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Hollander SA, Chung S, Reddy S, Zook N, Yang J, Vella T, Navaratnam M, Price E, Sutherland SM, Algaze CA. Intraoperative and Postoperative Hemodynamic Predictors of Acute Kidney Injury in Pediatric Heart Transplant Recipients. J Pediatr Intensive Care 2024; 13:37-45. [PMID: 38571984 PMCID: PMC10987224 DOI: 10.1055/s-0041-1736336] [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: 08/05/2021] [Accepted: 08/28/2021] [Indexed: 10/20/2022] Open
Abstract
Acute kidney injury (AKI) is common after pediatric heart transplantation (HT) and is associated with inferior patient outcomes. Hemodynamic risk factors for pediatric heart transplant recipients who experience AKI are not well described. We performed a retrospective review of 99 pediatric heart transplant patients at Lucile Packard Children's Hospital Stanford from January 1, 2015, to December 31, 2019, in which clinical and demographic characteristics, intraoperative perfusion data, and hemodynamic measurements in the first 48 postoperative hours were analyzed as risk factors for severe AKI (Kidney Disease: Improving Global Outcomes [KDIGO] stage ≥ 2). Univariate analysis was conducted using Fisher's exact test, Chi-square test, and the Wilcoxon rank-sum test, as appropriate. Multivariable analysis was conducted using logistic regression. Thirty-five patients (35%) experienced severe AKI which was associated with lower intraoperative cardiac index ( p = 0.001), higher hematocrit ( p < 0.001), lower body temperature ( p < 0.001), lower renal near-infrared spectroscopy ( p = 0.001), lower postoperative mean arterial blood pressure (MAP: p = 0.001), and higher central venous pressure (CVP; p < 0.001). In multivariable analysis, postoperative CVP >12 mm Hg (odds ratio [OR] = 4.27; 95% confidence interval [CI]: 1.48-12.3, p = 0.007) and MAP <65 mm Hg (OR = 4.9; 95% CI: 1.07-22.5, p = 0.04) were associated with early severe AKI. Children with severe AKI experienced longer ventilator, intensive care, and posttransplant hospital days and inferior survival ( p = 0.01). Lower MAP and higher CVP are associated with severe AKI in pediatric HT recipients. Patients, who experienced AKI, experienced increased intensive care unit (ICU) morbidity and inferior survival. These data may guide the development of perioperative renal protective management strategies to reduce AKI incidence and improve patient outcomes.
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Affiliation(s)
- Seth A. Hollander
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, California, United States
| | - Sukyung Chung
- Quantitative Sciences Unit, Stanford University, Stanford, California, United States
| | - Sushma Reddy
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, California, United States
| | - Nina Zook
- Department of Pediatrics, Stanford University, Stanford, California, United States
| | - Jeffrey Yang
- Department of Pediatrics, Stanford University, Stanford, California, United States
| | - Tristan Vella
- Perfusion Services, Lucile Packard Children's Hospital Stanford, Palo Alto, California, United States
| | - Manchula Navaratnam
- Department of Anesthesia, Stanford University School of Medicine, Stanford, California, United States
| | - Elizabeth Price
- Patient Care Services, Cardiovascular Intensive Care Unit, Lucile Packard Children's Hospital Stanford, Palo Alto, California, United States
| | - Scott M. Sutherland
- Department of Pediatrics (Nephrology), Scott M Sutherland, Stanford University School of Medicine, Stanford, California, United States
| | - Claudia A. Algaze
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, California, United States
- Center for Pediatric and Maternal Value, Stanford University, Palo Alto, California, Unites States
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Mai DH, Sutherland S, Blinder J, Hollander SA. A novel acute kidney injury scoring system for renal and clinical outcomes in pediatric heart transplant patients. Pediatr Transplant 2023; 27:e14565. [PMID: 37409513 DOI: 10.1111/petr.14565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/21/2023] [Accepted: 06/28/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND The development of acute kidney injury (AKI) has been associated with worse outcomes in children after heart transplantation. Our study compares the application of a cumulative six-point Kidney Diseases Improving Global Outcomes (KDIGO) AKI scoring system, utilizing both creatinine and urine output criteria that we term as the AKI-6 criteria, to traditional AKI staging as a predictor for clinical and renal outcomes in the pediatric heart transplant recipients. METHODS We conducted a retrospective single-center chart review on 155 pediatric patients who underwent heart transplantation from May 2014 to December 2021. The primary independent variable was the presence of severe AKI. Severe AKI by KDIGO was defined as Stage ≥2, whereas severe AKI by AKI-6 was defined as cumulative scores ≥4 or Stage 3 AKI based on either KDIGO criterion alone. Primary outcomes included actuarial survival and renal dysfunction by 1-year post-transplant, defined as an estimated glomerular filtration rate <60 mL/min/1.73 m2 . RESULTS In total, 140 (90%) patients developed AKI; 98 (63%) patients developed severe AKI by KDIGO, and 60 (39%) by AKI-6. Severe AKI by AKI-6 was associated with worse actuarial survival following heart transplantation compared with KDIGO (p = 0.01). Of the 143 patients with 1-year creatinine data, 6 (11%) patients out of 54 with severe AKI by AKI-6 had evidence of renal dysfunction (p = 0.01), compared with 6 (7%) patients out of 88 by KDIGO (p = 0.3). CONCLUSIONS AKI-6 scoring provides greater prognostic utility for actuarial survival and renal dysfunction by 1-year post-heart transplantation in pediatric patients than traditional KDIGO staging.
