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Avcı B, Bilir ÖA, Özlü SG, Kanbur ŞM, Gökçebay DG, Bozkaya İO, Bayrakçı US, Özbek NY. Acute kidney injury and risk factors in pediatric patients undergoing hematopoietic stem cell transplantation. Pediatr Nephrol 2024; 39:2199-2207. [PMID: 38324191 DOI: 10.1007/s00467-024-06290-z] [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: 05/23/2023] [Revised: 12/11/2023] [Accepted: 01/04/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common complication of hematopoietic stem cell transplantation (HSCT) with increased mortality and morbidity. Understanding the risk factors for AKI is essential. This study aimed to identify AKI incidence, risk factors, and prognosis in pediatric patients post-HSCT. METHODS We conducted a retrospective case-control study of 278 patients who were divided into two groups: those with AKI and those without AKI (non-AKI). The groups were compared based on the characteristics and clinical symptoms of patients, as well as post-HSCT complications and the use of nephrotoxic drugs. Logistic regression analysis was employed to identify the risk factors for AKI. RESULTS A total of 16.9% of patients had AKI, with 8.5% requiring kidney replacement therapy. Older age (OR 1.129, 95% CI 1.061-1.200, p < 0.001), sinusoidal obstruction syndrome (OR 2.562, 95% CI 1.216-5.398, p = 0.011), hemorrhagic cystitis (OR 2.703, 95% CI 1.178-6.199, p = 0.016), and nephrotoxic drugs, including calcineurin inhibitors, amikacin, and vancomycin (OR 17.250, 95% CI 2.329-127.742, p < 0.001), were identified as significant independent risk factors for AKI following HSCT. Mortality rate and mortality due to AKI were higher in stage 3 patients than those in stage 1 and 2 AKI (p = 0.019, p = 0.007, respectively). Chronic kidney disease developed in 1 patient (0.4%), who was in stage 1 AKI (2.1%). CONCLUSIONS AKI poses a serious threat to children post-HSCT, leading to alarming rates of mortality and morbidity. To enhance outcomes and mitigate these risks, it is vital to identify AKI risk factors, adopt early preventive strategies, and closely monitor this patient group.
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Affiliation(s)
- Begüm Avcı
- Department of Pediatric Nephrology, Baskent University, Adana Dr. Turgut Noyan Application and Research Center, Adana, Turkey.
- Department of Pediatric Nephrology, Ankara Bilkent City Hospital, Health Sciences University, Ankara, Turkey.
| | - Özlem Arman Bilir
- Department of Pediatric Hematology/Oncology and Pediatric Bone Marrow Transplantation Unit, Ankara Bilkent City Hospital, Health Sciences University, Ankara, Turkey
| | - Sare Gülfem Özlü
- Department of Pediatric Nephrology, Ankara Bilkent City Hospital, Yıldırım Beyazıt University, Ankara, Turkey
| | - Şerife Mehtap Kanbur
- Department of Pediatric Hematology/Oncology and Pediatric Bone Marrow Transplantation Unit, Ankara Bilkent City Hospital, Health Sciences University, Ankara, Turkey
| | - Dilek Gürlek Gökçebay
- Department of Pediatric Hematology/Oncology and Pediatric Bone Marrow Transplantation Unit, Ankara Bilkent City Hospital, Health Sciences University, Ankara, Turkey
| | - İkbal Ok Bozkaya
- Department of Pediatric Hematology/Oncology and Pediatric Bone Marrow Transplantation Unit, Ankara Bilkent City Hospital, Health Sciences University, Ankara, Turkey
| | - Umut Selda Bayrakçı
- Department of Pediatric Nephrology, Ankara Bilkent City Hospital, Yıldırım Beyazıt University, Ankara, Turkey
| | - Namık Yaşar Özbek
- Department of Pediatric Hematology/Oncology and Pediatric Bone Marrow Transplantation Unit, Ankara Bilkent City Hospital, Health Sciences University, Ankara, Turkey
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Ashruf OS, Ashruf Z, Orozco Z, Zinter M, Abu-Arja R, Yerigeri K, Haq IU, Kaelber DC, Bissler J, Raina R. Epidemiology, Risk Factors, and Clinical Outcomes of AKI in Pediatric Hematopoietic Stem Cell Transplant Patients. KIDNEY360 2024; 5:802-811. [PMID: 38935491 PMCID: PMC11219119 DOI: 10.34067/kid.0000000000000410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 02/26/2024] [Indexed: 06/29/2024]
Abstract
