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Soynov IA, Gorbatikh YN, Kulyabin YY, Manukian SN, Rzaeva KA, Velyukhanov IA, Nichay NR, Kornilov IA, Arkhipov AN. Evaluation of end-organ protection in newborns and infants after surgery of aortic arch hypoplasia: A prospective randomized study. Perfusion 2024:2676591241276980. [PMID: 39177467 DOI: 10.1177/02676591241276980] [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: 08/24/2024]
Abstract
INTRODUCTION Surgical repair of aortic arch hypoplasia in children requires a "dry" surgical field with reliable end-organ protection. Perfusion strategies commonly involve deep hypothermic circulatory arrest (DHCA) and variations of the continuous perfusion techniques, such as selective antegrade cerebral perfusion (SACP) and full-flow perfusion with double aortic cannulation (DAC). We aimed to evaluate the end-organ protection in the surgery of aortic arch hypoplasia in newborns and infants using DHCA and DAC. MATERIALS AND METHODS 66 newborns and infants with aortic arch hypoplasia and biventricular anatomy were enrolled in this prospective study. Patients were randomly assigned into two groups according to the perfusion strategy - DHCA (n = 33); and DAC (n = 33). Primary endpoint: acute kidney injury (AKI), graded according to the KDIGO score. Secondary endpoints: neurological sequelae (pre- and postoperative MRI), in-hospital mortality. RESULTS The lowest temperature was 32 (28; 34)°С in the DAC group and 23 (20; 25)°С in the DHCA group. The patients with DAC had lower incidence of AKI (6 patients (18.2%) versus 19 patients (57.6%); p = .017). In the multivariate analysis, the inotropic index at 48 h was identified as a risk factor, increasing the risk of AKI by 4%. The DHCA group was associated with a 3.8-fold increase in the risk of AKI. There was no difference in hospital mortality between the DAC and DHCA groups (1 patient (3%) versus 3 patients (9.1%); p = .61). Neurological sequelae by MRI scan were observed in 18 patients (54.5%) in the DHCA group compared to 5 patients (15.15%) in the DAC group (p = .026). The only risk factor identified in the multivariate analysis for neurological lesions on MRI scan was the DHCA group, which increased the risk by 8.8 times. CONCLUSIONS Surgical reconstruction of the aortic arch hypoplasia using the method of full-body perfusion reduces the incidence of neurological lesions and renal complications requiring renal replacement therapy compared with the deep hypothermic circulatory arrest in neonates and infants.
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Affiliation(s)
- I A Soynov
- Federal State Budgetary Institution "Meshalkin National Medical Research Center", Ministry of Health of the Russian Federation, Novosibirsk, Russian Federation
| | - Yu N Gorbatikh
- Federal State Budgetary Institution "Meshalkin National Medical Research Center", Ministry of Health of the Russian Federation, Novosibirsk, Russian Federation
| | - Yu Yu Kulyabin
- Federal State Budgetary Institution "Meshalkin National Medical Research Center", Ministry of Health of the Russian Federation, Novosibirsk, Russian Federation
| | - S N Manukian
- Federal State Budgetary Institution "Meshalkin National Medical Research Center", Ministry of Health of the Russian Federation, Novosibirsk, Russian Federation
| | - K A Rzaeva
- Federal State Budgetary Institution "Meshalkin National Medical Research Center", Ministry of Health of the Russian Federation, Novosibirsk, Russian Federation
| | - I A Velyukhanov
- Federal State Budgetary Institution "Meshalkin National Medical Research Center", Ministry of Health of the Russian Federation, Novosibirsk, Russian Federation
| | - N R Nichay
- Federal State Budgetary Institution "Meshalkin National Medical Research Center", Ministry of Health of the Russian Federation, Novosibirsk, Russian Federation
| | - I A Kornilov
- Milton S. Hershey Medical Center, Penn State University College of Medicine, Hershey, PA, USA
| | - A N Arkhipov
- Federal State Budgetary Institution "Meshalkin National Medical Research Center", Ministry of Health of the Russian Federation, Novosibirsk, Russian Federation
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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.
