1
|
Blinder JJ, Alten J, Bailly D, Buckley J, Clarke S, Diddle JW, Garcia X, Gist KM, Koch J, Kwiatkowski DM, Rahman AKMF, Reichle G, Valentine K, Hock KM, Borasino S. Diuretic response after neonatal cardiac surgery: a report from the NEPHRON collaborative. Pediatr Nephrol 2024; 39:2797-2805. [PMID: 38713228 DOI: 10.1007/s00467-024-06380-y] [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: 01/22/2024] [Revised: 04/05/2024] [Accepted: 04/05/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND Multicenter early diuretic response (DR) analysis of single furosemide dosing following neonatal cardiac surgery is lacking to inform whether early DR predicts adverse clinical outcomes. METHODS We performed a retrospective cohort study utilizing data from the NEPHRON registry. Random forest machine learning generated receiver operating characteristic-area under the curve (ROC-AUC) and odds ratios for mechanical ventilation (MV) and respiratory support (RS). Prolonged MV and RS were defined using ≥ 90th percentile of observed/expected ratios. Secondary outcomes were prolonged CICU and hospital length of stay (LOS) and kidney failure (stage III acute kidney injury (AKI), peritoneal dialysis, and/or continuous kidney replacement therapy on postoperative day three) assessed using covariate-adjusted ROC-AUC curves. RESULTS A total of 782 children were included. Cumulative urine output (UOP) metrics were lower in prolonged MV and RS patients, but DR poorly predicted prolonged MV (highest AUC 0.611, OR 0.98, sensitivity 0.67, specificity 0.53, p = 0.006, 95% OR CI 0.96-0.99 for cumulative 6-h UOP) and RS (highest AUC 0.674, OR 0.94, sensitivity 0.75, specificity 0.54, p < 0.001, 95% CI 0.91-0.97 UOP between 3 and 6 h). Secondary outcome results were similar. DR had fair discrimination for kidney failure (AUC 0.703, OR 0.94, sensitivity 0.63, specificity 0.71, 95% OR CI 0.91-0.98, p < 0.001, cumulative 6-h UOP). CONCLUSIONS Early DR poorly discriminated patients with prolonged MV, RS, and LOS in this cohort, though it may identify severe postoperative AKI phenotype. Future work is warranted to determine if early DR or late postoperative DR later, in combination with other AKI metrics, may identify a higher-risk phenotype.
Collapse
Affiliation(s)
- Joshua J Blinder
- Division of Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, CA, 94304, USA.
| | - Jeffrey Alten
- Division of Pediatric Cardiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - David Bailly
- Department of Pediatrics, Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
| | - Jason Buckley
- Division of Cardiology, Department of Pediatrics, Medical University of South Carolina Children's Hospital, Charleston, SC, USA
| | - Shanelle Clarke
- Division of Cardiology, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - J Wesley Diddle
- Division of Cardiac Critical Care Medicine, Department of Anesthesia/Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Xiomara Garcia
- Division of Pediatric Cardiology, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, AK, USA
| | - Katja M Gist
- Division of Pediatric Cardiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Joshua Koch
- Division of Critical Care, Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - David M Kwiatkowski
- Division of Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, CA, 94304, USA
| | - A K M Fazlur Rahman
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Garrett Reichle
- Division of Pediatric Cardiology, Department of Pediatrics, C. S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI, USA
| | - Kevin Valentine
- Division of Pediatric Critical Care, Department of Pediatrics, Riley Children's Hospital, Indiana University, Indianapolis, IN, USA
| | - Kristal M Hock
- Section of Pediatric Cardiac Critical Care, Division of Cardiology, Department of Pediatrics, University of Alabama, Birmingham, Birmingham, AL, USA
| | - Santiago Borasino
- Section of Pediatric Cardiac Critical Care, Division of Cardiology, Department of Pediatrics, University of Alabama, Birmingham, Birmingham, AL, USA
| |
Collapse
|
2
|
Menon S, Starr MC, Zang H, Collins M, Damian MA, Fuhrman D, Krallman K, Soranno DE, Webb TN, Slagle C, Joseph C, Martin SD, Mohamed T, Beebe ME, Ricci Z, Ollberding N, Selewski D, Gist KM. Characteristics and outcomes of children ≤ 10 kg receiving continuous kidney replacement therapy: a WE-ROCK study. Pediatr Nephrol 2024:10.1007/s00467-024-06438-x. [PMID: 39164502 DOI: 10.1007/s00467-024-06438-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 05/23/2024] [Accepted: 06/07/2024] [Indexed: 08/22/2024]
Abstract
BACKGROUND Continuous kidney replacement therapy (CKRT) is often used for acute kidney injury (AKI) or fluid overload (FO) in children ≤ 10 kg. Intensive care unit (ICU) mortality in children ≤ 10 kg reported by the prospective pediatric CRRT (ppCRRT, 2001-2003) registry was 57%. We aimed to evaluate characteristics associated with ICU mortality using a contemporary registry. METHODS The Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK) registry is a retrospective, multinational, observational study of children and young adults aged 0-25 years receiving CKRT (2015-2021) for AKI or FO. This analysis included patients ≤ 10 kg at hospital admission. PRIMARY AND SECONDARY OUTCOMES ICU mortality and major adverse kidney events at 90 days (MAKE-90) defined as death, persistent kidney dysfunction, or dialysis within 90 days, respectively. RESULTS A total of 210 patients were included (median age 0.53 years (IQR, 0.1, 0.9)). ICU mortality was 46.5%. MAKE-90 occurred in 150/207 (72%). CKRT was initiated at a median 3 days (IQR 1, 9) after ICU admission and lasted a median 6 days (IQR 3, 16). On multivariable analysis, pediatric logistic organ dysfunction score (PELOD-2) at CKRT initiation was associated with increased odds of ICU mortality (aOR 2.64, 95% CI 1.68-4.16), and increased odds of MAKE-90 (aOR 2.2, 95% CI 1.31-3.69). Absence of comorbidity was associated with lower MAKE-90 (aOR 0.29, 95%CI 0.13-0.65). CONCLUSIONS We report on a contemporary cohort of children ≤ 10 kg treated with CKRT for acute kidney injury and/or fluid overload. ICU mortality is decreased compared to ppCRRT. The extended risk of death and morbidity at 90 days highlights the importance of close follow-up.
Collapse
Affiliation(s)
- Shina Menon
- Department of Pediatrics, Center for Academic Medicine, Pediatric Nephrology, Lucile Packard Children's Hospital, Stanford University, MC-5660, 453 Quarry Rd, Palo Alto, CA, 94304, USA.
- Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA.
| | - Michelle C Starr
- Department of Pediatrics, Riley Children's Hospital, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Huaiyu Zang
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Michaela Collins
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Mihaela A Damian
- Department of Pediatrics, Center for Academic Medicine, Pediatric Nephrology, Lucile Packard Children's Hospital, Stanford University, MC-5660, 453 Quarry Rd, Palo Alto, CA, 94304, USA
| | - Dana Fuhrman
- Department of Pediatrics, Pittsburgh Children's Hospital, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kelli Krallman
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Danielle E Soranno
- Department of Pediatrics, Riley Children's Hospital, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Tennille N Webb
- Department of Pediatrics, Children's Hospital of Alabama, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Cara Slagle
- Department of Pediatrics, Riley Children's Hospital, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Catherine Joseph
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Susan D Martin
- Division of Pediatric Critical Care, University of Rochester, Golisano Children's Hospital, Rochester, NY, USA
| | - Tahagod Mohamed
- The Kidney and Urinary Tract Center, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Morgan E Beebe
- The Kidney and Urinary Tract Center, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Zaccaria Ricci
- AOU Meyer Children's Hospital, IRCCS, Florence, University of Florence, Florence, Italy
| | - Nicholas Ollberding
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - David Selewski
- Medical University of South Carolina, Charleston, SC, USA
| | - Katja M Gist
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| |
Collapse
|
3
|
Sullivan E, Melink K, Pettit K, Goldstein SL, Zang H, Ollberding NJ, SooHoo M, Alten JA, Stanski NL, Gist KM. Prediction of cardiac surgery associated acute kidney injury using response to loop diuretic and urine neutrophil gelatinase associated lipocalin. Pediatr Nephrol 2024:10.1007/s00467-024-06469-4. [PMID: 39120723 DOI: 10.1007/s00467-024-06469-4] [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: 05/09/2024] [Revised: 07/05/2024] [Accepted: 07/16/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND Cardiac surgery associated acute kidney injury (CS-AKI) is common. Urine response to loop diuretic and urine neutrophil gelatinase associated lipocalin (uNGAL) are separately associated with CS-AKI. We aimed to determine whether urine response to loop diuretic and uNGAL together were associated with postoperative day 2-4 CS-AKI. METHODS Two-center prospective observational study (ages 0-18 years). uNGAL (8-12 h after admission) (ng/mL) and urine response to loop diuretic (6 h for bolus furosemide and 12 h for infusion bumetanide) (mL/kg/hr) were measured. All diuretic doses were converted to furosemide equivalents. The primary outcome was day 2-4 CS-AKI. Patients were sub-phenotyped using a priori cutoffs (uNGAL + ≥ 100 ng/mL and UOP + < 1.5 mL/kg/hr) and optimal cutoffs (uNGAL + ≥ 127 ng/mL and UOP + ≤ 0.79 mL/kg/hr): 1) uNGAL-/UOP-, 2) uNGAL-/UOP + , 3) uNGAL + /UOP-, and 4) uNGAL + /UOP + . Multivariable regression was used to assess the association of uNGAL, UOP and each sub-phenotype with outcomes. RESULTS 476 patients were included. CS-AKI occurred in 52 (10.9%). uNGAL was associated with 2.59-fold greater odds (95%CI: 1.52-4.41) of CS-AKI. UOP was not associated with CS-AKI. Compared with uNGAL + alone, uNGAL + /UOP + improved prediction of CS-AKI using a priori and optimal cutoffs respectively (AUC 0.70 vs. 0.75). Both uNGAL + /UOP + (IQR OR:4.63, 95%CI: 1.74-12.32) and uNGAL + /UOP- (IQR OR:5.94, 95%CI: 2.09-16.84) were associated with CS-AKI when compared with uNGAL-/UOP-. CONCLUSIONS uNGAL is associated with CS-AKI. The sub-phenotype association was largely driven by uNGAL. Future studies standardizing diuretic dose and timing may be needed to refine the combined performance for clinical decision making.
Collapse
Affiliation(s)
- Emily Sullivan
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45226, USA
| | - Katherine Melink
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45226, USA
| | - Kevin Pettit
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Stuart L Goldstein
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45226, USA
| | - Huiayu Zang
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45226, USA
| | - Nicholas J Ollberding
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45226, USA
| | - Megan SooHoo
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jeffrey A Alten
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45226, USA
| | - Natalja L Stanski
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45226, USA
| | - Katja M Gist
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45226, USA.
| |
Collapse
|
4
|
Strong AE, Zee J, Laskin BL, Howarth K, Blinder J, Chrischilles EA, Erez DL, Denburg MR. Urine dipstick blood and acute kidney injury in infants undergoing cardiopulmonary bypass. Pediatr Nephrol 2024:10.1007/s00467-024-06464-9. [PMID: 39093456 DOI: 10.1007/s00467-024-06464-9] [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: 05/15/2024] [Revised: 06/14/2024] [Accepted: 07/05/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND Cardiopulmonary bypass (CPB) is associated with hemolysis and acute kidney injury (AKI). The study aim was to determine if urine dipstick blood in infants after CPB was associated with AKI and urine neutrophil gelatinase-associated lipocalin (NGAL). METHODS Infants who underwent CPB at a single center were enrolled prospectively between October 2017 and June 2019. Urine samples prior to CPB and 6 h after CPB cessation were analyzed in batch for NGAL and dipstick blood. AKI was defined using creatinine-based KDIGO criteria within 72 h of CPB. Spearman correlation examined associations between urine dipstick blood and NGAL at each time point. Linear regression estimated the associations between urine dipstick blood and log-transformed NGAL 6 h after CPB. Logistic regression estimated associations and compared discrimination between urine dipstick blood and NGAL for predicting AKI. RESULTS At baseline, 7/63 samples (11%) had > trace blood. Six hours after CPB, 62/98 samples (63%) had > trace blood and 26% had 3 + (large) blood. In total, 18/98 (18%) with a 6-h post-CPB sample had postoperative AKI. Urine dipstick blood values correlated with urine NGAL 6 h after CPB (r = 0.52, p < 0.01), but not at baseline (r = 0.06, p = 0.66). Those with 3 + (large) blood on urine dipstick had 6 times higher mean NGAL values compared to those with negative/trace blood (mean ratio 6.6, 95%CI 3.1-14.4, p < 0.01). Those with 3 + (large) blood had 8 times higher odds of AKI (OR 7.99, 95%CI 1.5-41.9, p = 0.01). CONCLUSIONS Urine dipstick blood post CPB may be a simple and inexpensive tool to help predict AKI in infants.
Collapse
Affiliation(s)
- Amy E Strong
- Division of Nephrology, Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA.
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Jarcy Zee
- Children's Hospital of Philadelphia Research Institute, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin L Laskin
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Kathryn Howarth
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joshua Blinder
- Division of Cardiology, Stanford Medicine Children's Health, Palo Alto, CA, USA
| | | | - Daniella Levy Erez
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michelle R Denburg
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
5
|
Chu WY, Nijman M, Stegeman R, Breur JMPJ, Jansen NJG, Nijman J, van Loon K, Koomen E, Allegaert K, Benders MJNL, Dorlo TPC, Huitema ADR. Population Pharmacokinetics and Target Attainment of Allopurinol and Oxypurinol Before, During, and After Cardiac Surgery with Cardiopulmonary Bypass in Neonates with Critical Congenital Heart Disease. Clin Pharmacokinet 2024; 63:1205-1220. [PMID: 39147988 PMCID: PMC11343829 DOI: 10.1007/s40262-024-01401-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2024] [Indexed: 08/17/2024]
Abstract
BACKGROUND The CRUCIAL trial (NCT04217421) is investigating the effect of postnatal and perioperative administration of allopurinol on postoperative brain injury in neonates with critical congenital heart disease (CCHD) undergoing cardiac surgery with cardiopulmonary bypass (CPB) shortly after birth. OBJECTIVE This study aimed to characterize the pharmacokinetics (PK) of allopurinol and oxypurinol during the preoperative, intraoperative, and postoperative phases in this population, and to evaluate target attainment of the current dosing strategy. METHODS Nonlinear mixed-effects modeling was used to develop population PK models in 14 neonates from the CRUCIAL trial who received up to five intravenous allopurinol administrations throughout the postnatal and perioperative periods. Target attainment was defined as achieving an allopurinol concentration >2 mg/L in at least two-thirds of the patients during the first 24 h after birth and between the start and 36 h after cardiac surgery with CPB. RESULTS A two-compartment model for allopurinol was connected to a one-compartment model for oxypurinol with an auto-inhibition effect on the conversion, which best described the PK. In a typical neonate weighing 3.5 kg who underwent cardiac surgery at a postnatal age (PNA) of 5.6 days, the clearance (CL) of allopurinol and oxypurinol at birth was 0.95 L/h (95% confidence interval 0.75-1.2) and 0.21 L/h (0.17-0.27), respectively, which subsequently increased with PNA to 2.97 L/h and 0.41 L/h, respectively, before CPB. During CPB, allopurinol and oxypurinol CL decreased to 1.38 L/h (0.9-1.87) and 0.12 L/h (0.05-0.22), respectively. Post-CPB, allopurinol CL increased to 2.21 L/h (1.74-2.83), while oxypurinol CL dropped to 0.05 L/h (0.01-0.1). Target attainment was 100%, 53.8%, and 100% at 24 h postnatally, 24 h after the start of CPB, and 36 h after the end of cardiac surgery, respectively. The combined concentrations of allopurinol and oxypurinol maintained ≥ 90% inhibition of xanthine oxidase (IC90XO) throughout the postnatal and perioperative period. CONCLUSIONS The minimal target concentration of allopurinol was not achieved at every predefined time interval in the CRUCIAL trial; however, the dosing strategy used was deemed adequate, since it yielded concentrations well exceeding the IC90XO. The decreased CL of both compounds during CPB suggests influence of the hypothermia, hemofiltration, and the potential sequestration of allopurinol in the circuit. The reduced CL of oxypurinol after CPB is likely attributable to impaired kidney function.