Key Points The cumulative incidence of AKI diagnosis post–hematopoietic stem cell transplantation was 12.9%. Calcineurin inhibitor use was associated with the highest cumulative incidence, 21.6%, after hematopoietic stem cell transplantation. Patients with AKI with hypertension/hypertensive disease had a 30-day survival probability of 63.9% (hazard ratio, 4.86, 95% confidence interval, 3.58 to 6.60). Patients with AKI were 2.5 times more likely to experience composite hospitalization and/or mortality at 30 days. Of patients who developed AKI, dialysis dependence has nearly tripled since 2014. Background AKI is a common complication in pediatric patients undergoing hematopoietic stem cell transplantation (HSCT), with a reported prevalence ranging from 68% to 84%. Few multicenter pediatric studies comprehensively assess the epidemiologic associations and clinical outcomes associated with AKI development. Methods An observational, retrospective analysis was conducted using an aggregated electronic health record data platform. The study population consisted of pediatric patients (age <18 years) who underwent HSCT over a 20-year period. The study groups consisted of patients with an encounter diagnosis of AKI (n =713) and those without AKI (n =4455). Both groups were propensity matched for age, sex, race, prior cancer diagnosis, and other comorbidities. End points were incidence, mortality risk, clinical outcomes, and prevalence of dialysis dependence. Competing risks analysis, Cox proportional hazard analyses, Kaplan–Meier survival curves, and incidence/prevalence rates were calculated. Results After matching, 688 patients were identified. Cumulative incidence of AKI diagnosis post-HSCT was 13.7%. Hypertensive disease, calcineurin inhibitors, and vancomycin were the most prevalent risk factors for AKI, with calcineurin inhibitors showing the highest cumulative incidence (21.6%). Patients with AKI with hypertensive disease had a survival probability of 63.9% at 30 days, followed by calcineurin inhibitors (64.4%) and vancomycin (65.9%). Patients with AKI were 1.7 times more likely to experience composite hospitalization and/or mortality at 30 days. At 365 days post-HSCT, patients with AKI had higher rates of all-cause emergency department visits, intensive care unit admissions, and mechanical ventilation compared with non-AKI. Of patients who developed AKI, the prevalence of dialysis dependence has nearly tripled since 2014. Conclusions The findings highlight a strong association between specific risk factors, such as hypertension, calcineurin inhibitor use, and vancomycin use, with increased mortality and adverse clinical outcomes in patients with AKI after HSCT. These results emphasize the need for preventative actions such as 24-hour BP monitoring and discontinuation of potential nephrotoxic medications.
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Affiliation(s)
- Omer S. Ashruf
- Department of Internal Medicine, Northeast Ohio Medical University, Rootstown, Ohio
| | - Zaid Ashruf
- Department of Nephrology, Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio
| | - Zara Orozco
- Department of Internal Medicine, Northeast Ohio Medical University, Rootstown, Ohio
| | - Matt Zinter
- Division of Critical Care Medicine, Department of Pediatrics, School of Medicine, University of California, San Francisco, California
| | - Rolla Abu-Arja
- Division of Hematology, Oncology, Blood and Bone Marrow Transplant, Nationwide Children's Hospital, Columbus, Ohio
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Keval Yerigeri
- Department of Internal Medicine-Pediatrics, The MetroHealth System, Cleveland, Ohio
| | - Imad U. Haq
- Department of Internal Medicine, Northeast Ohio Medical University, Rootstown, Ohio
| | - David C. Kaelber
- Center for Clinical Informatics Research and Education, The MetroHealth System and the Departments of Internal Medicine, Pediatrics, and Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
| | - John Bissler
- Department of Pediatrics, University of Tennessee Health Science Center and Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Rupesh Raina
- Department of Nephrology, Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio
- Department of Nephrology, Akron Children's Hospital, Akron, Ohio
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Musiał K, Stojanowski J, Augustynowicz M, Miśkiewicz-Migoń I, Kałwak K, Ussowicz M. Assessment of Risk Factors for Acute Kidney Injury with Machine Learning Tools in Children Undergoing Hematopoietic Stem Cell Transplantation. J Clin Med 2024; 13:2266. [PMID: 38673539 PMCID: PMC11050842 DOI: 10.3390/jcm13082266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
Background: Although acute kidney injury (AKI) is a common complication in patients undergoing hematopoietic stem cell transplantation (HSCT), its prophylaxis remains a clinical challenge. Attempts at prevention or early diagnosis focus on various methods for the identification of factors influencing the incidence of AKI. Our aim was to test the artificial intelligence (AI) potential in the construction of a model defining parameters predicting AKI development. Methods: The analysis covered the clinical data of children followed up for 6 months after HSCT. Kidney function was assessed before conditioning therapy, 24 h after HSCT, 1, 2, 3, 4, and 8 weeks after transplantation, and, finally, 3 and 6 months post-transplant. The type of donor, conditioning protocol, and complications were incorporated into the model. Results: A random forest classifier (RFC) labeled the 93 patients according to presence or absence of AKI. The RFC model revealed that the values of the estimated glomerular filtration rate (eGFR) before and just after HSCT, as well as methotrexate use, acute graft versus host disease (GvHD), and viral infection occurrence, were the major determinants of AKI incidence within the 6-month post-transplant observation period. Conclusions: Artificial intelligence seems a promising tool in predicting the potential risk of developing AKI, even before HSCT or just after the procedure.
