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Ashkenazi-Hoffnung L, Schiller O, Krubiner M, Dagan O, Haskin O, Manor-Shulman O, Feinstein Y, Shochat T, Shostak E, Yarden-Bilavsky H. Vancomycin Dosing and Its Association With Acute Kidney Injury in Pediatric Cardiac Intensive Care Patients Under 3 Months of Age. Pediatr Infect Dis J 2024:00006454-990000000-00879. [PMID: 38808996 DOI: 10.1097/inf.0000000000004415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Abstract
BACKGROUND The standard vancomycin regimen for term neonates is 45 mg/kg/day. However, the optimal starting vancomycin dosing for achieving therapeutic levels in young infants in cardiac intensive care units remains unknown. Moreover, data on the association of supratherapeutic vancomycin levels with acute kidney injury (AKI) are limited. METHODS Retrospective study of infants ≤3 months old, receiving vancomycin following congenital heart surgery at postoperative intensive care unit admission. Assessed were vancomycin dosing, achievement of therapeutic trough concentration of 10-20 mg/L and development of AKI, based on the modified Kidney Disease Improving Global Outcomes criteria. RESULTS Inclusion criteria were met by 109 patients with a median age of 8 days (IQR: 6-16). The mean (SD) vancomycin dose required for achieving therapeutic concentration was 28.9 (9.1) mg/kg at the first postoperative day. Multivariate logistic regression identified higher preoperative creatinine levels and shorter cardiopulmonary bypass time as predictors of supratherapeutic vancomycin concentrations (c-index 0.788). During the treatment course, 62 (56.9%) developed AKI. Length of stay and mortality were higher in those who developed AKI as compared with those who did not. Multivariate logistic regression identified higher vancomycin concentration as a predictor for postoperative AKI, OR, 3.391 (95% CI: 1.257-9.151), P = 0.016 (c-index 0.896). CONCLUSION Our results support a lower starting vancomycin dose of ~30 mg/kg/day followed by an early personalized therapeutic approach, to achieve therapeutic trough concentrations of 10-20 mg/L in cardiac postoperative term infants. Supratherapeutic concentrations are associated with an increased risk for AKI, which is prevalent in this population and associated with adverse outcomes.
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Affiliation(s)
- Liat Ashkenazi-Hoffnung
- From the Department of Day Hospitalization, Schneider Children's Medical Center, Petach Tikva, Israel
- Faculty of Medicine and Health Sciences, Tel Aviv University, Tel Aviv, Israel
- Pediatric Infectious Diseases Unit, Schneider Children's Medical Center, Petach Tikva, Israel
| | - Ofer Schiller
- Faculty of Medicine and Health Sciences, Tel Aviv University, Tel Aviv, Israel
- Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Mor Krubiner
- Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Ovadia Dagan
- Faculty of Medicine and Health Sciences, Tel Aviv University, Tel Aviv, Israel
- Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Orly Haskin
- Faculty of Medicine and Health Sciences, Tel Aviv University, Tel Aviv, Israel
- Pediatric Institute of Nephrology, Schneider Children's Medical Center, Petach Tikva, Israel
| | - Orit Manor-Shulman
- Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Yael Feinstein
- Faculty of Medicine and Health Sciences, Tel Aviv University, Tel Aviv, Israel
- Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Tzippy Shochat
- Faculty of Medicine and Health Sciences, Tel Aviv University, Tel Aviv, Israel
- Statistical Consultant, Clinical Research Authority, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel
| | - Eran Shostak
- Faculty of Medicine and Health Sciences, Tel Aviv University, Tel Aviv, Israel
- Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Havatzelet Yarden-Bilavsky
- Faculty of Medicine and Health Sciences, Tel Aviv University, Tel Aviv, Israel
- Pediatric Clinical Pharmacology Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
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2
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Gingrich AR, Hagenow AM, Steinbach EJ, Klein JM, Jetton JG, Misurac JM. Acute kidney injury surveillance in the high-risk neonatal population following implementation of creatinine screening protocol. Acta Paediatr 2024; 113:692-699. [PMID: 38084834 DOI: 10.1111/apa.17055] [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: 09/15/2023] [Revised: 11/19/2023] [Accepted: 11/28/2023] [Indexed: 03/12/2024]
Abstract
AIM Acute kidney injury (AKI) in neonates is associated with longer hospital stays and higher mortality rates. However, there is significant variability in prevalence rates of AKI and the true burden is incompletely understood. In November 2020, the University of Iowa Stead Family Children's Hospital Neonatal Intensive Care Unit implemented a creatinine screening protocol to enhance kidney function monitoring. We sought to evaluate adherence to the protocol to determine if increased surveillance led to increased detection of AKI events. METHODS A retrospective chart review was conducted for neonates born at <30 weeks' gestation admitted between 2015 and 2020. We reviewed 100 charts in both the pre (2015-2016) and post (2020-2021) implementation era of the AKI surveillance protocol. AKI was defined according to neonatal modified KDIGO criteria. RESULTS Following implementation of the protocol, neonates were significantly more likely to have creatinine checked (p < 0.001). Serum creatinine was drawn according to protocol guidelines 68% of the time, and 42% of patients (34/82) had an 80% or higher adherence to the protocol. There was a significant increase in detection of AKI in the post-protocol cohort (13/82, incidence of 16%) compared to the pre-protocol cohort (5/83, incidence of 6%), (p = 0.047). CONCLUSION The implementation of a serum creatinine screening protocol increased the frequency of creatinine draws and detection of AKI.
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Affiliation(s)
| | | | - Emily J Steinbach
- Stead Family Department of Pediatrics, Division of Nephrology, Dialysis, and Transplantation, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Jonathan M Klein
- Stead Family Department of Pediatrics, Division of Neonatology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Jennifer G Jetton
- Department of Pediatrics, Medical College of Wisconsin, Section of Pediatric Nephology, Milwaukee, Wisconsin, USA
| | - Jason M Misurac
- Stead Family Department of Pediatrics, Division of Nephrology, Dialysis, and Transplantation, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
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3
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Thompson EJ, Zimmerman KO, Gonzalez D, Foote HP, Park S, Hill KD, Hurst JH, Hornik CD, Chamberlain RC, Gbadegesin RA, Hornik CP. Population Pharmacokinetics of Caffeine in Neonates with Congenital Heart Disease and Associations with Acute Kidney Injury. J Clin Pharmacol 2024; 64:300-311. [PMID: 37933788 PMCID: PMC10898646 DOI: 10.1002/jcph.2382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 11/03/2023] [Indexed: 11/08/2023]
Abstract
Cardiac surgery-associated acute kidney injury (CS-AKI) occurs in approximately 65% of neonates undergoing cardiac surgery on cardiopulmonary bypass and contributes to morbidity and mortality. Caffeine may reduce CS-AKI by counteracting adenosine receptor upregulation after bypass, but pharmacokinetics (PK) in this population are unknown. The goal of our analysis is to address knowledge gaps in age-, disease-, and bypass-related effects on caffeine disposition and explore preliminary associations between caffeine exposure and CS-AKI using population PK modeling techniques and an opportunistic, electronic health record-integrated trial design. We prospectively enrolled neonates receiving preoperative caffeine per standard of care and collected PK samples. We retrospectively identified neonates without caffeine exposure undergoing surgery on bypass as a control cohort. We followed US Food and Drug Administration guidance for population PK model development using NONMEM. Effects of clinical covariates on PK parameters were evaluated. We simulated perioperative exposures and used multivariable logistic regression to evaluate the association between caffeine exposure and CS-AKI. Twenty-seven neonates were included in model development. A 1-compartment model with bypass time as a covariate on clearance and volume of distribution best fit the data. Twenty-three neonates with caffeine exposure and 109 controls were included in the exposure-response analysis. Over half of neonates developed CS-AKI. On multivariable analysis, there were no significant differences between CS-AKI with and without caffeine exposure. Neonates with single-ventricle heart disease without CS-AKI had consistently higher simulated caffeine exposures. Our results highlight areas for further study to better understand disease- and bypass-specific effects on drug disposition and identify populations where caffeine may be beneficial.
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Affiliation(s)
- Elizabeth J Thompson
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Kanecia O Zimmerman
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Henry P Foote
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
| | | | - Kevin D Hill
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
| | - Jillian H Hurst
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
| | - Chi D Hornik
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | | | | | - Christoph P Hornik
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
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4
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Fincher S, Gibbons K, Johnson K, Trnka P, Mattke AC. Urinary Chloride Excretion Postcardiopulmonary Bypass in Pediatric Patients-A Pilot Study. J Pediatr Intensive Care 2024; 13:80-86. [PMID: 38571987 PMCID: PMC10987220 DOI: 10.1055/s-0041-1736549] [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: 06/06/2021] [Accepted: 09/10/2021] [Indexed: 10/20/2022] Open
Abstract
The aim of this study was to describe renal chloride metabolism following cardiopulmonary bypass (CPB) surgery in pediatric patients. A prospective observational trial in a tertiary pediatric intensive care unit (PICU) with 20 recruited patients younger than 2 years following CPB surgery was conducted. Urinary electrolytes, plasma urea, electrolytes, creatinine, and arterial blood gases were collected preoperatively, on admission to PICU and at standardized intervals thereafter. The urinary and plasma strong ion differences (SID) were calculated from these results at each time point. Fluid input and output and electrolyte and drug administration were also recorded. Median chloride administration was 67.7 mmol/kg over the first 24 hours. Urinary chloride (mmol/L; median interquartile range [IQR]) was 30 (19, 52) prior to surgery, 15 (15, 65) on admission, and remained below baseline until 24 hours. Plasma chloride (mmol/L; median [IQR]) was 105 (98, 107) prior to surgery and 101 (101, 106) on admission to PICU. It then increased from baseline, but remained within normal limits, for the remainder of the study. The urinary SID increased from 49.8 (19.1, 87.2) preoperatively to a maximum of 122.7 (92.5, 151.8) at 6 hours, and remained elevated until 48 hours. Plasma and urinary chloride concentrations were not associated with the development of acute kidney injury. Urinary chloride excretion is impaired after CPB. The urinary SID increase associated with the decrease in chloride excretion suggests impaired production and/or excretion of ammonium by the nephron following CPB, with gradual recovery postoperatively.
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Affiliation(s)
- Sophie Fincher
- Department of Pediatric Intensive Care, Queensland Children's Hospital, Brisbane, Australia
- Pediatric Critical Care Research Group, Brisbane, Australia
| | - Kristen Gibbons
- Pediatric Critical Care Research Group, Brisbane, Australia
- Child Health Research Centre, The University of Queensland, Brisbane, Australia
| | - Kerry Johnson
- Department of Pediatric Intensive Care, Queensland Children's Hospital, Brisbane, Australia
- Pediatric Critical Care Research Group, Brisbane, Australia
- Child Health Research Centre, The University of Queensland, Brisbane, Australia
| | - Peter Trnka
- School of Medicine, The University of Queensland, Brisbane, Australia
- Queensland Child and Adolescent Renal Service, Queensland Children's Hospital, Brisbane, Australia
| | - Adrian C. Mattke
- Department of Pediatric Intensive Care, Queensland Children's Hospital, Brisbane, Australia
- Pediatric Critical Care Research Group, Brisbane, Australia
- Child Health Research Centre, The University of Queensland, Brisbane, Australia
- School of Medicine, The University of Queensland, Brisbane, Australia
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Rutledge AD, Griffin RL, Vincent K, Askenazi DJ, Segar JL, Kupferman JC, Rastogi S, Selewski DT, Steflik HJ. Incidence, Risk Factors, and Outcomes Associated With Recurrent Neonatal Acute Kidney Injury in the AWAKEN Study. JAMA Netw Open 2024; 7:e2355307. [PMID: 38329754 PMCID: PMC10853837 DOI: 10.1001/jamanetworkopen.2023.55307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 12/15/2023] [Indexed: 02/09/2024] Open
Abstract
Importance The incidence and associated outcomes of recurrent acute kidney injury (rAKI) in neonates remain largely unknown. Objective To determine the incidence, risk factors, and clinical outcomes associated with rAKI in critically ill neonates. Design, Setting, and Participants This cohort study was a secondary analysis of the multicenter, international Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates retrospective study. Comparisons were made among neonates with no AKI, a single AKI episode (sAKI), and rAKI. All neonates younger than 14 days who were admitted between January 1 and March 31, 2014, to 24 participating level II to IV neonatal intensive care units and received intravenous fluids for at least 48 hours were considered for inclusion. Neonates with congenital heart disease requiring surgery within the first week of life, lethal chromosomal anomalies, death within 48 hours of admission, or severe congenital kidney abnormalities were excluded. Data were analyzed from May 23, 2022, to December 8, 2023. Exposure Recurrent AKI using the neonatal Kidney Disease: Improving Global Outcomes criteria. Determination of each rAKI required a complete return to the baseline serum creatinine level that defined the prior AKI episode. Main Outcomes and Measures Incidence and risk factors of rAKI and associations of rAKI with length of stay (LOS; ie, birth to hospital discharge) and mortality. Results The study cohort (n = 2162) included 1233 male neonates (57.0%). Gestational age distribution was less than 29 weeks for 276 neonates (12.8%), 29 to less than 36 weeks for 958 (44.3%), and 36 weeks or older for 928 (42.9%). Of 605 neonates with AKI, 133 (22.0%) developed rAKI with risk factors including younger gestational age, lower birthweight, and higher stage of initial AKI. Infants with rAKI experienced longer median LOS (no AKI, 17 [IQR, 8-34] days; sAKI, 18 [IQR, 9-45] days; rAKI, 60 [IQR, 25-109] days; P < .001). Time-varying Cox proportional hazards regression models suggest rAKI is independently associated with a lower hazard of discharge (adjusted hazard ratio, 0.7 [95% CI, 0.6-0.9]; P = .01) when compared with sAKI, but mortality did not differ between groups (adjusted hazard ratio, 1.4 [95% CI, 0.6-3.0]; P = .44). Conclusions and Relevance In this cohort study, neonatal rAKI was independently associated with longer LOS when compared with sAKI, suggesting that rAKI in neonates may be an important clinical distinction warranting further study and careful monitoring after an initial AKI episode.