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Affiliation(s)
- Daniel H Mai
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Scott Sutherland
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Joshua Blinder
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Seth A Hollander
- Stanford University School of Medicine, Palo Alto, California, USA
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3
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Garg PM, Paschal JL, Zhang M, Pippins M, Taylor C, Sanderson K, Reddy K, Askenazi D, Padbury JF, Hillegass WB. Clinical impact of severe acute kidney injury on post-operative and brain injury outcomes in preterm infants following surgical necrotizing enterocolitis. J Matern Fetal Neonatal Med 2022; 35:10124-10136. [PMID: 36093832 PMCID: PMC10986639 DOI: 10.1080/14767058.2022.2121917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 06/24/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND To evaluate post-operative outcomes and white matter injury (WMI) using brain MRI at term equivalent in neonates with and without severe acute kidney injury (AKI) following surgical necrotizing enterocolitis (NEC). METHODS A retrospective cohort study comparing neonates with severe (Stage 2/3) vs. other (no AKI/Stage 1) AKI using KDIGO classification with multivariable models assessing this association in the context of multiple systemic comorbidities. RESULTS Of 103 neonates with surgical NEC, 60 (58%) had severe AKI. Those with severe AKI had lower birth weight (BW; 715 vs. 950 g; p = .023), more frequently treated with indomethacin (18.3 vs. 2.4%); p = .014), higher CRP levels at 24 h after NEC onset (14.4 [6.4-19.8] vs. 4.8 [1.6-13.4]; p = .005), higher presence of cholestasis (73.3 vs. 51.2%); p = .023), later age of NEC onset (14 vs. 7 d); p = .004), longer length of bowel resected (14.9 vs. 4.3 cm); p = .011), longer post-operative ileus days (14 vs. 9 d); p < .001), longer post-operative days at starting enteral feedings (15 vs. 10 d; p < .001), longer days of attainment of full enteral feedings (75 vs. 44.5 d; p = .008) and longer length of stay (140.5 vs. 94 d; p = .028) compared to those without severe AKI. Compared to infants without AKI by serum creatinine, those with AKI had significantly more cases of white matter abnormality (WMA; 90 vs. 36.6%; p < .001) and retinopathy of prematurity (63.9 vs. 35.3%; p = .017). In addition, the presence of AKI Stage 2 and 3 by serum creatinine was independently associated with higher odds of sustaining severe WMI level on an ordinal scale (OR = 6.2; 95% CI = (1.1-35.5); p = .041). CONCLUSIONS Neonates with severe AKI following surgical NEC were more likely to experience longer post-operative morbidity and higher WMI by MRI at term.
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Affiliation(s)
- Parvesh Mohan Garg
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Jaslyn L Paschal
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Mengna Zhang
- Department of Data Sciences, University of Mississippi Medical Center, Jackson, MS, USA
| | - Melissa Pippins
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Charlotte Taylor
- Department of Radiology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Keia Sanderson
- Department of Medicine, UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kartik Reddy
- Department of Radiology, University of Mississippi Medical Center, Jackson, MS, USA
| | - David Askenazi
- Department of Pediatrics/Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - James F Padbury
- Department of Pediatrics, Davis School of Medicine, University of California, Sacramento, CA, USA
| | - William B Hillegass
- Department of Data Sciences, University of Mississippi Medical Center, Jackson, MS, USA
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
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Alali A, Acosta S, Ahmed M, Spinner J, Akcan-Arikan A, Morris SA, Jain PN. Postoperative physiological parameters associated with severe acute kidney injury after pediatric heart transplant. Pediatr Transplant 2022; 26:e14267. [PMID: 35279933 DOI: 10.1111/petr.14267] [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: 10/16/2021] [Revised: 01/26/2022] [Accepted: 03/01/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The primary objective was to evaluate associations between perioperative clinical variables and postoperative hemodynamic indices after HT with the development of severe AKI. The secondary objective was to evaluate associations between UOP or creatinine as AKI indicators and morbidity after HT. METHODS Retrospective study of all patients who underwent HT 1/2016-11/2019 at a quaternary pediatric institution. Severe AKI was defined as KDIGO stage 2 or higher. RESULTS Of 94 HT patients, 73 met inclusion criteria; 45% of patients developed severe AKI. In univariate analysis, non-Hispanic Black race, preoperative AKI, longer CPB duration, lower weight, and peak lactate within 12 h post-HT were associated with severe AKI. CVP ≤12 h post-HT had a quadratic relationship, rather than linear, with severe AKI. PPV >18% was significantly associated with severe AKI but equated to noncontiguous 10 min of high variation over a 12-h period, and thus was deemed not clinically significant. In multivariate analysis, Black race, longer CPB duration, and higher CVP remained associated with severe AKI (c: 0.84, 95% CI 0.73-0.92). Severe AKI per creatinine, but not UOP criteria, was associated with longer duration of ventilation (p = .012) and longer intensive care unit length of stay (p = .003). CONCLUSIONS In pediatric HT patients, non-Hispanic Black race, longer CPB time, and higher postoperative CVP ≤12 h post-HT were associated with severe AKI. AKI based on creatinine, not UOP, was associated with postoperative HT morbidity.
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Affiliation(s)
- Alexander Alali
- Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Sebastian Acosta
- Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Mubbasheer Ahmed
- Section of Critical Care, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Joseph Spinner
- Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Ayse Akcan-Arikan
- Section of Critical Care, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,Section of Nephrology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Shaine A Morris
- Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Parag N Jain
- Section of Critical Care, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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Bai L, Jin Y, Zhang P, Li Y, Gao P, Wang W, Wang X, Feng Z, Zhao J, Liu J. Risk factors and outcomes associated with acute kidney injury following extracardiac total cavopulmonary connection: a retrospective observational study. Transl Pediatr 2022; 11:848-858. [PMID: 35800273 PMCID: PMC9253948 DOI: 10.21037/tp-21-474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 03/01/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Total cavopulmonary connection (TCPC) is an important operation for the treatment of complex congenital heart disease. Epidemiology and outcomes for pediatric patients with acute kidney injury (AKI) following extracardiac TCPC have not been well documented. This study investigates the prevalence, risk factors, and outcomes of AKI in children after extracardiac TCPC surgery. METHODS We retrospectively evaluated patients (age at surgery <18 years) who underwent extracardiac TCPC surgery between January 2008 and January 2020 in the Pediatric Cardiac Surgical Center of Fuwai Hospital, Beijing, China. AKI was defined according to the pediatric-modified risk, injury, failure, loss of function, and end-stage renal disease criteria. RESULTS A total of 377 pediatric patients were included in this study; 123 patients (32.6%) had some degree of AKI. Among the patients with AKI, 101 (82.1%) were diagnosed with AKI-risk (AKI-R), while 22 (17.9%) were diagnosed with acute kidney injury/failure (AKI/F) (16 with AKI, and 6 with AKF). Preoperative estimated creatinine clearance (OR: 1.039, 95% CI: 1.024-1.055, P<0.001), neutrophil-to-lymphocyte ratio (OR: 1.208, 95% CI: 1.128-1.294, P<0.001), and renal perfusion pressure (OR: 0.962, 95% CI: 0.938-0.986, P=0.002) on postoperative day (POD) 0 were significantly associated with AKI after TCPC. Having previously undergone a bidirectional Glenn was significantly associated with the severity of postoperative AKI (OR: 0.253, 95% CI: 0.088-0.731, P=0.011). Furthermore, AKI was associated with prolonged mechanical ventilation time, prolonged intensive care unit stay, and composite adverse outcome. Compared with non-AKI patients, the 10-year survival rate of patients with severe AKI was significantly lower (95.5% vs. 65.9%, P=0.009). CONCLUSIONS Although the incidence of AKI was high in patients undergoing TCPC surgery, most cases were AKI-R. Severe AKI was significantly associated with early adverse outcomes and poor long-term survival.