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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
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Thompson EJ, Zimmerman KO, Gonzalez D, Foote HP, Park S, Hill KD, Hurst JH, Hornik CD, Chamberlain RC, Gbadegesin RA, Hornik CP. Population Pharmacokinetics of Caffeine in Neonates with Congenital Heart Disease and Associations with Acute Kidney Injury. J Clin Pharmacol 2024; 64:300-311. [PMID: 37933788 PMCID: PMC10898646 DOI: 10.1002/jcph.2382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 11/03/2023] [Indexed: 11/08/2023]
Abstract
Cardiac surgery-associated acute kidney injury (CS-AKI) occurs in approximately 65% of neonates undergoing cardiac surgery on cardiopulmonary bypass and contributes to morbidity and mortality. Caffeine may reduce CS-AKI by counteracting adenosine receptor upregulation after bypass, but pharmacokinetics (PK) in this population are unknown. The goal of our analysis is to address knowledge gaps in age-, disease-, and bypass-related effects on caffeine disposition and explore preliminary associations between caffeine exposure and CS-AKI using population PK modeling techniques and an opportunistic, electronic health record-integrated trial design. We prospectively enrolled neonates receiving preoperative caffeine per standard of care and collected PK samples. We retrospectively identified neonates without caffeine exposure undergoing surgery on bypass as a control cohort. We followed US Food and Drug Administration guidance for population PK model development using NONMEM. Effects of clinical covariates on PK parameters were evaluated. We simulated perioperative exposures and used multivariable logistic regression to evaluate the association between caffeine exposure and CS-AKI. Twenty-seven neonates were included in model development. A 1-compartment model with bypass time as a covariate on clearance and volume of distribution best fit the data. Twenty-three neonates with caffeine exposure and 109 controls were included in the exposure-response analysis. Over half of neonates developed CS-AKI. On multivariable analysis, there were no significant differences between CS-AKI with and without caffeine exposure. Neonates with single-ventricle heart disease without CS-AKI had consistently higher simulated caffeine exposures. Our results highlight areas for further study to better understand disease- and bypass-specific effects on drug disposition and identify populations where caffeine may be beneficial.
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Affiliation(s)
- Elizabeth J Thompson
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Kanecia O Zimmerman
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Henry P Foote
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
| | | | - Kevin D Hill
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
| | - Jillian H Hurst
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
| | - Chi D Hornik
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | | | | | - Christoph P Hornik
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
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Ueno K, Shimozono T, Takahashi Y, Nakae K, Kawamura J, Okamoto Y. Association of albuminuria with kidney function and hemodynamic disturbance in pre-school children who undergo congenital heart disease surgery. Pediatr Nephrol 2024; 39:493-503. [PMID: 37646871 DOI: 10.1007/s00467-023-06130-6] [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: 03/04/2023] [Revised: 07/22/2023] [Accepted: 08/08/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND We validated the prevalence of albuminuria and its association with kidney function and hemodynamics in pre-school children who underwent surgery for congenital heart disease (CHD). METHODS From 403 patients who had undergone surgery for CHD at least 6 months before pre-school and were admitted to our hospital between 2011 and 2015, 75 who underwent blood and urine tests and cardiac catheterization were included in this study. The urinary albumin-to-creatinine ratio (ACR) was quantified, and the relationship of ACR with physical and laboratory findings and hemodynamics assessed using cardiac catheterization was analyzed. RESULTS The study cohort was divided into three groups: Fontan group (n = 25), tetralogy of Fallot (TOF) group (n = 18), and control group (other biventricular CHDs; n = 32). The median age of patients was 5.9 years. ACR was higher in the Fontan group than in the TOF and control groups (median: 15.0 vs. 5.0 and 0.0 mg/g, p < 0.001). Moreover, albuminuria (ACR > 30 mg/g) was observed in 20.0% of Fontan patients, while ACR was associated with potential complicating factors of Fontan circulation: high central venous pressure, high mean pulmonary artery pressure, and worse than moderate atrioventricular regurgitation. ACR showed a moderate correlation with the cystatin C-based estimated glomerular filtration rate (r = - 0.725, p < 0.001). CONCLUSIONS Measurement of albuminuria in Fontan patients before they join elementary school is useful because it reflects kidney function and hemodynamic factors that can worsen their condition. Identification and management of patients with albuminuria may facilitate early therapeutic intervention for worsening Fontan factors, eventually delaying the deterioration of kidney function. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Kentaro Ueno
- Department of Pediatrics, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8544, Japan.