Collapse
Affiliation(s)
- Wan-Yu Chu
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Maaike Nijman
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center (UMC) Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Pediatric Cardiology, Wilhelmina Children's Hospital, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
- Utrecht Brain Center, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Raymond Stegeman
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center (UMC) Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Pediatric Cardiology, Wilhelmina Children's Hospital, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Pediatrics, Beatrix Children's Hospital, UMC Groningen, University of Groningen, Groningen, The Netherlands
| | - Johannes M P J Breur
- Department of Pediatric Cardiology, Wilhelmina Children's Hospital, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Nicolaas J G Jansen
- Department of Pediatrics, Beatrix Children's Hospital, UMC Groningen, University of Groningen, Groningen, The Netherlands
- Department of Pediatric Intensive Care, Wilhelmina Children's Hospital, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Joppe Nijman
- Department of Pediatric Intensive Care, Wilhelmina Children's Hospital, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Kim van Loon
- Department of Anaesthesiology, Wilhelmina Children's Hospital, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Erik Koomen
- Department of Pediatric Intensive Care, Wilhelmina Children's Hospital, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Karel Allegaert
- Department of Development and Regeneration, and Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Department of Clinical Pharmacy, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Manon J N L Benders
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center (UMC) Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Thomas P C Dorlo
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Alwin D R Huitema
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
- Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.
- Department of Clinical Pharmacy, UMC Utrecht, Utrecht University, Utrecht, The Netherlands.
| |
Collapse
|
6
|
Raina R, Nada A, Shah R, Aly H, Kadatane S, Abitbol C, Aggarwal M, Koyner J, Neyra J, Sethi SK. Artificial intelligence in early detection and prediction of pediatric/neonatal acute kidney injury: current status and future directions. Pediatr Nephrol 2024; 39:2309-2324. [PMID: 37889281 DOI: 10.1007/s00467-023-06191-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/27/2023] [Accepted: 09/26/2023] [Indexed: 10/28/2023]
Abstract
Acute kidney injury (AKI) has a significant impact on the short-term and long-term clinical outcomes of pediatric and neonatal patients, and it is imperative in these populations to mitigate the pathways leading to AKI and be prepared for early diagnosis and treatment intervention of established AKI. Recently, artificial intelligence (AI) has provided more advent predictive models for early detection/prediction of AKI utilizing machine learning (ML). By providing strong detail and evidence from risk scores and electronic alerts, this review outlines a comprehensive and holistic insight into the current state of AI in AKI in pediatric/neonatal patients. In the pediatric population, AI models including XGBoost, logistic regression, support vector machines, decision trees, naïve Bayes, and risk stratification scores (Renal Angina Index (RAI), Nephrotoxic Injury Negated by Just-in-time Action (NINJA)) have shown success in predicting AKI using variables like serum creatinine, urine output, and electronic health record (EHR) alerts. Similarly, in the neonatal population, using the "Baby NINJA" model showed a decrease in nephrotoxic medication exposure by 42%, the rate of AKI by 78%, and the number of days with AKI by 68%. Furthermore, the "STARZ" risk stratification AI model showed a predictive ability of AKI within 7 days of NICU admission of AUC 0.93 and AUC of 0.96 in the validation and derivation cohorts, respectively. Many studies have reported the superiority of using biomarkers to predict AKI in pediatric patients and neonates as well. Future directions include the application of AI along with biomarkers (NGAL, CysC, OPN, IL-18, B2M, etc.) in a Labelbox configuration to create a more robust and accurate model for predicting and detecting pediatric/neonatal AKI.
Collapse
Affiliation(s)
- Rupesh Raina
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA.
- Department of Nephrology, Akron Children's Hospital, Akron, OH, USA.
- Department of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA.
| | - Arwa Nada
- Le Bonheur Children's Hospital & St. Jude Research Hospital, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Raghav Shah
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
- Department of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Hany Aly
- Department of Neonatology, Cleveland Clinic Children's, Cleveland, OH, USA
| | - Saurav Kadatane
- Department of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Carolyn Abitbol
- Department of Pediatrics, Division of Pediatric Nephrology, University of Miami Miller School of Medicine/Holtz Children's Hospital, Miami, FL, USA
| | - Mihika Aggarwal
- Paediatric Nephrology & Paediatric Kidney Transplantation, Kidney and Urology Institute, Medanta, The Medicity Hospital, Gurgaon, India
| | - Jay Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, Pritzker School of Medicine, Chicago, IL, USA
| | - Javier Neyra
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sidharth Kumar Sethi
- Paediatric Nephrology & Paediatric Kidney Transplantation, Kidney and Urology Institute, Medanta, The Medicity Hospital, Gurgaon, India
| |
Collapse
|
7
|
Torres de Melo Bezerra Girão A, Torres de Melo Bezerra Cavalcante C, Pereira Castello Branco KM, Consuelo de Oliveira Teles A, Libório AB. Urine Output and Acute Kidney Injury in Neonates/Younger Children: A Prospective Study of Cardiac Surgery Patients with Indwelling Urinary Catheters. Clin J Am Soc Nephrol 2024:01277230-990000000-00434. [PMID: 39058926 DOI: 10.2215/cjn.0000000000000534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 07/22/2024] [Indexed: 07/28/2024]
Abstract
Introduction:
Pediatric acute kidney injury (AKI) is associated with significant morbidity and mortality, yet a precise definition, especially concerning urine output (UO) thresholds, remains unproven. We evaluate UO thresholds for AKI in neonates and children aged 1-24 months with indwelling urinary catheters undergoing cardiac surgery.
Methodology:
A six-year prospective cohort study (2018-2023) after cardiac surgery was conducted at a reference center in Brazil. All patients had indwelling urinary catheters up to 48 hours after surgery and at least two serum creatinine (sCr) measurements, including one before surgery. The main objective of this study was to determine the optimal UO thresholds for AKI definition and staging in neonates and younger children compared with the currently used criteria—neonatal and adult Kidney Disease Improving Global Outcomes (KDIGO) definitions. The outcome was a composite of severe AKI (stage 3 AKI diagnosed by the sCr criterion only), kidney replacement therapy, or hospital mortality.
Results:
The study included 1,024 patients: 253 in the neonatal group and 772 in the younger children group. In both groups, the lowest UO at 24 hours as a continuous variable had good discriminatory capacity for the composite outcome (AUC-ROC 0.75 [95% CI 0.70–0.81] and 0.74 [95% CI 0.68–0.79]). In neonates, the best thresholds were 3.0, 2.0 and 1.0 mL/kg/hour, and in younger children, the thresholds were 1.8, 1.0 and 0.5 mL/kg/hour. These values were used for modified AKI staging for each age group. In neonates, this modified criterion was associated with the best discriminatory capacity (AUC-ROC 0.74 [0.67-0.80] vs. 0.68 [0.61-0.75], P<0.05) and net reclassification improvement (NRI) in comparison with the neonatal KDIGO criteria. In younger children, the modified criteria had good discriminatory capacity but were comparable to the adult KDIGO criteria, and the NRI was near zero.
Conclusion:
Using indwelling catheters for UO measurements, our study reinforced that the current KDIGO criteria may require adjustments to better serve the neonate population. Additionally, using the UO criteria, we validated the adult KDIGO criteria in children aged 1-24 months.
Collapse
|
8
|
Bie D, Li Y, Wang H, Liu Q, Dou D, Jia Y, Yuan S, Li Q, Wang J, Yan F. Relationship between intra-operative urine output and postoperative acute kidney injury in paediatric cardiac surgery: A retrospective cohort study. Eur J Anaesthesiol 2024:00003643-990000000-00204. [PMID: 39021216 DOI: 10.1097/eja.0000000000002044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
BACKGROUND Intra-operative urine output (UO) has been shown to predict postoperative acute kidney injury (AKI) in adults; however, its significance in children undergoing cardiac surgery remains unknown. OBJECTIVE To explore the association between intra-operative UO and postoperative AKI in children with congenital heart disease. DESIGN A retrospective observational study. SETTING A tertiary hospital. PATIENTS Children aged >28 days and <6 years who underwent cardiac surgery at Fuwai Hospital from 1 April 2022 to 30 August 2022. MAIN OUTCOME MEASURES AKI was identified by the highest serum creatinine value within postoperative 7 days using Kidney Disease Improving Global Outcomes (KDIGO) criteria. RESULTS In total, 1184 children were included. The incidence of AKI was 23.1% (273/1184), of which 17.7% (209/1184) were stage 1, 4.2% (50/1184) were stage 2, and others were stage 3 (1.2%, 14/1184). Intra-operative UO was calculated by dividing the total intra-operative urine volume by the duration of surgery and the actual body weight measured before surgery. There was no significant difference in median [range] intra-operative UO between the AKI and non-AKI groups (2.6 [1.4 to 5.4] and 2.7 [1.4 to 4.9], respectively, P = 0.791), and multivariate logistic regression analyses showed that intra-operative UO was not associated with postoperative AKI [adjusted odds ratio (OR) 0.971; 95% confidence interval (CI), 0.930 to 1.014; P = 0.182]. Regarding the clinical importance of severe forms of AKI, we further explored the association between intra-operative UO and postoperative moderate-to-severe AKI (adjusted OR 0.914; 95% CI, 0.838 to 0.998; P = 0.046). CONCLUSIONS Intra-operative UO was not associated with postoperative AKI during paediatric cardiac surgery. However, we found a significant association between UO and postoperative moderate-to-severe AKI. This suggests that reductions in intra-operative urine output below a specific threshold may be associated with postoperative renal dysfunction. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT05489263.
Collapse
Affiliation(s)
- Dongyun Bie
- From the Department of Anaesthesiology, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (DB, YL, HW, QL, DD, YJ, SY, JW, FY), and Medical Research and Biometrics Centre, National Clinical Research Centre for Cardiovascular Diseases, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (QL)
| | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Reidy KJ, Guillet R, Selewski DT, Defreitas M, Stone S, Starr MC, Harer MW, Todurkar N, Vuong KT, Gogcu S, Askenazi D, Tipple TE, Charlton JR. Advocating for the inclusion of kidney health outcomes in neonatal research: best practice recommendations by the Neonatal Kidney Collaborative. J Perinatol 2024:10.1038/s41372-024-02030-1. [PMID: 38969825 DOI: 10.1038/s41372-024-02030-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/21/2024] [Accepted: 06/06/2024] [Indexed: 07/07/2024]
Abstract
Acute kidney injury (AKI) occurs in nearly 30% of sick neonates. Chronic kidney disease (CKD) can be detected in certain populations of sick neonates as early as 2 years. AKI is often part of a multisystem syndrome that negatively impacts developing organs resulting in short- and long-term pulmonary, neurodevelopmental, and cardiovascular morbidities. It is critical to incorporate kidney-related data into neonatal clinical trials in a uniform manner to better understand how neonatal AKI or CKD could affect an outcome of interest. Here, we provide expert opinion recommendations and rationales to support the inclusion of short- and long-term neonatal kidney outcomes using a tiered approach based on study design: (1) observational studies (prospective or retrospective) limited to data available within a center's standard practice, (2) observational studies involving prospective data collection where prespecified kidney outcomes are included in the design, (3) interventional studies with non-nephrotoxic agents, and (4) interventional studies with known nephrotoxic agents. We also provide recommendations for biospecimen collection to facilitate ancillary kidney specific research initiatives. This approach balances the costs of AKI and CKD ascertainment with knowledge gained. We advocate that kidney outcomes be included routinely in neonatal clinical study design. Consistent incorporation of kidney outcomes across studies will increase our knowledge of neonatal morbidity.
Collapse
Affiliation(s)
- Kimberly J Reidy
- Division of Nephrology, Department of Pediatrics, Children's Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, NY, 10467, USA
| | - Ronnie Guillet
- Division of Neonatology, Golisano Children's Hospital, University of Rochester, Rochester, NY, USA
| | - David T Selewski
- Division of Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Marissa Defreitas
- Division of Nephrology, Department of Pediatrics, University of Miami/Holtz Children's Hospital, Miami, FL, USA
| | - Sadie Stone
- Department of Pharmacy, Children's of Alabama, Birmingham, AL, UK
| | - Michelle C Starr
- Division of Pediatric Nephrology, Division of Child Health Service Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Matthew W Harer
- Division of Neonatology, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Namrata Todurkar
- Division of Neonatal Perinatal Medicine, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Kim T Vuong
- Division of Pediatric Nephrology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Semsa Gogcu
- Section of Neonatal-Perinatal Medicine, Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - David Askenazi
- Division of Nephrology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, UK
| | - Trent E Tipple
- Section of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Jennifer R Charlton
- Division of Nephrology, Department of Pediatrics, University of Virginia, Box 800386, Charlottesville, VA, 22903, USA.
| |
Collapse
|
10
|
Gorga SM, Selewski DT, Goldstein SL, Menon S. An update on the role of fluid overload in the prediction of outcome in acute kidney injury. Pediatr Nephrol 2024; 39:2033-2048. [PMID: 37861865 DOI: 10.1007/s00467-023-06161-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/29/2023] [Accepted: 08/29/2023] [Indexed: 10/21/2023]
Abstract
Over the past two decades, our understanding of the impact of acute kidney injury, disorders of fluid balance, and their interplay have increased significantly. In recent years, the epidemiology and impact of fluid balance, including the pathologic state of fluid overload on outcomes has been studied extensively across multiple pediatric and neonatal populations. A detailed understating of fluid balance has become increasingly important as it is recognized as a target for intervention to continue to work to improve outcomes in these populations. In this review, we provide an update on the epidemiology and outcomes associated with fluid balance disorders and the development of fluid overload in children with acute kidney injury (AKI). This will include a detailed review of consensus definitions of fluid balance, fluid overload, and the methodologies to define them, impact of fluid balance on the diagnosis of AKI and the concept of fluid corrected serum creatinine. This review will also provide detailed descriptions of future directions and the changing paradigms around fluid balance and AKI in critical care nephrology, including the incorporation of the sequential utilization of risk stratification, novel biomarkers, and functional kidney tests (furosemide stress test) into research and ultimately clinical care. Finally, the review will conclude with novel methods currently under study to assess fluid balance and distribution (point of care ultrasound and bioimpedance).
