1
|
Bertrandt RA, Gist K, Hasson D, Zang H, Reichle G, Krawczeski C, Winlaw D, Bailly D, Goldstein S, Selewski D, Alten J. Cardiac Surgery-Associated Acute Kidney Injury in Neonates Undergoing the Norwood Operation: Retrospective Analysis of the Multicenter Neonatal and Pediatric Heart and Renal Outcomes Network Dataset, 2015-2018. Pediatr Crit Care Med 2024; 25:e246-e257. [PMID: 38483198 DOI: 10.1097/pcc.0000000000003498] [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: 05/03/2024]
Abstract
OBJECTIVES Cardiac surgery-associated acute kidney injury (CS-AKI) is associated with adverse outcomes. Single-center studies suggest that the prevalence of CS-AKI is high after the Norwood procedure, or stage 1 palliation (S1P), but multicenter data are lacking. DESIGN A secondary analysis of the Neonatal and Pediatric Heart and Renal Outcomes Network (NEPHRON) multicenter cohort who underwent S1P. Using neonatal modification of Kidney Disease Improving Global Outcomes (KDIGO) criteria, perioperative associations between CS-AKI with morbidity and mortality were examined. Sensitivity analysis, with the exclusion of prophylactic peritoneal dialysis (PD) patients, was performed. SETTING Twenty-two hospitals participating in the Pediatric Cardiac Critical Care Consortium (PC 4 ) and contributing to NEPHRON. PATIENTS Three hundred forty-seven neonates (< 30 d old) with S1P managed between September 2015 and January 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 347 patients, CS-AKI occurred in 231 (67%). The maximum stages were as follows: stage 1, in 141 of 347 (41%); stage 2, in 51 of 347 (15%); and stage 3, in 39 of 347 (11%). Severe CS-AKI (stages 2 and 3) peaked on the first postoperative day. In multivariable analysis, preoperative feeding was associated with lower odds of CS-AKI (odds ratio [OR] 0.48; 95% CI, 0.27-0.86), whereas prophylactic PD was associated with greater odds of severe CS-AKI (OR 3.67 [95% CI, 1.88-7.19]). We failed to identify an association between prophylactic PD and increased creatinine (OR 1.85 [95% CI, 0.82-4.14]) but cannot exclude the possibility of a four-fold increase in odds. Hospital mortality was 5.5% ( n = 19). After adjusting for risk covariates and center effect, severe CS-AKI was associated with greater odds of hospital mortality (OR 3.67 [95% CI, 1.11-12.16]). We failed to find associations between severe CS-AKI and respiratory support or length of stay. The sensitivity analysis using PD failed to show associations between severe CS-AKI and outcome. CONCLUSIONS KDIGO-defined CS-AKI occurred frequently and early postoperatively in this 2015-2018 multicenter PC 4 /NEPHRON cohort of neonates after S1P. We failed to identify associations between resource utilization and CS-AKI, but there was an association between severe CS-AKI and greater odds of mortality in this high-risk cohort. Improving the precision for defining clinically relevant neonatal CS-AKI remains a priority.
