however, 40 to 60% of cases need kidney replacement therapy (KRT). The aim of this study was to analyze procedure complications, especially peritonitis, and clinical outcomes in children with AKI secondary to STEC-HUS treated with acute PD. METHODS This is a multicenter retrospective study conducted among thirty-seven Argentinian centers. We reviewed medical records of 389 children with STEC-HUS hospitalized between January 2015 and February 2019 that required PD. RESULTS Complications associated with PD were catheter malfunction (n = 93, 24%), peritonitis (n = 75, 19%), fluid leaks (n = 45, 11.5%), bleeding events (n = 23, 6%), and hyperglycemia (n = 8, 2%). In the multivariate analysis, the use of antibiotic prophylaxis was independently associated with a decreased risk of peritonitis (hazard ratio 0.49, IC 95% 0.29-0.81; p = 0.001), and open-surgery catheter insertion was independently associated with a higher risk (hazard ratio 2.8, IC 95% 1.21-6.82; p = 0.001). Discontinuation of PD due to peritonitis, severe leak, or mechanical complications occurred in 3.8% of patients. No patient needed to be transitioned to other modality of KRT due to inefficacy of the technique. Mortality during the acute phase occurred in 2.8% patients due to extrarenal complications (neurological and cardiac involvement), not related to PD. CONCLUSIONS Acute PD was a safe and effective method to manage AKI in children with STEC-HUS. Prophylactic antibiotics prior to insertion of the PD catheter should be considered to decrease the incidence of peritonitis.
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Affiliation(s)
- Paula A Coccia
- Division of Pediatric Nephrology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - Flavia B Ramírez
- Pediatric Department, Hospital Provincial Dr. Castro Rendon, Neuquen, Argentina
| | - Angela D C Suárez
- Department of Pediatric Nephrology, Hospital de Niños Sor María Ludovica, La Plata, Buenos Aires, Argentina
| | - Laura F Alconcher
- Division of Pediatric Nephrology, Hospital Dr. José Penna, Bahía Blanca, Argentina
| | - Alejandro Balestracci
- Division of Pediatric Nephrology, Hospital General de Niños Pedro de Elizalde, Buenos Aires, Argentina
| | - Laura A García Chervo
- Department of Nephrology, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | - Iliana Principi
- Department of Pediatric Nephrology, Hospital Pediátrico Humberto J Notti, Mendoza, Argentina
| | - Aída Vázquez
- Department of Pediatric Nephrology, Hospital Municipal del Niño, San Justo, Buenos Aires, Argentina
| | - Viviana M Ratto
- Department of Pediatric Nephrology, Hospital de Niños Dr. Ricardo Gutierrez, Buenos Aires, Argentina
| | - María Celia Planells
- Department of Pediatric Nephrology, Hospital de Niños de la Santísima Trinidad, Cordoba, Argentina
| | - Jorge Montero
- Department of Pediatric Nephrology, Hospital Materno Infantil de Mar del Plata, Buenos Aires, Argentina
| | - Mariana Saurit
- Pediatric Nephrology Department Hospital Materno Infantil, Salta, Argentina
| | | | - María Celeste Puga
- Department of Clinical Investigation, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Elsa M Isern
- Division of Pediatric Nephrology, Hospital Nacional Profesor Dr. Alejandro Posadas, Buenos Aires, Argentina
| | | | | | - Marta Bazán
- Pediatric Nephrology Unit, Hospital Pediátrico del Niño Jesús, Cordoba, Argentina
| | - Mario A Polischuk
- Pediatric Intensive Care Unit, Clínica Pediátrica San Lucas, Neuquen, Argentina
| | | | - Adriana Aralde
- Division of Pediatric Nephrology, Hospital del Niño Jesús, Tucuman, Argentina
| | - Diego B Ripeau
- Department of Pediatrics, Sanatorio de la Trinidad de Palermo, Buenos Aires, Argentina
| | - Daniela C Leroy
- Department of Pediatrics, Hospital Interzonal de Agudos, Junin, Buenos Aires, Argentina
| | - Nahir E Quijada
- Division of Pediatric Nephrology, Hospital Infantil Municipal, Cordoba, Argentina
| | - Romina S Escalante
- Pediatric Nephrology Unit, Hospital Provincial de Rosario, Santa Fe, Argentina
| | - Marta I Giordano
- Department of Pediatrics, Complejo Sanitario San Luis, San Luis, Argentina
| | - Cristian Sánchez
- Department of Pediatric Nephrology, Hospital Juan Pablo II, Corrientes, Argentina
| | - Verónica S Selva
- Department of Pediatrics Clinica, Universitaria Reina Faviola, Cordoba, Argentina
| | | | - José María Ojeda
- Department of Pediatrics, Hospital de la Madre y el Niño, La Rioja, Argentina
| | - Pablo Bonany
- Department of Pediatrics, Dr. Lucio Molas, Santa Rosa, La Pampa, Argentina
| | - Sandra E Morales
- Department of Pediatrics, Hospital Pediátrico Dr Fernando Barreyro, Posadas, Misiones, Argentina