Collapse
Affiliation(s)
- Stephen M Gorga
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - David T Selewski
- Department of Pediatrics, Medical University of South Carolina, 125 Doughty St., MSC 608 Ste 690, Charleston, SC, 29425, USA.
| | - Stuart L Goldstein
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Shina Menon
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| |
Collapse
|
11
|
Puente BN, Mastropietro CW, Flores S, Cheung EW, Amula V, Radman M, Kwiatkowski D, Buckley JR, Allen K, Loomba R, Karki K, Chiwane S, Cashen K, Piggott K, Kapileshwarkar Y, Gowda KMN, Badheka A, Raman R, Costello JM, Zang H, Iliopoulos I. Comparison of Ductal Stent Versus Surgical Shunt as Initial Intervention for Neonates with Pulmonary Atresia with Intact Ventricular Septum. Pediatr Cardiol 2024:10.1007/s00246-024-03529-2. [PMID: 38842558 DOI: 10.1007/s00246-024-03529-2] [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: 12/21/2023] [Accepted: 05/20/2024] [Indexed: 06/07/2024]
Abstract
Data comparing surgical systemic-to-pulmonary artery shunt and patent ductus arteriosus (PDA) stent as the initial palliation procedure for patients with pulmonary atresia with intact ventricular septum (PA-IVS) are limited. We sought to compare characteristics and outcomes in a multicenter cohort of patients with PA-IVS undergoing surgical shunts versus PDA stents. We retrospectively reviewed neonates with PA-IVS from 2009 to 2019 in 19 United States centers. Bivariate comparisons and multivariable logistic regression analysis were performed to determine the relationship between initial palliation strategy and outcomes including major adverse cardiovascular events (MACE): stroke, mechanical circulatory support, cardiac arrest, or death. 187 patients were included: 38 PDA stents and 149 surgical shunts. Baseline characteristics did not differ statistically between groups. Post-procedural MACE occurred in 4 patients (11%) with PDA stents versus 38 (26%) with surgical shunts, p = 0.079. Overall, the initial palliation strategy was not significantly associated with MACE (aOR:0.37; 95% CI,0.13-1.02). In patients with moderate-to-severe right ventricle hypoplasia, PDA stents were significantly associated with decreased odds of MACE (aOR:0.36; 95% CI,0.13-0.99). PDA stents were associated with lower vasoactive inotrope scores (median 0 versus 5, p < 0.001), greater likelihood to be extubated at the end of their procedure (37% versus 4%, p < 0.001), and shorter duration of mechanical ventilation (median 24 versus 96 h, p < 0.001). PDA stents were associated with significantly more unplanned reinterventions for hypoxemia compared to surgical shunts (42% vs. 20%, p = 0.009). In this multicenter study, neonates with PA-IVS who underwent PDA stenting received less vasoactive and ventilatory support postoperatively compared to those who had surgical shunts. Furthermore, patients with the most severe morphology had decreased odds of MACE.
Collapse
Affiliation(s)
- Bao Nguyen Puente
- Division of Cardiac Critical Care, Children's National Health System, 111 Michigan Ave NW M4800, Washington, DC, 20010, USA.
| | - Christopher W Mastropietro
- Division of Critical Care, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Saul Flores
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Eva W Cheung
- Division of Critical Care & Hospital Medicine, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA
| | - Venugopal Amula
- Division of Critical Care, Department of Pediatrics, University of Utah Health, Salt Lake City, UT, USA
| | - Monique Radman
- Division of Critical Care, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - David Kwiatkowski
- Division of Cardiology, Department of Pediatrics, Lucille Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Jason R Buckley
- Division of Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Kiona Allen
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Rohit Loomba
- Department of Pediatrics, Chicago Medical School, Advocate Children's Hospital, Chicago, IL, USA
| | - Karan Karki
- Division of Cardiology, Department of Pediatrics, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Saurabh Chiwane
- Division of Critical Care, Department of Pediatrics, Cardinal Glennon Children's Hospital, Saint Louis University, Saint Louis, MO, USA
| | - Katherine Cashen
- Division of Critical Care Medicine, Duke Children's Hospital, Duke University, Durham, NC, USA
| | - Kurt Piggott
- Division of Pediatrics, Nemours Children's Hospital, Orlando, FL, USA
| | | | | | - Aditya Badheka
- Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - Rahul Raman
- Department of Pediatrics, Mercy Medical Center, Des Moines, IA, USA
| | - John M Costello
- Division of Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Huaiyu Zang
- Cincinnati Children's Hospital Medical Center, Heart Institute, Cincinnati, OH, USA
| | - Ilias Iliopoulos
- Department of Pediatrics, Inova Children's Hospital, Fairfax, VA, USA
| |
Collapse
|
12
|
Ulrich EH, Bedi PK, Alobaidi R, Morgan CJ, Paulden M, Zappitelli M, Bagshaw SM. Outcomes of Prophylactic Peritoneal Dialysis Catheter Insertion in Children Undergoing Cardiac Surgery: A Systematic Review and Meta-Analysis. Pediatr Crit Care Med 2024; 25:e291-e302. [PMID: 38334438 DOI: 10.1097/pcc.0000000000003465] [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: 02/10/2024]
Abstract
OBJECTIVES The objective of this Prospective Register of Systematic Reviews (CRD42022384192) registered systematic review and meta-analysis was to determine whether prophylactic peritoneal dialysis (PD) catheter insertion at the time of pediatric cardiac surgery is associated with improved short-term outcomes. DATA SOURCES Databases search of the MEDLINE, EMBASE, CINAHL, and Cochrane Library completed in April 2021 and updated October 2023. STUDY SELECTION Two reviewers independently completed study selection, data extraction, and bias assessment. Inclusion criteria were randomized controlled trials (RCTs) and observational studies of children (≤ 18 yr) undergoing cardiac surgery with cardiopulmonary bypass. We evaluated use of prophylactic PD catheter versus not. DATA EXTRACTION The primary outcome was in-hospital mortality, as well as secondary short-term outcomes. Pooled random-effect meta-analysis odds ratio with 95% CI are reported. DATA SYNTHESIS Seventeen studies met inclusion criteria, including four RCTs. The non-PD catheter group received supportive care that included diuretics and late placement of PD catheters in the ICU. Most study populations included children younger than 1 year and weight less than 10 kg. Cardiac surgery was most commonly used for arterial switch operation. In-hospital mortality was reported in 13 studies; pooled analysis showed no association between prophylactic PD catheter placement and in-hospital mortality. There were mixed results for ICU length of stay and time to negative fluid balance, with some studies showing shortened duration associated with use of prophylactic PD catheter insertion and others showing no difference. Overall, the studies had high risk for bias, mainly due to small sample size and lack of generalizability. CONCLUSIONS In this meta-analysis, we have failed to demonstrate an association between prophylactic PD catheter insertion in children and infants undergoing cardiac surgery and reduced in-hospital mortality. Other relevant short-term outcomes, including markers of fluid overload, require further study.
Collapse
Affiliation(s)
- Emma H Ulrich
- Division of Pediatric Nephrology, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Prabhjot K Bedi
- Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada
| | - Rashid Alobaidi
- Division of Pediatric Critical Care, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Catherine J Morgan
- Division of Pediatric Nephrology, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Mike Paulden
- Health Economics, School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Michael Zappitelli
- Division of Pediatric Nephrology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada
| |
Collapse
|
13
|
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
|
14
|
Hasson DC, Alten JA, Bertrandt RA, Zang H, Selewski DT, Reichle G, Bailly DK, Krawczeski CD, Winlaw DS, Goldstein SL, Gist KM. Persistent acute kidney injury and fluid accumulation with outcomes after the Norwood procedure: report from NEPHRON. Pediatr Nephrol 2024; 39:1627-1637. [PMID: 38057432 DOI: 10.1007/s00467-023-06235-y] [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: 10/05/2023] [Revised: 11/13/2023] [Accepted: 11/14/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Cardiac surgery-associated acute kidney injury (CS-AKI) is common, but its impact on clinical outcomes is variable. Parsing AKI into sub-phenotype(s) and integrating pathologic positive cumulative fluid balance (CFB) may better inform prognosis. We sought to determine whether durational sub-phenotyping of CS-AKI with CFB strengthens association with outcomes among neonates undergoing the Norwood procedure. METHODS Multicenter, retrospective cohort study from the Neonatal and Pediatric Heart and Renal Outcomes Network. Transient CS-AKI: present only on post-operative day (POD) 1 and/or 2; persistent CS-AKI: continued after POD 2. CFB was evaluated per day and peak CFB during the first 7 postoperative days. Primary and secondary outcomes were mortality, respiratory support-free and hospital-free days (at 28, 60 days, respectively). The primary predictor was persistent CS-AKI, defined by modified neonatal Kidney Disease: Improving Global Outcomes criteria. RESULTS CS-AKI occurred in 59% (205/347) neonates: 36.6% (127/347) transient and 22.5% (78/347) persistent; CFB > 10% occurred in 18.7% (65/347). Patients with either persistent CS-AKI or peak CFB > 10% had higher mortality. Combined persistent CS-AKI with peak CFB > 10% (n = 21) associated with increased mortality (aOR: 7.8, 95% CI: 1.4, 45.5; p = 0.02), decreased respiratory support-free (predicted mean 12 vs. 19; p < 0.001) and hospital-free days (17 vs. 29; p = 0.048) compared to those with neither. CONCLUSIONS The combination of persistent CS-AKI and peak CFB > 10% after the Norwood procedure is associated with mortality and hospital resource utilization. Prospective studies targeting intra- and postoperative CS-AKI risk factors and reducing CFB have the potential to improve outcomes.
Collapse
Affiliation(s)
- Denise C Hasson
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., MLC 2003, CincinnatiCincinnati, OH, 45226, USA
- Hassenfeld Children's Hospital, Division of Pediatric Critical Care, NYU Langone, New York, NY, USA
| | - Jeffrey A Alten
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., MLC 2003, CincinnatiCincinnati, OH, 45226, USA
| | - Rebecca A Bertrandt
- Department of Pediatrics, Medical College of Wisconsin, Children's Wisconsin, Milwaukee, WI, USA
| | - Huaiyu Zang
- Department of Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David T Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Garrett Reichle
- Department of Pediatrics, Primary Children's Hospital, University of Michigan Medical School, Ann Arbor, MI, USA
| | | | | | - David S Winlaw
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., MLC 2003, CincinnatiCincinnati, OH, 45226, USA
- Lurie Children's Hospital, Department of Pediatric Surgery, Northwestern University School of Medicine, Chicago, IL, USA
| | - Stuart L Goldstein
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., MLC 2003, CincinnatiCincinnati, OH, 45226, USA
| | - Katja M Gist
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., MLC 2003, CincinnatiCincinnati, OH, 45226, USA.
| |
Collapse
|
15
|
Nagy M, Onder AM, Rosen D, Mullett C, Morca A, Baloglu O. Predicting pediatric cardiac surgery-associated acute kidney injury using machine learning. Pediatr Nephrol 2024; 39:1263-1270. [PMID: 37934270 DOI: 10.1007/s00467-023-06197-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 09/29/2023] [Accepted: 10/02/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Prediction of cardiac surgery-associated acute kidney injury (CS-AKI) in pediatric patients is crucial to improve outcomes and guide clinical decision-making. This study aimed to develop a supervised machine learning (ML) model for predicting moderate to severe CS-AKI at postoperative day 2 (POD2). METHODS This retrospective cohort study analyzed data from 402 pediatric patients who underwent cardiac surgery at a university-affiliated children's hospital, who were separated into an 80%-20% train-test split. The ML model utilized demographic, preoperative, intraoperative, and POD0 clinical and laboratory data to predict moderate to severe AKI categorized by Kidney Disease: Improving Global Outcomes (KDIGO) stage 2 or 3 at POD2. Input feature importance was assessed by SHapley Additive exPlanations (SHAP) values. Model performance was evaluated using accuracy, area under the receiver operating curve (AUROC), precision, recall, area under the precision-recall curve (AUPRC), F1-score, and Brier score. RESULTS Overall, 13.7% of children in the test set experienced moderate to severe AKI. The ML model achieved promising performance, with accuracy of 0.91 (95% CI: 0.82-1.00), AUROC of 0.88 (95% CI: 0.72-1.00), precision of 0.92 (95% CI: 0.70-1.00), recall of 0.63 (95% CI: 0.32-0.96), AUPRC of 0.81 (95% CI: 0.61-1.00), F1-score of 0.73 (95% CI: 0.46-0.99), and Brier score loss of 0.09 (95% CI: 0.00-0.17). The top ten most important features assessed by SHAP analyses in this model were preoperative serum creatinine, surgery duration, POD0 serum pH, POD0 lactate, cardiopulmonary bypass duration, POD0 vasoactive inotropic score, sex, POD0 hematocrit, preoperative weight, and POD0 serum creatinine. CONCLUSIONS A supervised ML model utilizing demographic, preoperative, intraoperative, and immediate postoperative clinical and laboratory data showed promising performance in predicting moderate to severe CS-AKI at POD2 in pediatric patients.
Collapse
Affiliation(s)
- Matthew Nagy
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Ali Mirza Onder
- Division of Pediatric Nephrology, Nemours Children's Hospital, Wilmington, DE, USA
| | - David Rosen
- Division of Pediatric Cardiothoracic Anesthesiology, Department of Anesthesiology, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Charles Mullett
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Ayse Morca
- Department of Pediatric Critical Care Medicine and Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, OH, USA
| | - Orkun Baloglu
- Department of Pediatric Critical Care Medicine and Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, OH, USA.
- Department of Pediatric Critical Care Medicine and Pediatric Cardiology, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, 9500 Euclid Ave. M14, Cleveland, OH, 44195, USA.
| |
Collapse
|
16
|
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
|
17
|
Vincent K, Rutledge A, Laney Z, Newman JC, Selewski DT, Steflik HJ. Recurrent neonatal acute kidney injury: incidence, predictors, and outcomes in the neonatal intensive care unit. J Perinatol 2024; 44:428-433. [PMID: 37932405 DOI: 10.1038/s41372-023-01800-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/26/2023] [Accepted: 10/06/2023] [Indexed: 11/08/2023]
Abstract
OBJECTIVE Determine recurrent neonatal acute kidney injury (rAKI) incidence, risk factors, and associated outcomes. STUDY DESIGN Single-center retrospective cohort of neonates admitted to the NICU 1/1/20-6/30/21. Comparisons were made between those with no AKI, single AKI episode (sAKI), and rAKI. Multivariable linear and logistic regression models were used to assess associations between rAKI and length of mechanical ventilation (LMV), length of hospitalization stay (LOS), mortality, and hypertension (HTN) at discharge. RESULTS The incidence of AKI in the cohort of 869 infants was 19%: 705 (81%) no AKI, 100 (12%) sAKI, 64 (7%) rAKI. Both sAKI and rAKI were independently associated with longer LMV and LOS. sAKI was independently associated with almost 4x higher odds of mortality than rAKI. CONCLUSION In this single center cohort of neonates, sAKI independently predicts mortality, however rAKI is independently associated with increased LMV and LOS suggesting rAKI is clinically important and warrants further study.