| | - Tsubasa Shimozono
- Department of Pediatrics, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8544, Japan
| | - Yoshihiro Takahashi
- Department of Pediatrics, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8544, Japan
| | - Koji Nakae
- Department of Pediatrics, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8544, Japan
| | - Junpei Kawamura
- Department of Pediatrics, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8544, Japan
| | - Yasuhiro Okamoto
- Department of Pediatrics, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8544, Japan
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Hsiao W, Li Y, Getz K, Cao L, Krause E, Ramos M, Lee J, Gramatges MM, Rabin KR, Scheurer ME, Aplenc R, Denburg M, Miller TP. Acute and chronic kidney injury during therapy for pediatric acute leukemia: A report from the Leukemia Electronic Abstraction of Records Network (LEARN). Pediatr Blood Cancer 2023; 70:e30696. [PMID: 37776085 PMCID: PMC10793071 DOI: 10.1002/pbc.30696] [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: 08/25/2023] [Revised: 09/15/2023] [Accepted: 09/18/2023] [Indexed: 10/01/2023]
Abstract
Children with acute leukemia are at increased risk of kidney injury. Using electronic health record data from three centers between 2010 and 2018, this study retrospectively described acute kidney injury (AKI) and chronic kidney disease (CKD) prevalence in children with acute lymphoblastic or myeloid leukemia (ALL, AML) using Common Terminology Criteria for Adverse Events (CTCAE) and Kidney Disease Improving Global Outcomes (KDIGO) definitions. AKI during therapy was 25% (ALL) and 32% (AML) using CTCAE, versus 84% (ALL) and 74% (AML) using KDIGO. CKD prevalence was low and Grade 1/Stage 2. Further investigation is needed to optimally define kidney injury in acute leukemia.
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Affiliation(s)
- Wendy Hsiao
- Division of Nephrology, Children’s Hospital Los Angeles, Los Angeles, California, USA
- Division of Nephrology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Yimei Li
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kelly Getz
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lusha Cao
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Edward Krause
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Mark Ramos
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Judy Lee
- Aflac Cancer & Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Maria Monica Gramatges
- Cancer and Hematology Center, Texas Children’s Hospital, Houston, Texas, USA
- Division of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Karen R. Rabin
- Cancer and Hematology Center, Texas Children’s Hospital, Houston, Texas, USA
- Division of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Michael E. Scheurer
- Cancer and Hematology Center, Texas Children’s Hospital, Houston, Texas, USA
- Division of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Richard Aplenc
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michelle Denburg
- Division of Nephrology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tamara P. Miller
- Aflac Cancer & Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
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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.
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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
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Georges M, Engelhardt T, Ingelmo P, Mentegazzi F, Bertolizio G. Glycemic Stress Index: Does It Correlate with the Intensive Care Length of Stay? CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020328. [PMID: 36832457 PMCID: PMC9954865 DOI: 10.3390/children10020328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 02/01/2023] [Accepted: 02/07/2023] [Indexed: 02/11/2023]
Abstract
Postoperative hyperglycemia is an independent risk factor for postoperative complications. In adults, perioperative hyperglycemia is influenced by prolonged fasting, but data in children are lacking. The Glycemic Stress Index (GSI) has been shown to predict prolonged Pediatric Intensive Care Unit (PICU) stays in neurosurgical patients. This study aimed to confirm the correlation between GSI and duration of intubation, PICU stay, and postoperative complications in infants undergoing elective open heart surgery. The correlation between preoperative fasting and GSI was also investigated. METHODS A retrospective chart review of 85 infants ≤ 6 months undergoing elective open heart surgery was performed. GSI values ≥ 3.9 and 4.5 were tested to determine whether they carried a higher incidence of postoperative complications (metabolic uncoupling, kidney injury, ECMO, and death). The correlation between GSI and the length of intubation, PICU stay, and duration of fasting were also investigated. Perioperative factors such as age, weight, blood gas analysis, use of inotropes, and risk adjustment for congenital heart surgery were also analyzed as possible predictors. RESULTS GSI correlated with the duration of intubation and PICU stay. A GSI ≥ 4.5, but not 3.9, was associated with a higher incidence of metabolic uncoupling. GSI was not influenced by preoperative fasting. None of the preoperative patient factors analyzed was associated with prolonged intubation, PICU stay, or PICU complications. An abnormal creatinine before surgery increased the risk of developing acute kidney injury postoperatively. CONCLUSIONS GSI may be valuable to predict prolonged intubation, PICU stay, and metabolic derangement in infants undergoing cardiac surgery. Fasting does not appear to affect GSI.