| | - Daniel Allende
- Department of Pediatrics, Policlínico de Neuquen, Neuquen, Argentina
| | - María Andrea Arias
- Department of Pediatric Nephrology, Hospital Materno Infantil Dr. Héctor Quintana Jujuy, San Salvador de Jujuy, Argentina
| | - Andrea M Exeni
- Division of Pediatric Nephrology, Hospital Austral, Pilar, Buenos Aires, Argentina
| | - Jésica D Geuna
- Division of Pediatric Nephrology, Hospital de Niños Victor J. Vilela, Rosario, Santa Fe, Argentina
| | - Larisa Arrúa
- Department of Pediatrics, Hospital Pediátrico Dr Avelino Castellan, Resistencia, Chaco, Argentina
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Fluid Balance Management Informs Renal Replacement Therapy Use During Pediatric Extracorporeal Membrane Oxygenation: A Survey Report From the Kidney Intervention During Extracorporeal Membrane Oxygenation Group. ASAIO J 2021; 68:407-412. [PMID: 34570725 DOI: 10.1097/mat.0000000000001471] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Fluid overload (FO) and acute kidney injury (AKI) occur commonly in children supported with extracorporeal membrane oxygenation (ECMO). Continuous renal replacement therapy (CRRT) may be used to manage AKI and FO in children on ECMO. In 2012, our group surveyed ECMO centers to begin to understand the practice patterns around CRRT and ECMO. Since then, more centers are initiating ECMO for increasingly diverse indications and an increased volume of research quantifies the detrimental impacts of AKI and FO. We, therefore, investigated practice patterns of CRRT utilization during ECMO in children. A multi-point survey instrument was distributed to 116 international neonatal and pediatric ECMO centers. Sixty of 116 (51.7%) international neonatal and pediatric ECMO centers responded. All reports using CRRT on ECMO, compared with 75% from the 2012 survey. Eighty-five percent use CRRT to treat or prevent FO, an increased from 59%. The modality of CRRT therapy differed between in-line (slow continuous ultrafiltration, 84.4%) and machine-based (continuous venovenous hemodiafiltration, 87.3%) methods. Most (65%) do not have protocols for fluid management, AKI, or CRRT on ECMO. Trialing off CRRT is dictated by physician preference in 90% (54/60), with varying definitions of success. In this survey study, we found that CRRT use during pediatric ECMO has increased since 2012 with fluid management representing the predominant indication for initiation. Despite the expanded utilization of CRRT with ECMO, there remains significant practice variation in terms of method, modality, indication, the timing of initiation, fluid management, and discontinuation.
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87
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Murugan R, Bellomo R, Palevsky PM, Kellum JA. Ultrafiltration in critically ill patients treated with kidney replacement therapy. Nat Rev Nephrol 2021; 17:262-276. [PMID: 33177700 PMCID: PMC9826716 DOI: 10.1038/s41581-020-00358-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2020] [Indexed: 01/30/2023]
Abstract
Management of fluid overload is one of the most challenging problems in the care of critically ill patients with oliguric acute kidney injury. Various clinical practice guidelines support fluid removal using ultrafiltration during kidney replacement therapy. However, ultrafiltration is associated with considerable risks. Emerging evidence from observational studies suggests that both slow and fast rates of net fluid removal (that is, net ultrafiltration (UFNET)) during continuous kidney replacement therapy are associated with increased mortality compared with moderate UFNET rates. In addition, fast UFNET rates are associated with an increased risk of cardiac arrhythmias. Experimental studies in patients with kidney failure who were treated with intermittent haemodialysis suggest that fast UFNET rates are also associated with ischaemic injury to the heart, brain, kidney and gut. The UFNET rate should be prescribed based on patient body weight in millilitres per kilogramme per hour with close monitoring of patient haemodynamics and fluid balance. Dialysate cooling and sodium modelling may prevent haemodynamic instability and facilitate large volumes of fluid removal in patients with kidney failure who are treated with intermittent haemodialysis, but the effects of this strategy on organ injury are less well studied in critically ill patients treated with continuous kidney replacement therapy. Randomized trials are required to examine whether moderate UFNET rates are associated with a reduced risk of haemodynamic instability, organ injury and improved outcomes in critically ill patients.
