Kidney Disease: Improving Global Outcomes in neonates with acute kidney injury after cardiac surgery

Contrast-Associated Acute Kidney Injury Requiring Continuous Renal Replacement Therapy in A Neonate with Aortic Stenosis-A Case Report

BACKGROUND

Acute kidney injury occurs commonly in the Neonatal Intensive Care Unit and is associated with increased mortality and morbidity. We report a case of a neonate with congenital heart disease who developed acute kidney injury after cardiac surgery, administration of iodinated contrast media for cardiac catheterization, and a combination of nephrotoxic drugs.

CASE REPORT

A term neonate without a prenatal diagnosis of congenital heart disease and with a good postnatal transition was transferred at 13 days of life to the MS Curie Emergency Hospital for Children, Newborn Intensive Care Unit, from a regional hospital where he was admitted at 10 days of life with severe general status, respiratory distress, cyanosis, and arterial hypotension. The cardiac ultrasound detected critical aortic valve stenosis, hypoplastic descending aorta, acute heart failure, and pulmonary hypertension. The patient was intubated and mechanically ventilated and received antibiotherapy (meropenem, vancomycin, and colistin), inotropic and vasoactive support (epinephrine, norepinephrine, dopamine, and milrinone), and diuretic support (furosemide, aminophylline, and ethacrynic acid). A balloon aortic valvuloplasty was performed several hours after admission, but after two days the patient required reintervention by open heart surgery due to relapsing severe aortic stenosis. He developed oligo-anuria, generalized edema, and altered renal function tests on the second postoperative and fourth day post-contrast media administration. Continuous renal replacement therapy was initiated for 75 h, leading to almost instant improvement in blood pressure, then diuresis and creatinine levels. The patient required long-term treatment for heart, respiratory, and liver failure. He was discharged at almost four months of age with normal renal function tests, blood pressure, and good urine output without diuretic support. The literature review indicates that contrast-associated acute kidney injury (CA-AKI) requiring continuous renal replacement therapy is rare.

CONCLUSIONS

Our current case proves that iodinated contrast media administration in a neonate with concomitant insults, such as cardiac surgery for a specific pathology, aortic stenosis, coarctation, arch stenosis, arterial hypotension, and administration of nephrotoxic drugs, may lead to severe kidney injury.

Clinical impact of severe acute kidney injury on post-operative and brain injury outcomes in preterm infants following surgical necrotizing enterocolitis

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.

Practice patterns and outcomes for pediatric ANCA vasculitis transplant recipients in a national cohort

BACKGROUND

Anti-neutrophil cytoplasmic autoantibody (ANCA) vasculitis is a rare condition in pediatric patients. Little is known about practice patterns and outcomes of pediatric transplant patients. The purpose of our study was to examine differences in patient characteristics, immunosuppression, and long-term graft outcomes between ANCA and non-ANCA vasculitis recipients.

METHODS

We used the Scientific Registry of Transplant Recipients to evaluate pediatric ANCA vasculitis recipients between the ages of 1 and 22 years old from 1991 to 2017 and compared them to non-ANCA vasculitis patients during the same time cohort in the USA.

RESULTS

A total of 26,431 transplant recipients were identified, of these, 337 with ANCA vasculitis. Mean 1-year eGFR was 62.46 and 64.92 ml/min/1.73 m² (p = 0.002), and mean 5-year eGFR was 57.95 and 59.38 ml/min/1.73 m² (p = 0.18) between the non-ANCA and ANCA groups, respectively. Five-year graft survival was similar in both groups (non-ANCA 75.5 vs. ANCA 78.6%; p = 0.19). Of those with graft loss within the ANCA group, only 0.6% was secondary to disease recurrence (p = 0.14).