Collapse
Affiliation(s)
- Katherine Vincent
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA.
| | - Austin Rutledge
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Zegilor Laney
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, OH, USA
| | - Jill C Newman
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - David T Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Heidi J Steflik
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| |
Collapse
|
18
|
Fuhrman DY, Stanski NL, Krawczeski CD, Greenberg JH, Arikan AAA, Basu RK, Goldstein SL, Gist KM. A proposed framework for advancing acute kidney injury risk stratification and diagnosis in children: a report from the 26th Acute Disease Quality Initiative (ADQI) conference. Pediatr Nephrol 2024; 39:929-939. [PMID: 37670082 PMCID: PMC10817991 DOI: 10.1007/s00467-023-06133-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 07/24/2023] [Accepted: 08/09/2023] [Indexed: 09/07/2023]
Abstract
Acute kidney injury (AKI) in children is associated with increased morbidity, reduced health-related quality of life, greater resource utilization, and higher mortality. Improvements in the timeliness and precision of AKI diagnosis in children are needed. In this report, we highlight existing, novel, and on-the-horizon diagnostic and risk-stratification tools for pediatric AKI, and outline opportunities for integration into clinical practice. We also summarize pediatric-specific high-risk diagnoses and exposures for AKI, as well as the potential role of real-time risk stratification and clinical decision support to improve outcomes. Lastly, the key characteristics of important pediatric AKI phenotypes will be outlined. Throughout, we identify key knowledge gaps, which represent prioritized areas of focus for future research that will facilitate a comprehensive, timely and personalized approach to pediatric AKI diagnosis and management.
Collapse
Affiliation(s)
- Dana Y Fuhrman
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Suite 2000, Pittsburgh, PA, 15224, USA.
- Department of Pediatrics, Division of Nephrology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
| | - Natalja L Stanski
- Department of Pediatrics, Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Catherine D Krawczeski
- Department of Pediatrics, Division of Cardiology, Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA
| | - Jason H Greenberg
- Department of Pediatrics, Division of Nephrology, Yale University Medical Center, New Haven, CT, USA
| | - A Ayse Akcan Arikan
- Department of Pediatrics, Division of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
- Department of Pediatrics, Division of Nephrology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Raj K Basu
- Department of Pediatrics, Division of Critical Care Medicine, Northwestern University Feinberg School of Medicine, Ann & Robert Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Stuart L Goldstein
- Department of Pediatrics, Division of Nephrology & Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Katja M Gist
- Department of Pediatrics, Division of Cardiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| |
Collapse
|
19
|
Tjoeng YL, Werho DK, Algaze C, Nawathe P, Benjamin S, Schumacher KR, Chan T. Development of an Equity, Diversity, and Inclusion Committee for a collaborative quality improvement network: Pediatric Cardiac Critical Care Consortium (PC 4) Equity, Diversity and Inclusion (EDI) Committee: white paper 2023. Cardiol Young 2024; 34:563-569. [PMID: 37577942 DOI: 10.1017/s1047951123002950] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
Racial and ethnic disparities are well described in paediatric cardiac critical care outcomes. However, understanding the mechanisms behind these outcomes and implementing interventions to reduce and eliminate disparities remain a gap in the field of paediatric cardiac critical care. The Pediatric Cardiac Critical Care Consortium (PC4) established the Equity, Diversity, and Inclusion (EDI) Committee in 2020 to promote an equity lens to its aim of improving paediatric cardiac critical care quality and outcomes across North America. The PC4 EDI Committee is working to increase research, quality improvement, and programming efforts to work towards health equity. It also aims to promote health equity considerations in PC4 research. In addition to a focus on patient outcomes and research, the committee aims to increase the inclusion of Black, Indigenous, and People of Color (BIPOC) members in the PC4 collaborative. The following manuscript outlines the development, structure, and aims of the PC4 EDI Committee and describes an analysis of social determinants of health in published PC4 research.
Collapse
Affiliation(s)
- Yuen Lie Tjoeng
- Division of Critical Care Medicine and the Heart Center, Seattle Children's Hospital, Seattle, WA, USA
- University of Washington School of Medicine, University of Washington, Seattle, WA, USA
| | - David K Werho
- Division of Pediatric Cardiology, Rady Children's Hospital, University of California San Diego, San Diego, CA, USA
| | - Claudia Algaze
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
| | - Pooja Nawathe
- Division of Pediatric Critical Care, Guerin Children's, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Solange Benjamin
- Division of Pediatric Cardiology, Levine Children's Hospital, Charlotte, NC, USA
| | - Kurt R Schumacher
- Division of Pediatric Cardiology, C. S. Mott Children's Hospital, University of Michigan. Ann Arbor, MI, USA
| | - Titus Chan
- Division of Critical Care Medicine and the Heart Center, Seattle Children's Hospital, Seattle, WA, USA
- University of Washington School of Medicine, University of Washington, Seattle, WA, USA
| |
Collapse
|
20
|
Neumayr TM, Bayrakci B, Chanchlani R, Deep A, Morgan J, Arikan AA, Basu RK, Goldstein SL, Askenazi DJ. Programs and processes for advancing pediatric acute kidney support therapy in hospitalized and critically ill children: a report from the 26th Acute Disease Quality Initiative (ADQI) consensus conference. Pediatr Nephrol 2024; 39:993-1004. [PMID: 37930418 PMCID: PMC10817827 DOI: 10.1007/s00467-023-06186-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/24/2023] [Accepted: 09/25/2023] [Indexed: 11/07/2023]
Abstract
Pediatric acute kidney support therapy (paKST) programs aim to reliably provide safe, effective, and timely extracorporeal supportive care for acutely and critically ill pediatric patients with acute kidney injury (AKI), fluid and electrolyte derangements, and/or toxin accumulation with a goal of improving both hospital-based and lifelong outcomes. Little is known about optimal ways to configure paKST teams and programs, pediatric-specific aspects of delivering high-quality paKST, strategies for transitioning from acute continuous modes of paKST to facilitate rehabilitation, or providing effective short- and long-term follow-up. As part of the 26th Acute Disease Quality Initiative Conference, the first to focus on a pediatric population, we summarize here the current state of knowledge in paKST programs and technology, identify key knowledge gaps in the field, and propose a framework for current best practices and future research in paKST.
Collapse
Affiliation(s)
- Tara M Neumayr
- Department of Pediatrics, Divisions of Pediatric Critical Care Medicine and Pediatric Nephrology, Washington University School of Medicine, St. Louis, MO, USA
| | - Benan Bayrakci
- Department of Pediatric Intensive Care Medicine, The Center for Life Support Practice and Research, Hacettepe University, Ankara, Türkiye
| | - Rahul Chanchlani
- Department of Pediatrics, Division of Pediatric Nephrology, McMaster University, McMaster Children's Hospital, Hamilton, ON, Canada
| | - Akash Deep
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK.
- Pediatric Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK.
| | - Jolyn Morgan
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ayse Akcan Arikan
- Department of Pediatrics, Divisions of Critical Care Medicine and Nephrology, Baylor College of Medicine, Houston, TX, USA
| | - Rajit K Basu
- Department of Pediatrics, Division of Critical Care Medicine, Northwestern University Feinberg School of Medicine, Ann & Robert Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Stuart L Goldstein
- Department of Pediatrics, Division of Nephrology & Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David J Askenazi
- Department of Pediatrics, Division of Pediatric Nephrology, Pediatric and Infant Center for Acute Nephrology, Children's of Alabama, University of Alabama at Birmingham, Birmingham, AL, USA
| |
Collapse
|
21
|
Starr MC, Gist KM, Zang H, Ollberding NJ, Balani S, Cappoli A, Ciccia E, Joseph C, Kakajiwala A, Kessel A, Muff-Luett M, Santiago Lozano MJ, Pinto M, Reynaud S, Solomon S, Slagle C, Srivastava R, Shih WV, Webb T, Menon S. Continuous Kidney Replacement Therapy and Survival in Children and Young Adults: Findings From the Multinational WE-ROCK Collaborative. Am J Kidney Dis 2024:S0272-6386(24)00610-3. [PMID: 38364956 PMCID: PMC11324858 DOI: 10.1053/j.ajkd.2023.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 11/28/2023] [Accepted: 12/08/2023] [Indexed: 02/18/2024]
Abstract
RATIONALE & OBJECTIVE There are limited studies describing the epidemiology and outcomes in children and young adults receiving continuous kidney replacement therapy (CKRT). We aimed to describe associations between patient characteristics, CKRT prescription, and survival. STUDY DESIGN Retrospective multicenter cohort study. SETTING & PARTICIPANTS 980 patients aged from birth to 25 years who received CKRT between 2015 and 2021 at 1 of 32 centers in 7 countries participating in WE-ROCK (Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Diseases). EXPOSURE CKRT for acute kidney injury or volume overload. OUTCOMES Death before intensive care unit (ICU) discharge. ANALYTICAL APPROACH Descriptive statistics. RESULTS Median age was 8.8 years (IQR, 1.6-15.0), and median weight was 26.8 (IQR, 11.6-55.0) kg. CKRT was initiated a median of 2 (IQR, 1-6) days after ICU admission and lasted a median of 6 (IQR, 3-14) days. The most common CKRT modality was continuous venovenous hemodiafiltration. Citrate anticoagulation was used in 62%, and the internal jugular vein was the most common catheter placement location (66%). 629 participants (64.1%) survived at least until ICU discharge. CKRT dose, filter type, and anticoagulation were similar in those who did and did not survive to ICU discharge. There were apparent practice variations by institutional ICU size. LIMITATIONS Retrospective design; limited representation from centers outside the United States. CONCLUSIONS In this study of children and young adults receiving CKRT, approximately two thirds survived at least until ICU discharge. Although variations in dialysis mode and dose, catheter size and location, and anticoagulation were observed, survival was not detected to be associated with these parameters. PLAIN-LANGUAGE SUMMARY In this large contemporary epidemiological study of children and young adults receiving continuous kidney replacement therapy in the intensive care unit, we observed that two thirds of patients survived at least until ICU discharge. However, patients with comorbidities appeared to have worse outcomes. Compared with previously published reports on continuous kidney replacement therapy practice, we observed greater use of continuous venovenous hemodiafiltration with regional citrate anticoagulation.
Collapse
Affiliation(s)
- Michelle C Starr
- Division of Nephrology, Pediatric and Adolescent Comparative Effectiveness Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Katja M Gist
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Huaiyu Zang
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Nicholas J Ollberding
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Shanthi Balani
- Division of Nephrology, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Andrea Cappoli
- Division of Nephrology, Department of Pediatrics, Children Hospital Bambino Gesù, Rome, Italy
| | - Eileen Ciccia
- Division of Nephrology, Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, Missouri
| | - Catherine Joseph
- Division of Nephrology, Department of Pediatrics, Texas Children's Hospital, Houston, Texas
| | - Aadil Kakajiwala
- Division of Critical Care Medicine and Nephrology, Department of Pediatrics, Children's National Hospital, Washington, DC
| | - Aaron Kessel
- Division of Critical Care, Department of Pediatrics, Cohen Children's Medical Center, Zucker School of Medicine, New Hyde Park
| | - Melissa Muff-Luett
- Division of Nephrology, Department of Pediatrics, University of Nebraska Medical Center, Children's Hospital & Medical Center, Omaha, NE
| | - María J Santiago Lozano
- Division of Intensive Care, Department of Pediatrics, Gregorio Marañón University Hospital; School of Medicine, Madrid, Spain
| | - Matthew Pinto
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, New York
| | - Stephanie Reynaud
- Division of Pediatric and Neonatal Critical Care, Department of Pediatrics, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Sonia Solomon
- Division of Pediatric Nephrology, Department of Pediatrics, Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, New York
| | - Cara Slagle
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Rachana Srivastava
- Division of Nephrology, Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles, California
| | - Weiwen V Shih
- Division of Nephrology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Tennille Webb
- Division of Nephrology, Department of Pediatrics, Children's of Alabama and University of Alabama at Birmingham, Birmingham, Alabama
| | - Shina Menon
- Division of Nephrology, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington; Division of Nephrology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California.
| |
Collapse
|
22
|
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.
Collapse
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
| |
Collapse
|
23
|
Fuhrman DY, Stenson EK, Alhamoud I, Alobaidi R, Bottari G, Fernandez S, Guzzi F, Haga T, Kaddourah A, Marinari E, Mohamed TH, Morgan CJ, Mottes T, Neumayr TM, Ollberding NJ, Raggi V, Ricci Z, See E, Stanski NL, Zang H, Zangla E, Gist KM. Major Adverse Kidney Events in Pediatric Continuous Kidney Replacement Therapy. JAMA Netw Open 2024; 7:e240243. [PMID: 38393726 PMCID: PMC10891477 DOI: 10.1001/jamanetworkopen.2024.0243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/26/2023] [Indexed: 02/25/2024] Open
Abstract
Importance Continuous kidney replacement therapy (CKRT) is increasingly used in youths with critical illness, but little is known about longer-term outcomes, such as persistent kidney dysfunction, continued need for dialysis, or death. Objective To characterize the incidence and risk factors, including liberation patterns, associated with major adverse kidney events 90 days after CKRT initiation (MAKE-90) in children, adolescents, and young adults. Design, Setting, and Participants This international, multicenter cohort study was conducted among patients aged 0 to 25 years from The Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK) registry treated with CKRT for acute kidney injury or fluid overload from 2015 to 2021. Exclusion criteria were dialysis dependence, concurrent extracorporeal membrane oxygenation use, or receipt of CKRT for a different indication. Data were analyzed from May 2 to December 14, 2023. Exposure Patient clinical characteristics and CKRT parameters were assessed. CKRT liberation was classified as successful, reinstituted, or not attempted. Successful liberation was defined as the first attempt at CKRT liberation resulting in 72 hours or more without return to dialysis within 28 days of CKRT initiation. Main Outcomes and Measures MAKE-90, including death or persistent kidney dysfunction (dialysis dependence or ≥25% decline in estimated glomerular filtration rate from baseline), were assessed. Results Among 969 patients treated with CKRT (529 males [54.6%]; median [IQR] age, 8.8 [1.7-15.0] years), 630 patients (65.0%) developed MAKE-90. On multivariable analysis, cardiac comorbidity (adjusted odds ratio [aOR], 1.60; 95% CI, 1.08-2.37), longer duration of intensive care unit admission before CKRT initiation (aOR for 6 days vs 1 day, 1.07; 95% CI, 1.02-1.13), and liberation pattern were associated with MAKE-90. In this analysis, patients who successfully liberated from CKRT within 28 days had lower odds of MAKE-90 compared with patients in whom liberation was attempted and failed (aOR, 0.32; 95% CI, 0.22-0.48) and patients without a liberation attempt (aOR, 0.02; 95% CI, 0.01-0.04). Conclusions and Relevance In this study, MAKE-90 occurred in almost two-thirds of the population and patient-level risk factors associated with MAKE-90 included cardiac comorbidity, time to CKRT initiation, and liberation patterns. These findings highlight the high incidence of adverse outcomes in this population and suggest that future prospective studies are needed to better understand liberation patterns and practices.