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Affiliation(s)
- Kinga Musiał
- Department of Pediatric Nephrology, Wrocław Medical University, Borowska 213, 50-556 Wrocław, Poland
| | - Jakub Stojanowski
- Department of Nephrology and Transplantation Medicine, Wrocław Medical University, 50-556 Wrocław, Poland;
| | - Monika Augustynowicz
- Clinic of Pediatric Nephrology, University Clinical Hospital, Borowska 213, 50-556 Wroclaw, Poland
| | - Izabella Miśkiewicz-Migoń
- Clinical Department of Pediatric Oncology and Hematology, Mother and Child Health Center, Karol Marcinkowski University Hospital, 65-046 Zielona Góra, Poland
| | - Krzysztof Kałwak
- Department of Pediatric Bone Marrow Transplantation, Oncology and Hematology, Wrocław Medical University, 50-556 Wrocław, Poland; (K.K.); (M.U.)
| | - Marek Ussowicz
- Department of Pediatric Bone Marrow Transplantation, Oncology and Hematology, Wrocław Medical University, 50-556 Wrocław, Poland; (K.K.); (M.U.)
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Huang B, Shan J, Yi L, Xin Y, Zhong Z, Xu H. Risk factors for acute kidney injury in pediatric patients after hematopoietic stem cell transplantation: a systematic review and meta-analysis. Pediatr Nephrol 2024; 39:397-408. [PMID: 37079103 DOI: 10.1007/s00467-023-05964-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/26/2023] [Accepted: 03/27/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND Risk factors for acute kidney injury (AKI) in pediatric patients after hematopoietic stem cell transplantation (HSCT) remain controversial. OBJECTIVES This study aimed to identify risk factors for AKI following HSCT in the pediatric population. DATA SOURCES PubMed, Embase, Web of Science, Cochrane Library, and Scopus databases were searched from inception to February 8, 2023. STUDY ELIGIBILITY CRITERIA Studies meeting the following criteria were included: (1) The study was a case-control, cohort study, or cross-sectional design, (2) the study was performed among pediatric and young patients aged 21 years or younger undergoing HSCT, (3) the study measured at least one related factor for AKI after pediatric HSCT, (4) the study included a sample of at least ten patients, and (5) original articles published in English in peer-reviewed scientific journals. PARTICIPANTS AND INTERVENTIONS Children who were undergoing pediatric HSCT. STUDY APPRAISAL AND SYNTHESIS METHODS We assessed the quality of the included studies and analyzed them with a random-effect model. RESULTS Fifteen studies with a total of 2,093 patients were included. All were cohort studies of high quality. The overall pooled incidence of AKI was 47.4% (95%CI 0.35, 0.60). We found significant associations between post-transplant AKI in pediatric patients and unrelated donor [odds ratio (OR) = 1.74, 95% confidence interval (CI) 1.09-2.79], cord blood stem cell transplantation (OR = 3.14, 95%CI 2.14-4.60), and veno-occlusive disease (VOD)/sinusoidal obstruction syndrome (SOS) (OR = 6.02, 95%CI 1.40-25.88). Other controversial factors such as myeloablative conditioning (MAC), acute graft vs. host disease (aGVHD), and the use of calcineurin inhibitors (CNI) were not found to be related to AKI after pediatric HSCT. LIMITATIONS Results were limited mainly by heterogeneity in the characteristics of patients and transplantation. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS Posttransplant AKI in children is a common complication. Unrelated donors, cord blood stem cell transplantation, and VOD/SOS might be risk factors for AKI after pediatric HSCT. Further large-scale studies are still needed to draw firm conclusions. SYSTEMATIC REVIEW REGISTRATION NUMBER CRD42022382361 A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Baoyi Huang
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jiayi Shan
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Lichen Yi
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yijun Xin
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhishan Zhong
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Hua Xu
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China.