CONCLUSIONS

Kidney transplant is a safe treatment modality for children with ANCA-related kidney failure. ANCA patients have comparable graft survival when compared to the general transplant population with a low risk of recurrence. Thymoglobulin was used in a higher proportion within the ANCA group compared to the non-ANCA group. Tacrolimus, mycophenolate mofetil/mycophenolic acid, and steroids were the predominant maintenance immunosuppression used in both groups. A higher resolution version of the Graphical abstract is available as Supplementary information.

The lower threshold of hypothermic oxygen delivery to prevent neonatal acute kidney injury

BACKGROUND

Oxygen delivery during cardiopulmonary bypass (CPB) is closely related to postoperative acute kidney injury (AKI). The value of critical indexed oxygen delivery (DO₂i) is a key indicator to reflect oxygen supply in cardiovascular surgery. However, the target DO₂i value for neonates undergoing hypothermic CPB remains unclear.

METHODS

One hundred and twenty-six consecutive newborns (≤28 days) undergoing arterial switch operations were retrospectively divided into two groups according to AKI occurrence. Baseline characteristics, intraoperative variables, and clinical outcomes were collected. Multivariate logistic regression analysis and receiver-operating characteristic curve were performed to investigate the association between DO₂i and AKI.

RESULTS

Neonates in the no-AKI group (n = 67) had significantly higher nadir bypass flow and DO₂i during the hypothermic phase compared with the AKI group (n = 59). AKI group had remarkably higher incidences of hepatic dysfunction and peritoneal dialysis requirement compared with newborns without AKI. Mixed venous oxygen saturation (SvO₂) was comparable between the two groups. Base excess (BE)(P = 0.011) value during the hypothermic phase of the AKI group was higher than the no-AKI group. Multivariate analysis showed that hypothermic DO₂i was negatively associated with AKI. The cut-off value of hypothermic DO₂i was 269 mL min^-1 m^-2.

CONCLUSIONS

The importance of hypothermic DO₂i should be highlighted, even when SvO₂ was satisfactory. A lower threshold of DO₂i > 269 mL min^-1 m^-2 may help protect neonates from the risk of postoperative AKI.

IMPACT

The key message of our article is that the lower threshold of DO₂i > 269 mL min^-1 m^-2 may help protect neonates from the risk of AKI after on-pump hypothermic cardiovascular surgery. The critical DO₂i value for neonates undergoing hypothermic CPB remains unclear, and our study may add new evidence for this matter based on the 6-year experience of our center. In this study, the lowest critical value of DO₂i in neonatal hypothermic CPB is determined for the first time, which provides a reference for intra-CPB management strategy to improve the postoperative outcomes of newborns.

Association between fluid overload and mortality in newborns: a systematic review and meta-analysis

Fluid overload (FO) is associated with higher rates of mortality and morbidity in pediatric and adult populations. The aim of this systematic review and meta-analysis was to investigate the association between FO and mortality in critically ill neonates. Systematic search of Ovid MEDLINE, EMBASE, Cochrane Library, trial registries, and gray literature from inception to January 2021. We included all studies that examined neonates admitted to neonatal intensive care units and described FO and outcomes of interest. We identified 17 observational studies with a total of 4772 critically ill neonates who met the inclusion criteria. FO was associated with higher mortality (OR, 4.95 [95% CI, 2.26-10.87]), and survivors had a lower percentage of FO compared with nonsurvivors (WMD, - 4.33 [95% CI, - 8.34 to - 0.32]). Neonates who did not develop acute kidney injury (AKI) had lower FO compared with AKI patients (WMD, - 2.29 [95% CI, - 4.47 to - 0.10]). Neonates who did not require mechanical ventilation on postnatal day 7 had lower fluid balance (WMD, - 1.54 [95% CI, - 2.21 to - 0.88]). FO is associated with higher mortality, AKI, and need for mechanical ventilation in critically ill neonates in the intensive care unit. Strict control of fluid balance to prevent FO is essential. A higher resolution version of the Graphical abstract is available as Supplementary information.