Collapse
Affiliation(s)
- Rebecca A Bertrandt
- Division of Critical Care, Department of Pediatrics, Herma Heart Institute, Children's Wisconsin, Medical College of Wisconsin, Milwaukee, WI
| | - Katja Gist
- Division of Pediatric Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Denise Hasson
- Division of Pediatric Critical Care Medicine, New York University Langone Health, New York University Grossman School of Medicine, New York, NY
| | - Huaiyu Zang
- Division of Pediatric Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Garrett Reichle
- Department of Pediatrics, Division of Cardiology, C. S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI
| | - Catherine Krawczeski
- Department of Pediatrics, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH
| | - David Winlaw
- Department of Pediatrics, Lurie Children's Hospital of Chicago, Chicago, IL
| | - David Bailly
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Primary Children's Hospital, Salt Lake City, UT
| | - Stuart Goldstein
- Division of Pediatric Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - David Selewski
- Division of Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Jeffrey Alten
- Division of Pediatric Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| |
Collapse
|
2
|
Cunningham TW, Bai S, Krawczeski CD, Spencer JD, Phelps C, Yates AR. Acute kidney injury in hypoplastic left heart syndrome patients following the comprehensive stage two palliation. Cardiol Young 2024; 34:552-558. [PMID: 37565360 DOI: 10.1017/s1047951123002974] [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: 08/12/2023]
Abstract
BACKGROUND An alternative surgical approach for hypoplastic left heart syndrome is the Hybrid pathway, which delays the risk of acute kidney injury outside of the newborn period. We sought to determine the incidence, and associated morbidity, of acute kidney injury after the comprehensive stage 2 and the cumulative incidence after the first two operations in the Hybrid pathway. DESIGN A single centre, retrospective study was conducted of hypoplastic left heart patients completing the second-stage palliation in the Hybrid pathway from 2009 to 2018. Acute kidney injury was defined utilising Kidney Diseases Improving Global Outcomes criteria. Perioperative and post-operative characteristics were analysed. RESULTS Sixty-one patients were included in the study cohort. The incidence of acute kidney injury was 63.9%, with 36.1% developing severe injury. Cumulatively after the Hybrid Stage 1 and comprehensive stage 2 procedures, 69% developed acute kidney injury with 36% developing severe injury. The presence of post-operative acute kidney injury was not associated with an increase in 30-day mortality (acute kidney injury 7.7% versus none 9.1%; p = > 0.9). There was a significantly longer median duration of intubation among those with acute kidney injury (acute kidney injury 32 (8, 155) hours vs. no injury 9 (0, 94) hours; p = 0.018). CONCLUSIONS Acute kidney injury after the comprehensive stage two procedure is common and accounts for most of the kidney injury in the first two operations of the Hybrid pathway. No difference in mortality was detected between those with acute kidney injury and those without, although there may be an increase in morbidity.
Collapse
Affiliation(s)
- Tyler W Cunningham
- Department of Pediatrics, Section of Cardiology and Critical Care, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Shasha Bai
- Pediatric Biostatistics, Emory University, Atlanta, GA, USA
| | | | - John D Spencer
- Section of Nephrology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Christina Phelps
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA
| | - Andrew R Yates
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA
| |
Collapse
|
3
|
Prabhu NK, Nellis JR, Meza JM, Benkert AR, Zhu A, McCrary AW, Allareddy V, Andersen ND, Turek JW. Sustained Total All-Region Perfusion During the Norwood Operation and Postoperative Recovery. Semin Thorac Cardiovasc Surg 2023; 35:140-147. [PMID: 35176496 DOI: 10.1053/j.semtcvs.2022.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 12/21/2022]
Abstract
We developed a technique for the Norwood operation utilizing continuous perfusion of the head, heart, and lower body at mild hypothermia named Sustained Total All-Region (STAR) perfusion. We hypothesized that STAR perfusion would be associated with shorter operative times, decreased coagulopathy, and expedited post-operative recovery compared to standard perfusion techniques. Between 2012 and 2020, 80 infants underwent primary Norwood reconstruction at our institution. Outcomes for patients who received successful STAR perfusion (STAR, n = 37) were compared to those who received standard Norwood reconstruction utilizing regional cerebral perfusion only (SNR, n = 33), as well as to Norwood patients reported in the PC4 national database during the same timeframe (n = 1238). STAR perfusion was performed with cannulation of the innominate artery, descending aorta, and aortic root at 32-34°C. STAR patients had shorter median CPB time compared to SNR (171 vs 245 minutes, P < 0.0001), shorter operative time (331 vs 502 minutes, P < 0.0001), and decreased intraoperative pRBC transfusion (100 vs 270 mL, P < 0.0001). STAR patients had decreased vasoactive-inotropic score on ICU admission (6 vs 10.8, P = 0.0007) and decreased time to chest closure (2 vs 4.5 days, P = 0.0004). STAR patients had lower peak lactate (8.1 vs 9.9 mmol/L, P = 0.03) and more rapid lactate normalization (18.3 vs 27.0 hours, P = 0.003). In-hospital mortality in STAR patients was 2.7% vs 15.1% with SNR (P = 0.06) and 10.3% in the PC4 aggregate (P = 0.14). STAR perfusion is a novel approach to Norwood reconstruction associated with excellent survival, decreased transfusions, shorter operative time, and improved convalescence in the early post-operative period.