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Affiliation(s)
- Raghavan Murugan
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Rinaldo Bellomo
- Department of Intensive Care Medicine, The University of Melbourne, Austin Hospital, Melbourne, Victoria, Australia
| | - Paul M Palevsky
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - John A Kellum
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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88
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Selewski DT, Askenazi DJ, Kashani K, Basu RK, Gist KM, Harer MW, Jetton JG, Sutherland SM, Zappitelli M, Ronco C, Goldstein SL, Mottes TA. Quality improvement goals for pediatric acute kidney injury: pediatric applications of the 22nd Acute Disease Quality Initiative (ADQI) conference. Pediatr Nephrol 2021; 36:733-746. [PMID: 33433708 DOI: 10.1007/s00467-020-04828-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 09/24/2020] [Accepted: 10/15/2020] [Indexed: 02/07/2023]
Affiliation(s)
- David T Selewski
- Department of Pediatric, Medical University of South Carolina, 96 Jonathan Lucas St, CSB 428 MSC 608, Charleston, SC, 29425, USA.
| | - David J Askenazi
- Department of Pediatrics, University of Alabama Birmingham, Birmingham, AL, USA
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rajit K Basu
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Katja M Gist
- Department of Pediatrics, Children's Hospital of Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Matthew W Harer
- Division of Neonatology, Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Jennifer G Jetton
- Division of Nephrology, Dialysis, and Transplantation, Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Scott M Sutherland
- Department of Pediatrics, Division of Nephrology, Stanford University, Stanford, CA, USA
| | - Michael Zappitelli
- Department of Pediatrics, Toronto Hospital for Sick Children, Toronto, Canada
| | - Claudio Ronco
- Department of Medicine, Department. Nephrology Dialysis & Transplantation, International Renal Research Institute, San Bortolo Hospital, University of Padova, Vicenza, Italy
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Abstract
Emerging evidence from observational studies suggests that both slower and faster net ultrafiltration rates during kidney replacement therapy are associated with increased mortality in critically ill patients with acute kidney injury and fluid overload. Faster rates are associated with ischemic organ injury. The net ultrafiltration rate should be prescribed based on patient body weight in milliliters per kilogram per hour, with close monitoring of patient hemodynamics and fluid balance. Randomized trials are required to examine whether moderate net ultrafiltration rates compared with slower and faster rates are associated with reduced risk of hemodynamic instability, organ injury, and improved outcomes.
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Affiliation(s)
- Vikram Balakumar
- Department of Critical Care Medicine, Mercy Hospitals, Springfield, MO, USA; Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. https://twitter.com/vikrambalakumar
| | - Raghavan Murugan
- Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, University of Pittsburgh, 3347 Forbes Avenue, Suite 220, Room 206, Pittsburgh, PA 15261, USA.
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90
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Redant S, Barbance O, Tolwani A, Beretta-Piccoli X, Massaut J, De Bels D, Taccone FS, Honoré PM, Biarent D. Impact of CRRT in Patients with PARDS Treated with VV-ECMO. MEMBRANES 2021; 11:membranes11030195. [PMID: 33799847 PMCID: PMC7999958 DOI: 10.3390/membranes11030195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/04/2021] [Accepted: 03/08/2021] [Indexed: 11/25/2022]
Abstract
The high mortality of pediatric acute respiratory distress syndrome (PARDS) is partly related to fluid overload. Extracorporeal membrane oxygenation (ECMO) is used to treat pediatric patients with severe PARDS, but can result in acute kidney injury (AKI) and worsening fluid overload. The objective of this study was to determine whether the addition of CRRT to ECMO in patients with PARDS is associated with increased mortality. Methods: We conducted a retrospective 7-year study of patients with PARDS requiring ECMO and divided them into those requiring CRRT and those not requiring CRRT. We calculated severity of illness scores, the amount of blood products administered to both groups, and determined the impact of CRRT on mortality and morbidity. Results: We found no significant difference in severity of illness scores except the vasoactive inotropic score (VIS, 45 ± 71 vs. 139 ± 251, p = 0.042), which was significantly elevated during the initiation and the first three days of ECMO. CRRT was associated with an increase in the use of blood products and noradrenaline (p < 0.01) without changing ECMO duration, length of PICU stay or mortality. Conclusion: The addition of CRRT to ECMO is associated with a greater consumption of blood products but no increase in mortality.