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Affiliation(s)
- Liting Bai
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Jin
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Peiyao Zhang
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yixuan Li
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Peng Gao
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenting Wang
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xu Wang
- Department of Pediatric Intensive Care Unit, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhengyi Feng
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ju Zhao
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinping Liu
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Algaze CA, Margetson TD, Sutherland SM, Kwiatkowski DM, Maeda K, Navaratnam M, Samreth SP, Price EP, Zook NB, Yang JK, Hollander SA. Impact of a clinical pathway on acute kidney injury in patients undergoing heart transplant. Pediatr Transplant 2022; 26:e14166. [PMID: 34727417 DOI: 10.1111/petr.14166] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 08/17/2021] [Accepted: 08/30/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND To evaluate the impact of a clinical pathway on the incidence and severity of acute kidney injury in patients undergoing heart transplant. METHODS This was a 2.5-year retrospective evaluation using 3 years of historical controls within a cardiac intensive care unit in an academic children's hospital. Patients undergoing heart transplant between May 27, 2014, and April 5, 2017 (pre-pathway) and May 1, 2017, and November 30, 2019 (pathway) were included. The clinical pathway focused on supporting renal perfusion through hemodynamic management, avoiding or delaying nephrotoxic medications, and providing pharmacoprophylaxis against AKI. RESULTS There were 57 consecutive patients included. There was an unadjusted 20% reduction in incidence of any acute kidney injury (p = .05) and a 17% reduction in Stage 2/3 acute kidney injury (p = .09). In multivariable adjusted analysis, avoidance of Stage 2/3 acute kidney injury was independently associated with the clinical pathway era (AOR -1.3 [95% CI -2.5 to -0.2]; p = .03), achieving a central venous pressure of or less than 12 mmHg (AOR -1.3 [95% CI -2.4 to -0.2]; p = .03) and mean arterial pressure above 60 mmHg (AOR -1.6 [95% CI -3.1 to -0.01]; p = .05) in the first 48 h post-transplant, and older age at transplant (AOR - 0.2 [95% CI -0.2 to -0.06]; p = .002). CONCLUSIONS This report describes a renal protection clinical pathway associated with a reduction in perioperative acute kidney injury in patients undergoing heart transplant and highlights the importance of normalizing perioperative central venous pressure and mean arterial blood pressure to support optimal renal perfusion.
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Affiliation(s)
- Claudia A Algaze
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA.,Center for Pediatric and Maternal Value, Stanford University School of Medicine, Palo Alto, California, USA
| | - Tristan D Margetson
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Scott M Sutherland
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - David M Kwiatkowski
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Katsuhide Maeda
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Manchula Navaratnam
- Department of Anesthesia, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California, USA
| | - Sarah P Samreth
- Center for Pediatric and Maternal Value, Stanford University School of Medicine, Palo Alto, California, USA
| | - Elizabeth P Price
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Nina B Zook
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jeffrey K Yang
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Seth A Hollander
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
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Kirpalani A, Teoh CW, Ng VL, Dipchand AI, Matsuda-Abedini M. Kidney disease in children with heart or liver transplant. Pediatr Nephrol 2021; 36:3595-3605. [PMID: 33599850 DOI: 10.1007/s00467-021-04949-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 12/09/2020] [Accepted: 01/13/2021] [Indexed: 11/27/2022]
Abstract
Over the past few decades, there has been increasing recognition of kidney disease in children with non-kidney solid organ transplantation. The risk of kidney disease in children undergoing heart or liver transplantation is higher than the general population as the underlying disease and its associated management may directly impair kidney function. Both heart and liver failures contribute to hypoperfusion and kidney ischemia before patients reach the point of transplant. The transplant surgery itself can often be complicated by acute kidney injury (AKI), which may be further exacerbated by a complicated postoperative course. In the short- and long-term post-transplant period, these children are at risk of acute illness, exposed to nephrotoxic medications, and susceptible to rare but severe infections and immunologic insults that may contribute to AKI and chronic kidney disease (CKD). In some, CKD can progress to kidney failure with replacement therapy (KFRT). CKD and KFRT are associated with increased morbidity and mortality in this patient population. Therefore, it is critical to monitor for and recognize the risk factors for kidney injury in this population and mitigate these risks. In this paper, the authors provide an overview of kidney disease pertaining to heart and liver transplantation in children with guidance on monitoring, diagnosis, prevention, and management.
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Affiliation(s)
- Amrit Kirpalani
- Division of Nephrology, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Chia Wei Teoh
- Division of Nephrology, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Vicky Lee Ng
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada.,Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada
| | - Anne I Dipchand
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada.,Labatt Family Heart Center, The Hospital for Sick Children, Toronto, ON, Canada
| | - Mina Matsuda-Abedini
- Division of Nephrology, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada. .,Department of Paediatrics, University of Toronto, Toronto, ON, Canada.
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8
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Dasgupta MN, Montez-Rath ME, Hollander SA, Sutherland SM. Using kinetic eGFR to identify acute kidney injury risk in children undergoing cardiac transplantation. Pediatr Res 2021; 90:632-636. [PMID: 33446916 DOI: 10.1038/s41390-020-01307-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 10/12/2020] [Accepted: 11/18/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is common following pediatric cardiac transplantation. Since no treatments exist, strategies focus on early identification and prevention. Kinetic glomerular filtration rate (kGFR) was developed to assess renal function in the non-steady state. Although used to predict AKI in adults, kGFR has not been explored in children. Our study examines AKI and the ability of kGFR to identify AKI risk in pediatric heart transplant recipients. METHODS One hundred and seventy-five patients under 21 years who underwent cardiac transplantation at Lucile Packard Children's Hospital between September 2007-December 2017 were included. kGFR1 was calculated using pre-operative and immediate post-operative creatinines; kGFR2 was calculated with the first two post-operative creatinines. The primary outcome was AKI as defined by the Kidney Disease: Improving Global Outcomes criteria. RESULTS One hundred and thirty-one (75%) and 78 (45%) patients developed AKI and severe AKI, respectively; 5 (2.9%) required dialysis. kGFR was moderately associated with post-operative AKI risk. The adjusted area under the curve (AUC) for kGFR1 was 0.72 (discovery) and 0.65 (validation). The AUC for kGFR2 was 0.72 (discovery) and 0.68 (validation). CONCLUSIONS AKI is pervasive in children undergoing cardiac transplant, particularly in the 24 h after surgery. kGFR moderately identifies AKI risk and may represent a novel risk stratification technique. IMPACT Our research suggests that kGFR, a dynamic assessment of renal function that uses readily available laboratory values, can moderately identify AKI risk in children undergoing cardiac transplantation. Current published studies on kGFR are in adult populations; this study represents the first formal study of kGFR in a pediatric population. kGFR may serve as an early AKI indicator, allowing providers to implement preventative strategies sooner in a patient's clinical course.