Collapse
Affiliation(s)
- Neel K Prabhu
- Duke Congenital Heart Surgery Research and Training Laboratory, Duke University Medical Center, Durham, North Carolina
| | - Joseph R Nellis
- Duke Congenital Heart Surgery Research and Training Laboratory, Duke University Medical Center, Durham, North Carolina; Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - James M Meza
- Duke Congenital Heart Surgery Research and Training Laboratory, Duke University Medical Center, Durham, North Carolina; Department of Surgery, Duke University Medical Center, Durham, North Carolina; Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Abigail R Benkert
- Duke Congenital Heart Surgery Research and Training Laboratory, Duke University Medical Center, Durham, North Carolina; Department of Surgery, Duke University Medical Center, Durham, North Carolina; Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Alexander Zhu
- Duke Congenital Heart Surgery Research and Training Laboratory, Duke University Medical Center, Durham, North Carolina
| | - Andrew W McCrary
- Division of Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Veerajalandhar Allareddy
- Section of Pediatric Cardiac Critical Care, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Nicholas D Andersen
- Duke Congenital Heart Surgery Research and Training Laboratory, Duke University Medical Center, Durham, North Carolina; Department of Surgery, Duke University Medical Center, Durham, North Carolina; Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Joseph W Turek
- Duke Congenital Heart Surgery Research and Training Laboratory, Duke University Medical Center, Durham, North Carolina; Department of Surgery, Duke University Medical Center, Durham, North Carolina; Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
| |
Collapse
|
4
|
Kwiatkowski DM, Ball MK, Savorgnan FJ, Allan CK, Dearani JA, Roth MD, Roth RZ, Sexson KS, Tweddell JS, Williams PK, Zender JE, Levy VY. Neonatal Congenital Heart Disease Surgical Readiness and Timing. Pediatrics 2022; 150:189888. [PMID: 36317977 DOI: 10.1542/peds.2022-056415d] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- David M Kwiatkowski
- Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Molly K Ball
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Fabio J Savorgnan
- Department of Pediatrics, UT Southwestern, Children's Health, Dallas, Texas
| | - Catherine K Allan
- Department of Cardiology, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo College of Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | - Kristen S Sexson
- Department of Pediatrics, UT Southwestern, Children's Health, Dallas, Texas
| | - James S Tweddell
- Department of Surgery, University of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Patricia K Williams
- Department of Pediatrics, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Jill E Zender
- Department of Pediatrics, UT Southwestern, Children's Health, Dallas, Texas
| | - Victor Y Levy
- Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, Texas
| |
Collapse
|
5
|
Böttcher W, Weixler V, Redlin M, Murin P, Dehmel F, Schmitt K, Cho MY, Miera O, Sinzobahamvya N, Photiadis J. Acute Kidney Injury After Neonatal Aortic Arch Surgery: Deep Hypothermic Circulatory Arrest Versus Moderate Hypothermia With Distal Aortic Perfusion. World J Pediatr Congenit Heart Surg 2021; 12:573-580. [PMID: 34597201 DOI: 10.1177/21501351211014824] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common complication observed after neonatal aortic arch repair. We studied its incidence after procedures carried out using deep hypothermic circulatory arrest (DHCA) versus moderate hypothermia with distal aortic perfusion (MHDP), usually through the common femoral artery. In both groups, continuous regional cerebral perfusion (RCP) was used during the time required for aortic arch repair. METHODS A total of 125 neonates underwent aortic arch repair. Between 2007 and 2012, DHCA with RCP was used in 51 neonates. From 2013 to 2019, MHDP with RCP was performed on 74 newborns. Operative complexity was similar in both periods. Acute kidney injury was defined as a significant elevation of serum creatinine and was classified according to the neonatal modified n-KDIGO (neonatal Kidney Disease: Improving Global Outcomes) stages 1 to 3 (Kidney Disease Improving: Global Outcomes). RESULTS Acute kidney injury was observed in a total of 68 patients (68/125: 54.4%). In the majority (44/68: 64.7%), n-KDIGO stage 1 occurred. Stage 2 (n = 14) and stage 3 (n = 10) were observed more frequently after DHCA versus MHDP: 29.4% (15/51) versus 12.2% (9/74), P = .02. At cardiopulmonary bypass end, lactate levels were significantly higher (P = .001) after DHCA: 3.4 (2.9-4.3) mmol/L compared to 2.7 (2.3-3.7) mmol/L after MHDP. Early mortality was 12% (15/125) in the entire cohort. It was 17.6% (9/51) after DHCA versus 8.1% (6/74) after MHDP, however not statistically significant (P = .16). CONCLUSION Mild (stage 1) AKI occurred frequently after neonatal aortic arch repair. The use of MHDP was associated with a significantly lower incidence of moderate (stage 2) and severe (stage 3) AKI forms.