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Affiliation(s)
- Sébastien Redant
- Departments of Intensive Care, Brugmann University Hospital, 1020 Brussels, Belgium; (O.B.); (J.M.); (D.D.B.); (P.M.H.)
- Departments of Intensive Care, Hospital Universitaire des Enfants Reine Fabiola (HUDERF), 1020 Brussels, Belgium; (X.B.-P.); (D.B.)
- Correspondence:
| | - Océane Barbance
- Departments of Intensive Care, Brugmann University Hospital, 1020 Brussels, Belgium; (O.B.); (J.M.); (D.D.B.); (P.M.H.)
- Departments of Intensive Care, Hospital Universitaire des Enfants Reine Fabiola (HUDERF), 1020 Brussels, Belgium; (X.B.-P.); (D.B.)
| | - Ashita Tolwani
- Division of Nephrology, University of Alabama at Birmingham School of Medicine, Birmingham, AL 35233, USA;
| | - Xavier Beretta-Piccoli
- Departments of Intensive Care, Hospital Universitaire des Enfants Reine Fabiola (HUDERF), 1020 Brussels, Belgium; (X.B.-P.); (D.B.)
| | - Jacques Massaut
- Departments of Intensive Care, Brugmann University Hospital, 1020 Brussels, Belgium; (O.B.); (J.M.); (D.D.B.); (P.M.H.)
| | - David De Bels
- Departments of Intensive Care, Brugmann University Hospital, 1020 Brussels, Belgium; (O.B.); (J.M.); (D.D.B.); (P.M.H.)
| | - Fabio S. Taccone
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles, 1020 Brussels, Belgium;
| | - Patrick M. Honoré
- Departments of Intensive Care, Brugmann University Hospital, 1020 Brussels, Belgium; (O.B.); (J.M.); (D.D.B.); (P.M.H.)
| | - Dominique Biarent
- Departments of Intensive Care, Hospital Universitaire des Enfants Reine Fabiola (HUDERF), 1020 Brussels, Belgium; (X.B.-P.); (D.B.)
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91
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Valdenebro M, Martín-Rodríguez L, Tarragón B, Sánchez-Briales P, Portolés J. Renal replacement therapy in critically ill patients with acute kidney injury: 2020 nephrologist's perspective. Nefrologia 2021; 41:102-114. [PMID: 36166210 DOI: 10.1016/j.nefroe.2021.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 07/28/2020] [Indexed: 06/16/2023] Open
Abstract
Renal replacement therapies (RRT) as support for acute kidney injury in critically ill patients have become a routine and essential practice in their management, resulting in the widespread use of various techniques among these patients, such as intermittent hemodialysis (IHD), extended hemodialysis and continuous RRT (CRRT). In this review we aim to summarize current evidence of indication, choice of modality, timing of initiation, dosing and technical aspects of RRT. We carried out a narrative review based on guidelines, consensus documents by main working groups and the latest relevant clinical trials on RRT in the critically ill. We did not find enough evidence of any RRT modality having superior benefits in terms of patient survival, length of intensive care unit/hospital stay or renal outcomes among critically ill patients, in spite of optimization of clinical indication, modality, timing of initiation and intensity of initial therapy. This is still a controverted matter, since only early start of high-flux CRRT has been proven beneficial over IHD among hemodynamically unstable postoperative patients. Our objective is to portrait current RRT practices in multidisciplinary management of critically ill patients by intensive care and nephrology professionals. Implication of a nephrologist in the assessment of hemodynamic status, coexisting medical conditions, renal outcome expectations and management of resources could potentially have benefits at the time of RRT selection and troubleshooting.
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Affiliation(s)
- María Valdenebro
- Servicio de Nefrología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain; RedinRen RETIC ISCIII 16/009/009
| | - Leyre Martín-Rodríguez
- Servicio de Nefrología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain; RedinRen RETIC ISCIII 16/009/009
| | - Blanca Tarragón
- Servicio de Nefrología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Paula Sánchez-Briales
- Servicio de Nefrología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Jose Portolés
- Servicio de Nefrología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain; RedinRen RETIC ISCIII 16/009/009.