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Affiliation(s)
- Austin D. Rutledge
- Department of Pediatrics, Medical University of South Carolina, Charleston
| | | | - Katherine Vincent
- Department of Pediatrics, Medical University of South Carolina, Charleston
| | | | - Jeffrey L. Segar
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee
| | - Juan C. Kupferman
- Department of Pediatrics, Maimonides Medical Center, Brooklyn, New York
| | - Shantanu Rastogi
- Department of Pediatrics, Children’s Hospital at Montefiore, Bronx, New York
| | - David T. Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston
| | - Heidi J. Steflik
- Department of Pediatrics, Medical University of South Carolina, Charleston
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6
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Marosi A, Conway J, Morgan C, Yaskina M, Foshaug R, Chappell A, Ryerson L, Martin BJ, Ash A, Al-Aklabi M, Myers K, Mackie AS. Acute kidney injury and renal recovery following Fontan surgery. JTCVS OPEN 2024; 17:248-256. [PMID: 38420533 PMCID: PMC10897650 DOI: 10.1016/j.xjon.2023.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 11/01/2023] [Accepted: 11/16/2023] [Indexed: 03/02/2024]
Abstract
Objectives Acute kidney injury has been described after Fontan surgery, but the duration and outcomes are unknown. We sought to describe the incidence of and risk factors for acute kidney injury and the phenotype of renal recovery, and evaluate the impact of renal recovery phenotype on outcomes. Methods All children who underwent a Fontan operation at a single center between 2009 and 2022 were included. Data collected included Fontan characteristics, vasopressor use, all measures of creatinine, and postoperative outcomes. Logistic regression models were used to assess predictors of acute kidney injury and the association between acute kidney injury and outcomes. Results We enrolled 141 children (45% female). Acute kidney injury occurred in 100 patients (71%). Acute kidney injury duration was transient (<48 hours) in 77 patients (55%), persistent (2-7 days) in 15 patients (11%), more than 7 days in 4 patients (3%), and unknown in 4 patients (3%). Risk factors for acute kidney injury included higher preoperative indexed pulmonary vascular resistance (odds ratio, 3.90; P = .004) and higher postoperative inotrope score on day 0 (odds ratio, 1.13, P = .047). Risk factors for acute kidney injury duration more than 48 hours included absence of a fenestration (odds ratio, 3.43, P = .03) and longer duration of cardiopulmonary bypass (odds ratio, 1.22 per 15-minute interval, P = .01). Acute kidney injury duration more than 48 hours was associated with longer length of stay compared with transient acute kidney injury (median 18 days [interquartile range, 9-62] vs 10 days [interquartile range, 8-16], P = .006) and more sternal wound infections (17% vs 4%, P = .049). Conclusions Acute kidney injury after the Fontan operation is common. The occurrence and duration of acute kidney injury have significant implications for postoperative outcomes.
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Affiliation(s)
- Anna Marosi
- Faculty of Science, University of Alberta, Edmonton, Alberta, Canada
| | - Jennifer Conway
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
- Stollery Children's Hospital, Edmonton, Alberta, Canada
- Women and Children's Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Catherine Morgan
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
- Stollery Children's Hospital, Edmonton, Alberta, Canada
- Women and Children's Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Maryna Yaskina
- Women and Children's Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Rae Foshaug
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Alyssa Chappell
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Lindsay Ryerson
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
- Stollery Children's Hospital, Edmonton, Alberta, Canada
- Women and Children's Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Billie-Jean Martin
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | - Alanna Ash
- Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Mohammed Al-Aklabi
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Kim Myers
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Andrew S Mackie
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
- Stollery Children's Hospital, Edmonton, Alberta, Canada
- Women and Children's Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
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7
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Shi S, Xiong C, Bie D, Li Y, Wang J. Development and Validation of a Nomogram for Predicting Acute Kidney Injury in Pediatric Patients Undergoing Cardiac Surgery. Pediatr Cardiol 2024:10.1007/s00246-023-03392-7. [PMID: 38217691 DOI: 10.1007/s00246-023-03392-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 12/20/2023] [Indexed: 01/15/2024]
Abstract
Acute kidney injury (AKI) is a common complication after cardiac surgery and associated with adverse outcomes. The purpose of this study is to construct a nomogram to predict the probability of postoperative AKI in pediatric patients undergoing cardiac surgery. We conducted a single-center retrospective cohort study of 1137 children having cardiac surgery under cardiopulmonary bypass. We randomly divided the included patients into development and validation cohorts at a ratio of 7:3. The least absolute shrinkage and selection operator regression model was used for feature selection. We constructed a multivariable logistic regression model to select predictors and develop a nomogram to predict AKI risk. Discrimination, calibration and clinical benefit of the final prediction model were evaluated in the development and validation cohorts. A simple nomogram was developed to predict risk of postoperative AKI using six predictors including age at operation, cyanosis, CPB duration longer than 120 min, cross-clamp time, baseline albumin and baseline creatinine levels. The area under the receiver operator characteristic curve of the nomogram was 0.739 (95% CI 0.693-0.786) and 0.755 (95% CI 0.694-0.816) for the development and validation cohort, respectively. The calibration curve showed a good correlation between predicted and observed risk of postoperative AKI. Decision curve analysis presented great clinical benefit of the nomogram. This novel nomogram for predicting AKI after pediatric cardiac surgery showed good discrimination, calibration and clinical practicability.
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Affiliation(s)
- Sheng Shi
- Department of Anesthesiology, National Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chao Xiong
- Department of Anesthesiology, National Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dongyun Bie
- Department of Anesthesiology, National Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yinan Li
- Department of Anesthesiology, National Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jianhui Wang
- Department of Anesthesiology, National Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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8
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Shibbani K, Randall JT, Mohammad Nijres B, Aldoss O. Medium-Term Outcomes in Pediatric Patients Undergoing Cardiac Catheterization Early After Congenital Cardiac Surgery. Pediatr Cardiol 2023; 44:1808-1814. [PMID: 37129601 DOI: 10.1007/s00246-023-03171-4] [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: 01/02/2023] [Accepted: 04/19/2023] [Indexed: 05/03/2023]
Abstract
Safety and acute outcomes for patients who need catheterization shortly after congenital cardiac surgery has been established; literature on mid-term outcomes is lacking. We sought to evaluate the mid-term outcomes of patients who undergo early postoperative cardiac catheterization. This is a retrospective cohort study of patients who underwent cardiac catheterization within 6 weeks of congenital cardiac surgery with longitudinal follow-up and assessment of mid-term outcomes. Multivariable analysis was utilized to relate variables of interest to outcomes. 99 patients underwent cardiac catheterizations within 6 weeks of cardiac surgery between January 2008 and September 2016. Forty-six (45.5%) interventional procedures were performed at a median age of 41 days (IQR 21-192) and a median weight of 3.9 kg (3.3-6.6). During a median follow-up duration of 4.24 years (1.6-5.6) in study survivors, 61% of patients remained free from the primary endpoint (death and/or transplant). Sixty-nine patients (69.7%) underwent an unplanned surgical or catheter procedure. Renal failure at catheterization (OR 280.5, p 0.0199), inotropic medication at catheterization (OR 14.8, p 0.002), and younger age were all significantly associated with meeting the primary endpoint. Patients requiring surgical intervention as an initial additional intervention underwent more unplanned re-interventions, while patients who survived to hospital discharge demonstrated favorable mortality, though with frequent need for re-intervention. In patients requiring early postoperative cardiac catheterization, renal failure, younger age, and need for inotropic support at catheterization are significantly associated with meeting the primary endpoint.
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Affiliation(s)
- Kamel Shibbani
- Division of Pediatric Cardiology, Stead Family Children's Hospital, University of Iowa, Iowa City, IA, USA
| | - Jess T Randall
- Department of Cardiology, Albany Medical Center, 22 New Scotland, Albany, NY, 12208, USA.
| | - Bassel Mohammad Nijres
- Division of Pediatric Cardiology, Stead Family Children's Hospital, University of Iowa, Iowa City, IA, USA
| | - Osamah Aldoss
- Division of Pediatric Cardiology, Stead Family Children's Hospital, University of Iowa, Iowa City, IA, USA
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9
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Starr MC, Gilley SP, See EJ, Slagle C, Soranno DE. Adults are just big kids: pediatric considerations for adult critical care nephrology. Curr Opin Crit Care 2023; 29:580-586. [PMID: 37861193 DOI: 10.1097/mcc.0000000000001100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
PURPOSE OF REVIEW In recent years, there has been growing attention to pediatric kidney health, especially pediatric acute kidney injury (AKI). However, there has been limited focus on the role of pediatric AKI on adult kidney health, specifically considerations for the critical care physician. RECENT FINDINGS We summarize what is known in the field of pediatric AKI to inform adult medical care including factors throughout the early life course, including perinatal, neonatal, and pediatric exposures that impact survivor care later in adulthood. SUMMARY The number of pediatric AKI survivors continues to increase, leading to a higher burden of chronic kidney disease and other long-term co-morbidities later in life. Adult medical providers should consider pediatric history and illnesses to inform the care they provide. Such knowledge may help internists, nephrologists, and intensivists alike to improve risk stratification, including a lower threshold for monitoring for AKI and kidney dysfunction in their patients.
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Affiliation(s)
- Michelle C Starr
- Indiana University School of Medicine, Department of Pediatrics, Pediatric Nephrology
- Child Health Service Research Division, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Stephanie P Gilley
- University of Colorado School of Medicine, Department of Pediatrics, Section of Nutrition, Aurora, Colorado, USA
| | - Emily J See
- Royal Melbourne Hospital, Departments of Intensive Care and Nephrology, Melbourne, VIC, Australia
| | - Cara Slagle
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Department of Pediatrics, Cincinnati, Ohio
| | - Danielle E Soranno
- Indiana University School of Medicine, Department of Pediatrics, Pediatric Nephrology
- Purdue University, Weldon School of Bioengineering, Department of Bioengineering, West Lafayette, Indiana, USA
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10
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Dreher M, Min J, Mavroudis C, Ryba D, Ostapenko S, Melchior R, Rosenthal T, Nuri M, Blinder J. Indexed oxygen delivery during pediatric cardiopulmonary bypass is a modifiable risk factor for postoperative acute kidney injury. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2023; 55:112-120. [PMID: 37682209 PMCID: PMC10487348 DOI: 10.1051/ject/2023029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 07/07/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Acute kidney injury after pediatric cardiac surgery is a common complication with few established modifiable risk factors. We sought to characterize whether indexed oxygen delivery during cardiopulmonary bypass was associated with postoperative acute kidney injury in a large pediatric cohort. METHODS This was a retrospective analysis of patients under 1 year old undergoing cardiac surgery with cardiopulmonary bypass between January 1, 2013, and January 1, 2020. Receiver operating characteristic curves across values ranging from 260 to 400 mL/min/m2 were used to identify the indexed oxygen delivery most significantly associated with acute kidney injury risk. RESULTS We included 980 patients with acute kidney injury occurring in 212 (21.2%). After adjusting for covariates associated with acute kidney injury, an indexed oxygen delivery threshold of 340 mL/min/m2 predicted acute kidney injury in STAT 4 and 5 neonates (area under the curve = 0.66, 95% CI = 0.60 - 0.72, sensitivity = 56.1%, specificity = 69.4%). An indexed oxygen delivery threshold of 400 mL/min/m2 predicted acute kidney injury in STAT 1-3 infants (area under the curve = 0.65, 95% CI = 0.58 - 0.72, sensitivity = 52.6%, specificity = 74.6%). CONCLUSION Indexed oxygen delivery during cardiopulmonary bypass is a modifiable variable independently associated with postoperative acute kidney injury in specific pediatric populations. Strategies aimed at maintaining oxygen delivery greater than 340 mL/min/m2 in complex neonates and greater than 400 mL/min/m2 in infants may reduce the occurrence of postoperative acute kidney injury in the pediatric population.
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Affiliation(s)
- Molly Dreher
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Department of Cardiovascular Perfusion, Children’s Hospital of Philadelphia Philadelphia PA 19104 USA
| | - Jungwon Min
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Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia Philadelphia PA 19104 USA
| | - Constantine Mavroudis
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Children’s Hospital of Philadelphia, Cardiac Center, Division of Cardiothoracic Surgery Philadelphia PA 19104 USA
| | - Douglas Ryba
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Information Services Department, Children’s Hospital of Philadelphia Philadelphia PA 19104 USA
| | - Svetlana Ostapenko
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Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia Philadelphia PA 19104 USA
| | - Richard Melchior
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Department of Cardiovascular Perfusion, Children’s Hospital of Philadelphia Philadelphia PA 19104 USA
| | - Tami Rosenthal
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Department of Cardiovascular Perfusion, Children’s Hospital of Philadelphia Philadelphia PA 19104 USA
| | - Muhammad Nuri
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Children’s Hospital of Philadelphia, Cardiac Center, Division of Cardiothoracic Surgery Philadelphia PA 19104 USA
| | - Joshua Blinder
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Stanford University School of Medicine, Lucile Packard Children’s Hospital, Department of Pediatrics, Division of Pediatric Cardiology Palo Alto CA 94304 USA
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11
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Zapf F, Butt W, Namachivayam SP. Opinion: on the importance of maintaining the functional form of explanatory variables. Cardiol Young 2023; 33:1337-1341. [PMID: 35924311 DOI: 10.1017/s1047951122002384] [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] [Indexed: 11/07/2022]
Abstract
In medical research, continuous variables are often categorised into two or more groups before being included in the analysis; this practice often comes with a cost, such as loss of power in analysis, less reliable estimates, and can often leave residual confounding in the results. In this research report, we show this by way of estimates from a regression analysis looking at the association between acute kidney injury and post-operative mortality in a sample of 194 neonates who underwent the Norwood operation. Two models were developed, one using a continuous measure of renal function as the main explanatory variable and second using a categorised version of the same variable. A continuous measure of renal function is more likely to yield reliable estimates and also maintains more statistical power in the analysis to detect a relation between the exposure and outcome. It also reveals the true biological relationship between the exposure and outcome. Categorising a continuous variable may not only miss an important message, it can also get it wrong. Additionally, given a non-linear relationship is commonly encountered between the exposure and outcome variable, investigators are advised to retain a predictor with a linear term only when supported by data. All of this is particularly important in small data sets which account for the majority of clinical research studies.
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Affiliation(s)
- Florian Zapf
- Cardiac Intensive Care Unit, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Warwick Butt
- Cardiac Intensive Care Unit, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
| | - Siva P Namachivayam
- Cardiac Intensive Care Unit, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
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12
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Schuermans A, Van den Eynde J, Mekahli D, Vlasselaers D. Long-term outcomes of acute kidney injury in children. Curr Opin Pediatr 2023; 35:259-267. [PMID: 36377251 DOI: 10.1097/mop.0000000000001202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE OF REVIEW Acute kidney injury (AKI) affects up to 35% of all critically ill children and is associated with substantial short-term morbidity and mortality. However, the link between paediatric AKI and long-term adverse outcomes remains incompletely understood. This review highlights the most recent clinical data supporting the role of paediatric AKI as a risk factor for long-term kidney and cardiovascular consequences. In addition, it stresses the need for long-term surveillance of paediatric AKI survivors. RECENT FINDINGS Recent large-scale studies have led to an increasing understanding that paediatric AKI is a significant risk factor for adverse outcomes such as hypertension, cardiovascular disease and chronic kidney disease (CKD) over time. These long-term sequelae of paediatric AKI are most often observed in vulnerable populations, such as critically ill children, paediatric cardiac surgery patients, children who suffer from severe infections and paediatric cancer patients. SUMMARY A growing body of research has shown that paediatric AKI is associated with long-term adverse outcomes such as CKD, hypertension and cardiovascular disease. Although therapeutic pathways tailored to individual paediatric AKI patients are yet to be validated, we provide a framework to guide monitoring and prevention in children at the highest risk for developing long-term kidney dysfunction.