Collapse
Affiliation(s)
- Wolfgang Böttcher
- Department of Congenital Heart Surgery-Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Viktoria Weixler
- Department of Congenital Heart Surgery-Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Mathias Redlin
- Department of Anesthesiology, German Heart Center Berlin, Berlin, Germany
| | - Peter Murin
- Department of Congenital Heart Surgery-Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Frank Dehmel
- Department of Congenital Heart Surgery-Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Katharina Schmitt
- Department of Congenital Heart Disease-Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Mi-Young Cho
- Department of Congenital Heart Surgery-Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Oliver Miera
- Department of Congenital Heart Disease-Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Nicodème Sinzobahamvya
- Department of Congenital Heart Surgery-Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Joachim Photiadis
- Department of Congenital Heart Surgery-Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| |
Collapse
|
6
|
Alten JA, Cooper DS, Blinder JJ, Selewski DT, Tabbutt S, Sasaki J, Gaies MG, Bertrandt RA, Smith AH, Reichle G, Gist KM, Banerjee M, Zhang W, Hock KM, Borasino S. Epidemiology of Acute Kidney Injury After Neonatal Cardiac Surgery: A Report From the Multicenter Neonatal and Pediatric Heart and Renal Outcomes Network. Crit Care Med 2021; 49:e941-e951. [PMID: 34166288 DOI: 10.1097/ccm.0000000000005165] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Cardiac surgery-associated acute kidney injury occurs commonly following congenital heart surgery and is associated with adverse outcomes. This study represents the first multicenter study of neonatal cardiac surgery-associated acute kidney injury. We aimed to describe the epidemiology, including perioperative predictors and associated outcomes of this important complication. DESIGN This Neonatal and Pediatric Heart and Renal Outcomes Network study is a multicenter, retrospective cohort study of consecutive neonates less than 30 days. Neonatal modification of The Kidney Disease Improving Global Outcomes criteria was used. Associations between cardiac surgery-associated acute kidney injury stage and outcomes (mortality, length of stay, and duration of mechanical ventilation) were assessed through multivariable regression. SETTING Twenty-two hospitals participating in Pediatric Cardiac Critical Care Consortium. PATIENTS Twenty-two-thousand forty neonates who underwent major cardiac surgery from September 2015 to January 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Cardiac surgery-associated acute kidney injury occurred in 1,207 patients (53.8%); 983 of 1,657 in cardiopulmonary bypass patients (59.3%) and 224 of 583 in noncardiopulmonary bypass patients (38.4%). Seven-hundred two (31.3%) had maximum stage 1, 302 (13.5%) stage 2, 203 (9.1%) stage 3; prevalence of cardiac surgery-associated acute kidney injury peaked on postoperative day 1. Cardiac surgery-associated acute kidney injury rates varied greatly (27-86%) across institutions. Preoperative enteral feeding (odds ratio = 0.68; 0.52-0.9) and open sternum (odds ratio = 0.76; 0.61-0.96) were associated with less cardiac surgery-associated acute kidney injury; cardiopulmonary bypass was associated with increased cardiac surgery-associated acute kidney injury (odds ratio = 1.53; 1.01-2.32). Duration of cardiopulmonary bypass was not associated with cardiac surgery-associated acute kidney injury in the cardiopulmonary bypass cohort. Stage 3 cardiac surgery-associated acute kidney injury was independently associated with hospital mortality (odds ratio = 2.44; 1.3-4.61). No cardiac surgery-associated acute kidney injury stage was associated with duration of mechanical ventilation or length of stay. CONCLUSIONS Cardiac surgery-associated acute kidney injury occurs frequently after neonatal cardiac surgery in both cardiopulmonary bypass and noncardiopulmonary bypass patients. Rates vary significantly across hospitals. Only stage 3 cardiac surgery-associated acute kidney injury is associated with mortality. Cardiac surgery-associated acute kidney injury was not associated with any other outcomes. Kidney Disease Improving Global Outcomes criteria may not precisely define a clinically meaningful renal injury phenotype in this population.