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92
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Sethi SK, Bunchman T, Chakraborty R, Raina R. Pediatric acute kidney injury: new advances in the last decade. Kidney Res Clin Pract 2021; 40:40-51. [PMID: 33663033 PMCID: PMC8041642 DOI: 10.23876/j.krcp.20.074] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 08/19/2020] [Accepted: 08/28/2020] [Indexed: 12/25/2022] Open
Abstract
Pediatric acute kidney injury (AKI) is a frequently missed complication. AKI has a significant impact on both short- and long-term outcomes in children. Within the last decade, there have been major landmark developments in this field of critical care pediatric nephrology. The topic was searched by two independent researchers using Google Scholar and PubMed and related studies published in the last 10 years. The terms used for the search were 'pediatric acute kidney injury,' 'pediatric acute renal failure,' 'pediatric dialysis,' 'biomarkers,' 'nephrotoxins,' 'nephrotoxicity in children,' and 'pediatric critical care nephrology.' We found that AKI is common in critically ill neonates and children. Among the various definitions, the Kidney Disease: Improving Global Outcomes (KDIGO) definition is most commonly used. In addition, it is imperative to risk stratify sick children at admission in the hospital to predict AKI and worse outcomes as this aids in early management. There are now major landmark trials that describe the epidemiology, prevention, and management guidelines in this field and health care professionals need to be aware they should diagnose AKI early. Overall, this review highlights the landmark studies in the last decade and shows that early diagnosis and management of AKI in 'at risk' children can improve outcomes.
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Affiliation(s)
- Sidharth K. Sethi
- Department of Pediatric Nephrology, Kidney Institute, Medanta-The Medicity Hospital, Gurgaon, India
| | - Timothy Bunchman
- Departments of Pediatric Nephrology and Transplantation, Children’s Hospital of Richmond at VCU, Richmond, VA, USA
| | - Ronith Chakraborty
- Akron Nephrology Associates and Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Rupesh Raina
- Akron Nephrology Associates and Cleveland Clinic Akron General Medical Center, Akron, OH, USA
- Department of Nephrology, Akron Children’s Hospital, Akron, OH, USA
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93
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Erkol Tuncer GH, Ekim M, Okulu E, Atasay B, Kendirli T. Continuous renal replacement therapy in critically ill children: single-center experience. Turk J Med Sci 2021; 51:188-194. [PMID: 33172226 PMCID: PMC7991869 DOI: 10.3906/sag-2006-227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 11/07/2020] [Indexed: 11/22/2022] Open
Abstract
Background/aim Continuous renal replacement therapy (CRRT) has significant benefits in the treatment of critically ill children.The objective of this study is to describe the treatment indications, methods, demographics, and outcome of the patients who received CRRT in our pediatric intensive care unit and neonatal care unit, and, according to these results, we also aimto make improvements in our unit-based interventions. Materials and methods In this single-centered study, we retrospectively evaluated medical charts of the patients admitted to our intensive care units and received CRRT between February 2010 and November 2015. Results Fifty of 60 patients were included in this study. Newborns made up 28% (n = 14) of the patients. The mean body weight was 18.4 kg (2.3-98 kg). CRRT indications were fluid overload (30%), acute kidney injury (40%), metabolic disease (24%), electrolyte impairment (4%), and drug intoxication (2%). The most common method of CRRT was continuous venovenous hemodiafiltration (CVVHDF) (72%). The mean duration of CRRT was 135 hours (1-864) and totally 143 filters, polyarylethersulfon (n = 23.46%) and polyacrylonitrile (n = 27.54%) were used. Overall survival was 42%. The survival rate of newborns was significantly higher (P = 0.046). Conclusion CRRT is a lifesaving method that can be applied to critically ill children with acute kidney injury and fluid overload at any age and weight by experienced teams.
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Affiliation(s)
| | - Mesiha Ekim
- Department of Pediatrics, Faculty of Medicine, Ankara University, Ankara, Turkey,Department of Pediatric Nephrology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Emel Okulu
- Department of Pediatrics, Faculty of Medicine, Ankara University, Ankara, Turkey,Department of Neonatology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Begum Atasay
- Department of Pediatrics, Faculty of Medicine, Ankara University, Ankara, Turkey,Department of Neonatology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Tanil Kendirli
- Department of Pediatrics, Faculty of Medicine, Ankara University, Ankara, Turkey,Department of Pediatric Intensive Care Unit, Faculty of Medicine, Ankara University, Ankara, Turkey
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94
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Abstract
Acute kidney injury (AKI) and chronic kidney disease are common interconnected syndromes that represent a public health problem. Acute kidney disease (AKD) is defined as the post-AKI status of acute or subacute kidney damage/dysfunction manifested by persistence of AKI beyond 7 to 90 days after the initial AKI diagnosis. Limited clinical data exist regarding AKD epidemiology but its incidence is observed in ∼25% of AKI survivors. Useful risk-stratification tools to predict risk of AKD and its prognosis are needed. Interventions on fluid management, nephrotoxic exposure, and follow-up care hold promise to ameliorate the burden of AKD and its complications.