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Affiliation(s)
- Mathieu Georges
- Department of Anesthesia, Montreal Children’s Hospital, McGill University, Montreal, QC H4A 3J1, Canada
| | - Thomas Engelhardt
- Department of Anesthesia, Montreal Children’s Hospital, McGill University, Montreal, QC H4A 3J1, Canada
- Correspondence: ; Tel.: +1-(514)-412-4400 (ext. 24453); Fax: +1-(514)-938-7399
| | - Pablo Ingelmo
- Department of Anesthesia, Montreal Children’s Hospital, McGill University, Montreal, QC H4A 3J1, Canada
| | - Federico Mentegazzi
- Intensive Care Medicine, Queens Hospital, BHR University Hospital, Romford RM7 0AG, UK
| | - Gianluca Bertolizio
- Department of Anesthesia, Montreal Children’s Hospital, McGill University, Montreal, QC H4A 3J1, Canada
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8
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Iyengar A, Shroff R. TINKER-ing with neonatal acute kidney injury. ARCH ESP UROL 2022; 42:443-446. [PMID: 35920778 DOI: 10.1177/08968608221103750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- A Iyengar
- Department of Paediatric Nephrology, St. John's National Academy of Health Sciences, Bangalore, India
| | - R Shroff
- Renal Unit, UCL Great Ormond Street Hospital for Children and Institute of Child Health, London, UK
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9
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Lu C, Lian J, Cao Z, Chen L, Liang J, Wang S. Comparing the pRIFLE, AKIN, KDIGO, and modified KDIGO criteria in neonates after cardiac surgery. Pediatr Nephrol 2022; 37:1399-1405. [PMID: 34716482 DOI: 10.1007/s00467-021-05306-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 09/13/2021] [Accepted: 09/13/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND While several standardized criteria for acute kidney injury (AKI) have been studied, there is no consensus on which criteria to use in neonates after cardiac surgery. The goal of this research was to compare the AKI incidence and outcomes according to the pediatric Risk, Injury, Failure and Loss, and End-Stage (pRIFLE), AKI Network (AKIN), Kidney Disease Improving Global Outcomes (KDIGO), and modified KDIGO (mKDIGO) criteria in neonates following congenital cardiac surgery. METHODS A clinical database of all neonates undergoing congenital cardiac surgery admitted to the Cantonese cardiac center from 2014 to 2020 was retrospectively analyzed. AKI was based on the pRIFLE, AKIN, KDIGO, and mKDIGO classification. The predictive abilities for postoperative outcomes were compared by receiver operating curves, and multivariate logistic regression analysis was used to assess the association of AKI definitions with postoperative outcomes. RESULTS In the study population of 522 patients, 177, 110, 131, and 114 neonates had AKI according to the pRIFLE, AKIN, KDIGO, and mKDIGO criteria, respectively. After multivariate analysis, all definitions were found to be significant predictors of increased mortality. The AUCs for mortality were substantially different with pRIFLE (AUC, 0.795), AKIN (AUC, 0.724), KDIGO (AUC, 0.819), and mKDIGO (AUC, 0.831) (P < 0.01) across the entire population, whereas the mKDIGO system was more accurate than the pRIFLE, AKIN, and KDIGO systems. CONCLUSIONS The incidence of AKI varied across all definitions. However, the mKDIGO system was more accurate in predicting in-hospital mortality than the pRIFLE, AKIN, and KDIGO systems in neonates after heart surgery.
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Affiliation(s)
- Chao Lu
- Department of Anesthesiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jiaxin Lian
- Department of Anesthesiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zhongming Cao
- Department of Anesthesiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Liwen Chen
- Department of Anesthesiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jiexian Liang
- Department of Anesthesiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Sheng Wang
- Department of Anesthesiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.