Collapse
Affiliation(s)
- Jeffrey A Alten
- Division of Pediatric Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - David S Cooper
- Division of Pediatric Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Joshua J Blinder
- Division of Cardiac Critical Care Medicine, Department of Anesthesia/Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - David T Selewski
- Division of Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Sarah Tabbutt
- Department of Pediatrics, University of California San Francisco, Benioff Children's Hospital, San Francisco, CA
| | - Jun Sasaki
- Division of Cardiac Critical Care Medicine, Nicklaus Children's Hospital, Miami, FL
| | - Michael G Gaies
- Department of Pediatrics, Division of Cardiology, C. S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI
| | - Rebecca A Bertrandt
- Division of Critical Care, Department of Pediatrics, Medical College of Wisconsin, Children's Wisconsin, Milwaukee, WI
| | - Andrew H Smith
- Divisions of Cardiology and Critical Care Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | - Garrett Reichle
- Department of Pediatrics, Division of Cardiology, C. S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI
| | - Katja M Gist
- Department of Pediatrics, School of Medicine, University of Colorado, Anschutz Medical Campus, Division of Cardiology, Children's Hospital Colorado, Aurora, CO
| | - Mousumi Banerjee
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
| | - Wenying Zhang
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Kristal M Hock
- Department of Pediatric Cardiology, Section of Cardiac Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Santiago Borasino
- Department of Pediatric Cardiology, Section of Cardiac Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL
| |
Collapse
|
7
|
Ricci Z, Raggi V, Marinari E, Vallesi L, Di Chiara L, Rizzo C, Gist KM. Acute Kidney Injury in Pediatric Cardiac Intensive Care Children: Not All Admissions Are Equal: A Retrospective Study. J Cardiothorac Vasc Anesth 2021; 36:699-706. [PMID: 33994318 DOI: 10.1053/j.jvca.2021.04.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 04/01/2021] [Accepted: 04/10/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To describe the incidence, associated characteristics, and outcomes of the maximum severity of acute kidney injury (AKI) in a heterogeneous population of critically ill children with cardiac disease. DESIGN Retrospective cohort study. SETTING Pediatric cardiac intensive care unit (PCICU). PARTICIPANTS Patients admitted to the PCICU. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS From January 2018 to July 2020 all patients admitted to a tertiary PCICU were included. Only the first admission was considered. Neonates ≤seven days old were excluded. Of 742 patients, 53 were medical cases, 69 catheterization laboratory cases, and 620 surgical cases (with five subgroups). The median age was 2.47 years (interquartile range [IQR], 0.38-9.85 years), with a median Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery score of 2 (IQR, 1-3). Median PCICU length of stay was three days (IQR, 2-7 days), and 21 (2.8%) patients died. Any incidence of AKI occurred in 70% of patients, 26% of which were classified as mild (stage 1) and 43% as severe (stages 2 and 3). AKI was diagnosed by urine output criteria in 56%, serum creatinine in 28%, and both in 16% of patients. Severe AKI occurred in subgroups as follows: medical (38%), catheterization laboratory (45%), correction (35%), palliation (55%), transplantation (85%), mechanical assistance (70%), and redo surgery (58%). Severe AKI patients were significantly older (p = 0.004), had a higher Pediatric Index of Mortality 3 score (p = 0.0004), had a higher cumulative fluid balance (p < 0.0001), and had a longer cardiopulmonary bypass time (p < 0.0001). Early AKI (≤24 hours from admission) was the most frequent presentation, with a greater proportion of severe cases in the early group compared with the intermediate (>24 and ≤48 hours) and late (>48 hours) (p < 0.0001) groups. Presentation of late severe AKI had a higher mortality (odds ratio, 4.9; 95% confidence interval, 1.8-15; p = 0.001). CONCLUSIONS Severe AKI occurs in 43% of cardiac children and is diagnosed early, most often by urine output criteria. Severe AKI incidence varies significantly within subgroups of cardiac patients. Late AKI is associated with worse outcomes.