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Affiliation(s)
- Art Schuermans
- PKD Research Group, Department of Cellular and Molecular Medicine, KU Leuven
| | - Jef Van den Eynde
- PKD Research Group, Department of Cellular and Molecular Medicine, KU Leuven
| | - Djalila Mekahli
- PKD Research Group, Department of Cellular and Molecular Medicine, KU Leuven
- Department of Pediatric Nephrology, University Hospitals Leuven
| | - Dirk Vlasselaers
- Department of Intensive Care Medicine, University Hospitals Leuven
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
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13
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Gritti MN, Farid P, Manlhiot C, Noone D, Sakha S, Ali S, Bernknopf B, McCrindle BW. Factors Associated With Acute Kidney Injury After Cardiopulmonary Bypass in Children. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:20-29. [PMID: 37970105 PMCID: PMC10642090 DOI: 10.1016/j.cjcpc.2022.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 11/29/2022] [Indexed: 11/17/2023]
Abstract
Background Acute kidney injury (AKI) is a common complication after cardiovascular surgery in children, noted in approximately 40% of children undergoing cardiopulmonary bypass (CPB). We sought to determine the risk factors including inflammatory and vascular endothelial markers associated with AKI in children undergoing cardiac surgery. Methods A secondary analysis of a prospective observational cohort study of paediatric patients with a cardiac defect requiring CPB and a weight of >2.5 kg was performed. AKI was defined as a 1.5 times increase from the preoperative value in serum creatinine or an absolute increase by ≥0.3 mg/dL (≥26.5 μmol/L). Plasma inflammatory markers (interleukin [IL]-1a, IL-1b, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p70, and tumour necrosis factor α) and vascular endothelial markers (vascular endothelial growth factor, von Willebrand factor, regulated on activation, normal T-cell expressed and secreted, granulocyte macrophage colony-stimulating factor, monocyte chemoattractant protein-1, platelet-derived growth factor, and microparticles) were assessed at 5 perioperative time points. Associations with AKI were found using generalized linear regression models adjusted for repeated measures. Results A total of 207 patients were assessed, of whom 56% (n = 116) were male. Thirty-three percent (n = 68) developed AKI. In univariable analyses, adverse outcomes significantly related to the presence of AKI included increased intensive care unit stay (3.0 vs 5.6 hours, P < 0.001). In multivariable analysis, independent factors that were significantly associated with AKI included longer duration of CPB (111 vs 154 minutes, P < 0.001) and lower preoperative creatinine. Inflammatory and vascular endothelial biomarkers were not associated with AKI. Conclusions AKI remains a prevalent problem after cardiac surgery, and renal ischemia related to longer bypass time potentially plays a key role in the etiology. Inflammatory and vascular endothelial biomarkers were not significantly related to AKI.
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Affiliation(s)
- Michael N. Gritti
- Labatt Family Heart Centre, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Pedrom Farid
- Labatt Family Heart Centre, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Cedric Manlhiot
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Damien Noone
- Division of Pediatric Nephrology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Seaher Sakha
- Labatt Family Heart Centre, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Sam Ali
- Labatt Family Heart Centre, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Bailey Bernknopf
- Labatt Family Heart Centre, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Brian W. McCrindle
- Labatt Family Heart Centre, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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14
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Early Mortality in Infants Born with Neonatally Operated Congenital Heart Defects and Low or Very-Low Birthweight: A Systematic Review and Meta-Analysis. J Cardiovasc Dev Dis 2023; 10:jcdd10020047. [PMID: 36826543 PMCID: PMC9966697 DOI: 10.3390/jcdd10020047] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 01/16/2023] [Accepted: 01/20/2023] [Indexed: 02/01/2023] Open
Abstract
Mortality outcomes of children with isolated neonatally operated congenital heart defects (CHDs) born with a low (LBW), moderately low (MLBW) or very-low birthweight (VLBW) remain ambiguous. We searched Medline and Embase (inception until October 2021) and included studies that evaluated early mortality. The risk of bias was assessed using the Critical Appraisal Skills Program cohort checklist. Meta-analysis involved random-effects models. We explored variability in mortality across birthweight subgroups, CHD types, and study designs. From 2035 reports, we included 23 studies in qualitative synthesis, and the meta-analysis included 11 studies (1658 CHD cases), divided into 30 subcohorts. The risk of bias was low in 4/11 studies included in the meta-analysis. Summary mortality before discharge or within one month after surgery was 37% (95%CI 27-47). Early mortality varied by birthweight (VLBW 56%, MLBW 15%, LBW 16%; p = 0.003) and CHD types (hypoplastic left heart syndrome (HLHS) 50%, total anomalous pulmonary venous return (TAPVR) 47%, transposition of the great arteries (TGA) 34%, coarctation of the aorta (CoA) 16%; p = 0.13). Mortality was higher in population-based studies (49% vs. 10%; p = 0.006). One-third of infants born with neonatally operated isolated CHDs and LBW, MLBW, or VLBW died within 30 days after surgery. Mortality varied across infant and study characteristics. These results may help clinicians assess neonatal prognosis. PROSPERO registration CRD42020170289.
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15
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Vodiskar J, Mertin J, Heinisch PP, Burri M, Kido T, Strbad M, Hager A, Ewert P, Hörer J, Ono M. Impact of Extracardiac Anomalies on Mortality and Morbidity in Staged Single Ventricle Palliation. Ann Thorac Surg 2023; 115:1197-1204. [PMID: 36646244 DOI: 10.1016/j.athoracsur.2023.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 12/20/2022] [Accepted: 01/09/2023] [Indexed: 01/14/2023]
Abstract
BACKGROUND This study was intended to determine the impact of extracardiac anomalies on outcomes in patients with functional single ventricle who underwent staged palliation. METHODS We reviewed medical records of patients who underwent first-stage palliation at our center between 2001 and 2020. The prevalence and type of extracardiac anomalies were evaluated, and their impact on outcomes during staged palliation was analyzed. RESULTS Among 602 patients who underwent first-stage palliation, 81 (14%) patients had associated with extracardiac anomalies. They were more frequently associated with prematurity (P = .03) and low birth weight below 2.5 kg (P < .01). Mortality between first-stage palliation and stage II was similar in patients with and without extracardiac anomalies (24.7% vs 17.1%, P = .10). However, mortality between stage II and stage III was significantly higher in patients with extracardiac anomalies compared with those without (22.2% vs 12.5%, P = .02). Mortality after stage III was also higher in patients with extracardiac anomalies compared with those without (4.9% vs 1.5%, P = .04). In the subgroup analysis of 81 patients with extracardiac anomalies, renal anomalies were identified as a significant risk factor for mortality (P = .03, hazard ratio 2.44). CONCLUSIONS The incidence of extracardiac anomalies in this study was 14%, and patients with extracardiac anomalies were highly associated with prematurity and low birth weight. Presence of extracardiac anomalies was associated with higher mortality between stage II and stage III palliation and after stage III phase, but not before stage II. Among extracardiac anomalies, renal anomalies were identified as a risk factor for mortality.
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Affiliation(s)
- Janez Vodiskar
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany; Division of Congenital and Pediatric Heart Surgery, Department of Cardiac Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany.
| | - Jannik Mertin
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany; Division of Congenital and Pediatric Heart Surgery, Department of Cardiac Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Paul Philipp Heinisch
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany; Division of Congenital and Pediatric Heart Surgery, Department of Cardiac Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Melchior Burri
- Department of Cardiovascular Surgery, German Heart Center Munich at the Technical University of Munich, Munich, Germany
| | - Takashi Kido
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany; Division of Congenital and Pediatric Heart Surgery, Department of Cardiac Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Martina Strbad
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany; Division of Congenital and Pediatric Heart Surgery, Department of Cardiac Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Alfred Hager
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich at the Technical University of Munich, Munich, Germany
| | - Peter Ewert
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich at the Technical University of Munich, Munich, Germany
| | - Jürgen Hörer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany; Division of Congenital and Pediatric Heart Surgery, Department of Cardiac Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Masamichi Ono
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany; Division of Congenital and Pediatric Heart Surgery, Department of Cardiac Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
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16
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Van den Eynde J, Rotbi H, Schuermans A, Hassanabad AF, Gewillig M, Budts W, Kutty S, Mekahli D. Long-Term Consequences of Acute Kidney Injury After Pediatric Cardiac Surgery: A Systematic Review. J Pediatr 2023; 252:83-92.e5. [PMID: 36096176 DOI: 10.1016/j.jpeds.2022.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 09/01/2022] [Accepted: 09/06/2022] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the available data on long-term kidney dysfunction, hypertension, and mortality after cardiac surgery-associated acute kidney injury (AKI) in the pediatric population. STUDY DESIGN PubMed/MEDLINE, Embase, Scopus, and reference lists of relevant articles were searched for eligible studies published from inception through March 2022. Long-term outcomes after pediatric cardiac surgery complicated by AKI and those without were investigated. RESULTS We identified 14 studies published between 2013 and 2022 that included a total of 6701 patients (AKI: 1376 patients; no AKI: 5325 patients). These studies used different well-established classifications to define AKI. All the studies suggested that AKI after heart surgery is common in the pediatric patient population and reported a potential link between cardiac surgery-associated AKI and important clinical outcomes. However, only 4 out of 11 studies found a strong association between (absence of recovery from) cardiac surgery-associated AKI and risk of developing chronic kidney disease, and 3 out of 5 studies found a significant increase in mortality rates for pediatric patients who developed AKI after cardiac surgery. Only 1 out of 4 studies found an association between AKI and hypertension at 12 months postoperatively, but found no association at later follow-up times. CONCLUSIONS Although there is a trend, evidence on the long-term consequences of cardiac surgery-associated AKI in the pediatric population is mixed. Genetic syndromes, preexisting kidney disease, univentricular or cyanotic heart conditions, and/or high-complexity surgery may be more important for the development of kidney dysfunction by adolescence and early adulthood. Regardless, these children may benefit from a long-term kidney follow-up.
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Affiliation(s)
- Jef Van den Eynde
- Helen B. Taussig Heart Center, The Johns Hopkins Hospital and School of Medicine, Baltimore, MA; Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.
| | - Hajar Rotbi
- Faculty of Medicine, Radboud University, Nijmegen, The Netherlands; Radboud Institute for Health Sciences, Department of Physiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Art Schuermans
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Ali Fatehi Hassanabad
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Marc Gewillig
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium; Pediatric Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Werner Budts
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium; Congenital and Structural Cardiology, UZ Leuven, Leuven, Belgium
| | - Shelby Kutty
- Helen B. Taussig Heart Center, The Johns Hopkins Hospital and School of Medicine, Baltimore, MA
| | - Djalila Mekahli
- Department of Pediatric Nephrology, University Hospitals of Leuven, Leuven, Belgium; PKD Research Group, GPURE, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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17
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Zeng X, Shi S, Sun Y, Feng Y, Tan L, Lin R, Li J, Duan H, Shu Q, Li H. A time-aware attention model for prediction of acute kidney injury after pediatric cardiac surgery. J Am Med Inform Assoc 2022; 30:94-102. [PMID: 36287639 PMCID: PMC9748588 DOI: 10.1093/jamia/ocac202] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/16/2022] [Accepted: 10/12/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE Acute kidney injury (AKI) is a common complication after pediatric cardiac surgery, and the early detection of AKI may allow for timely preventive or therapeutic measures. However, current AKI prediction researches pay less attention to time information among time-series clinical data and model building strategies that meet complex clinical application scenario. This study aims to develop and validate a model for predicting postoperative AKI that operates sequentially over individual time-series clinical data. MATERIALS AND METHODS A retrospective cohort of 3386 pediatric patients extracted from PIC database was used for training, calibrating, and testing purposes. A time-aware deep learning model was developed and evaluated from 3 clinical perspectives that use different data collection windows and prediction windows to answer different AKI prediction questions encountered in clinical practice. We compared our model with existing state-of-the-art models from 3 clinical perspectives using the area under the receiver operating characteristic curve (ROC AUC) and the area under the precision-recall curve (PR AUC). RESULTS Our proposed model significantly outperformed the existing state-of-the-art models with an improved average performance for any AKI prediction from the 3 evaluation perspectives. This model predicted 91% of all AKI episodes using data collected at 24 h after surgery, resulting in a ROC AUC of 0.908 and a PR AUC of 0.898. On average, our model predicted 83% of all AKI episodes that occurred within the different time windows in the 3 evaluation perspectives. The calibration performance of the proposed model was substantially higher than the existing state-of-the-art models. CONCLUSIONS This study showed that a deep learning model can accurately predict postoperative AKI using perioperative time-series data. It has the potential to be integrated into real-time clinical decision support systems to support postoperative care planning.
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Affiliation(s)
- Xian Zeng
- Clinical Data Center, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
- The College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China
| | - Shanshan Shi
- CICU, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Yuhan Sun
- The College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China
| | - Yuqing Feng
- Clinical Data Center, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Linhua Tan
- CICU, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Ru Lin
- CICU, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
- Cardiac Surgery, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Jianhua Li
- Cardiac Surgery, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Huilong Duan
- The College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China
| | - Qiang Shu
- Cardiac Surgery, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Haomin Li
- Clinical Data Center, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
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18
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Boettcher W, O'Brien B, Photiadis J, Habazettl H, Eggert-Doktor D. Acute Kidney Injury With a Miniaturized Extracorporeal Circuit for Neonatal Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2022; 36:4045-4053. [PMID: 36008209 DOI: 10.1053/j.jvca.2022.06.036] [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: 03/12/2022] [Revised: 06/17/2022] [Accepted: 06/24/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The objectives of this study were to evaluate the incidence and to identify risk factors for acute kidney injury (AKI) in neonates undergoing cardiopulmonary bypass (CPB) with a miniaturized bloodless primed extracorporeal circuit. DESIGN A retrospective cohort study. SETTING A single-center, tertiary academic hospital. PARTICIPANTS Data of 462 patients were analyzed. INTERVENTIONS With a retrospective analysis of neonates undergoing CPB with bloodless priming between May 2007 and August 2019, the incidence of AKI was determined according to the neonatal Kidney Disease: Improving Global Outcomes classification. Multivariate logistic regression analyses were performed to determine risk factors for AKI. MEASUREMENTS AND MAIN RESULTS The incidence of AKI was 41.1% (190 of 462); 30.3% (n = 140) had mild stage 1, 6.5% (n = 30) reached stage 2, and 4.3% (n = 20) reached stage 3. Multivariate logistic regression showed that degree of hypothermia (p = 0.05), duration of CPB (p = 0.03), and lower baseline serum creatinine (p < 0.001) were associated independently with AKI. In the authors' patient population, patients without transfusion of donor-derived erythrocytes had a lower incidence of AKI (p = 0.003). AKI stages 2 and 3 were associated with longer duration of mechanical ventilation (p = 0.008) and increased length of stay in the intensive care unit (p = 0.03). CONCLUSIONS With a miniaturized CPB circuit and bloodless priming, the AKI incidence was well within the range consistent with previously reported studies from other institutions.