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Affiliation(s)
| | | | - Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, CA, USA
| | - Scott M Sutherland
- Department of Pediatrics (Nephrology), Stanford University, Palo Alto, CA, USA
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9
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Anderson NM, Bond GY, Joffe AR, MacDonald C, Robertson C, Urschel S, Morgan CJ. Post-operative fluid overload as a predictor of hospital and long-term outcomes in a pediatric heart transplant population. Pediatr Transplant 2021; 25:e13897. [PMID: 33131128 DOI: 10.1111/petr.13897] [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: 01/15/2020] [Revised: 09/27/2020] [Accepted: 10/02/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pediatric patients undergoing heart transplant have a number of factors predisposing them to become fluid-overloaded, including capillary leak syndrome. Capillary leak and FO are associated with organ injury and may influence both short- and long-term outcomes. This study aimed to 1) determine the extent, timing, and predictors of post-operative FO and 2) investigate the association of FO with clinically important outcomes. METHODS Between 2000 and 2012, 70 children less than 6 years old had a heart transplant at our institution. This was a secondary analysis of data from an ongoing prospective cohort study. RESULTS FO, defined as cumulative fluid balance greater than 10% of body weight in the first 5 post-operative days, occurred in 16/70 patients (23%); 7 of these had more than 20% FO. Shorter donor ischemic time and longer cardiopulmonary bypass time were independently associated with increased risk of FO. FO >20% was a statistically significant independent predictor of mortality (P = .005), ventilation time, and PICU length of stay. There was no statistically significant association between identified neurodevelopment domains and FO. CONCLUSIONS Our single-center experience demonstrates that FO was common after pediatric heart transplant and was associated with worse clinical outcomes. FO is a potentially modifiable factor, and research is needed to better determine risk factors and whether intervention to reduce FO can improve outcomes in pediatric heart transplant patients.
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Affiliation(s)
- Nicole M Anderson
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Gwen Y Bond
- Glenrose Rehabilitation Hospital, Edmonton, AB, Canada
| | - Ari R Joffe
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | | | - Charlene Robertson
- Glenrose Rehabilitation Hospital, Edmonton, AB, Canada.,Division of Developmental Pediatrics, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Simon Urschel
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
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10
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Wang BC, Gordon BM, Chau P, Martens TP, Lion RP. Novel Multidisciplinary Management of Acute Kidney Injury After Infant Orthotopic Heart Transplantation. World J Pediatr Congenit Heart Surg 2020; 11:366-367. [PMID: 32294001 DOI: 10.1177/2150135119897902] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Acute kidney injury following orthotopic heart transplantation in pediatric recipients is often multifactorial, requiring balance of immune suppression, nephrotoxic medication exposure, nutrition, and fluid status. Therapeutic options are often limited by patient size and hemodynamic stability. We describe a four-month, 4.9-kg female bridged by mechanical circulatory support to transplant after failed stage 1 palliation secondary to recurrent aortic stenosis and severe ventricular dysfunction. Posttransplant, kidney injury was managed by transcatheter relief of central obstruction from an anastomotic stricture and continuous renal replacement therapy, allowing uninterrupted immune suppression, medication, and nutrition delivery until sufficient recovery of renal function.
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Affiliation(s)
- Billy C Wang
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Brent M Gordon
- Division of Pediatric Cardiology, Department of Pediatrics, Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Peter Chau
- Division of Pediatric Cardiology, Department of Pediatrics, Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Timothy P Martens
- Department of Cardiothoracic Surgery, Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Richard P Lion
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Loma Linda University Children's Hospital, Loma Linda, CA, USA
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11
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Hummel K, Glotzbach K, Menon S, Griffiths E, Lal AK. Thrombotic microangiopathy following heart transplant in pediatric Danon disease. Pediatr Transplant 2020; 24:e13669. [PMID: 32067323 DOI: 10.1111/petr.13669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 01/16/2020] [Indexed: 11/28/2022]
Abstract
This case describes an uncommon acute complication of diffuse thrombotic angiopathy and associated aHUS/TTP in an 11-year-old girl with Danon disease who underwent orthotopic heart transplant. Shortly after transplant, despite an uncomplicated operative course, the patient developed severe kidney injury and progressive altered mental status, culminating in cerebral edema, brain herniation, and death. She had received a single dose of tacrolimus (FK506) and a single dose of antithymocyte globulin. Sources of progressive somnolence, including oversedation from impaired renal clearance of opiates, and severe myopathy as has been previously described in Danon disease, were ruled out, and the patient continued to decline. Initial brain CT scan early after transplant showed no signs of cerebral edema, but repeat CT indicated severe cerebral edema. Based on autopsy, diffuse thrombotic angiopathy, with signs of hemolytic anemia with schistocytes, was likely responsible for her deterioration in the broader condition of aHUS/TTP.
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Affiliation(s)
- Kevin Hummel
- Division of Pediatric Critical Care Medicine, University of Utah, Salt Lake City, Utah.,Intermountain Healthcare Primary Children's Hospital, Salt Lake City, Utah
| | - Kristi Glotzbach
- Division of Pediatric Critical Care Medicine, University of Utah, Salt Lake City, Utah.,Intermountain Healthcare Primary Children's Hospital, Salt Lake City, Utah
| | - Shaji Menon
- Division of Pediatric Cardiology, University of Utah, Salt Lake City, Utah.,Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah
| | - Eric Griffiths
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Ashwin K Lal
- Intermountain Healthcare Primary Children's Hospital, Salt Lake City, Utah.,Division of Pediatric Cardiology, University of Utah, Salt Lake City, Utah
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12
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Acute kidney injury in hospitalized children: consequences and outcomes. Pediatr Nephrol 2020; 35:213-220. [PMID: 30386936 PMCID: PMC7223774 DOI: 10.1007/s00467-018-4128-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 10/18/2018] [Accepted: 10/19/2018] [Indexed: 12/18/2022]
Abstract
Over the past decade, the nephrology and critical care communities have adopted a consensus approach to diagnosing acute kidney injury (AKI) and, as a result, we have seen transformative changes in our understanding of pediatric AKI epidemiology. The data regarding outcomes among neonates and children who develop AKI have become far more robust and AKI has been clearly linked with an increased need for mechanical ventilation, longer inpatient stays, and higher mortality. Though AKI was historically thought to be self-limited, we now know that renal recovery is far from universal, particularly when AKI is severe; the absence of recovery from AKI also carries longitudinal prognostic implications. AKI survivors, especially those without full recovery, are at risk for chronic renal sequelae including proteinuria, hypertension, and chronic kidney disease. This review comprehensively describes AKI-related outcomes across the entire pediatric age spectrum, using the most rigorous studies to identify the independent effects of AKI events.