Collapse
Affiliation(s)
- Zaccaria Ricci
- Department of Emergency and Intensive Care, Pediatric Intensive Care Unit, Azienda Ospedaliero Universitaria Meyer, Firenze, Italy; Department of Health Science, University of Florence, Firenze, Italy; Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Valeria Raggi
- Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Eleonora Marinari
- Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Leonardo Vallesi
- Hospital Pharmacy Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Luca Di Chiara
- Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Caterina Rizzo
- Clinical Pathways and Epidemiology Functional Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Katja M Gist
- Department of Pediatrics, Division of Pediatric Cardiology, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO
| |
Collapse
|
8
|
Incidence and impact of acute kidney injury in patients with hypoplastic left heart syndrome following the hybrid stage 1 palliation. Cardiol Young 2021; 31:414-420. [PMID: 33261689 DOI: 10.1017/s1047951120004199] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Acute kidney injury leads to worse outcomes following paediatric cardiac surgery. There is a lack of literature focusing on acute kidney injury after the Hybrid stage 1 palliation for single ventricle physiology. Patients undergoing the Hybrid Stage 1, as a primary option, may have a lower incidence of kidney injury than previously reported. When present, kidney injury may increase the risk of post-operative morbidity and mortality. METHODS A retrospective, single centre review was conducted in patients with hypoplastic left heart syndrome who underwent Hybrid Stage 1 from 2008 to 2018. Acute kidney injury was defined as a dichotomous yes (meeting any injury criteria) or no (no injury) utilising two different criteria utilised in paediatrics. The impact of kidney injury on perioperative characteristics and 30-day mortality was analysed. RESULTS The incidence of acute kidney injury is 13.4-20.7%, with a severe injury rate of 2.4%. Patients without a prenatal diagnosis of hypoplastic left heart syndrome have a higher incidence of kidney injury than those prenatally diagnosed, (40% versus 14.5%, p = 0.024). Patients with acute kidney injury have a significantly higher incidence of 30-day mortality, 27.3%, compared to without, 5.6% (p = 0.047). DISCUSSION The incidence of severe acute kidney injury after the Hybrid Stage 1 palliation is low. A prenatal diagnosis may be associated with a lower incidence of kidney injury following the Hybrid Stage 1. Though uncommon, severe acute kidney injury following Hybrid Stage 1 may be associated with higher 30-day mortality.
Collapse
|
9
|
Haller C, Caldarone CA. The Evolution of Therapeutic Strategies: Niche Apportionment for Hybrid Palliation. Ann Thorac Surg 2018; 106:1873-1880. [PMID: 29913126 DOI: 10.1016/j.athoracsur.2018.05.048] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 05/14/2018] [Accepted: 05/16/2018] [Indexed: 01/21/2023]
Abstract
Hybrid palliation, the concept to stabilize univentricular circulation with bilateral pulmonary artery banding and maintenance of ductal patency, has significantly widened the therapeutic spectrum for patients with single-ventricle malformations or borderline hypoplasia. The concept has already been a part of early attempts to improve outcome in hypoplastic left heart syndrome but has not attracted much attention initially. Technical refinement and expertise have led to results that ultimately allowed the palliative strategy to gain traction and to be selectively adopted. By now, we have gained almost 2 decades of experience, and as much as hybrid palliation has changed our approach to single-ventricle management, new strategies and indications have been formed by this experience. We therefore review concepts and patterns of use of hybrid palliation as well as benefits and challenges of the respective pathways to highlight the current status of the hybrid procedure.
Collapse
Affiliation(s)
- Christoph Haller
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
| | - Christopher A Caldarone
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|