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Affiliation(s)
- Wolfgang Boettcher
- Department of Congenital Heart Surgery and Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany.
| | - Benjamin O'Brien
- Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Berlin, Berlin, Germany; Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité - Universitaetsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Joachim Photiadis
- Department of Congenital Heart Surgery and Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Helmut Habazettl
- Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Berlin, Berlin, Germany; Institute of Physiology, Charité - Universitaetsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Dirk Eggert-Doktor
- Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Berlin, Berlin, Germany
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19
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Wald R, Beaubien-Souligny W, Chanchlani R, Clark EG, Neyra JA, Ostermann M, Silver SA, Vaara S, Zarbock A, Bagshaw SM. Delivering optimal renal replacement therapy to critically ill patients with acute kidney injury. Intensive Care Med 2022; 48:1368-1381. [PMID: 36066597 DOI: 10.1007/s00134-022-06851-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/29/2022] [Indexed: 02/04/2023]
Abstract
Critical illness is often complicated by acute kidney injury (AKI). In patients with severe AKI, renal replacement therapy (RRT) is deployed to address metabolic dysfunction and volume excess until kidney function recovers. This review is intended to provide a comprehensive update on key aspects of RRT prescription and delivery to critically ill patients. Recently completed trials have enhanced the evidence base regarding several RRT practices, most notably the timing of RRT initiation and anticoagulation for continuous therapies. Better evidence is still needed to clarify several aspects of care including optimal targets for ultrafiltration and effective strategies for RRT weaning and discontinuation.
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Affiliation(s)
- Ron Wald
- Division of Nephrology, St. Michael's Hospital and the University of Toronto, 61 Queen Street East, 9-140, Toronto, ON, M5C 2T2, Canada. .,Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada.
| | | | - Rahul Chanchlani
- Division of Pediatric Nephrology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Edward G Clark
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Javier A Neyra
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Marlies Ostermann
- Department of Critical Care Medicine, Guys and St. Thomas Hospital, London, UK
| | - Samuel A Silver
- Division of Nephrology, Kingston Health Sciences Center, Queen's University, Kingston, ON, Canada
| | - Suvi Vaara
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, Muenster, Germany
| | - Sean M Bagshaw
- Department of Critical Care Medicine, University of Alberta and Alberta Health Services, Edmonton, AB, Canada
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20
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Cui Y, Fang X, Li J, Deng L. Evaluation of neonatal acute kidney injury (AKI) after emergency gastrointestinal surgery. Asian J Surg 2022; 46:1924-1930. [PMID: 36089435 DOI: 10.1016/j.asjsur.2022.08.086] [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: 06/20/2022] [Revised: 07/23/2022] [Accepted: 08/24/2022] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND The overall incidence of acute kidney injury (AKI) in neonates undergoing emergency gastrointestinal surgery is yet to be determined. The study aims are to analyze our experience in emergency gastrointestinal surgery for neonates and to evaluate the incidence of AKI. METHODS We conducted a retrospective study of neonates undergoing emergency gastrointestinal surgery between June 31, 2018 and May 10, 2022 (N = 329). The primary outcome was the overall incidence of AKI. The diagnostic AKI was based on the Modified Kidney Disease: Improving Global Outcomes (KDIGO) definition of neonatal AKI. The secondary outcomes, including the postoperative length of hospital stay (PLOS), 24-h mortality, in-hospital mortality, and total in-hospital cost, were analyzed. The risk factors associated with the development of postoperative AKI were also analyzed. RESULTS The incidence of postoperative AKI was 9.1% (30/329). No significant differences were detected in the 24-h mortality and in-hospital mortality between the two cohorts. In the final model, patients undergoing mechanical ventilation before surgery, vasopressor support, surgical duration, intraoperative oliguria and preoperative lowest serum creatinine (SCr), were independently associated with AKI. CONCLUSION Our study found that patients undergoing mechanical ventilation before surgery, vasopressor support, surgical duration, intraoperative oliguria and preoperative lowest SCr were independently associated with postoperative AKI in neonates who accepted emergency gastrointestinal surgeries.
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Affiliation(s)
- Yu Cui
- Department of Anesthesiology, The Affiliated Hospital, School of Medicine, UESTC Chengdu Women's & Children's Central Hospital, Chengdu, 610091, China.
| | - Xing Fang
- Department of Information, The Affiliated Hospital, School of Medicine, UESTC Chengdu Women's & Children's Central Hospital, Chengdu, 610091, China
| | - Jia Li
- Department of Anesthesiology, The Affiliated Hospital, School of Medicine, UESTC Chengdu Women's & Children's Central Hospital, Chengdu, 610091, China
| | - Lingmei Deng
- Department of Anesthesiology, The Affiliated Hospital, School of Medicine, UESTC Chengdu Women's & Children's Central Hospital, Chengdu, 610091, China
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21
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Inoue T, Kohira S, Ebine T, Shikata F, Fujii K, Miyaji K. Monitoring of intraoperative femoral oxygenation predicts acute kidney injury after pediatric cardiac surgery. Int J Artif Organs 2022; 45:981-987. [PMID: 36032034 DOI: 10.1177/03913988221119527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Cardiopulmonary bypass-associated acute kidney injury (CPB-AKI) is a pediatric cardiac surgery postoperative complication that is associated with a longer duration of mechanical ventilation and length of hospital stay. Identifying an early predictor of CPB-AKI is critical. Near infrared spectroscopy (NIRS), which can provide real-time monitoring of regional tissue oxygen saturation (rSO2) during CPB, may predict CPB-AKI in an early phase of surgical treatment. This study analyzed clinical data from 87 children who underwent an elective surgical repair of ventricular septal defect (VSD) from January 2013 to March 2019. NIRS sensors were placed on the patients' forehead, abdomen, and thighs. The pediatric modified risk, injury, failure, loss, and end-stage (p-RIFLE) score was determined for each patient postoperatively. The incidence of AKI based on the p-RIFLE classification was 11.5% at the end of surgery, 23.0% at 24 h after surgery, and 5.7% at 48 h after surgery. The AKI incidence rate was highest at 24 h after surgery. Multiple regression analysis revealed that femoral oxygenation (rSO2) during CPB, CPB time, oxygen delivery index (DO2i), and lactate at the end of CPB were independent risk factors for AKI. Receiver-operating characteristic curve analysis indicated that femoral oxygenation of 74% or less predicted AKI development within 24 h after surgery. In conclusion, rSO2 measured at the thigh during CPB is highly predictive of CPB-AKI.
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Affiliation(s)
- Takamichi Inoue
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Satoshi Kohira
- Department of Medical Engineering, Kitasato University School of Allied Health Sciences, Sagamihara, Kanagawa, Japan
| | - Tomoyo Ebine
- Department of Medical Engineering, Kitasato University School of Allied Health Sciences, Sagamihara, Kanagawa, Japan
| | - Fumiaki Shikata
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Kiyotaka Fujii
- Department of Medical Engineering, Kitasato University School of Allied Health Sciences, Sagamihara, Kanagawa, Japan
| | - Kagami Miyaji
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
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22
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Liu L, Huang X, Zhou Y, Han Y, Zhang J, Zeng F, Huang Y, Zhou H, Zhang Y. CYP3A4/5 genotypes and age codetermine tacrolimus concentration and dosage in pediatric heart transplant recipients. Int Immunopharmacol 2022; 111:109164. [PMID: 35998509 DOI: 10.1016/j.intimp.2022.109164] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/04/2022] [Accepted: 08/11/2022] [Indexed: 11/05/2022]
Abstract
Tacrolimus (TAC) is the cornerstone of immunosuppressive therapy for pediatric heart transplantation (HTx) recipients. However, little information is known on the interaction of developmental and genetic variants on TAC disposition in this population, which makes TAC dose optimization more difficult. The aim of study was to investigate the relationship between genotypes and age on TAC concentrations and dosage during the early post-operation period in pediatric HTx recipients. Sixty-six pediatric HTx recipients were enrolled and divided into three groups according to the age (<6, ≥6-≤12, 12-18 years old). CYP3A4/5, POR and ABCB1 polymorphisms were genotyped. The associations between genotypes and age on TAC dose-adjusted trough concentrations (C0/D), dose requirement as well as acute kidney injury (AKI) were evaluated. CYP3A5*3 and CYP3A4*1G were significantly correlated with TAC C0/D and dose requirement in the pediatric recipients ≥ 6 years. The C0/D in children aged ≥ 6-≤12 years and 12-18 years is 2.8 and 4.2 fold of these < 6 years old, respectively. TAC dose requirements in children aged < 6 years were 2.4 times and 3.5 times of these aged ≥ 6-≤12 years and 12-18 years, respectively. Among the same CYP3A5*3 or CYP3A4*1G genotypes, age was positively increased with TAC C0/D and negatively correlated with targeted dose. No genetic variants were found to be associated with AKI during the early post-operation period. CYP3A4/5 genotypes and age should be taken into consideration to TAC dosage in pediatric HTx recipients.
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Affiliation(s)
- Li Liu
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan 430022, China
| | - Xiao Huang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan 430022, China
| | - Ying Zhou
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan 430022, China
| | - Yong Han
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan 430022, China
| | - Jing Zhang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Fang Zeng
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan 430022, China
| | - Yifei Huang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan 430022, China
| | - Hong Zhou
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan 430022, China
| | - Yu Zhang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan 430022, China
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23
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Shaffer CL. The Use of Renal Biomarkers in Pediatric Cardiac Patients With Acute Kidney Injury. J Pediatr Pharmacol Ther 2022; 27:506-516. [DOI: 10.5863/1551-6776-27.6.506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 11/29/2021] [Indexed: 11/11/2022]
Abstract
Acute kidney injury (AKI) is a common and serious condition that occurs in approximately 30% to 50% of pediatric patients that undergo cardiac surgery. Currently used parameters to measure kidney function (serum creatinine and urine output) are often unreliable and delay the prediction of AKI, despite their adoption into clinical guidelines. Emerging evidence suggests that biomarkers such as neutrophil gelatinase-associated lipocalin, cystatin C, interleukin-18, kidney injury molecule 1, and liver-type fatty acid– binding protein may be useful in the identification and location of pediatric renal injury. Ontogeny-related changes in tubular function and nephrogenesis result in reference values that differ based on age and sex. In addition, changes in endogenous concentrations may result from factors such as cardiopulmonary bypass. The use of urine samples to measure renal biomarkers offers a significant advantage compared with routine blood sampling, especially in the neonatal patient population. Future research is warranted to determine age-dependent changes in AKI biomarkers and the relationship with pharmacokinetic clearance of commonly used medications in the postoperative cardiac patient.
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Affiliation(s)
- Christopher L. Shaffer
- University of Nebraska Medical Center College of Pharmacy and Pediatric Clinical Pharmacology Program, Child Health Research Institute, University of Nebraska Medical Center/Children's Hospital and Medical Center, Omaha, NE
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24
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Liu L, Zhang M, Chen X, Wang L, Xu Z. Prediction value of regional oxygen saturation in intestine and kidney for acute kidney injury in children with congenital heart disease after surgery. Zhejiang Da Xue Xue Bao Yi Xue Ban 2022; 51:334-340. [PMID: 36207833 PMCID: PMC9511473 DOI: 10.3724/zdxbyxb-2022-0069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/14/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To study the prediction value of regional oxygen saturation (rSO 2) in brain, intestine and kidney for acute kidney injury (AKI) in children with congenital heart disease after surgery. METHODS Fifty-seven children with congenital heart disease (CHD), whose weight >2.5 kg and age≤1 year were treated in Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine from January 2020 to December 2020. The rSO 2 of brain, intestine and kidney were monitored with near-infrared spectroscopy continuously for 48 h after surgery. The predictive values of cerebral, intestinal and renal rSO 2 for occurrence and severity of postoperative AKI were analyzed. RESULTS Among 57 patients, postoperative AKI developed in 38 cases (66.7%), including 18 cases of AKI-1 (47.4%), 9 cases of AKI-2 (23.7%) and 11 cases of AKI-3 (28.9%). There was no significant difference in cerebral rSO 2 between AKI group and non-AKI group ( F=0.012, P>0.05), while the intestinal rSO 2 and renal rSO 2 in AKI group were significantly lower than those in non-AKI group ( F=5.017 and 5.003, both P<0.05). There was no significant difference in brain rSO 2 between children with or without AKI-2 and above ( F=0.311, P>0.05), but the intestinal rSO 2 and renal rSO 2 in children with AKI-2 and above were lower than other children ( F=6.431 and 14.139, both P<0.05). The area under ROC curve (AUC) of intestinal rSO 2 3 h after surgery for predicting AKI was 0.823, and with intestinal rSO 2 3 h after surgery <85%, the sensitivity and specificity were 66.7% and 89.5%, respectively. The AUC of renal rSO 2 for the diagnosis of AKI at 31 h after surgery was 0.918, and with intestinal rSO 2 31 h after surgery <84%, the sensitivity and specificity were 72.2% and 84.2%, respectively. The AUC of intestinal rSO 23 h after surgery for the diagnosis of AKI-2 and above was 0.829, and with intestinal rSO 2 3 h after surgery <84%, the sensitivity and specificity were 62.2% and 90.0%, respectively. The AUC of renal rSO 2 for the diagnosis of AKI-2 and above was 0.826 at 34 h postoperatively, and with intestinal rSO 2 34 h after surgery <71%, the sensitivity and specificity were 91.9% and 55.0%, respectively. CONCLUSION The monitoring of intestinal and renal rSO 2 can predict the occurrence and severity of postoperative AKI in children with congenital heart disease after surgery.
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25
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Lu C, Lian J, Cao Z, Chen L, Liang J, Wang S. Comparing the pRIFLE, AKIN, KDIGO, and modified KDIGO criteria in neonates after cardiac surgery. Pediatr Nephrol 2022; 37:1399-1405. [PMID: 34716482 DOI: 10.1007/s00467-021-05306-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 09/13/2021] [Accepted: 09/13/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND While several standardized criteria for acute kidney injury (AKI) have been studied, there is no consensus on which criteria to use in neonates after cardiac surgery. The goal of this research was to compare the AKI incidence and outcomes according to the pediatric Risk, Injury, Failure and Loss, and End-Stage (pRIFLE), AKI Network (AKIN), Kidney Disease Improving Global Outcomes (KDIGO), and modified KDIGO (mKDIGO) criteria in neonates following congenital cardiac surgery. METHODS A clinical database of all neonates undergoing congenital cardiac surgery admitted to the Cantonese cardiac center from 2014 to 2020 was retrospectively analyzed. AKI was based on the pRIFLE, AKIN, KDIGO, and mKDIGO classification. The predictive abilities for postoperative outcomes were compared by receiver operating curves, and multivariate logistic regression analysis was used to assess the association of AKI definitions with postoperative outcomes. RESULTS In the study population of 522 patients, 177, 110, 131, and 114 neonates had AKI according to the pRIFLE, AKIN, KDIGO, and mKDIGO criteria, respectively. After multivariate analysis, all definitions were found to be significant predictors of increased mortality. The AUCs for mortality were substantially different with pRIFLE (AUC, 0.795), AKIN (AUC, 0.724), KDIGO (AUC, 0.819), and mKDIGO (AUC, 0.831) (P < 0.01) across the entire population, whereas the mKDIGO system was more accurate than the pRIFLE, AKIN, and KDIGO systems. CONCLUSIONS The incidence of AKI varied across all definitions. However, the mKDIGO system was more accurate in predicting in-hospital mortality than the pRIFLE, AKIN, and KDIGO systems in neonates after heart surgery.