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Homhuan W, Tosakulsak T, Pirojsakul K, Pakakasama S, Satawiriya M, Paksi W, Bunmee U. Ambulatory blood pressure monitoring in children and adolescents post-hematopoietic stem cell transplantation. Pediatr Nephrol 2024; 39:531-537. [PMID: 37672081 DOI: 10.1007/s00467-023-06119-1] [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: 06/14/2023] [Revised: 07/24/2023] [Accepted: 07/31/2023] [Indexed: 09/07/2023]
Abstract
BACKGROUND One of the long-term complications after hematopoietic stem cell transplantation (HSCT) is hypertension (HT). Previous studies showed that 10-15% of children post-HSCT had office HT, but only a few studies used ambulatory blood pressure monitoring (ABPM). The present study was aimed at exploring the frequency and factors associated with ABPM HT in children post-HSCT. METHODS Patients aged ≥ 6 years who survived ≥ 2 years after HSCT were enrolled. Clinical and ABPM data were reviewed. ABPM HT was defined according to the 2022 American Heart Association guidelines. Factors associated with HT were analyzed by logistic regression. RESULTS Ninety-eight (60 males) patients with a mean age of 15.1 years and a median follow-up time at 4.5 years after HSCT were included. Fifteen patients (15.3%) had ABPM HT (2 ambulatory HT and 13 masked HT). The ABPM HT group had a significantly older age (19 vs. 14 years), a higher proportion of males (87% vs. 57%), a higher office systolic BP index (0.93 vs. 0.85), a higher office diastolic BP index (0.96 vs. 0.82) and a higher proportion of current use of prednisolone and tacrolimus than those in the normal ABPM group. Multivariate analysis revealed that office diastolic BP index was associated with ABPM HT. Left ventricular mass index was significantly correlated with ABPM but not with office BP parameters. CONCLUSIONS HT in children post-HSCT was not uncommon and most could not be detected with office BP measurement. A diastolic BP index can be used as a screening tool for HT. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Warinpapha Homhuan
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Thitirat Tosakulsak
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kwanchai Pirojsakul
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
| | - Samart Pakakasama
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Marin Satawiriya
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Witchuri Paksi
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Uthen Bunmee
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Li Z, Liu J, Jing B, Shen W, Liu P, Liu Y, Han Z. Incidence of acute kidney injury after hematopoietic stem cell transplantation in children: a systematic review and meta-analysis. Eur J Pediatr 2023; 182:3511-3517. [PMID: 37191691 DOI: 10.1007/s00431-023-05018-9] [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: 11/18/2022] [Revised: 04/28/2023] [Accepted: 05/04/2023] [Indexed: 05/17/2023]
Abstract
While acute kidney injury (AKI) has been reported after hematopoietic stem cell transplantation (HCT) in children, the incidence of this condition in the pediatric population has not been fully addressed. To assess the incidence of pediatric AKI after HCT treatment,we conducted a systematic literature review. Databases PubMed, Embase, Cochrane Library, and WOS were searched as of June 2022 to identify studies on the incidence and the risk of death in AKI children undergoing HCT. Random effects and generic inverse variance methods were used, and effect estimates were subsequently derived from individual studies. Twelve cohort studies with 2 159 HCT cases were included in this analysis. The combined estimated incidence of AKI and severe AKI (stage AKI III) was 51% (95% confidence interval (CI) 39-64%) and 12% (95%CI 4-24%), respectively. The estimated incidence of AKI based on RIFLE (pRIFLE), AKIN, and KDIGO criteria was 61% (95%CI 40-82% score