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13
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Park JH, Ihn K, Han SJ, Kim S, Ham SY, Ko S, Kim MS. Incidence and Risk Factors of Acute Kidney Injury after Kasai Operation for Biliary Atresia: A Retrospective Study. Int J Med Sci 2020; 17:1023-1029. [PMID: 32410831 PMCID: PMC7211153 DOI: 10.7150/ijms.44163] [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: 01/21/2020] [Accepted: 03/18/2020] [Indexed: 12/14/2022] Open
Abstract
Background: Biliary atresia is a progressive, inflammatory, and destructive pathology of the bile ducts. Patients who undergo surgery for correction of biliary atresia (Kasai operation) are at risk of acute kidney injury (AKI) because of their young age at the time of surgery, long operation time, and liver fibrosis or failure as complication of biliary atresia. Conversely, AKI is associated with poor outcomes after surgery. This study therefore aimed to evaluate the incidence, risk factors, and outcomes of AKI after Kasai operation. Methods: All consecutive patients who underwent Kasai operation between March 2006 and December 2015 in a single tertiary-care university hospital were enrolled. AKI was defined based on the Acute Kidney Injury Network criteria. Multivariate logistic regression models were used to assess risk factors for AKI. Results: One hundred sixty-six patients received Kasai operation during study period. Of these, AKI occurred in 37 of 166 patients (22.3%). In multivariate logistic regression analysis, age older than 30 days, higher preoperative estimated glomerular filtration rate, and preoperative contrast use within 7 days were associated with the development of AKI. Perioperative packed red blood cells transfusion was related to reduced occurrence of AKI. AKI was associated with longer ICU stay (OR = 1.015, p = 0.016). More patients with AKI were also found to receive additional surgery except liver transplantation within 1 year compared to those without AKI (10.8 % vs. 2.3 %, p = 0.045). Conclusions: Increased age is strongly associated with the development of AKI after Kasai operation. These findings indicate a rational basis for early corrective surgery for biliary atresia, early screening for AKI, and intervention to improve the results of Kasai operation.
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Affiliation(s)
- Jin Ha Park
- Department of Anesthesiology and Pain Medicine, and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyong Ihn
- Department of Pediatric Surgery, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seok Joo Han
- Department of Pediatric Surgery, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sijin Kim
- Department of Anesthesiology and Pain Medicine, and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Yeon Ham
- Department of Anesthesiology and Pain Medicine, and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sangmin Ko
- Department of Anesthesiology and Pain Medicine, and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Min-Soo Kim
- Department of Anesthesiology and Pain Medicine, and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
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14
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Carlisle MA, Soranno DE, Basu RK, Gist KM. Acute Kidney Injury and Fluid Overload in Pediatric Cardiac Surgery. CURRENT TREATMENT OPTIONS IN PEDIATRICS 2019; 5:326-342. [PMID: 33282633 PMCID: PMC7717109 DOI: 10.1007/s40746-019-00171-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW Acute kidney injury (AKI) and fluid overload affect a large number of children undergoing cardiac surgery, and confers an increased risk for adverse complications and outcomes including death. Survivors of AKI suffer long-term sequelae. The purpose of this narrative review is to discuss the short and long-term impact of cardiac surgery associated AKI and fluid overload, currently available tools for diagnosis and risk stratification, existing management strategies, and future management considerations. RECENT FINDINGS Improved risk stratification, diagnostic prediction tools and clinically available early markers of tubular injury have the ability to improve AKI-associated outcomes. One of the major challenges in diagnosing AKI is the diagnostic imprecision in serum creatinine, which is impacted by a variety of factors unrelated to renal disease. In addition, many of the pharmacologic interventions for either AKI prevention or treatment have failed to show any benefit, while peritoneal dialysis catheters, either for passive drainage or prophylactic dialysis may be able to mitigate the detrimental effects of fluid overload. SUMMARY Until novel risk stratification and diagnostics tools are integrated into routine practice, supportive care will continue to be the mainstay of therapy for those affected by AKI and fluid overload after pediatric cardiac surgery. A viable series of preventative measures can be taken to mitigate the risk and severity of AKI and fluid overload following cardiac surgery, and improve care.
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Affiliation(s)
- Michael A Carlisle
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado, Aurora CO
| | - Danielle E. Soranno
- Department of Pediatrics, Division of Pediatric Nephrology, University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado, Aurora CO
| | - Rajit K Basu
- Department of Pediatrics, Division of Pediatric Critical Care, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta GA
| | - Katja M Gist
- Department of Pediatrics, Division of Pediatric Cardiology, University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado, Aurora CO
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Wang C, Fu P, Wang Y, Yang K, Peng YG, Li J, Gong J, Wang J, Luo Q, Gao Y, Wang S, Tian Y, Yan F. Epidemiology of acute kidney injury among paediatric patients after repair of anomalous origin of the left coronary artery from the pulmonary artery. Eur J Cardiothorac Surg 2019; 56:883-890. [PMID: 31005966 DOI: 10.1093/ejcts/ezz090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 02/17/2019] [Accepted: 02/24/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
OBJECTIVES
Acute kidney injury (AKI) is a prevalent complication after the surgical repair of paediatric cardiac defects and is associated with poor outcomes. Insufficient renal perfusion secondary to severe myocardial dysfunction in neonates is most likely an independent risk factor in patients undergoing repair for anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). We retrospectively investigated the epidemiology and outcomes of children with ALCAPA who developed AKI after repair.
METHODS
Eighty-nine children underwent left coronary reimplantation. The paediatric-modified risk, injury, failure, loss and end-stage (p-RIFLE) criteria were used to diagnose AKI.
RESULTS
The incidence of AKI was 67.4% (60/89) in our study. Among the patient cohort with AKI, 23 (38.3%) were diagnosed with acute kidney injury/failure (I/F) (20 with acute kidney injury and 3 with acute kidney failure). Poor cardiac function (left ventricular ejection fraction < 35%) prior to surgery was a significant contributing factor associated with the onset of AKI [odds ratio (OR) 5.55, 95% confidential interval (CI) 1.39–22.13; P = 0.015], while a longer duration from diagnosis to surgical repair (OR 0.97, 95% CI 0.95–1.00; P = 0.049) and a higher preoperative albumin level (OR 0.83, 95% CI 0.70–0.99; P = 0.041) were found to lower the risk of AKI. Neither the severity of preoperative mitral regurgitation nor mitral annuloplasty was associated with the onset of AKI. After reimplantation, there was 1 death in the no-AKI group and 2 deaths in the AKI/F group (P = 0.356); the remaining patients survived until hospital discharge. The median follow-up time was 46.5 months (34.0–63.25). During follow-up, patients in the AKI cohort were seen more often by specialists and reassessed more often by echocardiography.