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Affiliation(s)
- Javier A Neyra
- Department of Internal Medicine, Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky Medical Center, 800 Rose Street, MN668, Lexington, KY 40536, USA.
| | - Lakhmir S Chawla
- Department of Medicine, Veterans Affairs Medical Center, 3350 La Jolla Village Drive, San Diego, CA 92161, USA
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95
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Chegondi M, Devarashetty S, Balakumar N, Sendi P, Totapally BR. The need for hemodialysis is associated with increased mortality in mechanically ventilated children: a propensity score-matched outcome study. Pediatr Nephrol 2021; 36:409-416. [PMID: 32686034 DOI: 10.1007/s00467-020-04703-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 06/14/2020] [Accepted: 06/30/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Kidney replacement therapy (KRT) is frequently used in critically ill children. The objective of this study is to investigate if the requirement for hemodialysis (HD) is an independent risk factor for mortality in mechanically ventilated children METHODS: In this retrospective cohort study, we analyzed the 2012 and 2016 Kids Inpatient Database and used a weighted sample to obtain a national outcome estimate. For our analysis, we included children aged one month to 17 years who were mechanically ventilated; we then compared the demographics, comorbidities, and mortality rates of those patients who had undergone HD with those who did not. Statistical analysis was performed using the chi-squared test and regression models. The patients were matched 1:2 with a correlative propensity score using age, weekend admission, elective admission, gender, hospital region, income quartiles, race, presence of kidney failure, bone marrow transplantation (BMT), cardiac surgery, trauma, and All Patients Refined Diagnosis Related Groups (APR-DRG) severity score. The mortality rate was compared between the matched groups. RESULTS Out of 100,289 mechanically ventilated children, 1393 (1.4%) underwent HD. The mortality rate was 32.5% in the HD group, compared with 8.8% in the control group (p < 0.05). Factors that were associated with higher mortality in HD patients included severe sepsis, BMT, cardiopulmonary resuscitation (CPR), and extracorporeal membrane oxygenation therapy (ECMO). After propensity score-matched analysis, HD was still significantly associated with a higher risk of mortality (31.9% vs. 22.0%, p < 0.05) CONCLUSIONS: The requirement for HD in mechanically ventilated children is associated with higher mortality.
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Affiliation(s)
- Madhuradhar Chegondi
- Division of Critical Care Medicine, Stead Family Children's Hospital, Iowa City, IA, 52242, USA.
| | - Sushil Devarashetty
- Division of Critical Care Medicine, Nicklaus Children's Hospital, Miami, FL, USA
| | - Niveditha Balakumar
- Division of Critical Care Medicine, Nicklaus Children's Hospital, Miami, FL, USA
| | - Prithvi Sendi
- Division of Critical Care Medicine, Nicklaus Children's Hospital, Miami, FL, USA
| | - Balagangadhar R Totapally
- Division of Critical Care Medicine, Nicklaus Children's Hospital, Miami, FL, USA
- Department of Pediatrics, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
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96
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Improving the quality of neonatal acute kidney injury care: neonatal-specific response to the 22nd Acute Disease Quality Initiative (ADQI) conference. J Perinatol 2021; 41:185-195. [PMID: 32892210 DOI: 10.1038/s41372-020-00810-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/03/2020] [Accepted: 08/27/2020] [Indexed: 12/31/2022]
Abstract
With the adoption of standardized neonatal acute kidney injury (AKI) definitions over the past decade and the concomitant surge in research studies, the epidemiology of and risk factors for neonatal AKI have become much better understood. Thus, there is now a need to focus on strategies designed to improve AKI care processes with the goal of reducing the morbidity and mortality associated with neonatal AKI. The 22nd Acute Dialysis/Disease Quality Improvement (ADQI) report provides a framework for such quality improvement in adults at risk for AKI and its sequelae. While many of the concepts can be translated to neonates, there are a number of specific nuances which differ in neonatal AKI care. A group of experts in pediatric nephrology and neonatology came together to provide neonatal-specific responses to each of the 22nd ADQI consensus statements.