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10
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Yamada H, Yanagita M. Global Perspectives in Acute Kidney Injury: Japan. KIDNEY360 2022; 3:1099-1104. [PMID: 35845320 PMCID: PMC9255879 DOI: 10.34067/kid.0007892021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 03/25/2022] [Indexed: 01/10/2023]
Affiliation(s)
- Hiroyuki Yamada
- Department of Nephrology, Kyoto University, Kyoto, Japan,Department of Primary Care and Emergency Medicine, Kyoto University, Kyoto, Japan
| | - Motoko Yanagita
- Department of Nephrology, Kyoto University, Kyoto, Japan,Institute for the Advanced Study of Human Biology, Kyoto University, Kyoto, Japan
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11
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Eke C, Szabó A, Nagy Á, Párkányi B, Kertai MD, Fazekas L, Kovács A, Lakatos B, Hartyánszky I, Gál J, Merkely B, Székely A. Association between Preoperative Retrograde Hepatic Vein Flow and Acute Kidney Injury after Cardiac Surgery. Diagnostics (Basel) 2022; 12:diagnostics12030699. [PMID: 35328250 PMCID: PMC8946915 DOI: 10.3390/diagnostics12030699] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 12/05/2022] Open
Abstract
Key questions: Is there a predictive value of hepatic venous flow patterns for postoperative acute kidney injury (AKI) after cardiac surgery? Key findings: In patients who underwent cardiac surgery, retrograde hepatic venous waves (A, V) and their respective ratio to anterograde waves showed a strong association with postoperative AKI, defined as the percentage change of the highest postoperative serum creatinine from the baseline preoperative concentration (%ΔCr). The velocity time integral (VTI) of the retrograde A wave and the ratio of the retrograde and anterograde waves’ VTI were independently associated with AKI after adjustment for disease severity. Take-home message: A higher ratio of retrograde/antegrade waves in hepatic venous retrograde waves, which are related to hepatic stasis, may predict AKI after cardiac surgery. Introduction: Hepatic venous flow patterns reflect pressure changes in the right ventricle and are also markers of systemic venous congestion. Pulsatility of the inferior caval vein was used to predict the risk of acute kidney injury (AKI) after cardiac surgery. Aims: Our objective was to evaluate the association between preoperative hepatic venous flow patterns and the risk of AKI in patients after cardiac surgery. Methods: This prospective, observational study included 98 patients without preexisting liver disease who underwent cardiac surgery between 1 January 2018, and 31 March 2020, at a tertiary heart center. In addition to a routine echocardiographic examination, we recorded the maximal velocity and velocity time integral (VTI) of the standard four waves in the common hepatic vein with Doppler ultrasound. Our primary outcome measure was postoperative AKI, defined as the percentage change of the highest postoperative serum creatinine from the baseline preoperative concentration (%ΔCr). The secondary outcome was AKI, defined by KDIGO (Kidney Disease Improving Global Outcomes) criteria. Results: The median age of the patients was 69.8 years (interquartile range [IQR 25−75] 13 years). Seventeen patients (17.3%) developed postoperative AKI based on the KDIGO. The VTI of the retrograde A waves in the hepatic veins showed a strong correlation (B: 0.714; p = 0.0001) with an increase in creatinine levels after cardiac surgery. The velocity time integral (VTI) of the A wave (B = 0.038, 95% CI = 0.025−0.051, p < 0.001) and the ratio of VTI of the retrograde and anterograde waves (B = 0.233, 95% CI = 0.112−0.356, p < 0.001) were independently associated with an increase in creatinine levels. Conclusions: The severity of hepatic venous regurgitation can be a sign of venous congestion and seems to be related to the development of AKI.
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Affiliation(s)
- Csaba Eke
- Károly Rácz School of PhD Studies, Semmelweis University, 1085 Budapest, Hungary; (C.E.); (A.S.); (Á.N.)
| | - András Szabó
- Károly Rácz School of PhD Studies, Semmelweis University, 1085 Budapest, Hungary; (C.E.); (A.S.); (Á.N.)
| | - Ádám Nagy
- Károly Rácz School of PhD Studies, Semmelweis University, 1085 Budapest, Hungary; (C.E.); (A.S.); (Á.N.)
| | - Boglár Párkányi
- Faculty of Medicine, Semmelweis University, 1085 Budapest, Hungary;
| | - Miklós D. Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN 37212, USA;
| | - Levente Fazekas
- Heart and Vascular Center, Semmelweis University, 1085 Budapest, Hungary; (L.F.); (A.K.); (B.L.); (I.H.); (B.M.)