Evaluation of acute kidney injury after surgery for congenital heart disease in neonates: a tertiary hospital experience

PURPOSE OF THE ARTICLE

Acute kidney injury (AKI) after cardiac surgery in children with congenital heart disease (CHD) is a serious complication closely associated with high morbidity and mortality. Despite numerous studies on AKI in children, most studies have excluded neonates. We sought to characterize AKI associated with cardiac surgery in neonates, determine its incidence, perioperative and postoperative risk factors, and short-term results.

MATERIALS AND METHODS

This retrospective study included 177 neonates who were operated on for CHD in our hospital between January 2015 and December 2019. Data of the patients were analyzed according to nKDIGO (neonatal Kidney Disease Improving Global Outcomes) and nRIFLE (neonatal Risk, Injury, Failure, Loss of function, End-stage kidney disease) criteria for evaluating AKI retrospectively. Data of groups with and without AKI were analyzed.

RESULTS

The average age of 177 neonates were 8.2 ± 6.1 (1-28) days. Twenty-two (12.4%) neonates had CS-AKI defined according to nKDIGO criteria. Four (2.3%) neonates reached nKDIGO stage I, 1 (0.6%) reached stage II, 17 (9.6%) reached stage III. Thirty-eight (21.5%) neonates had CS-AKI defined according to nRIFLE criteria. Twenty-four (13.6%) neonates reached nRIFLE stage risk(R), 6 (3.4%) reached stage injury(I), 8 (4.5%) reached stage failure (F). The incidence of cardiac surgery-associated acute kidney injury (CS-AKI) in neonates was 12.5% and 21.5% for nKDIGO and nRIFLE, respectively. The percentage difference between nKDIGO and nRIFLE for AKI assessment was due to the criteria for nRIFLE stage risk(R) urine output < 1.5 mL/kg/h for 24 h. In both classifications, the duration of cardiopulmonary bypass, operation, inotropic treatment, and mechanical ventilation, length of intensive care unit (ICU), and hospital stay were significantly higher in the AKI group than those without AKI group (p˂.05). The mortality rate in the groups with AKI was found to be significantly higher (p˂.05) than in the groups without AKI. In Kappa analysis, when two classifications were compared according to AKI stages, a significant agreement was found between nKDIGO and nRIFLE classifications (p˂.05) (Kappa: 0.299).

CONCLUSION

AKI and mortality rates were similar between groups according to the nKDIGO and nRIFLE criteria. For early prediction of AKI and adverse outcomes, diagnostic reference intervals might be specified in more detail in neonates undergoing cardiac surgery for CHD.

Association of high-sensitivity C-reactive protein and anemia with acute kidney injury in neonates

BACKGROUND

The association of high-sensitivity C-reactive protein (hsCRP) and anemia with postoperative acute kidney injury (AKI) in neonates with congenital heart disease (CHD) is still unclear. The purpose of this study was to examine whether anemia-associated AKI is modulated by hsCRP in neonates.

METHODS

This study included 253 consecutive neonatal patients who underwent CHD surgery in a national tertiary hospital. We investigated the association between postoperative AKI with baseline hsCRP, anemia, and their interaction by multivariable logistic regression analyses.

RESULTS

The incidence of AKI was 24.1% in the entire cohort. After being adjusted for covariates, hsCRP level was negatively correlated with AKI (P < 0.01 for 1 mg/L threshold), whereas anemia emerged as an independent risk factor of AKI (P = 0.02). In addition, there was a significant interaction between anemia and hsCRP level (P = 0.01). In neonates with hsCRP < 1 mg/L, anemia was positively associated with AKI (P = 0.03). However, no significant association was found between anemia and AKI in the context of hsCRP ≥ 1 mg/L. Combination of anemia and hsCRP < 1 mg/L was independently correlated with the risk of AKI (P < 0.01), while concomitant anemia and hsCRP ≥ 1 mg/L or hsCRP < 1 mg/L combined with non-anemia was not.