CONCLUSIONS
Paediatric AKI after ALCAPA repair occurs at a relatively higher incidence than that suggested by previous reports and is linked to poor clinical outcomes. Preoperative cardiac dysfunction (left ventricular ejection fraction < 35%) is strongly associated with AKI. The beneficial effect of delaying surgery seen in some of our cases warrants further investigation, as it is not concordant with standard teaching regarding the timing of surgery for ALCAPA.
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Affiliation(s)
- Chunrong Wang
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Peng Fu
- Department of Anesthesiology, Qingdao Fuwai Cardiovascular Hospital, Qingdao, Shandong Province, China
| | - Yuefu Wang
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Keming Yang
- Department of Cardiac Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Yong G Peng
- Department of Anesthesiology, UF Health Shands Hospital, University of Florida, Gainesville, FL, USA
| | - Jun Li
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Junsong Gong
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Jianhui Wang
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Qipeng Luo
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Yuchen Gao
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Sudena Wang
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Yu Tian
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Fuxia Yan
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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16
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Uber AM, Montez-Rath ME, Kwiatkowski DM, Krawczeski CD, Sutherland SM. Nephrotoxin exposure and acute kidney injury in critically ill children undergoing congenital cardiac surgery. Pediatr Nephrol 2018; 33:2193-2199. [PMID: 29987455 DOI: 10.1007/s00467-018-4010-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 06/16/2018] [Accepted: 06/22/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Though acute kidney injury (AKI) is often multifactorial, investigators are now emphasizing the specific contribution of nephrotoxins. This study examines the epidemiology of nephrotoxin exposure and nephrotoxin-associated AKI among children undergoing congenital heart surgery (CHS). METHODS This is a retrospective cohort study of children admitted following CHS between June 1, 2014, and September 30, 2014. Nephrotoxins were defined according to the Nephrotoxic Injury Negated by Just-in-time-Action (NINJA) collaborative; high nephrotoxin exposure was defined as receipt of ≥ 3 nephrotoxins concurrently. AKI was diagnosed according to KDIGO creatinine criteria. Severe AKI was defined as KDIGO stage ≥ 2. Poisson models were used to compute adjusted relative risk (aRR) of high nephrotoxin exposure for AKI. RESULTS One hundred fifty-four children (median age 20.4 months, IQR 2.3-59.5) were included. One hundred thirty-one (85.1%) received at least one nephrotoxin; 32 (20.8%) received ≥ 3 nephrotoxins. The most commonly administered medications were ketorolac (n = 74, 48.1%), aspirin (n = 62, 40.3%), ibuprofen (n = 51, 33.1%), vancomycin (n = 39, 25.3%), piperacillin/tazobactam (n = 35, 22.7%), and enalapril (n = 14, 9.1%). AKI occurred more commonly in those exposed to ≥ 3 nephrotoxins (62.5 vs. 50.8%); this was not statistically significant after adjusting for confounders (aRR = 1.2, 95% CI 0.9-1.7). Severe AKI was similar between those with and without high nephrotoxin exposure (21.9 vs. 19.7%, p = 0.78). CONCLUSIONS Nephrotoxin use is common following pediatric CHS. While we found no association between high nephrotoxin exposure and AKI, this may be related to the multifactorial nature of AKI in this population. For many common nephrotoxins, less injurious agents exist and nephrotoxin exposure may represent a modifiable risk factor for AKI.
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Affiliation(s)
- Amanda M Uber
- Department of Pediatrics (General Pediatrics), Stanford University School of Medicine, Stanford, CA, USA. .,Stanford Children's Health/Lucile Packard Children's Hospital, Stanford, 725 Welch Road, MC 5906, Palo Alto, CA, 94304, USA.
| | - Maria E Montez-Rath
- Department of Nephrology, Stanford University School of Medicine, Stanford, CA, USA
| | - David M Kwiatkowski
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, CA, USA
| | - Catherine D Krawczeski
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, CA, USA
| | - Scott M Sutherland
- Department of Pediatrics (Nephrology), Stanford University School of Medicine, Stanford, CA, USA
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17
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Association of Whole Blood Tacrolimus Concentrations with Kidney Injury in Heart Transplantation Patients. Eur J Drug Metab Pharmacokinet 2018; 43:311-320. [PMID: 29236211 PMCID: PMC5956048 DOI: 10.1007/s13318-017-0453-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background and Objectives Acute kidney injury (AKI) is frequently observed after heart transplantation and is associated with morbidity and mortality. However, many confounding factors also contribute to the development of AKI in heart transplants. We hypothesized that supratherapeutic whole-blood tacrolimus trough concentrations are associated with AKI. Methods In a retrospective observational cohort from April 2005 to December 2012, all adult heart transplantation patients were included. AKI was assessed in the first 2 weeks after transplantation as classified by the Kidney Disease Improving Global Outcomes Network (KDIGO). Whole-blood tacrolimus trough concentrations were determined from day 1 to day 14 and at 1, 3, 6 and 12 months post-transplantation. The therapeutic range was 9 to 15 ng/ml in the first 2 months and tapered to 5–8 ng/ml thereafter. The relationship between supratherapeutic tacrolimus trough concentrations and AKI was evaluated. The impact of various potentially confounding factors on tacrolimus concentrations and AKI was considered. Results We included 110 patients. AKI occurred in 57% of patients in the first week. Recovery from AKI was seen in 24%. The occurrence of chronic kidney disease (CKD) was 19% at 1 year. Whole-blood tacrolimus trough concentrations were often supratherapeutic and, despite correction for confounding factors, independently associated with AKI (OR 1.66; 95% CI 1.20–2.31). Conclusions Supratherapeutic whole-blood tacrolimus trough concentrations are independently associated with the development of AKI in adult heart transplantation patients. More stringent dosing of tacrolimus early after transplantation may be critical in preserving the kidney function. Electronic supplementary material The online version of this article (10.1007/s13318-017-0453-7) contains supplementary material, which is available to authorized users.