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Affiliation(s)
- Chao Lu
- Department of Anesthesiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jiaxin Lian
- Department of Anesthesiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zhongming Cao
- Department of Anesthesiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Liwen Chen
- Department of Anesthesiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jiexian Liang
- Department of Anesthesiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Sheng Wang
- Department of Anesthesiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.
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26
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Bhombal S, Chock VY, Shashidharan S. The impact of prematurity and associated comorbidities on clinical outcomes in neonates with congenital heart disease. Semin Perinatol 2022; 46:151586. [PMID: 35525603 DOI: 10.1016/j.semperi.2022.151586] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Prematurity is a common risk factor in children, affecting approximately 10% of live births, globally. It is more common in children with critical congenital heart disease (CCHD) and carries important implications in this group of patients. While outcomes have been improving over the years, even late preterm birth is associated with worse outcomes in children born with critical congenital heart disease compared to those without. Infants with both prematurity and CCHD are at particularly high risk for important comorbidities, including: necrotizing enterocolitis, intraventricular hemorrhage, white matter injury, neurodevelopmental anomalies and retinopathy of prematurity. Lesion-specific intensive care management of these infants, interventional and peri-operative management specifically tailored to their needs, and multidisciplinary care all have the potential to improve outcomes in this challenging group.
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Affiliation(s)
- Shazia Bhombal
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, USA.
| | - Valerie Y Chock
- Department of Surgery, Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Emory School of Medicine, USA
| | - Subhadra Shashidharan
- Department of Surgery, Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Emory School of Medicine, USA
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27
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Davidson JA, Robison J, Khailova L, Frank BS, Jaggers J, Ing RJ, Lawson S, Iguidbashian J, Ali E, Treece A, Soranno DE, Osorio-Lujan S, Klawitter J. Metabolomic profiling demonstrates evidence for kidney and urine metabolic dysregulation in a piglet model of cardiac surgery-induced acute kidney injury. Am J Physiol Renal Physiol 2022; 323:F20-F32. [PMID: 35532069 PMCID: PMC9236877 DOI: 10.1152/ajprenal.00039.2022] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Acute kidney injury (AKI) is a common cause of morbidity after congenital heart disease surgery. Progress on diagnosis and therapy remains limited, however, in part due to poor mechanistic understanding and a lack of relevant translational models. Metabolomic approaches could help identify novel mechanisms of injury and potential therapeutic targets. In the present study, we used a piglet model of cardiopulmonary bypass with deep hypothermic circulatory arrest (CPB/DHCA) and targeted metabolic profiling of kidney tissue, urine, and serum to evaluate metabolic changes specific to animals with histological acute kidney injury. CPB/DHCA animals with acute kidney injury were compared with those without acute kidney injury and mechanically ventilated controls. Acute kidney injury occurred in 10 of 20 CPB/DHCA animals 4 h after CPB/DHCA and 0 of 7 control animals. Injured kidneys showed a distinct tissue metabolic profile compared with uninjured kidneys (R2 = 0.93, Q2 = 0.53), with evidence of dysregulated tryptophan and purine metabolism. Nine urine metabolites differed significantly in animals with acute kidney injury with a pattern suggestive of increased aerobic glycolysis. Dysregulated metabolites in kidney tissue and urine did not overlap. CPB/DHCA strongly affected the serum metabolic profile, with only one metabolite that differed significantly with acute kidney injury (pyroglutamic acid, a marker of oxidative stress). In conclusion, based on these findings, kidney tryptophan and purine metabolism are candidates for further mechanistic and therapeutic investigation. Urine biomarkers of aerobic glycolysis could help diagnose early acute kidney injury after CPB/DHCA and warrant further evaluation. The serum metabolites measured at this early time point did not strongly differentiate based on acute kidney injury. NEW & NOTEWORTHY This project explored the metabolic underpinnings of postoperative acute kidney injury (AKI) following pediatric cardiac surgery in a translationally relevant large animal model of cardiopulmonary bypass with deep hypothermic circulatory arrest. Here, we present novel evidence for dysregulated tryptophan catabolism and purine catabolism in kidney tissue and increased urinary glycolysis intermediates in animals who developed histological AKI. These pathways represent potential diagnostic and therapeutic targets for postoperative AKI in this high-risk population.
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Affiliation(s)
- Jesse A Davidson
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Justin Robison
- Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, United States
| | - Ludmila Khailova
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Benjamin S Frank
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - James Jaggers
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Richard J Ing
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - Scott Lawson
- Heart Institute, Children's Hospital Colorado, Aurora, CO, United States
| | - John Iguidbashian
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Eiman Ali
- Heart Institute, Children's Hospital Colorado, Aurora, CO, United States
| | - Amy Treece
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - Danielle E Soranno
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Suzanne Osorio-Lujan
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Jelena Klawitter
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
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Pettit K, Gist KM. Filtering Down to Risks and Solutions: Risk Factors and Stratification After Pediatric Cardiac Surgery. Semin Nephrol 2022; 42:151278. [PMID: 36411193 DOI: 10.1016/j.semnephrol.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Acute kidney injury after cardiac surgery (CS-AKI) is common in neonatal and pediatric populations and is a risk factor for poor outcomes, such as mortality and increased hospital resource utilization. This review presents a summary of CS-AKI risk factors, integration of biomarkers, and the need to improve risk stratification for targeting future clinical trials. To date, studies examining CS-AKI risk factors cannot be generalized easily owing to variability in patient age, surgical complexity or population, AKI definition, and center-specific practices. However, certain risk associations, such as younger age at surgery, history of prematurity, cardiopulmonary bypass time, and surgical complexity, have been identified across multiple, but not all, studies. CS-AKI appears to have different severity and duration phenotypes, and serum creatinine is limited in its ability to identify CS-AKI early and predict CS-AKI course. Treatment strategies are largely supportive, and efforts are ongoing to use biomarkers and clinical features to risk-stratify patients, which in turn may facilitate differential CS-AKI phenotyping and management with supportive care bundles, clinical decision support techniques, and modulation of modifiable risk factors.
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Affiliation(s)
- Kevin Pettit
- Department of Pediatrics, The Heart Institute, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Katja M Gist
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH.
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Blood pressure variability during pediatric cardiac surgery is associated with acute kidney injury. Pediatr Nephrol 2022; 37:871-879. [PMID: 34436673 DOI: 10.1007/s00467-021-05234-1] [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: 12/13/2020] [Revised: 07/08/2021] [Accepted: 07/13/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Blood pressure variability (BPV), defined as the degree of variation between discrete blood pressure readings, is associated with poor outcomes in acute care settings. Acute kidney injury (AKI) is a common and serious postoperative complication of cardiac surgery with cardiopulmonary bypass (CPB) in children. No studies have yet assessed the association between intraoperative BPV during cardiac surgery with CPB and the development of AKI in children. METHODS A retrospective chart review of children undergoing cardiac surgery with CPB was performed. Intraoperative BPV was calculated using average real variability (ARV) and standard deviation (SD). Multiple regression models were used to examine the association between BPV and outcomes of AKI, hospital and intensive care unit (PICU) length of stay, and length of mechanical ventilation. RESULTS Among 231 patients (58% males, median age 8.6 months) reviewed, 51.5% developed AKI (47.9% Stage I, 41.2% Stage II, 10.9% Stage III). In adjusted models, systolic and diastolic ARV were associated with development of any stage AKI (OR 1.40, 95% CI 1.08-1.8 and OR 1.4, 95% CI 1.05-1.8, respectively). Greater diastolic SD was associated with longer PICU length of stay (β 0.94, 95% CI 0.62-1.2). When stratified by age, greater systolic ARV and SD were associated with AKI in infants ≤ 12 months, but there was no relationship in children > 12 months. CONCLUSIONS Greater BPV during cardiac surgery with CPB was associated with development of postoperative AKI in infants, suggesting that BPV is a potentially modifiable risk factor for AKI in this high-risk population.
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Transient and persistent acute kidney injury phenotypes following the Norwood operation: a retrospective study. Cardiol Young 2022; 32:564-571. [PMID: 34233781 PMCID: PMC8741883 DOI: 10.1017/s1047951121002560] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Acute kidney injury is a common complication following the Norwood operation. Most neonatal studies report acute kidney injury peaking within the first 48 hours after cardiac surgery. The aim of this study was to evaluate if persistent acute kidney injury (>48 postoperative hours) after the Norwood operation was associated with clinically relevant outcomes. METHODS Two-centre retrospective study among neonates undergoing the Norwood operation. Acute kidney injury was initially identified as developing within the first 48 hours after cardiac surgery and stratified into transient (≤48 hours) and persistent (>48 hours) using the neonatal modification of the Kidney Disease: Improving Global Outcomes serum creatinine criteria. Severe was defined as stage ≥2. Primary and secondary outcomes were mortality and duration of ventilation and hospital length of stay. RESULTS One hundred sixty-eight patients were included. Transient and persistent acute kidney injuries occurred in 24 and 17%, respectively. Cardiopulmonary bypass and aortic cross clamp duration, and incidence of cardiac arrest were greater among those with persistent kidney injury. Mortality was four times higher (41 versus 12%, p < 0.001) and mechanical ventilation duration 50 hours longer in persistent acute kidney injury patients (158 versus 107 hours; p < 0.001). In multivariable analysis, persistent acute kidney injury was not associated with mortality, duration of ventilation or length of stay. Severe persistent acute kidney injury was associated with a 59% increase in expected ventilation duration (aIRR:1.59, 95% CI:1.16, 2.18; p = 0.004). CONCLUSIONS Future large studies are needed to determine if risk factors and outcomes change by delineating acute kidney injury into discrete timing phenotypes.
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31
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Gist KM, SooHoo M, Mack E, Ricci Z, Kwiatkowski DM, Cooper DS, Krawczeski CD, Alten JA, Goldstein SL, Basu RK. Modifying the Renal Angina Index for Predicting AKI and Related Adverse Outcomes in Pediatric Heart Surgery. World J Pediatr Congenit Heart Surg 2022; 13:196-202. [PMID: 35238710 DOI: 10.1177/21501351211073615] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background:Reliable prediction of severe acute kidney injury (AKI) and related poor outcomes has the potential to optimize treatment. The purpose of this study was to modify the renal angina index in pediatric cardiac surgery to predict severe AKI and related poor outcomes. Methods: We performed a multicenter retrospective study with the population divided into a derivation and validation cohort to assess the performance of a modified renal angina index assessed at 8 h after cardiac intensive care unit (CICU) admission to predict a complex outcome of severe day 3 AKI or related poor outcomes (ventilation duration >7 days, CICU length of stay >14 days, and mortality). The derivation sample was used to determine the optimal cut-off value. Results: There were 298 and 299 patients in the derivation and validation cohorts, respectively. The incidence of severe day 3 AKI and the complex outcome was 1.7% and 28% in the derivation and validation cohort. The sensitivity analysis for fulfillment of renal angina was a score >8 with a sensitivity of 63%, specificity of 73%, and negative predictive value of 83%. The cardiac renal angina index predicted the composite outcome with an area under the curve of 0.7 (95% confidence interval: 0.62-0.78). Renal angina patients had a significantly higher probability of the complex outcome when compared to individual risk and injury categories. Conclusions: We operationalized the renal angina index for use after cardiac surgery. Further revision and modification of the construct with integration of biomarkers in a prospective cohort are necessary to refine the prediction model.