Collapse
Affiliation(s)
- Dana Y. Fuhrman
- University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Erin K. Stenson
- Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora
| | - Issa Alhamoud
- University of Iowa Stead Family Children’s Hospital, Carver College of Medicine, Iowa City
| | | | | | - Sarah Fernandez
- Gregorio Marañón University Hospital, School of Medicine, Madrid, Spain
| | | | - Taiki Haga
- Osaka City General Hospital, Osaka, Japan
| | - Ahmad Kaddourah
- Sidra Medicine, Doha, Qatar
- Weill Cornell Medical College, Ar-Rayyan, Qatar
| | | | - Tahagod H. Mohamed
- Nationwide Children’s Hospital, The Heart Center, The Ohio State University College of Medicine, Columbus
| | | | - Theresa Mottes
- Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Tara M. Neumayr
- Washington University School of Medicine, St Louis Children’s Hospital, St Louis, Missouri
| | - Nicholas J. Ollberding
- Cincinnati Children’s Hospital Medical Center; University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Valeria Raggi
- Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | | | - Emily See
- Royal Children’s Hospital, University of Melbourne, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
| | - Natalja L. Stanski
- Cincinnati Children’s Hospital Medical Center; University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Huaiyu Zang
- Cincinnati Children’s Hospital Medical Center; University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Katja M. Gist
- Cincinnati Children’s Hospital Medical Center; University of Cincinnati College of Medicine, Cincinnati, Ohio
| |
Collapse
|
24
|
Kwiatkowski DM, Alten JA, Raymond TT, Selewski DT, Blinder JJ, Afonso NS, Coghill MT, Cooper DS, Koch JD, Krawczeski CD, Mah KE, Neumayr TM, Rahman AKMF, Reichle G, Tabbutt S, Webb TN, Borasino S. Peritoneal catheters in neonates undergoing complex cardiac surgery: a multi-centre descriptive study. Cardiol Young 2024; 34:272-281. [PMID: 37337694 DOI: 10.1017/s104795112300135x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND The use of peritoneal catheters for prophylactic dialysis or drainage to prevent fluid overload after neonatal cardiac surgery is common in some centres; however, the multi-centre variability and details of peritoneal catheter use are not well described. METHODS Twenty-two-centre NEonatal and Pediatric Heart Renal Outcomes Network (NEPHRON) study to describe multi-centre peritoneal catheter use after STAT category 3-5 neonatal cardiac surgery using cardiopulmonary bypass. Patient characteristics and acute kidney injury/fluid outcomes for six post-operative days are described among three cohorts: peritoneal catheter with dialysis, peritoneal catheter with passive drainage, and no peritoneal catheter. RESULTS Of 1490 neonates, 471 (32%) had an intraoperative peritoneal catheter placed; 177 (12%) received prophylactic dialysis and 294 (20%) received passive drainage. Sixteen (73%) centres used peritoneal catheter at some frequency, including six centres in >50% of neonates. Four centres utilised prophylactic peritoneal dialysis. Time to post-operative dialysis initiation was 3 hours [1, 5] with the duration of 56 hours [37, 90]; passive drainage cohort drained for 92 hours [64, 163]. Peritoneal catheter were more common among patients receiving pre-operative mechanical ventilation, single ventricle physiology, and higher complexity surgery. There was no association with adverse events. Serum creatinine and daily fluid balance were not clinically different on any post-operative day. Mortality was similar. CONCLUSIONS In neonates undergoing complex cardiac surgery, peritoneal catheter use is not rare, with substantial variability among centres. Peritoneal catheters are used more commonly with higher surgical complexity. Adverse event rates, including mortality, are not different with peritoneal catheter use. Fluid overload and creatinine-based acute kidney injury rates are not different in peritoneal catheter cohorts.
Collapse
Affiliation(s)
- David M Kwiatkowski
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Jeffrey A Alten
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Tia T Raymond
- Department of Pediatrics, Medical City Children's Hospital, Dallas, TX, USA
| | - David T Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Joshua J Blinder
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Natasha S Afonso
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Matthew T Coghill
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David S Cooper
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Joshua D Koch
- Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ, USA
| | | | - Kenneth E Mah
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Tara M Neumayr
- Department of Pediatrics, Washington University School of Medicine, St. Louis. MO, USA
| | - A K M Fazlur Rahman
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Garret Reichle
- Department of Pediatrics, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Sarah Tabbutt
- Department of Pediatrics, University of California - San Francisco School of Medicine, San Francisco, CA, USA
| | - Tennille N Webb
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Santiago Borasino
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| |
Collapse
|
25
|
Erez DL, Lokesh S, Howarth KD, Meloni S, Ballester L, Laskin B, Sullivan KE, Blinder J. Immune urinary biomarkers predict infant cardiac surgery-associated acute kidney injury. Pediatr Nephrol 2024; 39:589-595. [PMID: 37597103 DOI: 10.1007/s00467-023-06051-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/20/2023] [Accepted: 05/23/2023] [Indexed: 08/21/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) occurs frequently after infant cardiac surgery and is associated with poor outcomes, including mortality and prolonged length of stay. AKI mechanisms are poorly understood, limiting therapeutic targets. Emerging data implicates dysregulated immune activation in post-cardiac surgery AKI development. We sought to identify immune-mediated AKI biomarkers after infant cardiopulmonary bypass (CPB)-assisted cardiac surgery. METHODS A single-center prospective study of 126 infants less than 1 year old undergoing CPB-assisted surgery enrolled between 10/2017 and 6/2019. Urine samples were collected before CPB and at 6, 24, 48, and 72 h after surgery. Immune-mediated biomarkers were measured using commercial ELISA and Luminex™ multiplex kits. Based on subject age, neonatal KDIGO (< 1 month) or KDIGO criteria defined AKI. The Kruskal-Wallis rank test determined the relationship between urinary biomarker measurements and AKI. RESULTS A total of 35 infants (27%) developed AKI. AKI subjects were younger, underwent more complex surgery, and had longer CPB time. Subjects with AKI vs. those without AKI had higher median urinary chemokine 10 (C-X-C motif) ligand levels at 24, 48, and 72 h, respectively: 14.3 pg/ml vs. 5.3 pg/ml, 3.4 pg/ml vs. 0.8 pg/ml, and 1.15 pg/ml vs. 0.22 pg/ml (p < 0.05) post-CPB. At 6 h post-CPB, median vascular cell adhesion protein 1 (VCAM) levels (pg/mL) were higher among AKI subjects (491 pg/ml vs. 0 pg/ml, p = 0.04). CONCLUSIONS Urinary CXCL10 and VCAM are promising pro-inflammatory biomarkers for early AKI detection and may indicate eventual AKI therapeutic targets. A higher resolution version of the Graphical abstract is available as Supplementary information.
Collapse
Affiliation(s)
- Daniella Levy Erez
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, USA.
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.
- Schneider Children's Medical Center Israel, 14 Kaplan Street, Petach Tiqva, Israel.
| | - Shah Lokesh
- Division of Pediatric Nephrology, Department of Pediatrics, Stanford University School of Medicine, Stanford, USA
| | - Kathryn D Howarth
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Sherin Meloni
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Lance Ballester
- Biostatistics and Data Management Core, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Benjamin Laskin
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Kathleen E Sullivan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Joshua Blinder
- Division of Cardiac Critical Care, Children's Hospital of Philadelphia, Philadelphia, USA
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Stanford, USA
| |
Collapse
|
26
|
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.
Collapse
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.
| |
Collapse
|
27
|
Law YM, Hsu C, Hingorani SR, Richards M, McMullan DM, Jefferies H, Himmelfarb J, Katz R. Randomized controlled trial of remote ischemic preconditioning in children having cardiac surgery. J Cardiothorac Surg 2024; 19:5. [PMID: 38172875 PMCID: PMC10765905 DOI: 10.1186/s13019-023-02450-8] [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: 03/01/2023] [Accepted: 11/04/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Children undergoing cardiac surgery are at risk for acute kidney injury (AKI) and cardiac dysfunction. Opportunity exists in protecting end organ function with remote ischemic preconditioning. We hypothesize this intervention lessens kidney and myocardial injury. METHODS We conducted a randomized, double blind, placebo controlled trial of remote ischemic preconditioning in children undergoing cardiac surgery. Pre-specified end points are change in creatinine, estimated glomerular filtration rate, development of AKI, B-type natriuretic peptide and troponin I at 6, 12, 24, 48, 72 h post separation from bypass. RESULTS There were 45 in the treatment and 39 patients in the control group, median age of 3.5 and 3.8 years, respectively. There were no differences between groups in creatinine, cystatin C, eGFR at each time point. There was a trend for a larger rate of decrease, especially for cystatin C (p = 0.042) in the treatment group but the magnitude was small. AKI was observed in 21 (54%) of control and 16 (36%) of treatment group (p = 0.094). Adjusting for baseline creatinine, the odds ratio for AKI in treatment versus control was 0.31 (p = 0.037); adjusting for clinical characteristics, the odds ratio was 0.34 (p = 0.056). There were no differences in natriuretic peptide or troponin levels between groups. All secondary end points of clinical outcomes were not different. CONCLUSIONS There is suggestion of RIPC delivering some kidney protection in an at-risk pediatric population. Larger, higher risk population studies will be required to determine its efficacy. Trial registration and date: Clinicaltrials.gov NCT01260259; 2021.
Collapse
Affiliation(s)
- Yuk M Law
- Pediatric Cardiology, Department of Pediatrics, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA.
- University of Washington School of Medicine, Seattle, WA, 98115, USA.
| | - Christine Hsu
- Kaiser Permanente of Washington, Seattle, WA, 98105, USA
| | - Sangeeta R Hingorani
- Pediatric Cardiology, Department of Pediatrics, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
- University of Washington School of Medicine, Seattle, WA, 98115, USA
| | - Michael Richards
- Pediatric Cardiology, Department of Pediatrics, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
- University of Washington School of Medicine, Seattle, WA, 98115, USA
| | - David M McMullan
- Pediatric Cardiology, Department of Pediatrics, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
- University of Washington School of Medicine, Seattle, WA, 98115, USA
| | - Howard Jefferies
- Pediatric Cardiology, Department of Pediatrics, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
- University of Washington School of Medicine, Seattle, WA, 98115, USA
| | | | - Ronit Katz
- University of Washington School of Medicine, Seattle, WA, 98115, USA
| |
Collapse
|
28
|
Gist KM, Menon S, Anton-Martin P, Bigelow AM, Cortina G, Deep A, De la Mata-Navazo S, Gelbart B, Gorga S, Guzzo I, Mah KE, Ollberding NJ, Shin HS, Thadani S, Uber A, Zang H, Zappitelli M, Selewski DT. Time to Continuous Renal Replacement Therapy Initiation and 90-Day Major Adverse Kidney Events in Children and Young Adults. JAMA Netw Open 2024; 7:e2349871. [PMID: 38165673 PMCID: PMC10762580 DOI: 10.1001/jamanetworkopen.2023.49871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 11/14/2023] [Indexed: 01/04/2024] Open
Abstract
Importance In clinical trials, the early or accelerated continuous renal replacement therapy (CRRT) initiation strategy among adults with acute kidney injury or volume overload has not demonstrated a survival benefit. Whether the timing of initiation of CRRT is associated with outcomes among children and young adults is unknown. Objective To determine whether timing of CRRT initiation, with and without consideration of volume overload (VO; <10% vs ≥10%), is associated with major adverse kidney events at 90 days (MAKE-90). Design, Setting, and Participants This multinational retrospective cohort study was conducted using data from the Worldwide Exploration of Renal Replacement Outcome Collaborative in Kidney Disease (WE-ROCK) registry from 2015 to 2021. Participants included children and young adults (birth to 25 years) receiving CRRT for acute kidney injury or VO at 32 centers across 7 countries. Statistical analysis was performed from February to July 2023. Exposure The primary exposure was time to CRRT initiation from intensive care unit admission. Main Outcomes and measures The primary outcome was MAKE-90 (death, dialysis dependence, or persistent kidney dysfunction [>25% decline in estimated glomerular filtration rate from baseline]). Results Data from 996 patients were entered into the registry. After exclusions (n = 27), 969 patients (440 [45.4%] female; 16 (1.9%) American Indian or Alaska Native, 40 (4.7%) Asian or Pacific Islander, 127 (14.9%) Black, 652 (76.4%) White, 18 (2.1%) more than 1 race; median [IQR] patient age, 8.8 [1.7-15.0] years) with data for the primary outcome (MAKE-90) were included. Median (IQR) time to CRRT initiation was 2 (1-6) days. MAKE-90 occurred in 630 patients (65.0%), of which 368 (58.4%) died. Among the 601 patients who survived, 262 (43.6%) had persistent kidney dysfunction. Of patients with persistent dysfunction, 91 (34.7%) were dependent on dialysis. Time to CRRT initiation was approximately 1 day longer among those with MAKE-90 (median [IQR], 3 [1-8] days vs 2 [1-4] days; P = .002). In the generalized propensity score-weighted regression, there were approximately 3% higher odds of MAKE-90 for each 1-day delay in CRRT initiation (odds ratio, 1.03 [95% CI, 1.02-1.04]). Conclusions and Relevance In this cohort study of children and young adults receiving CRRT, longer time to CRRT initiation was associated with greater risk of MAKE-90 outcomes, in particular, mortality. These findings suggest that prospective multicenter studies are needed to further delineate the appropriate time to initiate CRRT and the interaction between CRRT initiation timing and VO to continue to improve survival and reduce morbidity in this population.
Collapse
Affiliation(s)
- Katja M Gist
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Shina Menon
- Seattle Children's Hospital, University of Washington, Seattle
| | | | - Amee M Bigelow
- Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus
| | | | - Akash Deep
- King's College Hospital, London, England
| | - Sara De la Mata-Navazo
- Gregorio Marañón University Hospital; Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Ben Gelbart
- Royal Children's Hospital, University of Melbourne, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Stephen Gorga
- University of Michigan Medical School, C.S. Mott Children's Hospital, Ann Arbor
| | | | - Kenneth E Mah
- Stanford University School of Medicine, Palo Alto, California
| | - Nicholas J Ollberding
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - H Stella Shin
- Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia
| | - Sameer Thadani
- Baylor College of Medicine, Texas Children's Hospital, Houston
| | - Amanda Uber
- University of Nebraska Medical Center, Children's Hospital & Medical Center, Omaha
- University of Utah, Primary Children's Hospital, Salt Lake City
| | - Huaiyu Zang
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | | |
Collapse
|
29
|
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.