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18
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Peng YH, Yu XM, Yan C, Luo L, Li TS, Xiao J. Recovery of renal function in a heart transplantation recipient with over 300 days of iatrogenic anuria: A case report. Medicine (Baltimore) 2018; 97:e0451. [PMID: 29702997 PMCID: PMC5944477 DOI: 10.1097/md.0000000000010451] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 03/24/2018] [Accepted: 03/26/2018] [Indexed: 01/29/2023] Open
Abstract
RATIONALE Anuria is a severe symptom indicating severe kidney damage. Patient recovery from prolonged anuria is rarely reported. PATIENT CONCERNS A 15-year-old boy received gender- and weight-mismatch heart transplantation (HT) due to dilated cardiomyopathy. He developed severe hypotension, and heart failure 24 hours after surgery, which were relieved by preload reduction treatments. Although, routine examinations did not show any abnormalities in renal function before surgery, anuria occurred 4 days after preload reduction treatments (24-hour urine volume was 23 mL). DIAGNOSIS The patient was diagnosed with acute kidney injury (AKI). INTERVENTIONS He was admitted to continuous renal replacement therapy (CRRT) or hemodialysis. OUTCOMES Surprisingly, his urine volume was gradually, and miraculously, restored to more than 1000 mL/24 hours after over 300 days of anuria. Hemodialysis was not needed in the twentieth month after surgery. Moreover, he partially, recovered renal function. LESSONS This case indicates the likelihood of recovery from long-term anuria.
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Affiliation(s)
- Yong-Hua Peng
- Department of Nephrology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou
| | - Xiao-Min Yu
- Department of Nephrology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou
| | - Chen Yan
- Department of Stem Cell Biology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Department of Rheumatology, The Second Affiliated Hospital of Nanchang University, Nanchang
| | - Lan Luo
- Department of Stem Cell Biology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Medical Technology Institute of Xuzhou Medical University, Xuzhou, P.R. China
| | - Tao-Sheng Li
- Department of Stem Cell Biology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Jie Xiao
- Department of Nephrology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou
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19
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Hsu CN, Chen HL, Tain YL. Epidemiology and outcomes of community-acquired and hospital-acquired acute kidney injury in children and adolescents. Pediatr Res 2018; 83:622-629. [PMID: 29155805 DOI: 10.1038/pr.2017.262] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 09/29/2017] [Indexed: 01/22/2023]
Abstract
BackgroundHospital-acquired acute kidney injury (HA-AKI) is associated with an increased risk of childhood mortality; however, only a few studies have addressed community-acquired AKI (CA-AKI).MethodsAKI network classification was used to assess CA- and HA-AKI, 2010-2014. Patients with CA-AKI who were admitted to an inpatient setting were categorized as CAA-AKI. CANA-AKI was for CA-AKI not admitted to inpatient care. Epidemiology, factors associated with AKI, and in-hospital outcomes were assessed for variation.ResultsPrevalence of CANA-AKI was 4/1,000 outpatient visits, 17/1,000 hospital admissions for CAA-AKI, and 9.69/1,000 hospital admissions for HA-AKI. Mortality was higher among AKI patients (HA-AKI, 13.64%; CAA-AKI, 3.7%) than in no-AKI patients (0.57%). Patients with AKI and those with severe stages of AKI resulted in an increase in health-care service utilization (both P<0.001). Prior renal disease and recent hospitalization were associated with pediatric AKI in both outpatient and inpatient settings. Hematological malignancies, congenital anomalies, circulatory disease, and nephrotoxic medication use were associated with AKI, although the extent of associations varied slightly by setting.ConclusionIncreasing incidence of AKI in the community emphasizes the need for an increased awareness of AKI among health professionals to identify at-risk children and monitor SCr, so that modifiable risk factors can be managed.
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Affiliation(s)
- Chien-Ning Hsu
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.,School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsiao-Ling Chen
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - You-Lin Tain
- Division of Pediatric Nephrology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, College of Medicine, Kaohsiung, Taiwan
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21
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Urschel S, Bond GY, Dinu IA, Moradi F, Conway J, Garcia-Guerra G, Acton BV, Joffe AR, AlAklabi M, Rebeyka IM, Robertson CMT. Neurocognitive outcomes after heart transplantation in early childhood. J Heart Lung Transplant 2017; 37:740-748. [PMID: 29398281 DOI: 10.1016/j.healun.2017.12.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 12/05/2017] [Accepted: 12/17/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Children requiring heart transplantation (HTx) for congenital heart disease (CHD) or failing anatomically normal hearts (CMP) face different challenges pre-HTx. We compared the neurocognitive capabilities in pre-school-age children receiving HTx for CHD vs CMP and determined factors predicting outcomes. METHODS Data were collected within a prospective multi-provincial project from children who underwent HTx ≤4 years of age between 1999 and 2011. At age 54 ± 3 months, we obtained scores from the Wechsler Preschool and Primary Scales of Intelligence for full-scale intelligence quotient (FSIQ) verbal intelligence quotient (VIQ) and performance intelligence quotient (PIQ), and from the Beery-Buktenica Developmental Test for visual-motor integration (VMI). Possible predictive factors were collected prospectively from transplant listing. RESULTS Of the 76 patients included in the study, 61 survived to assessment, 2 were lost to follow-up and 4 were excluded for genetic disorders or heart-lung transplant. The CHD patients (n = 32) had significantly more previous surgeries, more severe kidney injuries, more days on ventilator and in intensive care, broader human leukocyte antigen (HLA) sensitization, longer cardipulmonary bypass (CPB) times and higher inotropic scores than CMP patients (n = 23). Mean IQ scores for the HTx children were below population norms and significantly lower in children with CHD. Intellectual disability (FSIQ <70) was more common in the CHD group (p = 0.036). The lower VMI in CHD patients approached significance. Lower FSIQ and VMI were independently associated with higher pre-HTx creatinine and lactate, longer stay in intensive care and lower socioeconomic status. CONCLUSIONS Children post-HTx showed IQ and VMI scores within the borderline to low-average range, with CHD children ranging significantly lower. Low scores are associated with a more difficult pre- and peri-transplant course. Careful follow-up is required to warrant early detection of deficits and introduction of interventions and supportive measures.
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Affiliation(s)
- Simon Urschel
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada; Alberta Transplant Institute, University of Alberta, Edmonton, Alberta, Canada; Department of Medical Microbiology and Immunology, University of Alberta, Edmonton, Alberta, Canada.
| | - Gwen Y Bond
- Department of Pediatrics, Glenrose Rehabilitation Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Irina A Dinu
- Department of Pediatrics, Glenrose Rehabilitation Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Fahime Moradi
- Department of Pediatrics, Glenrose Rehabilitation Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Jennifer Conway
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Gonzalo Garcia-Guerra
- Division of Pediatric Critical Care, University of Alberta, Edmonton, Alberta, Canada
| | - Bryan V Acton
- Department of Psychology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Ari R Joffe
- Division of Pediatric Critical Care, University of Alberta, Edmonton, Alberta, Canada
| | - Mohammed AlAklabi
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Ivan M Rebeyka
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
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Abstract
Acute kidney injury (AKI) has become one of the more common complications seen among hospitalized children. The development of a consensus definition has helped refine the epidemiology of pediatric AKI, and we now have a far better understanding of its incidence, risk factors, and outcomes. Strategies for diagnosing AKI have extended beyond serum creatinine, and the most current data underscore the diagnostic importance of oliguria as well as introduce the concept of urinary biomarkers of kidney injury. As AKI has become more widespread, we have seen that it is associated with a number of adverse consequences including longer lengths of stay and greater mortality. Though effective treatments do not currently exist for AKI once it develops, we hope that the diagnostic and definitional strides seen recently translate to the testing and development of more effective interventions.