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Affiliation(s)
- Katja M Gist
- 2518University of Cincinnati School of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Megan SooHoo
- 22095University of Colorado Anschutz Medical Campus, 2932Children's Hospital Colorado, Aurora, CO, USA
| | - Emily Mack
- 22095University of Colorado Anschutz Medical Campus, 2932Children's Hospital Colorado, Aurora, CO, USA
| | | | - David M Kwiatkowski
- 24349Stanford University School of Medicine, Stanford Children's Hospital, Palo Alto, CA, USA
| | - David S Cooper
- 2518University of Cincinnati School of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Catherine D Krawczeski
- 2650Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, OH, USA
| | - Jeffrey A Alten
- 2518University of Cincinnati School of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Stuart L Goldstein
- 2518University of Cincinnati School of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Rajit K Basu
- 12240Northwestern University School of Medicine, Ann and Robert Lurie Children's Hospital of Chicago, Chicago, IL, USA
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Van den Eynde J, Delpire B, Jacquemyn X, Pardi I, Rotbi H, Gewillig M, Kutty S, Mekahli D. Risk factors for acute kidney injury after pediatric cardiac surgery: a meta-analysis. Pediatr Nephrol 2022; 37:509-519. [PMID: 34595570 DOI: 10.1007/s00467-021-05297-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/16/2021] [Accepted: 09/16/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Cardiac surgery-associated acute kidney injury (AKI) is associated with increased morbidity and mortality in both adults and children. OBJECTIVES This study aimed to identify clinical risk factors for AKI following cardiac surgery in the pediatric population. DATA SOURCES PubMed/MEDLINE, Embase, Scopus, and reference lists of relevant articles were searched for studies published by August 2020. STUDY ELIGIBILITY CRITERIA Studies were included if (1) the population consisted of pediatric patients (< 18 years old), (2) patients underwent cardiac surgery, (3) risk factors were compared between patients who developed AKI and those who did not, and (4) studies were prospective or retrospective observational studies or randomized controlled trials. PARTICIPANTS AND INTERVENTIONS Children undergoing pediatric cardiac surgery. STUDY APPRAISAL AND SYNTHESIS METHODS Random-effects meta-analysis was performed, comparing potential risk factors between pediatric patients who developed CS-AKI and those who did not. RESULTS Sixty-one publications including a total of 19,680 participants (AKI: 7257 participants; no AKI: 12,423 participants) were included from studies published between 2008 and 2020. The pooled estimated incidence of AKI was 34.3% (95% confidence interval 30.0-38.8%, I2 = 96.8%). Binary risk factors that were significantly and consistently associated with AKI were the presence of pulmonary hypertension, cyanotic heart disease, univentricular heart, risk adjustment for congenital heart surgery 1 (RACHS-1) score ≥ 3, vasopressor use, cardiopulmonary bypass use, reoperation, and sepsis. Significant continuous risk factors included younger age, lower body weight, lower preoperative creatinine, higher preoperative estimated glomerular filtration rate (eGFR), higher RACHS-1 score, longer surgery time, longer cardiopulmonary bypass time, longer aortic cross-clamp time, and higher red blood cell transfusion volume. LIMITATIONS Results are limited by heterogeneity and potential residual confounding. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS Our meta-analysis identified clinical risk factors that are associated with AKI in children undergoing cardiac surgery. This might help clinicians anticipate and manage more carefully this population and implement standardized preventive strategies. SYSTEMATIC REVIEW REGISTRATION NUMBER CRD42021262699. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Jef Van den Eynde
- Helen B. Taussig Heart Center, The Johns Hopkins Hospital and School of Medicine, Baltimore, USA. .,Department of Cardiovascular Sciences, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - Boris Delpire
- Department of Cardiovascular Sciences, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Xander Jacquemyn
- Department of Cardiovascular Sciences, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Ismat Pardi
- Department of Cardiovascular Sciences, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Hajar Rotbi
- Faculty of Medicine, Radboud University, Nijmegen, The Netherlands.,Department of Physiology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Marc Gewillig
- Department of Cardiovascular Sciences, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.,Pediatric Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Shelby Kutty
- Helen B. Taussig Heart Center, The Johns Hopkins Hospital and School of Medicine, Baltimore, USA
| | - Djalila Mekahli
- Department of Pediatric Nephrology, University Hospitals of Leuven, Leuven, Belgium.,PKD Research Group, GPURE, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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33
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Assessing Risk Factors and Associated Adverse Outcomes of Acute Kidney Injury After Neonatal Cardiac Surgery. Crit Care Med 2022; 50:e324-e325. [PMID: 35191881 DOI: 10.1097/ccm.0000000000005365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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34
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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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LoBasso M, Schneider J, Sanchez-Pinto LN, Del Castillo S, Kim G, Flynn A, Sethna CB. Acute kidney injury and kidney recovery after cardiopulmonary bypass in children. Pediatr Nephrol 2022; 37:659-665. [PMID: 34386849 DOI: 10.1007/s00467-021-05179-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 06/05/2021] [Accepted: 06/14/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) that improves in the pediatric intensive care unit (PICU) is associated with better outcomes compared to AKI that persists, but no study has investigated whether this also occurs in children undergoing cardiopulmonary bypass (CPB). METHODS A retrospective study of children ≤18 years who underwent CPB in three children's hospitals was conducted. Patients were classified into groups by kidney recovery after AKI according to Acute Disease Quality Initiative (ADQI) guidelines. Adjusted regression models evaluated associations between kidney recovery group and hospital outcomes. RESULTS Among 3620 children, AKI developed in 701 (19.4%): 610 transient AKI, 47 persistent AKI, and 44 acute kidney disease (AKD). Mortality increased with severity of kidney recovery group: 4.5% in the never developed AKI group, 8.9% in the transient AKI group, 25.5% in the persistent AKI group, and 31.8% in the AKD group (p <0.0001). In adjusted analysis, transient AKI (HR 1.4, CI 1.02, 2), persistent AKI (HR 22.4, CI 10.2, 49.2), and AKD (HR 3.7, CI 1.7, 7.9) had a greater hazard of mortality when compared to the never developed AKI group. Patients with transient AKI had a longer length of PICU stay than those with never developed AKI (HR 5.1, CI 2.9, 7.3). CONCLUSIONS Patterns of kidney recovery after AKI were associated with worse PICU outcomes in children after CPB compared to those who did not develop AKI, even after rapid AKI recovery. Identification of factors that increase risk for these AKI patterns is necessary for prevention of AKI during CPB in children. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Michael LoBasso
- Division of Pediatric Nephrology, Cohen Children's Medical Center of New York, 269-01 76th Avenue, New Hyde Park, NY, 11040, USA
| | - James Schneider
- Division of Pediatric Critical Care, Cohen Children's Medical Center of New York, New Hyde Park, NY, USA
| | - L Nelson Sanchez-Pinto
- Division of Critical Care, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Sylvia Del Castillo
- Division of Critical Care, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Gina Kim
- Division of Critical Care, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Alysia Flynn
- Division of Critical Care, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Christine B Sethna
- Division of Pediatric Nephrology, Cohen Children's Medical Center of New York, 269-01 76th Avenue, New Hyde Park, NY, 11040, USA.
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36
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Yokota R, Kwiatkowski DM, Journel C, Adamson GT, Zucker E, Suarez G, Lechich KM, Chaudhuri A, Collins RT. Postoperative Acute Kidney Injury in Williams Syndrome Compared With Matched Controls. Pediatr Crit Care Med 2022; 23:e162-e170. [PMID: 34982759 DOI: 10.1097/pcc.0000000000002872] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Cardiovascular manifestations occur in over 80% of Williams syndrome (WS) patients and are the leading cause of morbidity and mortality. One-third of patients require cardiovascular surgery. Renal artery stenosis (RAS) is common in WS. No studies have assessed postoperative cardiac surgery-related acute kidney injury (CS-AKI) in WS. Our objectives were to assess if WS patients have higher risk of CS-AKI postoperatively than matched controls and if RAS could contribute to CS-AKI. DESIGN This was a retrospective study of all patients with WS who underwent cardiac surgery at our center from 2010 to 2020. The WS study cohort was compared with a group of controls matched for age, sex, weight, and surgical procedure. SETTING Patients underwent cardiac surgery and postoperative care at Lucile Packard Children's Hospital Stanford. PATIENTS There were 27 WS patients and 43 controls (31% vs 42% female; p = 0.36). Median age was 1.8 years (interquartile range [IQR], 0.7-3.8 yr) for WS and 1.7 years (IQR, 0.8-3.1 yr) for controls. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Postoperative hemodynamics, vasopressor, total volume input, diuretic administration, and urine output were collected in the first 72 hours. Laboratory studies were collected at 8-hour intervals. Multivariable analysis identified predictors of CS-AKI.Controlled for renal perfusion pressure (RPP) and vasoactive inotrope score (VIS), compared with controls, the odds ratio (OR) of CS-AKI in WS was 4.2 (95% CI, 1.1-16; p = 0.034). Higher RPP at postoperative hours 9-16 was associated with decreased OR of CS-AKI (0.88 [0.8-0.96]; p = 0.004). Increased VIS at hour 6 was associated with an increased OR of CS-AKI (1.47 [1.14-1.9]; p = 0.003). Younger age was associated with an increased OR of CS-AKI (1.9 [1.13-3.17]; p = 0.015). CONCLUSIONS The OR of CS-AKI is increased in pediatric patients with WS compared with controls. CS-AKI was associated with VIS at the sixth postoperative hour. Increases in RPP and mean arterial pressure were associated with decreased odds of CS-AKI.
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Affiliation(s)
- Rumi Yokota
- Lucile Packard Children's Hospital Stanford, Palo Alto, CA
| | - David M Kwiatkowski
- Lucile Packard Children's Hospital Stanford, Palo Alto, CA
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Chloe Journel
- Lucile Packard Children's Hospital Stanford, Palo Alto, CA
| | - Greg T Adamson
- Lucile Packard Children's Hospital Stanford, Palo Alto, CA
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Evan Zucker
- Lucile Packard Children's Hospital Stanford, Palo Alto, CA
- Department of Radiology, Stanford University School of Medicine, Palo Alto, CA
| | | | | | - Abanti Chaudhuri
- Lucile Packard Children's Hospital Stanford, Palo Alto, CA
- Division of Nephrology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - R Thomas Collins
- Lucile Packard Children's Hospital Stanford, Palo Alto, CA
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
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37
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Impact of Medical Interventions and Comorbidities on Norwood Admission for Patients with Hypoplastic Left Heart Syndrome. Pediatr Cardiol 2022; 43:267-278. [PMID: 35034159 DOI: 10.1007/s00246-022-02818-y] [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: 09/01/2021] [Accepted: 01/06/2022] [Indexed: 10/19/2022]
Abstract
The purpose of these analyses was to determine how specific comorbidities and medical interventions impact risk of inpatient mortality in those with hypoplastic left heart syndrome undergoing Norwood procedure. The secondary aims were to determine the impact of these on billed charges, postoperative length of stay, and risk of cardiac arrest. Admissions from 2004 to 2015 in the Pediatric Health Information System database with hypoplastic left heart syndrome and Norwood procedure were identified. Admission characteristics, patient interventions, and the presence of comorbidities were captured. A total of 5,138 admissions were identified meeting inclusion criteria. Of these 829 (16.1%) experienced inpatient mortality, and 352 (6.7%) experienced cardiac arrest. The frequency of inpatient mortality did not significantly change over the course of the study era. The frequency of cardiac arrest significantly decreased from 7.4% in 2004 to 4.3% in 2015 (p = 0.04). The frequency of pharmacologic therapies, particularly vasoactive use, decreased as the study period progressed. Regression analyses demonstrated a significant association between cardiac arrest and inpatient mortality with arrhythmias, acute kidney injury, and pulmonary hypertension. Similarly, regression analyses demonstrated a significant association between increase in billed charges and length of stay with year of surgery, presence of heart failure, syndromes, and acute kidney injury. For patients with hypoplastic left heart syndrome undergoing the Norwood procedure, the frequency of pharmacologic therapies and cardiac arrest has decreased over time. There are significant associations between acute kidney injury, arrythmias, and pulmonary hypertension with cardiac arrest and mortality.
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38
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Zhang P, Tong Y, Yuan D, Li Y, Jin Y, Bai L, Gao P, Wang W, Hu J, Duan X, Liu J. Association of high-sensitivity C-reactive protein and anemia with acute kidney injury in neonates. Front Pediatr 2022; 10:882739. [PMID: 36405830 PMCID: PMC9666738 DOI: 10.3389/fped.2022.882739] [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: 02/24/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
- Peiyao Zhang
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuanyuan Tong
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Deshan Yuan
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yixuan Li
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Jin
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Liting Bai
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Peng Gao
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenting Wang
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinxiao Hu
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin Duan
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinping Liu
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Ramírez M, Chakravarti S, Busovsky-McNeal M, McKinstry J, Al-qaqaa Y, Sahulee R, Kumar TS, Li X, Goldberg JD, Gefen AM, Malaga-Dieguez L. Elevated Levels of Urinary Biomarkers TIMP-2 and IGFBP-7 Predict Acute Kidney Injury in Neonates after Congenital Heart Surgery. J Pediatr Intensive Care 2021; 11:153-158. [PMID: 35734207 PMCID: PMC9208843 DOI: 10.1055/s-0041-1740359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 10/19/2021] [Indexed: 12/15/2022] Open
Abstract
Objectives This article investigated the utility of urine biomarkers tissue inhibitor of metalloproteinase-2 (TIMP-2) and insulin-like growth factor binding protein-7 (IGFBP-7) in identifying acute kidney injury (AKI) in neonates after congenital heart surgery (CHS). TIMP-2 and IGFBP-7 are cell cycle arrest proteins detected in urine during periods of kidney stress/injury. Methods We conducted a single-center, prospective study between September 2017 and May 2019 with neonates undergoing CHS requiring cardiopulmonary bypass (CPB). Urine samples were analyzed using NephroCheck prior to surgery and 6, 12, 24, and 96 hours post-CPB. All patients were evaluated using the Acute Kidney Injury Network (AKIN) criteria. Wilcoxon rank sum tests were used to compare the medians of the [TIMP-2*IGFBP-7] values in the AKIN negative and positive groups at each time point. Receiver operating characteristic curves were used to measure how well the [TIMP-2*IGFBP-7] values predict AKIN status. Results Thirty-six patients were included. No patients met the AKIN criteria for AKI preoperatively. Postoperatively, 19 patients (53%) met the AKIN criteria for AKI diagnosis: 13 (36%) stage 1, 5 (14%) stage 2, and 1 (3%) stage 3. None required renal replacement therapy. At the 24-hour time points, patients who met the AKIN criteria for AKI had a statistically significantly higher [TIMP-2*IGFBP7] values than the patients without AKI (1.1 vs. 0.27 [ng/mL] 2 /1,000) at 24 hours (adj- p = 0.0019). Conclusion AKI is a serious complication associated with adverse outcomes in patients undergoing cardiac surgery. [TIMP-2*IGFBP-7] urinary level 24 hours after CPB is a good predictor of AKI in this population.
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Affiliation(s)
- Michelle Ramírez
- Pediatric Cardiac Intensive Care, NYU Hassenfeld Children's Hospital, New York, United States,Address for correspondence Michelle Ramírez, MD 550 First Avenue New York, NY 10016United States
| | - Sujata Chakravarti
- Pediatric Cardiac Intensive Care, NYU Hassenfeld Children's Hospital, New York, United States
| | - Melissa Busovsky-McNeal
- Pediatric Cardiac Intensive Care, NYU Hassenfeld Children's Hospital, New York, United States
| | - Jaclyn McKinstry
- Pediatric Cardiac Intensive Care, NYU Hassenfeld Children's Hospital, New York, United States
| | - Yasir Al-qaqaa
- Pediatric Cardiac Intensive Care, NYU Hassenfeld Children's Hospital, New York, United States
| | - Raj Sahulee
- Pediatric Cardiac Intensive Care, NYU Hassenfeld Children's Hospital, New York, United States
| | - T.K. Susheel Kumar
- Department of Cardiothoracic Surgery, NYU Langone Medical Center, New York, United States
| | - Xiaochun Li
- Division of Biostatistics and NYU + HHC CTSI BERD, NYU Grossman School of Medicine, New York, United States
| | - Judith D. Goldberg
- Division of Biostatistics and NYU + HHC CTSI BERD, NYU Grossman School of Medicine, New York, United States
| | - Ashley M. Gefen
- Department of Nephrology, Cohen Children's Medical Center, New York, United States
| | - Laura Malaga-Dieguez
- Department of Nephrology, NYU Hassenfeld Children's Hospital, New York, United States
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40
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Sasaki J, Rodriguez Z, Alten JA, Rahman AF, Reichle G, Lin P, Banerjee M, Selewski D, Gaies M, Hock KM, Borasino S, Gist KM. Epidemiology of neonatal acute kidney injury after cardiac surgery without cardiopulmonary bypass. Ann Thorac Surg 2021; 114:1786-1792. [PMID: 34678277 DOI: 10.1016/j.athoracsur.2021.09.032] [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: 03/10/2021] [Revised: 08/15/2021] [Accepted: 09/07/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND The purpose of this Neonatal and Pediatric Heart and Renal Outcomes Network (NEPHRON) study was to describe the epidemiology and outcomes of CS-AKI after cardiac surgery without cardiopulmonary bypass (non-CPB). METHODS We performed a retrospective study of neonates (≤30 days) who underwent non-CPB cardiac surgery at 22 centers affiliated with the Pediatric Cardiac Critical Care Consortium. CS-AKI was defined using the modified Kidney Disease: Improving Global Outcomes (KDIGO) serum creatinine (SCr) and urine output criteria from postoperative day (POD) 0-6. CS-AKI by SCr was further subclassified into transient (resolved by POD3) and persistent/late (≥3 days). Multivariable regression analyses were used to determine risk factors for CS-AKI, and associations with outcomes of ventilation hours and cardiac intensive care unit length of stay (LOS). RESULTS 582 neonates [median age at surgery: 9 days (IQR:5-15 days), 25% functional single ventricle] were included. CS-AKI occurred in 38.3%: rate and severity varied across centers. Aggregate daily CS-AKI prevalence peaked on POD1 (17.1%). No stage of CS-AKI was associated with ventilation hours or LOS. Persistent/late CS-AKI occurred in 48 (8%). Prostaglandin use and single ventricle surgery were associated with persistent/late CS-AKI. Higher baseline SCr, but not persistent/late CS-AKI was associated with longer ventilation duration and ICU LOS after adjusting for confounders. CONCLUSIONS KDIGO-defined CS-AKI occurred commonly in neonates undergoing non-CPB cardiac surgery. However, most CS-AKI was transient, and no CS-AKI classification was associated with worse outcomes. Further work is needed to determine the CS-AKI definition that best associates with outcomes in this cohort.