Collapse
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
| |
Collapse
|
30
|
Greenberg JW, Hogue S, Raees MA, Ahmed HF, Abplanalp WA, Guzman-Gomez A, Abdelhamed Z, Thangappan K, Reagor JA, Rose JE, Collins M, Kasten JL, Goldstein SL, Zafar F, Morales DLS, Cooper DS. Exogenous nitric oxide delivery protects against cardiopulmonary bypass-associated acute kidney injury: Histologic and serologic evidence from an ovine model. J Thorac Cardiovasc Surg 2023; 166:e164-e173. [PMID: 37164051 DOI: 10.1016/j.jtcvs.2023.03.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 05/12/2023]
Abstract
OBJECTIVE Several human studies have associated nitric oxide administration via the cardiopulmonary bypass circuit with decreased incidence of cardiopulmonary bypass-associated acute kidney injury, but histopathologic and serologic evidence of nitric oxide efficacy for acute kidney injury attenuation are lacking. METHODS By using a survival ovine model (72 hours), acute kidney injury was induced by implementing low-flow cardiopulmonary bypass for 2 hours, followed by full-flow cardiopulmonary bypass for 2 hours. The nitric oxide cohort (n = 6) received exogenous nitric oxide through the cardiopulmonary bypass circuit via the oxygenator, and the control group (n = 5) received no nitric oxide. Serial serologic biomarkers and renal histopathology were obtained. RESULTS Baseline characteristics (age, weight) and intraoperative parameters (cardiopulmonary bypass time, urine output, heart rate, arterial pH, and lactate) were equivalent (P > .10) between groups. Postoperatively, urine output, heart rate, respiratory rate, and peripheral arterial saturation were equivalent (P > .10) between groups. Post-cardiopulmonary bypass creatinine elevations from baseline were significantly greater in the control group versus the nitric oxide group at 16, 24, and 48 hours (all P < .05). Histopathologic evidence of moderate/severe acute kidney injury (epithelial necrosis, tubular slough, cast formation, glomerular edema) occurred in 60% (3/5) of the control group versus 0% (0/6) of the nitric oxide group. Cortical tubular epithelial cilia lengthening (a sensitive sign of cellular injury) was significantly greater in the control group than in the nitric oxide group (P = .012). CONCLUSIONS In a survival ovine cardiopulmonary bypass model, nitric oxide administered with cardiopulmonary bypass demonstrated serologic and histologic evidence of renal protection from acute kidney injury. These results provide insight into 1 potential mechanism for cardiopulmonary bypass-associated acute kidney injury and supports continued study of nitric oxide via cardiopulmonary bypass circuit for prevention of acute kidney injury.
Collapse
Affiliation(s)
- Jason W Greenberg
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio.
| | - Spencer Hogue
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Muhammad Aanish Raees
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Hosam F Ahmed
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - William A Abplanalp
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Amalia Guzman-Gomez
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Zakia Abdelhamed
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Karthik Thangappan
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - James A Reagor
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - James E Rose
- Division of Nephrology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Michaela Collins
- Division of Nephrology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jennifer L Kasten
- Division of Pathology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Stuart L Goldstein
- Division of Nephrology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Farhan Zafar
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David L S Morales
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David S Cooper
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| |
Collapse
|
31
|
Chen CC, Chu CH, Lin YC, Wang ST, Huang CC. Preceding risks and mortality outcomes of different neonatal acute kidney injury in preterm infants. Pediatr Res 2023; 94:1530-1537. [PMID: 37208430 DOI: 10.1038/s41390-023-02650-x] [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: 10/12/2022] [Revised: 03/19/2023] [Accepted: 05/01/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND The aim of the study was to examine preceding risks and mortality outcomes of oliguric and non-oliguric acute kidney injury (AKI) in very preterm infants. METHODS Infants born ≤30 weeks' gestation were included. AKI was diagnosed based on neonatal Kidney Disease: Improving Global Outcomes criteria and was classified as oliguric and non-oliguric according to the urine-output criteria. We used modified Poisson and Cox proportional-hazards models for statistical comparisons. RESULTS Of 865 enrolled infants (gestational age 27.2 ± 2.2 weeks and birth weight 983 ± 288 gm), 204 (23.6%) developed AKI. Before AKI, the oliguric AKI group had significantly higher prevalence of small-for-gestational age (p = 0.008), lower 5-min Apgar score (p = 0.009) and acidosis (p = 0.009) on admission, and hypotension (p = 0.008) and sepsis (p = 0.001) during admission than the non-oliguric AKI group. Oliguric (adjusted risk ratio 3.58, 95% CI 2.33-5.51; adjusted hazard ratio 4.93, 95% CI 3.14-7.72) instead of non-oliguric AKI had significantly higher mortality risks than no AKI. Oliguric AKI showed significantly higher mortality risks than non-oliguric AKI, irrespective of serum creatinine and severity of AKI. CONCLUSIONS Categorizing AKI as oliguric and non-oliguric was crucial because of the distinct preceding risks and mortality outcomes of these two types of AKI in very preterm neonates. IMPACT The differences of the underlying risks and prognosis between oliguric and non-oliguric AKI in very preterm infants remain unclear. We found that oliguric AKI, but not non-oliguric AKI, carries higher mortality risks than infants without AKI. Oliguric AKI possessed higher mortality risks than non-oliguric AKI, irrespective of concomitant serum creatinine elevation and severe AKI. Oliguric AKI is more associated with prenatal small-for-the-gestational age and perinatal and postnatal adverse events, while non-oliguric AKI is associated with nephrotoxins exposures. Our finding highlighted the importance of oliguric AKI and is helpful in developing future protocol in neonatal critical care.
Collapse
Affiliation(s)
- Chih-Chia Chen
- Graduate Institute of Clinical Medicine, College of Medicine, National Cheng-Kung University, Tainan, Taiwan
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chi-Hsiang Chu
- Department of Statistics, Tunghai University, Taichung, Taiwan
| | - Yung-Chieh Lin
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Shan-Tair Wang
- Graduate Institute of Gerontology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Division of Research, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan
| | - Chao-Ching Huang
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
- Department of Pediatrics, College of Medicine, Taipei Medical University, Taipei, Taiwan.
| |
Collapse
|
32
|
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.
Collapse
Affiliation(s)
- Molly Dreher
-
Department of Cardiovascular Perfusion, Children’s Hospital of Philadelphia Philadelphia PA 19104 USA
| | - Jungwon Min
-
Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia Philadelphia PA 19104 USA
| | - Constantine Mavroudis
-
Children’s Hospital of Philadelphia, Cardiac Center, Division of Cardiothoracic Surgery Philadelphia PA 19104 USA
| | - Douglas Ryba
-
Information Services Department, Children’s Hospital of Philadelphia Philadelphia PA 19104 USA
| | - Svetlana Ostapenko
-
Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia Philadelphia PA 19104 USA
| | - Richard Melchior
-
Department of Cardiovascular Perfusion, Children’s Hospital of Philadelphia Philadelphia PA 19104 USA
| | - Tami Rosenthal
-
Department of Cardiovascular Perfusion, Children’s Hospital of Philadelphia Philadelphia PA 19104 USA
| | - Muhammad Nuri
-
Children’s Hospital of Philadelphia, Cardiac Center, Division of Cardiothoracic Surgery Philadelphia PA 19104 USA
| | - Joshua Blinder
-
Stanford University School of Medicine, Lucile Packard Children’s Hospital, Department of Pediatrics, Division of Pediatric Cardiology Palo Alto CA 94304 USA
| |
Collapse
|
33
|
Totapally A, Bridges BC, Selewski DT, Zivick EE. Managing the kidney - The role of continuous renal replacement therapy in neonatal and pediatric ECMO. Semin Pediatr Surg 2023; 32:151332. [PMID: 37871460 DOI: 10.1016/j.sempedsurg.2023.151332] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) represents a lifesaving therapy utilized in in the most critically ill neonates and children with reversible cardiopulmonary failure. As a result of the severity of their critical illness these patients are among the highest risk populations for developing acute kidney injury (AKI) and disorders of fluid balance including the pathologic state of fluid overload (FO). In multiple studies AKI has been shown to occur commonly in 60-80% children treated with ECMO and is associated with adverse outcomes. In early studies evaluating ECMO in neonatal respiratory populations, the importance of fluid balance and the development of FO was recognized as an important contributor to adverse outcomes. Multiple single center studies and multicenter work have confirmed that FO occurs commonly across ECMO populations and is consistently associated with adverse outcomes. As a result of the high rates of AKI and the high rates of FO, continuous renal replacement therapy (CRRT) is increasingly utilized in neonatal and pediatric ECMO. In this state-of-the-art review, we cover the definitions, pathophysiology, incidence, and impact of AKI and FO in neonates and children supported with ECMO and summarize and appraise the evidence regarding the use of CRRT concurrently with ECMO. This review will cover the appropriate timing of this initiation, the options for providing CRRT with ECMO, overview of CRRT prescription, and the long-term implications of kidney support therapy in this population.
Collapse
Affiliation(s)
- Abhinav Totapally
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Brian C Bridges
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - David T Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA.
| | - Elizabeth E Zivick
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| |
Collapse
|
34
|
Menon S, Krallman KA, Arikan AA, Fuhrman DY, Gorga SM, Mottes T, Ollberding N, Ricci Z, Stanski NL, Selewski DT, Soranno DE, Zappitelli M, Zang H, Gist KM. Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK). Kidney Int Rep 2023; 8:1542-1552. [PMID: 37547524 PMCID: PMC10403688 DOI: 10.1016/j.ekir.2023.05.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 05/17/2023] [Accepted: 05/28/2023] [Indexed: 08/08/2023] Open
Abstract
Introduction Continuous renal replacement therapy (CRRT) is used for the symptomatic management of acute kidney injury (AKI) and fluid overload (FO). Contemporary reports on pediatric CRRT are small and single center in design. Large international studies evaluating CRRT practice and outcomes are lacking. Herein, we describe the design of a multinational collaborative. Methods The Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK) is an international collaborative of pediatric specialists whose mission is to improve short- and long-term outcomes of children treated with CRRT. The aims of this multicenter retrospective study are to describe the epidemiology, liberation patterns, association of fluid balance and timing of CRRT initiation, and CRRT prescription with outcomes. Results We included children (n = 996, 0-25 years) admitted to an intensive care unit (ICU) and treated with CRRT for AKI or FO at 32 centers (in 7 countries) from 2018 to 2021. Demographics and clinical characteristics before CRRT initiation, during the first 7 days of both CRRT, and liberation were collected. Outcomes include the following: (i) major adverse kidney events at 90 days (mortality, dialysis dependence, and persistent kidney dysfunction), and (ii) functional outcomes (functional stats scale). Conclusion The retrospective WE-ROCK study represents the largest international registry of children receiving CRRT for AKI or FO. It will serve as a broad and invaluable resource for the field of pediatric critical care nephrology that will improve our understanding of practice heterogeneity and the association of CRRT with clinical and patient-centered outcomes. This will generate preliminary data for future interventional trials in this area.
Collapse
Affiliation(s)
- Shina Menon
- Department of Pediatrics, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, Washington, USA
| | - Kelli A. Krallman
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Ayse A. Arikan
- Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Dana Y. Fuhrman
- Department of Pediatrics, Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Stephen M. Gorga
- Department of Pediatrics, University of Michigan Medical School, C.S. Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - Theresa Mottes
- Department of Pediatrics, Anne and Robert Lurie Children’s Hospital, Northwestern University School of Medicine, Chicago, Illinois, USA
| | - Nicholas Ollberding
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Zaccaria Ricci
- Department of Pediatrics, Meyer University Hospital, University of Florence, Florence, Italy
| | - Natalja L. Stanski
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - David T. Selewski
- Department of Pediatrics, Children’s Hospital of South Carolina, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Danielle E. Soranno
- Department of Pediatrics and Bioengineering, Indiana University, Riley Children’s Hospital, Indianapolis, Indiana
| | - Michael Zappitelli
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Huaiyu Zang
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Katja M. Gist
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| |
Collapse
|
35
|
Cirstoveanu C, Georgescu C, Ruxandra N, Bizubac M, Cinteza E, Vasile CM, Filip C, Margarint I. Contrast-Associated Acute Kidney Injury Requiring Continuous Renal Replacement Therapy in A Neonate with Aortic Stenosis-A Case Report. Pediatr Rep 2023; 15:323-332. [PMID: 37218928 DOI: 10.3390/pediatric15020028] [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: 05/01/2023] [Revised: 05/16/2023] [Accepted: 05/16/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Acute kidney injury occurs commonly in the Neonatal Intensive Care Unit and is associated with increased mortality and morbidity. We report a case of a neonate with congenital heart disease who developed acute kidney injury after cardiac surgery, administration of iodinated contrast media for cardiac catheterization, and a combination of nephrotoxic drugs. CASE REPORT A term neonate without a prenatal diagnosis of congenital heart disease and with a good postnatal transition was transferred at 13 days of life to the MS Curie Emergency Hospital for Children, Newborn Intensive Care Unit, from a regional hospital where he was admitted at 10 days of life with severe general status, respiratory distress, cyanosis, and arterial hypotension. The cardiac ultrasound detected critical aortic valve stenosis, hypoplastic descending aorta, acute heart failure, and pulmonary hypertension. The patient was intubated and mechanically ventilated and received antibiotherapy (meropenem, vancomycin, and colistin), inotropic and vasoactive support (epinephrine, norepinephrine, dopamine, and milrinone), and diuretic support (furosemide, aminophylline, and ethacrynic acid). A balloon aortic valvuloplasty was performed several hours after admission, but after two days the patient required reintervention by open heart surgery due to relapsing severe aortic stenosis. He developed oligo-anuria, generalized edema, and altered renal function tests on the second postoperative and fourth day post-contrast media administration. Continuous renal replacement therapy was initiated for 75 h, leading to almost instant improvement in blood pressure, then diuresis and creatinine levels. The patient required long-term treatment for heart, respiratory, and liver failure. He was discharged at almost four months of age with normal renal function tests, blood pressure, and good urine output without diuretic support. The literature review indicates that contrast-associated acute kidney injury (CA-AKI) requiring continuous renal replacement therapy is rare. CONCLUSIONS Our current case proves that iodinated contrast media administration in a neonate with concomitant insults, such as cardiac surgery for a specific pathology, aortic stenosis, coarctation, arch stenosis, arterial hypotension, and administration of nephrotoxic drugs, may lead to severe kidney injury.