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23
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Acute kidney injury in pediatric patients. Best Pract Res Clin Anaesthesiol 2017; 31:427-439. [DOI: 10.1016/j.bpa.2017.08.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 08/17/2017] [Indexed: 01/09/2023]
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Talha S, Charloux A, Piquard F, Geny B. Brain natriuretic peptide and right heart dysfunction after heart transplantation. Clin Transplant 2017; 31. [PMID: 28314080 DOI: 10.1111/ctr.12969] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2017] [Indexed: 02/04/2023]
Abstract
Heart transplantation (HT) should normalize cardiac endocrine function, but brain natriuretic peptide (BNP) levels remain elevated after HT, even in the absence of left ventricular hemodynamic disturbance or allograft rejection. Right ventricle (RV) abnormalities are common in HT recipients (HTx), as a result of engraftment process, tricuspid insufficiency, and/or repeated inflammation due to iterative endomyocardial biopsies. RV function follow-up is vital for patient management as RV dysfunction is a recognized cause of in-hospital death and is responsible for a worse prognosis. Interestingly, few and controversial data are available concerning the relationship between plasma BNP levels and RV functional impairment in HTx. This suggests that infra-clinical modifications, such as subtle immune system disorders or hypoxic conditions, might influence BNP expression. Nevertheless, due to other altered circulating molecular forms of BNP, a lack of specificity of BNP assays is described in heart failure patients. This phenomenon could exist in HT population and could explain elevated BNP plasmatic levels despite a normal RV function. In clinical practice, intra-individual change in BNP over time, rather than absolute BNP values, might be more helpful in detecting right cardiac dysfunction in HTx.
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Affiliation(s)
- Samy Talha
- Department of Physiology and Functional Explorations, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,Equipe d'Accueil 3072, Université de Strasbourg, Strasbourg, France
| | - Anne Charloux
- Department of Physiology and Functional Explorations, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,Equipe d'Accueil 3072, Université de Strasbourg, Strasbourg, France
| | - François Piquard
- Equipe d'Accueil 3072, Université de Strasbourg, Strasbourg, France
| | - Bernard Geny
- Department of Physiology and Functional Explorations, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,Equipe d'Accueil 3072, Université de Strasbourg, Strasbourg, France
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Biglino G, Caputo M, Rajakaruna C, Angelini G, van Rooij E, Emanueli C. Modulating microRNAs in cardiac surgery patients: Novel therapeutic opportunities? Pharmacol Ther 2016; 170:192-204. [PMID: 27902930 DOI: 10.1016/j.pharmthera.2016.11.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
This review focuses on microRNAs (miRs) in cardiac surgery, where they are emerging as potential targets for therapeutic intervention as well as novel clinical biomarkers. Identification of the up/down-regulation of specific miRs in defined groups of cardiac surgery patients can lead to the development of novel strategies for targeted treatment in order to maximise therapeutic results and minimise acute, delayed or chronic complications. MiRs could also be involved in determining the outcome independently of complications, for example in relation to myocardial perfusion and fibrosis. Because of their relevance in disease, their known sequence and pharmacological properties, miRs are attractive candidates for therapeutic manipulation. Pharmacological inhibition of individual miRs can be achieved by modified antisense oligonucleotides, referred to as antimiRs, while miR replacement can be achieved by miR mimics to increase the level of a specific miR. MiR mimics can restore the function of a lost or down-regulated miR, while antimiRs can inhibit the levels of disease-driving or aberrantly expressed miRs, thus de-repressing the expression of mRNAs targeted by the miR. The main delivery methods for miR therapeutics involve lipid-based vehicles, viral systems, cationic polymers, and intravenous or local injection of an antagomiR. Local delivery is particularly desirable for miR therapeutics and options include the development of devices specific for local delivery, light-induced antimiR, and vesicle-encapsulated miRs serving as therapeutic delivery agents able to improve intracellular uptake. Here, we discuss the potential therapeutic use of miRNAs in the context of cardiac surgery.
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Affiliation(s)
| | - Massimo Caputo
- Bristol Heart Institute, University of Bristol, Bristol, UK; RUSH University Medical Center, Chicago, IL, USA
| | - Cha Rajakaruna
- Bristol Heart Institute, University of Bristol, Bristol, UK
| | | | | | - Costanza Emanueli
- Bristol Heart Institute, University of Bristol, Bristol, UK; National Heart and Lung Institute, Imperial College London, London, UK.
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Yang GZ, Xue FS. Assessing acute kidney injury after pediatric heart transplant. Pediatr Nephrol 2016; 31:1545-6. [PMID: 27048231 DOI: 10.1007/s00467-016-3375-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 03/14/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Gui-Zhen Yang
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 33 Ba-Da-Chu Road, Shi-Jing-Shan District, Beijing, 100144, People's Republic of China
| | - Fu-Shan Xue
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 33 Ba-Da-Chu Road, Shi-Jing-Shan District, Beijing, 100144, People's Republic of China.
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Morgan C, MacDonald C. Response to comments by Yang and Xue on: "Acute kidney injury after heart transplant in young children: risk factors and outcomes". Pediatr Nephrol 2016; 31:1547-8. [PMID: 27312385 DOI: 10.1007/s00467-016-3408-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 04/27/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Catherine Morgan
- Department of Pediatrics, University of Alberta, 11405-87 Avenue, Edmonton Clinic Health Academy, Room 4-557 , Edmonton, Alberta, T6G 1C9, Canada. .,Women and Children's Health Research Institute, Edmonton, Alberta, Canada.
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Reusz G, Cseprekal O, Degi A, Kis E. Subclinical cardiovascular changes in pediatric solid organ transplant recipients. Pediatr Transplant 2016; 20:482-4. [PMID: 27122060 DOI: 10.1111/petr.12718] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- George Reusz
- Ist Department of Paediatrics, Semmelweis University Budapest, Budapest, Hungary.
| | - Orsolya Cseprekal
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Arianna Degi
- Ist Department of Paediatrics, Semmelweis University Budapest, Budapest, Hungary
| | - Eva Kis
- Gottsegen György National Institute of Cardiology, Budapest, Hungary
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