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97
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Rajapreyar P, Castaneda L, Thompson NE, Petersen TL, Hanson SJ. Association of Fluid Balance and Survival of Pediatric Patients Treated With Extracorporeal Membrane Oxygenation. Front Pediatr 2021; 9:722477. [PMID: 34604140 PMCID: PMC8481698 DOI: 10.3389/fped.2021.722477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 08/12/2021] [Indexed: 12/27/2022] Open
Abstract
The effect of positive fluid balance (FB) on extracorporeal membrane oxygenation (ECMO) outcomes in pediatric patients remains unknown. We sought to evaluate if positive FB in pediatric intensive care unit (PICU) patients with respiratory and/or cardiac failure necessitating ECMO was associated with increased morbidity or mortality. This was a multicenter retrospective cohort study of data from the deidentified PEDiatric ECMO Outcomes Registry (PEDECOR). Patients entered into the database from 2014 to 2017, who received ECMO support, were included. A total of 168 subjects met the study criteria. Univariate analysis showed no significant difference in total FB on ECMO days 1-5 between survivors and non-survivors [median 90 ml/kg (IQR 18-208.5) for survivors vs. median 139.7 ml/kg (IQR 11.2-300.6) for non-survivors, p = 0.334]. There was also no difference in total FB on ECMO days 1-5 in patients with no change in functional outcome as reflected by the Pediatric Outcome Performance Category (POPC) score vs. those who had worsening in POPC score ≥2 at hospital discharge [median 98 ml/kg (IQR 18-267) vs. median 130 ml/kg (IQR 13-252), p = 0.91]. Subjects that required 50 ml/kg or more of blood products over the initial 5 days of ECMO support had an increased rate of mortality with an odds ratio of 5.8 (95% confidence interval of 2.7-12.3; p = 0.048). Our study showed no association of the noted FB with survival after ECMO cannulation. This FB trend was also not associated with POPC at hospital discharge, MV duration, or ECMO duration. The amount of blood product administered was found to be a significant predictor of mortality.
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Affiliation(s)
- Prakadeshwari Rajapreyar
- Department of Pediatric Critical Care, Medical College of Wisconsin, Milwaukee, WI, United States.,Children's Wisconsin, Milwaukee, WI, United States
| | - Lauren Castaneda
- Children's Hospital of Colorado, Colorado Springs, CO, United States
| | - Nathan E Thompson
- Department of Pediatric Critical Care, Medical College of Wisconsin, Milwaukee, WI, United States.,Children's Wisconsin, Milwaukee, WI, United States
| | - Tara L Petersen
- Department of Pediatric Critical Care, Medical College of Wisconsin, Milwaukee, WI, United States.,Children's Wisconsin, Milwaukee, WI, United States
| | - Sheila J Hanson
- Department of Pediatric Critical Care, Medical College of Wisconsin, Milwaukee, WI, United States.,Children's Wisconsin, Milwaukee, WI, United States
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98
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Abstract
OBJECTIVES To determine if the timing of excess fluid accumulation (fluid overload) is associated with adverse patient outcomes. DESIGN Secondary analysis of a prospectively collected dataset. SETTING PICU of a tertiary care hospital. PATIENTS Children 3 months to 25 years old admitted to the PICU with expected length of stay greater than or equal to 48 hours. INTERVENTIONS Patients were dichotomized by time of peak overload: peak fluid overload from ICU admission (Day0) to 48 hours (Day3-7) and peak fluid overload value after 48 hours of ICU admission, as well as time of first-time negative daily fluid balance: net fluid out greater than net fluid in for that 24-hour period. MEASUREMENTS AND MAIN RESULTS There were 177 patients who met inclusion criteria, 92 (52%) male, with an overall mortality rate of 7% (n = 12). There were no differences in severity of illness scores or fluid overload on Day0 between peak fluid overload from ICU admission (Day0) to 48 hours (Day3-7) (n = 97; 55%) and peak fluid overload value after 48 hours of ICU admission (n = 80; 45%) groups. Peak fluid overload value after 48 hours of ICU admission was associated with a longer median ICU course (8 [4-15] vs 4 d [3-8 d]; p ≤ 0.001], hospital length of stay (18 [10-38) vs 12 [8-24]; p = 0.01], and increased risk of mortality (n = 10 [13%] vs 2 [2%]; χ2 = 7.6; p = 0.006]. ICU length of stay was also longer in the peak fluid overload value after 48 hours of ICU admission group when only patients with at least 7 days of ICU stay were analyzed (p = 0.02). Timing of negative fluid balance was also correlated with outcome. Compared with Day0-2, a negative daily fluid balance on Day3-7 was associated with increased length of mechanical ventilation (3 [1-7] vs 1 d [2-10 d]; p ≤ 0.001) and increased hospital (17 [10-35] vs 11 d [7-26 d]; p = 0.006) and ICU (7 [4-13] vs 4 d [3-7 d]; p ≤ 0.001) length of stay compared with a negative fluid balance between Day0-2. CONCLUSIONS Our results show timing of fluid accumulation not just peak percentage accumulated is associated with patient outcome. Further exploration of the association between time and fluid accumulation is warranted.