Collapse
Affiliation(s)
- Catalin Cirstoveanu
- Department of Neonatal Intensive Care, "Carol Davila" University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Neonatal Intensive Care Unit, M.S. Curie Children's Hospital, 041451 Bucharest, Romania
| | - Carmina Georgescu
- Neonatal Intensive Care Unit, M.S. Curie Children's Hospital, 041451 Bucharest, Romania
| | - Nicolae Ruxandra
- Neonatal Intensive Care Unit, M.S. Curie Children's Hospital, 041451 Bucharest, Romania
| | - Mihaela Bizubac
- Department of Neonatal Intensive Care, "Carol Davila" University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Neonatal Intensive Care Unit, M.S. Curie Children's Hospital, 041451 Bucharest, Romania
| | - Eliza Cinteza
- Department of Pediatrics, "Carol Davila" University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Pediatric Cardiology, M.S. Curie Children's Hospital, 041451 Bucharest, Romania
| | - Corina Maria Vasile
- Pediatric Cardiology, M.S. Curie Children's Hospital, 041451 Bucharest, Romania
- Department of Pediatric and Adult Congenital Cardiology, University Hospital of Bordeaux, 33600 Pessac, France
| | - Cristina Filip
- Department of Pediatrics, "Carol Davila" University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Pediatric Cardiology, M.S. Curie Children's Hospital, 041451 Bucharest, Romania
| | - Irina Margarint
- PhD School Departemnt "Carol Davila", University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Pediatric Cardiovascular Surgery, M.S. Curie Children's Hospital, 041451 Bucharest, Romania
| |
Collapse
|
36
|
Weld J, Kim E, Chandra P, Savorgnan F, Acosta S, Flores S, Loomba RS. Fluid Overload and AKI After the Norwood Operation: The Correlation and Characterization of Routine Clinical Markers. Pediatr Cardiol 2023:10.1007/s00246-023-03167-0. [PMID: 37129600 DOI: 10.1007/s00246-023-03167-0] [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: 05/24/2022] [Accepted: 04/16/2023] [Indexed: 05/03/2023]
Abstract
The purpose of this study was to determine the correlation of different methods of assessing fluid overload and determine which metrics are associated with development of acute kidney injury (AKI) in the period immediately following Norwood palliation. This was a retrospective single-center study of Norwood patients from January 2011 through January 2021. AKI was defined using the Kidney Disease Improving Global Outcomes (KDIGO). Patients were separated into two groups: those with AKI and those without. A logistic regression analysis was conducted with AKI at any point in the study period as the dependent variable and clinical and laboratory data as independent variables. Analysis was conducted as a stepwise regression. The coefficients from the logistic regression were then used to develop a cumulative AKI risk score. Spearman correlations were conducted to analyze the correlation of fluid markers. 116 patients were included, and 49 (42.4%) developed AKI. The duration of open chest, duration of mechanical ventilation, need for dialysis, need for extracorporeal membrane oxygenation, and inpatient mortality were associated with AKI (p ≤ 0.05). Stepwise logistic regression demonstrated the following significant independent associations AKI: age at Norwood in days (p < 0.01), blood urea nitrogen (p < 0.01), central venous pressure (p = 0.04), and renal oxygen extraction ratio (p < 0.01). The area under the receiver operating characteristic curve for the logistic regression was 0.74. The fluid markers had weak R-value. Urea, central venous pressure, and renal oxygen extraction ratio are associated with AKI after the Norwood operation. Common clinical metrics used to assess fluid overload are poorly correlated with each other for postoperative Norwood patients.
Collapse
Affiliation(s)
- Julia Weld
- Division of Cardiology, Department of Pediatrics, Advocate Children's Hospital, Oak Lawn, IL, USA.
| | - Erin Kim
- Division of Nephrology, Department of Pediatrics, Advocate Children's Hospital, Oak Lawn, IL, USA
| | - Priya Chandra
- Division of Nephrology, Department of Pediatrics, Advocate Children's Hospital, Oak Lawn, IL, USA
| | - Fabio Savorgnan
- Division of Critical Care and Cardiology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Sebastian Acosta
- Division of Critical Care and Cardiology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Saul Flores
- Division of Critical Care and Cardiology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Rohit S Loomba
- Division of Cardiology, Department of Pediatrics, Advocate Children's Hospital, Oak Lawn, IL, USA
| |
Collapse
|
37
|
Thompson EJ, Chamberlain RC, Hill KD, Sullenger RD, Graham EM, Gbadegesin RA, Hornik CP. Association of Urine Biomarkers With Acute Kidney Injury and Fluid Overload in Infants After Cardiac Surgery: A Single Center Ancillary Cohort of the Steroids to Reduce Systemic Inflammation After Infant Heart Surgery Trial. Crit Care Explor 2023; 5:e0910. [PMID: 37151894 PMCID: PMC10155890 DOI: 10.1097/cce.0000000000000910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023] Open
Abstract
To examine the association between three perioperative urine biomarker concentrations (urine cystatin C [uCysC], urine neutrophil gelatinase-associated lipocalin [uNGAL], and urine kidney injury molecule 1 [uKIM-1]), and cardiac surgery-associated acute kidney injury (CS-AKI) and fluid overload (FO) in infants with congenital heart disease undergoing surgery on cardiopulmonary bypass. To explore how urine biomarkers are associated with distinct CS-AKI phenotypes based on FO status. DESIGN Ancillary prospective cohort study. SETTING Single U.S. pediatric cardiac ICU. PATIENTS Infants less than 1 year old enrolled in the Steroids to Reduce Systemic Inflammation after Infant Heart Surgery trial (NCT03229538) who underwent heart surgery from June 2019 to May 2020 and opted into biomarker collection at a single center. Infants with preoperative CS-AKI were excluded. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Forty infants met inclusion criteria. Median (interquartile) age at surgery was 103 days (5.5-161 d). Modified Kidney Disease Improving Global Outcomes-defined CS-AKI was diagnosed in 22 (55%) infants and 21 (53%) developed FO. UCysC and uNGAL peaked in the early postoperative period and uKIM-1 peaked later. In unadjusted analysis, bypass time was longer, and Vasoactive-Inotropic Score at 24 hours was higher in infants with CS-AKI. On multivariable analysis, higher uCysC (odds ratio [OR], 1.023; 95% CI, 1.004-1.042) and uNGAL (OR, 1.019; 95% CI, 1.004-1.035) at 0-8 hours post-bypass were associated with FO. UCysC, uNGAL, and uKIM-1 did not significantly correlate with CS-AKI. In exploratory analyses of CS-AKI phenotypes, uCysC and uNGAL were highest in CS-AKI+/FO+ infants. CONCLUSIONS In this study, uCysC and uNGAL in the early postoperative period were associated with FO at 48 hours. UCysC, uNGAL, and uKIM-1 were not associated with CS-AKI. Further studies should focus on defining expected concentrations of these biomarkers, exploring CS-AKI phenotypes and outcomes, and establishing clinically meaningful endpoints for infants post-cardiac surgery.
Collapse
Affiliation(s)
- Elizabeth J Thompson
- Department of Pediatrics, Duke University, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | | | - Kevin D Hill
- Department of Pediatrics, Duke University, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | | | - Eric M Graham
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | | | - Christoph P Hornik
- Department of Pediatrics, Duke University, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| |
Collapse
|
38
|
Pettit KA, Selewski DT, Askenazi DJ, Basu RK, Bridges BC, Cooper DS, Fleming GM, Gien J, Gorga SM, Jetton JG, King EC, Steflik HJ, Paden ML, Sahay RD, Zappitelli M, Gist KM. Synergistic association of fluid overload and acute kidney injury on outcomes in pediatric cardiac ECMO: a retrospective analysis of the KIDMO database. Pediatr Nephrol 2023; 38:1343-1353. [PMID: 35943578 DOI: 10.1007/s00467-022-05708-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 07/25/2022] [Accepted: 07/26/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) and fluid overload (FO) are associated with poor outcomes in children receiving extracorporeal membrane oxygenation (ECMO). Our objective is to evaluate the impact of AKI and FO on pediatric patients receiving ECMO for cardiac pathology. METHODS We performed a secondary analysis of the six-center Kidney Interventions During Extracorporeal Membrane Oxygenation (KIDMO) database, including only children who underwent ECMO for cardiac pathology. AKI was defined using Kidney Disease: Improving Global Outcomes (KDIGO) creatinine criteria. FO was defined as < 10% (FO-) vs. ≥ 10% (FO +) and was evaluated at ECMO initiation, peak during ECMO, and ECMO discontinuation. Primary outcomes were mortality and length of stay (LOS). RESULTS Data from 191 patients were included. Non-survivors (56%) were more likely to be FO + than survivors at peak ECMO fluid status and ECMO discontinuation. There was a significant interaction between AKI and FO. In the presence of AKI, the adjusted odds of mortality for FO + was 4.79 times greater than FO- (95% CI: 1.52-15.12, p = 0.01). In the presence of FO + , the adjusted odds of mortality for AKI + was 2.7 times higher than AKI- [95%CI: 1.10-6.60; p = 0.03]. Peak FO + was associated with a 55% adjusted relative increase in LOS [95%CI: 1.07-2.26, p = 0.02]. CONCLUSIONS The association of peak FO + with mortality is present only in the presence of AKI + . Similarly, AKI + is associated with mortality only in the presence of peak FO + . FO + was associated with LOS. Studies targeting fluid management have the potential to improve LOS and mortality outcomes. A higher resolution version of the Graphical abstract is available as Supplementary information.
Collapse
Affiliation(s)
- Kevin A Pettit
- Department of Pediatrics, Children's Hospital of Colorado, University of Colorado Anschutz Medical Campus, 13123 E 16th Ave, B100, Aurora, CO, 80045, USA.
| | - David T Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - David J Askenazi
- Department of Pediatrics, University of Alabama Birmingham, Birmingham, AL, USA
| | - Rajit K Basu
- Division of Critical Care Medicine, Lurie Children's Hospital, Chicago, IL, USA
| | - Brian C Bridges
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - David S Cooper
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Geoffrey M Fleming
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Jason Gien
- Department of Pediatrics, Children's Hospital of Colorado, University of Colorado Anschutz Medical Campus, 13123 E 16th Ave, B100, Aurora, CO, 80045, USA
| | - Stephen M Gorga
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jennifer G Jetton
- Divison of Nephrology, Dialysis and Transplantation, Stead Family Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, IO, USA
| | - Eileen C King
- Divison of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Heidi J Steflik
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Matthew L Paden
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Rashmi D Sahay
- Divison of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Michael Zappitelli
- Department of Pediatrics, Toronto Hospital for Sick Children, Toronto Canada and McGill University Health Centre, Montreal, Canada
| | - Katja M Gist
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| |
Collapse
|
39
|
Barhight MF, Selewski DT. Hyperchloremia and acute kidney injury: chicken or the egg? Pediatr Nephrol 2023:10.1007/s00467-023-05895-0. [PMID: 36752931 DOI: 10.1007/s00467-023-05895-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 01/19/2023] [Accepted: 01/23/2023] [Indexed: 02/09/2023]
Affiliation(s)
- Matthew F Barhight
- Division of Critical Care, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - David T Selewski
- Division of Nephrology, Department of Pediatrics, Medical University of South Carolina, 96 Jonathan Lucas St, CSB 428 MSC 608, Charleston, SC, 29425, USA.
| |
Collapse
|
40
|
Abstract
PURPOSE OF REVIEW The purpose of this review is to describe acute kidney injury (AKI) phenotypes in children. RECENT FINDINGS AKI is a heterogenous disease that imposes significant morbidity and mortality on critically ill and noncritically ill patients across the age spectrum. As our understanding of AKI and its association with outcomes has improved, it is becoming increasingly apparent that there are distinct AKI subphenotypes that vary by cause or associated conditions. We have also learned that severity, duration, and repeated episodes of AKI impact outcomes, and that integration of novel urinary biomarkers of tubular injury can also reveal unique subphenotypes of AKI that may not be otherwise readily apparent. SUMMARY Studies that further delineate these unique AKI subphenotypes are needed to better understand the impact of AKI in children. Further delineation of these phenotypes has both prognostic and therapeutic implications.
Collapse
|
41
|
Onal O, Chhabada S, Pu X, Liu L, Shimada T, Ruetzler K, Turan A. Mild acute kidney injury after pediatric surgery is not-associated with long-term renal dysfunction: A retrospective cohort study. J Clin Anesth 2022; 83:110985. [PMID: 36332365 DOI: 10.1016/j.jclinane.2022.110985] [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: 05/11/2022] [Revised: 10/04/2022] [Accepted: 10/16/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND STUDY OBJECTIVE Acute kidney injury (AKI) is a sudden deterioration in renal function and is common in pediatric patients undergoing cardiac and non-cardiac surgery. Few studies have investigated the association of postoperative AKI with kidney dysfunction seen long-term and other adverse outcomes in pediatric patients. The study aimed to determine the association between postoperative AKI (mild AKI vs. no AKI and mild AKI vs. moderate-severe AKI) and chronic kidney dysfunction (CKD) seen long-term in pediatric patients undergoing cardiac and non-cardiac major surgery. DESIGN Restrospective, cohort study. SETTING Tertiary care hospital. PATIENTS This retrospective cohort study included patients aged 2-18 years who underwent cardiac and non-cardiac major surgery lasting >2 h at the Cleveland Clinic Main Campus between June 2005 and December 2020. MEASUREMENTS Postoperative AKI and CKD seen in long-term were defined and staged according to the Kidney Disease: Improving Global Outcomes criteria. MAIN RESULTS Among 10,597 children who had cardiac and non-cardiac major surgery, 1,302 were eligible. A total of 682 patients were excluded for missing variables and baseline kidney dysfunction and 620 patients were included. The mean age was 11 years, and 307 (49.5%) were female. Postoperative mild AKI was detected in 5.8% of the patients, while moderate-severe AKI was detected in 2.4%. There was no significant difference in CKD seen in long-term between patients with and without postoperative AKI, p = 0.83. The CKD seen in long-term developed in 27.7% of patients with postoperative mild AKI and 33.3% of patients with postoperative moderate and severe AKI. Patients without postoperative AKI had an estimated 1.09 times higher odds of having CKD seen in long-term compared with patients who have postoperative mild AKI (odds ratio [95% CI] 1.09 [0.48,2.52]). CONCLUSION In contrast to adult patients, the authors did not find any association between postoperative AKI and CKD seen in long-term in pediatric patients.
Collapse
Affiliation(s)
- Ozkan Onal
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America; Department of Anesthesiology and Reanimation, Selcuk University Faculty of Medicine, Konya, Turkey; Outcomes Research Consortium, Cleveland, OH, United States of America
| | - Surendrasingh Chhabada
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America; Department of Pediatric Anesthesia and Congenital Cardiac Anesthesia, Cleveland Clinic, Cleveland, OH, United States of America; Outcomes Research Consortium, Cleveland, OH, United States of America
| | - Xuan Pu
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America; Department of Quantitative Health Sciences, Cleveland Clinic, OH, United States of America; Outcomes Research Consortium, Cleveland, OH, United States of America
| | - Liu Liu
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America; Department of Quantitative Health Sciences, Cleveland Clinic, OH, United States of America; Outcomes Research Consortium, Cleveland, OH, United States of America
| | - Tetsuya Shimada
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America; Department of Anesthesiology, National Hospital Organization, Murayama Medical Center, Musashimurayama, Tokyo, Japan; Department of Anesthesiology, National Defense Medical College, Tokorozawa, Saitama, Japan; Outcomes Research Consortium, Cleveland, OH, United States of America
| | - Kurt Ruetzler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America; Department of General Anesthesia, Cleveland Clinic, Cleveland, OH, United States of America; Outcomes Research Consortium, Cleveland, OH, United States of America
| | - Alparslan Turan
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America; Department of General Anesthesia, Cleveland Clinic, Cleveland, OH, United States of America; Outcomes Research Consortium, Cleveland, OH, United States of America.
| |
Collapse
|
42
|
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
|
43
|
Tao Y, Heskia F, Zhang M, Qin R, Kang B, Chen L, Wu F, Huang J, Brengel-Pesce K, Chen H, Mo X, Liang J, Wang W, Xu Z. Evaluation of acute kidney injury by urinary tissue inhibitor metalloproteinases-2 and insulin-like growth factor-binding protein 7 after pediatric cardiac surgery. Pediatr Nephrol 2022; 37:2743-2753. [PMID: 35211796 DOI: 10.1007/s00467-022-05477-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 01/18/2022] [Accepted: 01/19/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND With adult patients, the measurement of [TIMP-2]*[IGFBP7] can predict the risk of moderate to severe AKI within 12 h of testing. In pediatrics, however, the performance of [TIMP-2]*[IGFBP7] as a predictor of AKI was less studied and yet to be widely utilized in clinical practice. This study was conducted to validate the utility of [TIMP-2]*[IGFBP7] as an earlier biomarker for AKI prediction in Chinese infants and small children. METHODS We measured urinary [TIMP-2]*[IGFBP7] using NEPHROCHECK® at eight perioperative time points in 230 patients undergoing complex cardiac surgery and evaluated the performance of [TIMP-2]*[IGFBP7] for predicting severe AKI within 72 h of surgery. RESULTS A total of 50 (22%) of 230 developed AKI stages 2-3 within 72 h after CPB initiation. In the AKI stage 2-3 patients, two patterns of serum creatinine (SCr) elevations were observed. The patients with only a transient increase in SCr within 24 h (< 24 h, early AKI 2-3) did not experience a worse outcome than patients in AKI stage 0-1. AKI stage 2-3 patients with SCr elevation after 24 h (24-72 h, late AKI 2-3), as well as AKI dialysis patients (together designated severe AKI), did experience worse outcomes. Compared to AKI stages 0-1, significant elevations of [TIMP-2]*[IGFBP7] values were observed in severe AKI patients at hours T2, T4, T12, and T24 following CPB initiation. The AUC for predicting severe AKI with [TIMP-2]*[IGFBP7] at T2 (AUC = 0.76) and maximum T2/T24 (AUC = 0.80) are higher than other time points. The addition of the NEPHROCHECK® test to the postoperative parameters improved the risk assessment of severe AKI. CONCLUSIONS Multiple AKI phenotypes (early versus late AKI) were identified after pediatric complex cardiac surgery according to SCr-based AKI definition. Urinary [TIMP-2]*[IGFBP7] predicts late severe AKI (but not early AKI) as early as 2 h following CPB initiation. A higher resolution version of the Graphical abstract is available as Supplementary information.