CONCLUSIONS

In neonates with CHD, the risk of anemia-associated AKI may be modulated by hsCRP level. Attention should be paid to neonates with preoperative anemia and baseline hsCRP < 1 mg/L to reduce the risk of postoperative AKI.

Acute Kidney Injury After Neonatal Aortic Arch Surgery: Deep Hypothermic Circulatory Arrest Versus Moderate Hypothermia With Distal Aortic Perfusion

BACKGROUND

Acute kidney injury (AKI) is a common complication observed after neonatal aortic arch repair. We studied its incidence after procedures carried out using deep hypothermic circulatory arrest (DHCA) versus moderate hypothermia with distal aortic perfusion (MHDP), usually through the common femoral artery. In both groups, continuous regional cerebral perfusion (RCP) was used during the time required for aortic arch repair.

METHODS

A total of 125 neonates underwent aortic arch repair. Between 2007 and 2012, DHCA with RCP was used in 51 neonates. From 2013 to 2019, MHDP with RCP was performed on 74 newborns. Operative complexity was similar in both periods. Acute kidney injury was defined as a significant elevation of serum creatinine and was classified according to the neonatal modified n-KDIGO (neonatal Kidney Disease: Improving Global Outcomes) stages 1 to 3 (Kidney Disease Improving: Global Outcomes).

RESULTS

Acute kidney injury was observed in a total of 68 patients (68/125: 54.4%). In the majority (44/68: 64.7%), n-KDIGO stage 1 occurred. Stage 2 (n = 14) and stage 3 (n = 10) were observed more frequently after DHCA versus MHDP: 29.4% (15/51) versus 12.2% (9/74), P = .02. At cardiopulmonary bypass end, lactate levels were significantly higher (P = .001) after DHCA: 3.4 (2.9-4.3) mmol/L compared to 2.7 (2.3-3.7) mmol/L after MHDP. Early mortality was 12% (15/125) in the entire cohort. It was 17.6% (9/51) after DHCA versus 8.1% (6/74) after MHDP, however not statistically significant (P = .16).

CONCLUSION

Mild (stage 1) AKI occurred frequently after neonatal aortic arch repair. The use of MHDP was associated with a significantly lower incidence of moderate (stage 2) and severe (stage 3) AKI forms.

A meta-analysis of the incidence rate of postoperative acute kidney injury in patients with congenital heart disease

Background

Acute kidney injury (AKI) is a common complication of cardiac surgery. However, the incidence rate of AKI in patients with congenital heart disease (CHD) greatly varies between reports owing to the different definitions used for AKI. Therefore, this study was designed as a meta-analysis aimed at summarizing the incidence rate of AKI in patients with congenital heart disease (CHD) on the basis of different AKI criteria.

Methods

Studies published till April 24, 2020, on the incidence rate of AKI in patients with CHD, were retrieved from electronic databases and printed literature. To pool data from the included studies, the effect size, a combined statistics, was chosen and presented with the incidence rate and 95% confidence interval (CI). Heterogeneity was evaluated using I² statistics and Cochran Q test. The incidence rates obtained from the subgroup analysis according to study location, type of surgery, type of cohort, age, and AKI criteria) were also evaluated to determine the correlation of AKI with these factors. Publication bias was estimated using the Egger test.

Results

Thirty studies, comprising 9925 patients with AKI who had CHD, were included. Overall, the pooled incidence rate of AKI in the patients with CHD was 38.4% (95% CI, 32.0–44.7%). However, the incidence rate was not significantly affected by gender, study location, type of surgery, type of cohort, and AKI criteria. Moreover, age was significantly associated with the incidence of AKI, and the incidence rate was higher in the patients aged < 1 month than in those aged 1 month to 18 years, < 18 years, and ≥ 18 years (P < 0.05).