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99
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Rutledge A, Murphy HJ, Harer MW, Jetton JG. Fluid Balance in the Critically Ill Child Section: "How Bad Is Fluid in Neonates?". Front Pediatr 2021; 9:651458. [PMID: 33959572 PMCID: PMC8093499 DOI: 10.3389/fped.2021.651458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 03/15/2021] [Indexed: 12/16/2022] Open
Abstract
Fluid overload (FO) in neonates is understudied, and its management requires nuanced care and an understanding of the complexity of neonatal fluid dynamics. Recent studies suggest neonates are susceptible to developing FO, and neonatal fluid balance is impacted by multiple factors including functional renal immaturity in the newborn period, physiologic postnatal diuresis and weight loss, and pathologies that require fluid administration. FO also has a deleterious impact on other organ systems, particularly the lung, and appears to impact survival. However, assessing fluid balance in the postnatal period can be challenging, particularly in extremely low birth weight infants (ELBWs), given the confounding role of maternal serum creatinine (Scr), physiologic weight changes, insensible losses that can be difficult to quantify, and difficulty in obtaining accurate intake and output measurements given mixed diaper output. Although significant FO may be an indication for kidney replacement therapy (KRT) in older children and adults, KRT may not be technically feasible in the smallest infants and much remains to be learned about optimal KRT utilization in neonates. This article, though not a meta-analysis or systematic review, presents a comprehensive review of the current evidence describing the effects of FO on outcomes in neonates and highlights areas where additional research is needed.
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Affiliation(s)
- Austin Rutledge
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - Heidi J Murphy
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - Matthew W Harer
- Department of Pediatrics (Neonatology), University of Wisconsin, Madison, WI, United States
| | - Jennifer G Jetton
- Stead Family Department of Pediatrics (Nephrology), University of Iowa Health Care, Iowa City, IA, United States
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100
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Anton-Martin P, Quigley R, Dhar A, Bhaskar P, Modem V. Early Fluid Accumulation and Intensive Care Unit Mortality in Children Receiving Extracorporeal Membrane Oxygenation. ASAIO J 2021; 67:84-90. [PMID: 32433305 DOI: 10.1097/mat.0000000000001167] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Purpose of this study was to evaluate the impact of early fluid accumulation and renal dysfunction on mortality in children receiving extracorporeal membrane oxygenation (ECMO). Retrospective cohort study of neonatal and pediatric patients who received ECMO between January 2010 and December 2012 in a tertiary level multidisciplinary pediatric intensive care unit (ICU). Ninety-six patients were included, and forty-six (48%) of them received continuous renal replacement therapy (CRRT) during ECMO. Overall mortality was 38.5%. Proportion of patients with acute kidney injury (AKI) at ICU admission was 33% and increased to 47% at ECMO initiation. High-risk diagnoses, extracorporeal cardiopulmonary resuscitation (ECPR), and venoarterial (VA)-ECMO were more common among nonsurvivors. Nonsurvivors had significantly higher proportion of AKI at ICU admission (OR: 2.59, p = 0.04) and fluid accumulation on ECMO day 1 (9% vs. 1%, p = 0.05) compared with survivors. Multivariable logistic regression analysis (adjusted for a propensity score based on nonrenal factors associated with increased mortality) demonstrated that fluid accumulation on ECMO day 1 is significantly associated with increased ICU mortality (OR: 1.07, p = 0.04). Fluid accumulation within the first 24 hours after ECMO cannulation is significantly associated with increased ICU mortality in neonatal and pediatric patients. Prospective studies evaluating the impact of conservative fluid management and CRRT during the initial phase of ECMO may help further define this relationship.
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Affiliation(s)
- Pilar Anton-Martin
- From the Department of Pediatrics, Division of Cardiology - Cardiac Critical Care, University of Tennessee Medical Science Center / Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Raymond Quigley
- Department of Pediatrics, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Archana Dhar
- Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; and
| | - Priya Bhaskar
- Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; and
| | - Vinai Modem
- Department of Pediatrics, Divisions of Critical Care and Nephrology, University of Texas Health Science Center Houston, Houston, Texas
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