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Affiliation(s)
- Jun Sasaki
- Division of Cardiac Critical Care, Department of Cardiology, Nicklaus Children's Hospital, Florida International University Herbert Wertheim College of Medicine, Miami, FL
| | - Zahidee Rodriguez
- Divsion of Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta GA
| | - Jeffrey A Alten
- Division of Cardiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH
| | - Akm Fazlur Rahman
- University of Alabama at Birmingham, Department of Biostatistics, Birmingham AL
| | - Garrett Reichle
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor MI
| | - Paul Lin
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor MI
| | - Mousumi Banerjee
- Department of Biostatistics, School of Public Health & Institute for Healthcare Policy and Innovation
| | - David Selewski
- Division of Pediatric Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston SC
| | - Michael Gaies
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | - Kristal M Hock
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | - Santiago Borasino
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Alabama, University of Alabama School of Medicine, Birmingham, AL
| | - Katja M Gist
- Division of Cardiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH.
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41
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Downs E, Oslen B, Gist KM. Perfusion Strategies for Neonatal Aortic Arch Surgery-Comparing AKI Risk: Apples and Apples? Or Apples and Oranges? World J Pediatr Congenit Heart Surg 2021; 12:581-582. [PMID: 34597204 DOI: 10.1177/21501351211022589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Emily Downs
- Department of Surgery, School of Medicine, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Benjamin Oslen
- Department of Graduate Medical Education, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Katja M Gist
- Department of Pediatrics, School of Medicine, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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42
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Davidson JA, Frank BS, Urban TT, Twite M, Jaggers J, Khailova L, Klawitter J. Serum metabolic profile of postoperative acute kidney injury following infant cardiac surgery with cardiopulmonary bypass. Pediatr Nephrol 2021; 36:3259-3269. [PMID: 33954809 PMCID: PMC8448922 DOI: 10.1007/s00467-021-05095-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/06/2021] [Accepted: 04/23/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND We sought to determine differences in the circulating metabolic profile of infants with or without acute kidney injury (AKI) following cardiothoracic surgery with cardiopulmonary bypass (CPB). METHODS We performed a secondary analysis of preoperative and 24-h postoperative serum samples from infants ≤ 120 days old undergoing CPB. Metabolic profiling of the serum samples was performed by targeted analysis of 165 serum metabolites via tandem mass spectrometry. We then compared infants who did or did not develop AKI in the first 72 h postoperatively to determine global differences in the preoperative and 24-h metabolic profiles in addition to specific differences in individual metabolites. RESULTS A total of 57 infants were included in the study. Six infants (11%) developed KDIGO stage 2/3 AKI and 13 (23%) developed stage 1 AKI. The preoperative metabolic profile did not differentiate between infants with or without AKI. Infants with severe AKI could be moderately distinguished from infants without AKI by their 24-h metabolic profile, while infants with stage 1 AKI segregated into two groups, overlapping with either the no AKI or severe AKI groups. Differences in these 24-h metabolic profiles were driven by 21 metabolites significant at an adjusted false discovery rate of < 0.05. Prominently altered pathways include purine, methionine, and kynurenine/nicotinamide metabolism. CONCLUSION Moderate-to-severe AKI after infant cardiac surgery is associated with changes in the serum metabolome, including prominent changes to purine, methionine, and kynurenine/nicotinamide metabolism. A portion of infants with mild AKI demonstrated similar metabolic changes, suggesting a potential role for metabolic analysis in the evaluation of lower stage injury.
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Affiliation(s)
- Jesse A Davidson
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA.
| | - Benjamin S Frank
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Tracy T Urban
- Children's Hospital Colorado Research Institute, Aurora, CO, USA
| | - Mark Twite
- Department of Anesthesiology, University of Colorado, Aurora, CO, USA
| | - James Jaggers
- Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Ludmila Khailova
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Jelena Klawitter
- Department of Anesthesiology, University of Colorado, Aurora, CO, USA
- Division of Renal Diseases and Hypertension, University of Colorado, Aurora, CO, USA
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43
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Guo X, Qi X, Fan P, Gilbert M, La AD, Liu Z, Bertz R, Kellum JA, Chen Y, Wang L. Effect of ondansetron on reducing ICU mortality in patients with acute kidney injury. Sci Rep 2021; 11:19409. [PMID: 34593872 PMCID: PMC8484575 DOI: 10.1038/s41598-021-98734-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 09/01/2021] [Indexed: 12/02/2022] Open
Abstract
The purpose of this study is to identify medications with potentially beneficial effects on decreasing mortality in patients with acute kidney injury (AKI) while in the intensive care unit (ICU). We used logistic regression to investigate associations between medications received and ICU mortality in patients with AKI in the MIMIC III database. Drugs associated with reduced mortality were then validated using the eICU database. Propensity score matching (PSM) was used for matching the patients’ baseline severity of illness followed by a chi-square test to calculate the significance of drug use and mortality. Finally, we examined gene expression signatures to explore the drug’s molecular mechanism on AKI. While several drugs demonstrated potential beneficial effects on reducing mortality, most were used for potentially fatal illnesses (e.g. antibiotics, cardiac medications). One exception was found, ondansetron, a drug without previously identified life-saving effects, has correlation with lower mortality among AKI patients. This association was confirmed in a subsequent analysis using the eICU database. Based on the comparison of gene expression signatures, the presumed therapeutic effect of ondansetron may be elicited through the NF-KB pathway and JAK-STAT pathway. Our findings provide real-world evidence to support clinical trials of ondansetron for treatment of AKI.
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Affiliation(s)
- Xiaojiang Guo
- Department of Pharmaceutical Sciences, Computational Chemical Genomics Screening Center, School of Pharmacy, University of Pittsburgh, 5607 Baum Boulevard, Pittsburgh, PA, 15206, USA
| | - Xiguang Qi
- Department of Pharmaceutical Sciences, Computational Chemical Genomics Screening Center, School of Pharmacy, University of Pittsburgh, 5607 Baum Boulevard, Pittsburgh, PA, 15206, USA
| | - Peihao Fan
- Department of Pharmaceutical Sciences, Computational Chemical Genomics Screening Center, School of Pharmacy, University of Pittsburgh, 5607 Baum Boulevard, Pittsburgh, PA, 15206, USA
| | - Michael Gilbert
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, 15206, USA
| | - Andrew D La
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, 15206, USA
| | - Zeyu Liu
- The Dietrich School of Arts & Sciences, University of Pittsburgh, Pittsburgh, PA, 15206, USA
| | - Richard Bertz
- Department of Pharmaceutical Sciences, Computational Chemical Genomics Screening Center, School of Pharmacy, University of Pittsburgh, 5607 Baum Boulevard, Pittsburgh, PA, 15206, USA
| | - John A Kellum
- The Center for Critical Care Nephrology Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, 15206, USA.
| | - Yu Chen
- Eli Lilly and Company, Lilly Corporate Center, Indiana, IN, 46225, USA.
| | - Lirong Wang
- Department of Pharmaceutical Sciences, Computational Chemical Genomics Screening Center, School of Pharmacy, University of Pittsburgh, 5607 Baum Boulevard, Pittsburgh, PA, 15206, USA.
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44
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Galić S, Milošević D, Filipović-Grčić B, Rogić D, Vogrinc Ž, Ivančan V, Matić T, Rubić F, Cvitković M, Bakoš M, Premužić V. Early biochemical markers in the assessment of acute kidney injury in children after cardiac surgery. Ther Apher Dial 2021; 26:583-593. [PMID: 34558197 DOI: 10.1111/1744-9987.13736] [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: 02/12/2021] [Revised: 08/17/2021] [Accepted: 09/11/2021] [Indexed: 11/28/2022]
Abstract
Our aim was to evaluate biochemical markers in plasma (NGAL, CysC) and urine (NGAL, KIM-1) in children's early onset of acute kidney injury after congenital heart defect surgery using cardiopulmonary bypass. This study prospectively included 100 children with congenital heart defects who developed AKI. Patients with acute kidney injury had significantly higher CysC levels 6 and 12 h after cardiac surgery and plasma NGAL levels 2 and 6 h after cardiac surgery. The best predictive properties for the development of acute kidney injury are the combination (+CysCpl or +NGALu) after 12 h and a combination (+CysCpl and +NGALu) 6 and 24 h after cardiac surgery. We showed that plasma CysC and urinary NGAL could reliably predict the development of acute kidney injury. Measurement of early biochemical markers in plasma and urine, individually and combination, may predict the development of cardiac surgery-associated acute kidney injury in children.
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Affiliation(s)
- Slobodan Galić
- Pediatric Clinic, University Hospital Center Zagreb, Zagreb, Croatia
| | - Danko Milošević
- Pediatric Clinic, University Hospital Center Zagreb, Zagreb, Croatia.,School of Medicine, Zagreb, Croatia
| | - Boris Filipović-Grčić
- Pediatric Clinic, University Hospital Center Zagreb, Zagreb, Croatia.,School of Medicine, Zagreb, Croatia
| | - Dunja Rogić
- School of Medicine, Zagreb, Croatia.,Clinical Institute for Laboratory Diagnostics, University Hospital Center Zagreb, Zagreb, Croatia
| | - Željka Vogrinc
- Clinical Institute for Laboratory Diagnostics, University Hospital Center Zagreb, Zagreb, Croatia
| | - Višnja Ivančan
- Clinic of Anesthesiology Resuscitation and Intensive Care, University Hospital Center Zagreb, Zagreb, Croatia
| | - Toni Matić
- Pediatric Clinic, University Hospital Center Zagreb, Zagreb, Croatia
| | - Filip Rubić
- Pediatric Clinic, University Hospital Center Zagreb, Zagreb, Croatia
| | - Miran Cvitković
- Pediatric Clinic, University Hospital Center Zagreb, Zagreb, Croatia
| | - Matija Bakoš
- Pediatric Clinic, University Hospital Center Zagreb, Zagreb, Croatia
| | - Vedran Premužić
- School of Medicine, Zagreb, Croatia.,Department of Nephrology, Hypertension, Dialysis, and Transplantation, University Hospital Center Zagreb, Zagreb, Croatia
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45
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Zanaboni D, Min J, Seshadri R, Gaynor JW, Dreher M, Blinder JJ. Higher total ultrafiltration volume during cardiopulmonary bypass-assisted infant cardiac surgery is associated with acute kidney injury and fluid overload. Pediatr Nephrol 2021; 36:2875-2881. [PMID: 33651177 DOI: 10.1007/s00467-021-04976-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/20/2021] [Accepted: 01/28/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Ultrafiltration (UF) is used for fluid removal during and after infant cardiopulmonary bypass (CPB) surgery to reduce fluid overload. Excessive UF may have the opposite of its intended effect, resulting in acute kidney injury (AKI), oliganuria, and fluid retention. METHODS This is a single-center, retrospective review of infants treated with conventional and/or modified UF during CPB surgery. UF volume was indexed to weight. AKI was defined using serum creatinine "Kidney Disease Improving Global Outcome (KDIGO)" criteria. Fluid balance was defined according to: [Formula: see text]. Peak fluid overload was determined on postoperative day 3. Multivariable logistic regression adjusted for multiple covariates was used to explore associations with UF, AKI, and fluid overload. RESULTS Five hundred thirty subjects < 1 year of age underwent CPB-assisted congenital heart surgery with UF. Sixty-four (12%) developed postoperative AKI. On multivariable regression, higher indexed total UF volume was associated with increased AKI risk (OR 1.11, 95% CI=1.04-1.19, p = 0.003). UF volume > 119.9 mL/kg did not reduce peak fluid overload. Subjects with AKI took longer to reach a negative fluid balance (2 vs. 3 days, p = 0.04). Those with more complex surgery were at highest AKI risk (STAT 3 [25-75 percentile: 3-4] in AKI group versus STAT 3 [25-75 percentile: 2-4] in non-AKI group, p = 0.05). AKI was reduced in subjects undergoing more complex surgery and treated with UF volume < 119.9 mL/kg. CONCLUSIONS Judicious use of UF in more complex congenital cardiac surgery reduces the risk of AKI.
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Affiliation(s)
- Dominic Zanaboni
- Division of Pediatric Cardiology, University of Michigan C.S. Mott Children's Hospital, 1540 E Hospital Drive, Ann Arbor, MI, 48109, USA. .,Division of Cardiac Critical Care, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Jungwon Min
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Roopa Seshadri
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - J William Gaynor
- Department of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Molly Dreher
- Department of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Joshua J Blinder
- Division of Pediatric Cardiology, University of Michigan C.S. Mott Children's Hospital, 1540 E Hospital Drive, Ann Arbor, MI, 48109, USA
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46
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Nunes S, Hessey E, Dorais M, Perreault S, Jouvet P, Phan V, Lacroix J, Lafrance JP, Samuel S, Zappitelli M. Association of pediatric cardiac surgery-associated acute kidney injury with post-discharge healthcare utilization, mortality and kidney outcomes. Pediatr Nephrol 2021; 36:2865-2874. [PMID: 33770283 DOI: 10.1007/s00467-021-04999-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 01/18/2021] [Accepted: 02/10/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Acute kidney Injury (AKI) in children undergoing cardiac surgery (CS) is strongly associated with hospital morbidity. Post-discharge CS AKI outcomes are less clear. We evaluated associations between AKI and post-discharge (a) healthcare utilization, (b) chronic kidney disease (CKD) or hypertension and (c) mortality. METHODS This is a retrospective two-centre cohort study of children surviving to hospital discharge after CS. Primary exposures were post-operative ≥Stage 1 AKI and ≥Stage 2 AKI defined by Kidney Disease Impoving Global Outcomes. Association of AKI with time to outcomes was determined using multivariable Cox-Proportional Hazards analysis. RESULTS Of 350 participants included (age 3.1 (4.5) years), 180 [51.4%] developed AKI and 60 [17.1%] developed ≥Stage 2 AKI. Twenty-eight (9%) participants developed CKD or hypertension (composite outcome), and 17 (5%) died within 5 years of discharge. Post-operative ≥Stage 1 and ≥Stage 2 AKI were not associated with post-discharge hospitalizations, emergency room (ER) visits, physician visits or CKD or hypertension in adjusted analyses. A trend was observed between ≥Stage 2 AKI and mortality but was not statistically significant. In unadjusted stratified analyses, AKI was associated with post-discharge hospitalizations in children with RACHS-1 score ≥3, complex chronic disease classification and children living in urban areas. CONCLUSIONS Post-CS AKI is not associated with post-discharge healthcare utilization, death and CKD or hypertension, though it may be associated with healthcare utilization in more complex paediatric CS children. Studies should aim to better understand post-CS healthcare utilization patterns and non-AKI risk factors for CKD, hypertension and mortality, to reduce adverse long-term outcomes after CS.