Collapse
Affiliation(s)
- Yue Tao
- Shanghai Children's Medical Center-bioMérieux Laboratory, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,The Laboratory of Pediatric Infectious Diseases, Pediatric Translational Medicine Institute, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Fabienne Heskia
- Global Medical Affairs Department, bioMérieux SA, Marcy l'Etoile, France
| | - Mingjie Zhang
- Department of Thoracic and Cardiovascular Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Rong Qin
- Global Medical Affairs Department, bioMérieux SA, Marcy l'Etoile, France
| | - Bin Kang
- Shanghai Children's Medical Center-bioMérieux Laboratory, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,bioMérieux (Shanghai) Company Limited, Shanghai, China
| | - Luoquan Chen
- Shanghai Children's Medical Center-bioMérieux Laboratory, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,bioMérieux (Shanghai) Company Limited, Shanghai, China
| | - Fei Wu
- Shanghai Children's Medical Center-bioMérieux Laboratory, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,bioMérieux (Shanghai) Company Limited, Shanghai, China
| | - Jihong Huang
- Department of Thoracic and Cardiovascular Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Karen Brengel-Pesce
- Open Innovation & Partnerships Department, bioMérieux SA, Marcy l'Etoile, France
| | - Huiwen Chen
- Department of Thoracic and Cardiovascular Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xi Mo
- Shanghai Children's Medical Center-bioMérieux Laboratory, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,The Laboratory of Pediatric Infectious Diseases, Pediatric Translational Medicine Institute, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ji Liang
- Shanghai Children's Medical Center-bioMérieux Laboratory, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,bioMérieux (Shanghai) Company Limited, Shanghai, China
| | - Wei Wang
- Department of Thoracic and Cardiovascular Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhuoming Xu
- Department of Thoracic and Cardiovascular Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
| |
Collapse
|
44
|
Holsteen PE, Gist KM, Brinton JT, Hebert M, Iwanowski M, Kim A, Leath A, Shah A, Soranno DE, Marschner MN. Nephrotoxic Exposures and Acute Kidney Injury in Noncritically Ill Children Stratified by Service. Hosp Pediatr 2022; 12:866-877. [PMID: 36102129 DOI: 10.1542/hpeds.2021-006169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE The Nephrotoxic Injury Negated by Just-in-Time Action (NINJA) program is a multicenter, quality improvement initiative that identifies patients at risk for nephrotoxic medication-associated acute kidney injury (NTMx-AKI). The purpose of this study was to (1) evaluate the prevalence and types of NTMx exposures and (2) determine the prevalence of NTMx-AKI categorized by service. Exploratory analysis evaluated potential associations between hospital measures and NTMx-AKI. METHODS This is a single-center, retrospective chart review of NTMx exposures from January 2019 to June 2020 in noncritically ill children. High NTMx exposures were defined as ≥3 simultaneous nephrotoxins or ≥3 days of either intravenous vancomycin or aminoglycoside. Prevalence of high NTMx and NTMx-AKI rate were normalized to 1000 patient days. A retrospective case-control analysis assessed for potential associations with development of NTMx-AKI. RESULTS There were 609 NTMx exposures in 565 patients and 44 (7.2%) episodes of NTMx-AKI. The NTMx prevalence rate per 1000 patient days was highest among liver, neurosurgery, and gastroenterology services. The most commonly used NTMx were vancomycin, intravenous contrast, and nonsteroidal antiinflammatory drugs. The NTMx-AKI rate in exposed patients ranged from 0% to 14% across service lines. AKI was most often attributable to vancomycin. Univariable analyses suggest type and duration of NTMx exposure are associated with development of NTMx-AKI but not with severity. CONCLUSIONS NTMx exposures and NTMx-AKI are variable across services. Partnerships with antimicrobial stewardship and multicenter studies are needed to modify NTMx-AKI risk. Ongoing surveillance is needed in patients who do not have normalization of creatinine before discharge.
Collapse
Affiliation(s)
| | - Katja M Gist
- Section of Cardiology, Children's Hospital Colorado, Department of Pediatrics
| | - John T Brinton
- Department of Biostatistics and Informatics, Colorado School of Public Health
| | | | | | | | | | - Ananya Shah
- Heart Institute, Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado
| | - Danielle E Soranno
- Department of Pediatrics, Section of Nephrology, University of Colorado, Aurora, Colorado
| | | |
Collapse
|
45
|
Epidemiology of Acute Kidney Injury After Neonatal Cardiac Surgery: A Report From the Multicenter Neonatal and Pediatric Heart and Renal Outcomes Network: Erratum. Crit Care Med 2022; 50:e778. [DOI: 10.1097/ccm.0000000000005633] [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]
|
46
|
Hasson D, Menon S, Gist KM. Improving acute kidney injury diagnostic precision using biomarkers. Pract Lab Med 2022; 30:e00272. [PMID: 35494424 PMCID: PMC9046880 DOI: 10.1016/j.plabm.2022.e00272] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/08/2022] [Accepted: 03/21/2022] [Indexed: 01/20/2023] Open
Abstract
Acute kidney injury (AKI) is common in hospitalized patients of all ages and is associated with significant morbidity and mortality. Accurate prediction and early identification of AKI is of utmost importance because no therapy exists to mitigate AKI once it has occurred. Yet, serum creatinine lacks adequate sensitivity and specificity, and quantification of urine output is challenging in incontinent children without indwelling bladder catheters. Integration of clinically available biomarkers have the potential to delineate unique AKI phenotypes that could have important prognostic and therapeutic implications. Plasma Cystatin C, urine neutrophil gelatinase associated lipocalin (NGAL) and the urinary product of tissue inhibitor metalloproteinase (TIMP-2) and insulin growth factor binding protein-7 (IGFBP7) are clinically available. These biomarkers have been studied in heterogenous populations across the age spectrum and in a variety of clinical settings for prediction of AKI. The purpose of this review is to describe and discuss the clinically available AKI biomarkers including how they have been used to delineate AKI phenotypes.
Collapse
Affiliation(s)
- Denise Hasson
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Shina Menon
- Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Katja M. Gist
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| |
Collapse
|
47
|
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.
Collapse
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.
| |
Collapse
|
48
|
Biomarkers of acute kidney injury after pediatric cardiac surgery: a meta-analysis of diagnostic test accuracy. Eur J Pediatr 2022; 181:1909-1921. [PMID: 35039910 DOI: 10.1007/s00431-022-04380-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 01/05/2022] [Accepted: 01/09/2022] [Indexed: 12/29/2022]
Abstract
UNLABELLED Acute kidney injury (AKI) occurs frequently after cardiac surgery in children. Although current diagnostic criteria rely on serum creatinine and urine output, changes occur only after considerable loss of kidney function. This meta-analysis aimed to synthesize the knowledge on novel biomarkers and compare their ability to predict AKI. PubMed/MEDLINE, Embase, Scopus, and reference lists were searched for relevant studies published by March 2021. Diagnostic accuracy parameters were extracted and analyzed using hierarchical summary receiver operating characteristic (HSROC) method. Pooled estimates of the area under the curve (AUC) were calculated using conventional random-effects meta-analysis. Fifty-six articles investigating 49 biomarkers in 8617 participants fulfilled our eligibility criteria. Data from 37 studies were available for meta-analysis. Of the 10 biomarkers suitable for HSROC analysis, urinary neutrophil gelatinase-associated lipocalin (uNGAL) to creatinine (Cr) ratio yielded the highest diagnostic odds ratio (91.0, 95% CI 90.1-91.9), with a sensitivity of 91.3% (95% CI 91.2-91.3%) and a specificity of 89.7% (95% CI 89.6-89.7%). These results were confirmed in pooled AUC analysis, as uNGAL-to-Cr ratio and uNGAL were the only elaborately studied biomarkers (> 5 observations) with pooled AUCs ≥ 0.800. Liver fatty acid-binding protein (L-FABP), serum cystatin C (sCysC), serum NGAL (sNGAL), and interleukin-18 (IL-18) all had AUCs ≥ 0.700. CONCLUSION A variety of biomarkers have been proposed as predictors of cardiac surgery-associated AKI in children, of which uNGAL was the most prominent with excellent diagnostic qualities. However, more consolidatory evidence will be required before these novel biomarkers may eventually help realize precision medicine in AKI management. WHAT IS KNOWN • Acute kidney injury (AKI) occurs in about 30-60% of children undergoing cardiac surgery and is associated with increased in-hospital mortality and adverse short-term outcomes. However, in current clinical practice, AKI definitions and detection often rely on changes in serum creatinine and urine output, which are late and insensitive markers of kidney injury. • Although various novel biomarkers have been studied for the diagnosis of AKI in children after cardiac surgery, it remains unclear how these compare to one another in terms of diagnostic accuracy. WHAT IS NEW • Pooled analyses suggest that for the diagnosis of AKI in children who underwent cardiac surgery, NGAL is the most accurate among the most frequently studied biomarkers. • A number of other promising biomarkers have been reported, although they will require further research into their diagnostic accuracy and clinical applicability.
Collapse
|
49
|
Coleman C, Tambay Perez A, Selewski DT, Steflik HJ. Neonatal Acute Kidney Injury. Front Pediatr 2022; 10:842544. [PMID: 35463895 PMCID: PMC9021424 DOI: 10.3389/fped.2022.842544] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 03/01/2022] [Indexed: 11/13/2022] Open
Abstract
Acute kidney injury (AKI) is a common occurrence in the neonatal intensive care unit (NICU). In recent years, our knowledge of the incidence and impact of neonatal AKI on outcomes has expanded exponentially. Neonatal AKI has been shown to be associated with adverse outcomes including increased length of mechanical ventilation, prolonged length of stay, and rise in mortality. There has also been increasing work suggesting that neonates with AKI are at higher risk of chronic kidney disease (CKD). In the past, AKI had been defined multiple ways. The utilization of the neonatal modified Kidney Disease: Improving Global Outcomes (KDIGO) criteria as the standard definition for neonatal AKI in research and clinical care has driven the advances in our understanding of neonatal AKI over the last 10 years. This definition has allowed researchers and clinicians to better understand the incidence, risk factors, and outcomes associated with neonatal AKI across populations through a multitude of single-center studies and the seminal, multicenter Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates (AWAKEN) study. As the impacts of neonatal AKI have become clear, a shift in efforts toward identifying those at highest risk, protocolizing AKI surveillance, improving prevention and diagnosis, and expanding kidney support therapy (KST) for neonates has occurred. These efforts also include improving risk stratification (identifying high risk populations, including those with nephrotoxic medication exposure) and diagnostics (novel biomarkers and diagnostic tools). Recent work has also shown that the targeted use of methylxanthines may prevent AKI in a variety of high-risk populations. One of the most exciting developments in neonatal AKI is the advancement in technology to provide KST to neonates with severe AKI. In this comprehensive review we will provide an overview of recent work and advances in the field of neonatal AKI. This will include a detailed review of (1) the definition of neonatal AKI, (2) the epidemiology, risk factors, and outcomes associated with neonatal AKI, (3) improvements in risk stratification and diagnostics, (4) mitigation and treatment, (5) advancements in the provision of KST to neonates, and (6) the incidence and risk of subsequent CKD.
Collapse
Affiliation(s)
- Cassandra Coleman
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - Anita Tambay Perez
- Division of Pediatric Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - David T. Selewski
- Division of Pediatric Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - Heidi J. Steflik
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| |
Collapse
|
50
|
Pande CK, Noll L, Afonso N, Serrano F, Monteiro S, Guffey D, Puri K, Achuff BJ, Akcan-Arikan A, Shekerdemian L. Neurodevelopmental Outcomes in Infants with Cardiac Surgery Associated Acute Kidney Injury. Ann Thorac Surg 2022; 114:2347-2354. [PMID: 35346625 DOI: 10.1016/j.athoracsur.2022.03.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 02/28/2022] [Accepted: 03/12/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Infants who undergo surgery for congenital heart disease (CHD) are at risk of neurodevelopmental delay. Cardiac surgery associated acute kidney injury (CS-AKI) is common but its association with neurodevelopment has not been explored. METHODS Single center retrospective observational study of infants who underwent cardiac surgery in the first year of life who had neurodevelopmental testing using the Bayley Scale for Infant Development version 3. Single and recurrent episodes of Stage 2 and 3 CS-AKI were determined. RESULTS 203 children with median age at first surgery of 12 days. 31% had ≥ 1 episode of severe CS-AKI; of those, 16% had recurrent CS-AKI. Median age at neurodevelopmental assessment was 20 months. The incidence of delay was similar in patients with and without CS-AKI but all children with recurrent CS-AKI had a delay in ≥1 domain and had significantly lower scores in all 3 domains (cognitive, language, motor). CONCLUSIONS This is the first study to assess the association of CS-AKI with neurodevelopmental delay after surgery for CHD in infancy. Infants who develop recurrent CS-AKI in the first year of life were more likely to be delayed and have lower neurodevelopmental scores.
Collapse
Affiliation(s)
- Chetna K Pande
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine
| | - Lisa Noll
- Division of Psychology, Department of Pediatrics, Baylor College of Medicine
| | - Natasha Afonso
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine
| | - Faridis Serrano
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine
| | - Sonia Monteiro
- Division of Developmental Pediatrics, Department of Pediatrics, Baylor College of Medicine
| | - Danielle Guffey
- Institute for Clinical and Translational Research, Baylor College of Medicine
| | - Kriti Puri
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine
| | - Barbara-Jo Achuff
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine
| | - Ayse Akcan-Arikan
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine; Division of Nephrology, Department of Pediatrics, Baylor College of Medicine
| | - Lara Shekerdemian
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine.
| |
Collapse
|