Conclusions

In this study, the estimated incidence rate of AKI in patients with CHD was 38.4% and may be influenced by age. These findings highlight the importance of further investigation of the specific causes of and effective preventive measures for AKI.

Association of postoperative fluid overload with adverse outcomes after congenital heart surgery: a systematic review and dose-response meta-analysis

BACKGROUND

Pediatric cardiac surgery is commonly associated with acute kidney injury (AKI) and significant fluid retention, which complicate postoperative management and lead to increased rates of morbidity. This meta-analysis aimed to accumulate current literature evidence and evaluate the correlation of fluid overload degree with adverse outcome in patients undergoing congenital heart surgery.

METHODS

Medline, Scopus, CENTRAL, Clinicaltrials.gov, and Google Scholar were systematically searched from inception. All studies reporting the effects of fluid overload on postoperative clinical outcomes were selected. A dose-response meta-analytic method using restricted cubic splines was implemented in R-3.6.1.

RESULTS

Twelve studies were included, with a total of 3111 pediatric patients. Qualitative synthesis indicated that fluid overload was linked to significantly higher risk of mortality, AKI, prolonged hospital, and intensive care unit (ICU) stay, as well as with increased duration of mechanical ventilation, inotrope need, and infection rate. Meta-analysis demonstrated a linear correlation between fluid overload and the risk of mortality (χ² = 6.22, p value = 0.01) and AKI (χ² = 35.84, p value < 0.001), while a positive curvilinear relationship was estimated for the outcomes of hospital (χ² = 18.84, p value = 0.0001) and ICU stay (χ² = 63.69, p value = 0.0001).

CONCLUSIONS

The present meta-analysis supports that postoperative fluid overload is significantly linked to elevated risk of prolonged hospital stay, AKI development, and mortality in pediatric patients undergoing cardiac surgery. These findings warrant replication by future prospective studies, which should define the optimal cutoff values and assess the effectiveness of therapeutic strategies to limit fluid overload in the postoperative setting.

The Year in Review: Anesthesia for Congenital Heart Disease 2019

This review focuses on the literature published from January 2019 to February 2020 that is of interest to anesthesiologists taking care of children and adults with congenital heart disease. Five themes are addressed during this time period, and 59 peer-reviewed articles are discussed.

Prophylactic Peritoneal Drainage is Associated with Improved Fluid Output after Congenital Heart Surgery

Infants undergoing congenital heart surgery (CHS) with cardiopulmonary bypass (CPB) are at risk of acute kidney injury (AKI) and fluid overload. We hypothesized that placement of a passive peritoneal drain (PPD) can improve postoperative fluid output in such infants. We analyzed 115 consecutive patients, age birth to 60 days, admitted to the PICU after CHS with CPB between 2012 and 2018. Patients who needed postoperative ECMO were excluded. Linear and logistic regression models compared postoperative fluid balances, diuretics administration, AKI, vasoactive-inotropic scores (VIS), time intubated, and length of stay after adjusting for pre/operative predictors including STAT category, bypass time, age, weight, and open chest status. PPD patients had higher STAT category (p = 0.001), longer CPB times (p = 0.001), and higher VIS on POD 1-3 (p ≤ 0.005 daily). PPD patients also had higher AKI rates (p = 0.01) that did not reach significance in multivariable modeling. There were no postoperative deaths. Postoperative hours of intubation, hospital length of stay, and POD 1-5 fluid intake did not differ between groups. Over POD 1-5, PPD use accounted for 48.8 mL/kg increased fluid output (95% CI [2.2, 95.4], p = 0.043) and 3.41 mg/kg less furosemide administered (95% CI [1.69, 5.14], p < 0.001). No PPD complications were observed. Although PPD placement did not affect end-outcomes, it was used in higher acuity patients. PPD placement is associated with improved fluid output despite lower diuretic administration and may be a useful postoperative fluid management adjunct in some complex CHS patients.