I 95.1%), 64% (95%CI 49-79% score I 90.4%), and 51% (95%CI 2-100% score 99.0%), respectively. However, we found no significant correlation between the years of publication of the included studies and the incidence of AKI. Conclusions: AKI affects approximately half of the children after HCT. With the advancements in medical techniques, it is expected that AKI in this population will decrease gradually. What is Known: • Hematopoietic stem cell transplantation is recognized as a treatment for malignant and non-malignant diseases in children. • Hematopoietic stem cell transplantation causes acute kidney injury in children. What is New: • This metanalysis showed that the overall frequency of post-HCT AKI in children is 51%. • The frequency of severe AKI after HCT was found to be 12%.
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Affiliation(s)
- Zhuoyu Li
- Department of Pediatric, The First Affiliated Hospital of Xinxiang Medical University, Xinxiang, 453399, China
| | - Jia Liu
- Department of Pediatric, The First Affiliated Hospital of Xinxiang Medical University, Xinxiang, 453399, China
| | - Bo Jing
- Department of Pediatric, The First Affiliated Hospital of Xinxiang Medical University, Xinxiang, 453399, China
| | - Wenlong Shen
- Department of Life Science Research Center, The First Affiliated Hospital of Xinxiang Medical University, Xinxiang, 453399, China
| | - Pei Liu
- Department of Pediatric, Dongguan Maternal and Child Health Hospital, Dongguan, 523057, China
| | - Yaqian Liu
- Department of Life Science Research Center, The First Affiliated Hospital of Xinxiang Medical University, Xinxiang, 453399, China
| | - Ziming Han
- Department of Pediatric, The First Affiliated Hospital of Xinxiang Medical University, Xinxiang, 453399, China.
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Risk factors for severe acute kidney injury after pediatric hematopoietic cell transplantation. Pediatr Nephrol 2023; 38:1365-1372. [PMID: 36125547 DOI: 10.1007/s00467-022-05731-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 08/21/2022] [Accepted: 08/30/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is common after hematopoietic cell transplantation (HCT) and is associated with poorer outcomes. Risk factors for AKI after pediatric HCT are not fully understood. The study objective was to assess unique risk factors for AKI in the HCT population and evaluate post-HCT AKI patterns. METHODS We conducted a retrospective cohort study of patients < 21 years of age who underwent HCT at Seattle Children's Hospital/Fred Hutchinson Cancer Center from September 2008 to July 2017 (n = 484). We defined AKI using KDIGO criteria. We collected demographics, baseline HCT characteristics, post-HCT complications, and mortality. Multinomial logistic regression was used to estimate association between AKI and potential risk factors. We used adjusted Cox proportional hazard ratios to evaluate differences in mortality. RESULTS One hundred and eighty-six patients (38%) developed AKI. Seventy-nine (42%) had severe AKI and 27 (15%) required kidney replacement therapy. Fluid overload was common in all groups and 67% of those with severe AKI had > 10% fluid overload. Nephrology was consulted in less than 50% of those with severe AKI. In multivariable analysis, risk of severe AKI was lower in those taking a calcineurin inhibitor (CNI). Risk of death was higher in severe AKI compared to no AKI (RR 4.6, 95% CI 2.6-8.1). CONCLUSIONS AKI and fluid overload are common in pediatric patients after HCT. Severe AKI occurred less often with CNI use and was associated with higher mortality. Future interventions to reduce AKI and its associated complications such as fluid overload are approaches to reducing morbidity and mortality after HCT. A higher resolution version of the Graphical abstract is available as Supplementary information.
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