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Affiliation(s)
- Sophia Nunes
- Child Health Evaluative Sciences, The Hospital for Sick Children, 686 Bay St. 11th Floor, Room 11.9722, Toronto, Ontario, Canada
| | - Erin Hessey
- Child Health Evaluative Sciences, The Hospital for Sick Children, 686 Bay St. 11th Floor, Room 11.9722, Toronto, Ontario, Canada.,Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Marc Dorais
- StatSciences Inc., Notre-Dame-de-I'Île-Perrot, Canada
| | | | - Philippe Jouvet
- Department of Pediatrics, Pediatric Intensive Care Unit, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Canada
| | - Véronique Phan
- Department of Pediatrics, Division of Nephrology, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Canada
| | - Jacques Lacroix
- Department of Pediatrics, Pediatric Intensive Care Unit, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Canada
| | | | - Susan Samuel
- Department of Pediatrics, University of Calgary, Calgary, Canada
| | - Michael Zappitelli
- Child Health Evaluative Sciences, The Hospital for Sick Children, 686 Bay St. 11th Floor, Room 11.9722, Toronto, Ontario, Canada. .,Department of Pediatrics, Division of Nephrology, The Hospital for Sick Children, Toronto, Canada.
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47
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Soares H, Moita R, Maneira P, Gonçalves A, Gomes A, Flor-de-Lima F, Costa S, Soares P, Pissarra S, Rocha G, Silva J, Clemente F, Pinto H, Guimarães H. Nephrotoxicity in Neonates. Neoreviews 2021; 22:e506-e520. [PMID: 34341158 DOI: 10.1542/neo.22-8-e506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Acute kidney injury (AKI) is classified based on prerenal, intrinsic, and postrenal causes. In the newborn, AKI can occur after an insult during the prenatal, perinatal, or postnatal period. AKI is usually an underrecognized condition and its true incidence is unknown. AKI may result from the administration of a number of different nephrotoxic medications, which are often used concurrently in critically ill neonates, exponentially increasing the risk of renal injury. Drug toxicity may also compromise the formation and development of nephrons, and this is particularly important in preterm infants, who have incomplete nephrogenesis. Little is known about the pharmacokinetics and pharmacodynamics of different medications used in neonates, especially for the most immature infant, and the use of most medications in this population is off label. Strategies to prevent AKI include the avoidance of hypotension, hypovolemia, fluid imbalances, hypoxia, and sepsis as well as judicious use of nephrotoxic medications. Treatment strategies aim to maintain fluids and electrolytic and acid-base homeostasis, along with an adequate nutritional status. Neonates are especially prone to long-term sequelae of AKI and benefit from long-term follow-up. This review summarizes the most relevant aspects of nephrotoxicity in neonates and describes the prevention, treatment, and follow-up of AKI in neonates.
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Affiliation(s)
- Henrique Soares
- Neonatal Intensive Care Unit, Neonatology Department.,Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine of Porto University, Porto, Portugal
| | - Rita Moita
- Neonatal Intensive Care Unit, Neonatology Department.,Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine of Porto University, Porto, Portugal
| | - Pedro Maneira
- Neonatal Intensive Care Unit, Neonatology Department
| | | | - Ana Gomes
- Neonatal Intensive Care Unit, Neonatology Department.,Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine of Porto University, Porto, Portugal
| | - Filipa Flor-de-Lima
- Neonatal Intensive Care Unit, Neonatology Department.,Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine of Porto University, Porto, Portugal
| | - Sandra Costa
- Neonatal Intensive Care Unit, Neonatology Department.,Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine of Porto University, Porto, Portugal
| | - Paulo Soares
- Neonatal Intensive Care Unit, Neonatology Department
| | - Susana Pissarra
- Neonatal Intensive Care Unit, Neonatology Department.,Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine of Porto University, Porto, Portugal
| | - Gustavo Rocha
- Neonatal Intensive Care Unit, Neonatology Department.,Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine of Porto University, Porto, Portugal
| | - Jorge Silva
- Neonatal Intensive Care Unit, Neonatology Department.,Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine of Porto University, Porto, Portugal
| | - Fátima Clemente
- Neonatal Intensive Care Unit, Neonatology Department.,Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine of Porto University, Porto, Portugal
| | - Helena Pinto
- Neonatal Intensive Care Unit, Neonatology Department.,Pediatrics Nephrology Unit, Pediatric Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Hercília Guimarães
- Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine of Porto University, Porto, Portugal
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Guo S, Bai L, Tong Y, Yu J, Zhang P, Duan X, Liu J. Contrast media exposure in the perioperative period confers no additional risk of acute kidney injury in infants and young children undergoing cardiac surgery with cardiopulmonary bypass. Pediatr Nephrol 2021; 36:2485-2491. [PMID: 33550507 DOI: 10.1007/s00467-021-04964-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 12/29/2020] [Accepted: 01/21/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Recently, there has been an interest in the temporal relationship between contrast exposure (CM) and cardiac surgery suggesting that a "double hit" on the kidney function in close succession increases the risk of acute kidney injury (AKI) after cardiac surgery. However, data from young children is limited. The purpose of this study was to retrospectively evaluate the effects of preoperative CM exposure on postoperative AKI in infant and young children patients and to further analyze the influence of exposure time interval. METHODS Patients (age ≤ 3 years) who underwent diagnostic imaging within 14 days before on-pump cardiac surgery between 1 May 2017 and 31 May 2018 in Fuwai Hospital, Beijing, were analyzed. Kidney outcome was assessed according to Kidney Disease: Improving Global Outcomes creatinine-based criteria. RESULTS One thousand four hundred pediatric patients (192 CM and 1,248 non-CM) were identified. Postoperative AKI occurred in 57 (29.7%) of the 192 patients who were exposed to CM. Following propensity score adjustment, no difference in risk for AKI was observed between the CM and non-CM groups (RR 1.142, 95% CI 0.916-1.424; P = 0.264). Multivariable logistic regression of the CM group indicated that independent predictors of postoperative AKI were lower weight, lower preoperative creatinine level, and longer CPB duration. Time interval between CM exposure and on-pump cardiac surgery was not significantly associated with increased risk of AKI (OR 0.853, 95% CI 0.265~2.747; P = 0.790). CONCLUSIONS For pediatric patients who are soon to undergo on-pump cardiac procedures, there appears to be no need to hesitate in performing the diagnostic imaging investigations requiring CM, or delay CPB after CM exposure. These patients may benefit from increased diagnostic utility without increasing their risk of postoperative AKI.
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Affiliation(s)
- Shengwen Guo
- 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, 100037, China
| | - 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, 100037, China
| | - Yuanyuan Tong
- 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, 100037, China
| | - Jin Yu
- 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, 100037, 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, 100037, China
| | - Xin Duan
- 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, 100037, 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, 100037, China.
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49
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Beken S, Akbulut BB, Albayrak E, Güner B, Ünlü Y, Temur B, Aydin S, Ödemiş E, Erek E, Korkmaz A. Evaluation of neonatal acute kidney injury after critical congenital heart disease surgery. Pediatr Nephrol 2021; 36:1923-1929. [PMID: 33492453 DOI: 10.1007/s00467-020-04890-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 11/11/2020] [Accepted: 12/02/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common complication of congenital heart diseases (CHDs) after cardiac surgery. This study aimed to define the frequency and critical course, risk factors and short-term outcomes of AKI in postoperative CHD neonates. METHODS Postoperatively followed term CHD newborn infants were enrolled in the study. Infants with congenital anomalies of the urinary tract and other major congenital anomalies were excluded. Neonatal modified KDIGO criteria were used to assess AKI. RESULTS A total of 199 postoperatively followed newborn infants were included in the study. Acute kidney injury was detected in 71 (35.6%) patients. Of these patients, 24 (33.8%) were in stage 1, 14 (19.7%) in stage 2, and 33 (46.5%) in stage 3. Acute kidney injury occurred within the first week (median 1 day [IQR 1-2 days]) of cardiac surgery in 93% of the patients. The duration of invasive respiratory support and extracorporeal membrane oxygenation (ECMO) and mortality were significantly higher in stage 3 patients. Higher vasoactive-inotropic score (OR, 1.02; 95% CI, 1.0-1.04; p = 0.008) and receiving ECMO (OR, 7.9; 95% CI, 2.6-24.4; p = 0.001) were associated with risk for the development of AKI. The mortality rate was 52.1% in the AKI (+) patients, and having AKI (OR 7.1; 95% CI, 3.5-14.18) was significantly associated with mortality. CONCLUSION Acute kidney injury, a common early complication after critical neonatal CHD cardiac surgery, is associated with increased morbidity and mortality. Stage 3 AKI is associated with significantly higher mortality rates.
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Affiliation(s)
- Serdar Beken
- Department of Pediatrics, Neonatology Subdivision, Acıbadem University School of Medicine, İstanbul, Turkey.
| | - Burcu Bulum Akbulut
- Department of Pediatrics, Pediatric Nephrology Subdivision, Acıbadem University School of Medicine, İstanbul, Turkey
| | - Eda Albayrak
- Neonatal Intensive Care Unit, Acıbadem Mehmet Ali Aydınlar University, Atakent Hospital, İstanbul, Turkey
| | - Bengisu Güner
- Department of Pediatrics, Acıbadem University School of Medicine, İstanbul, Turkey
| | - Yasemin Ünlü
- Neonatal Intensive Care Unit, Acıbadem Mehmet Ali Aydınlar University, Atakent Hospital, İstanbul, Turkey
| | - Bahar Temur
- Department of Cardiovascular Surgery, Acıbadem University School of Medicine, İstanbul, Turkey
| | - Selim Aydin
- Department of Cardiovascular Surgery, Acıbadem University School of Medicine, İstanbul, Turkey
| | - Ender Ödemiş
- Department of Pediatrics Pediatric Cardiology Subdivision, Acıbadem University School of Medicine, İstanbul, Turkey
| | - Ersin Erek
- Department of Cardiovascular Surgery, Acıbadem University School of Medicine, İstanbul, Turkey
| | - Ayşe Korkmaz
- Department of Pediatrics, Neonatology Subdivision, Acıbadem University School of Medicine, İstanbul, Turkey
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50
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Sethi SK, Sharma R, Gupta A, Tibrewal A, Akole R, Dhir R, Soni K, Bansal SB, Jha PK, Bhan A, Kher V, Raina R. Long-Term Renal Outcomes in Children With Acute Kidney Injury Post Cardiac Surgery. Kidney Int Rep 2021; 6:1850-1857. [PMID: 34307979 PMCID: PMC8258583 DOI: 10.1016/j.ekir.2021.04.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/13/2021] [Accepted: 04/15/2021] [Indexed: 01/11/2023] Open
Abstract
Introduction The long-term renal outcomes of survivors of pediatric acute kidney injury (AKI) are varied within the current literature, and we aim to establish long-term renal outcomes for pediatric patients after cardiac surgery. We studied long-term renal outcomes and markers of kidney injury in pediatric patients after congenital cardiac surgery. Methods In a prospective case-control observational study (the Renal Outcomes in Children with acute Kidney injury post cardiac Surgery [ROCKS] trial) we reviewed all children who underwent cardiac surgery on cardiopulmonary bypass (December 2010–2017). Results During the study period, 2035 patients underwent cardiac surgery, of whom 9.8% developed AKI postoperatively. Forty-four patients who had postoperative AKI had a long-term follow-up, met our inclusion criteria, and were compared with 49 control subjects. We conducted a univariate analysis of reported parameters. At a median follow-up of 41 months, the cases had significantly higher urine levels of neutrophil gelatinase–associated lipocalin (NGAL), interleukin-18 (IL-18), and kidney injury molecule-1 (KIM-1). The biomarkers remained higher after adjusting for the urine creatinine, and the ratio of urine KIM-1/urine creatinine was significantly higher among cases. None of the patients had proteinuria or hypertension on follow-up. The presence of AKI, AKI stage, and younger age were not associated with the occurrence of low glomerular filtration rate (GFR) at follow-up. Conclusions Urinary biomarker abnormalities persist years after a congenital cardiac surgery in children, who may have a low GFR on follow-up. The presence of AKI, AKI stage, and younger age at surgery are not associated with the occurrence of low GFR at follow-up. Children with a higher surgical complexity score have lower GFR on follow-up.
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Affiliation(s)
- Sidharth Kumar Sethi
- Department of Pediatric Nephrology, Kidney Institute, Medanta – The Medicity, Gurgaon, Haryana, India
| | - Rajesh Sharma
- Pediatric Cardiac Intensive Care, Medanta – The Medicity, Gurgaon, Haryana, India
| | - Aditi Gupta
- Department of Biochemistry, Aster Clinical Lab, Bangalore, India
| | - Abhishek Tibrewal
- Department of Nephrology, Akron’s Children Hospital, Akron, Ohio, USA
| | - Romel Akole
- Pediatric Cardiac Intensive Care, Medanta – The Medicity, Gurgaon, Haryana, India
| | - Rohan Dhir
- Department of Pediatric Nephrology, Kidney Institute, Medanta – The Medicity, Gurgaon, Haryana, India
| | - Kritika Soni
- Department of Pediatric Nephrology, Kidney Institute, Medanta – The Medicity, Gurgaon, Haryana, India
| | | | - Pranaw Kumar Jha
- Kidney Institute, Medanta, The Medicity Hospital, Gurgaon, Haryana, India
| | - Anil Bhan
- CTVS, Medanta – The Medicity, Gurgaon, Haryana, India
| | - Vijay Kher
- Kidney Institute, Medanta, The Medicity Hospital, Gurgaon, Haryana, India
| | - Rupesh Raina
- Department of Nephrology, Akron’s Children Hospital, Akron, Ohio, USA
- Correspondence: Rupesh Raina, Department of Nephrology, Cleveland Clinic Akron General, 224 W Exchange St, Akron, OH 44302, USA.
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