| | - Attila Kovács
- Heart and Vascular Center, Semmelweis University, 1085 Budapest, Hungary; (L.F.); (A.K.); (B.L.); (I.H.); (B.M.)
| | - Bálint Lakatos
- Heart and Vascular Center, Semmelweis University, 1085 Budapest, Hungary; (L.F.); (A.K.); (B.L.); (I.H.); (B.M.)
| | - István Hartyánszky
- Heart and Vascular Center, Semmelweis University, 1085 Budapest, Hungary; (L.F.); (A.K.); (B.L.); (I.H.); (B.M.)
| | - János Gál
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1085 Budapest, Hungary;
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, 1085 Budapest, Hungary; (L.F.); (A.K.); (B.L.); (I.H.); (B.M.)
| | - Andrea Székely
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1085 Budapest, Hungary;
- Correspondence:
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12
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Holcomb RM, Ündar A. Are outcomes in congenital cardiac surgery better than ever? J Card Surg 2022; 37:656-663. [PMID: 35023592 DOI: 10.1111/jocs.16225] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 12/06/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIM OF THE STUDY Congenital heart disease is the most common congenital defect among infants born in the United States. Within the first year of life, 1 in 4 of these infants will need surgery. Only one generation removed from an overall mortality of 14%, many changes have been introduced into the field. Have these changes measurably improved outcomes? METHODS The literature search was conducted through PubMed MEDLINE and Google Scholar from inception to October 31, 2021. Ultimately, 78 publications were chosen for inclusion. RESULTS The outcome of overall mortality has experienced continuous improvements in the modern era of the specialty despite the performance of more technically demanding surgeries on patients with complex comorbidities. This modality does not account for case-mix, however. In turn, clinical outcomes have not been consistent from center to center. Furthermore, variation in practice between institutions has also been documented. A recurring theme in the literature is a movement toward standardization and universalization. Examples include mortality risk-stratification that has allowed direct comparison of outcomes between programs and improved definitions of morbidities which provide an enhanced framework for diagnosis and management. CONCLUSIONS Overall mortality is now below 3%, which suggests that more patients are surviving their interventions than in any previous era in congenital cardiac surgery. Focus has transitioned from survival to improving the quality of life in the survivors by decreasing the incidence of morbidity and associated long-term effects. With the transformation toward standardization and interinstitutional collaboration, future advancements are expected.
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Affiliation(s)
- Ryan M Holcomb
- Penn State Hershey Pediatric Cardiovascular Research Center, Departments of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, Pennsylvania, USA.,Surgery, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, Pennsylvania, USA
| | - Akif Ündar
- Penn State Hershey Pediatric Cardiovascular Research Center, Departments of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, Pennsylvania, USA.,Biomedical Engineering, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, Pennsylvania, USA
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13
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Alten JA, Cooper DS, Blinder JJ, Selewski DT, Tabbutt S, Sasaki J, Gaies MG, Bertrandt RA, Smith AH, Reichle G, Gist KM, Banerjee M, Zhang W, Hock KM, Borasino S. Epidemiology of Acute Kidney Injury After Neonatal Cardiac Surgery: A Report From the Multicenter Neonatal and Pediatric Heart and Renal Outcomes Network. Crit Care Med 2021; 49:e941-e951. [PMID: 34166288 DOI: 10.1097/ccm.0000000000005165] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Cardiac surgery-associated acute kidney injury occurs commonly following congenital heart surgery and is associated with adverse outcomes. This study represents the first multicenter study of neonatal cardiac surgery-associated acute kidney injury. We aimed to describe the epidemiology, including perioperative predictors and associated outcomes of this important complication. DESIGN This Neonatal and Pediatric Heart and Renal Outcomes Network study is a multicenter, retrospective cohort study of consecutive neonates less than 30 days. Neonatal modification of The Kidney Disease Improving Global Outcomes criteria was used. Associations between cardiac surgery-associated acute kidney injury stage and outcomes (mortality, length of stay, and duration of mechanical ventilation) were assessed through multivariable regression. SETTING Twenty-two hospitals participating in Pediatric Cardiac Critical Care Consortium. PATIENTS Twenty-two-thousand forty neonates who underwent major cardiac surgery from September 2015 to January 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Cardiac surgery-associated acute kidney injury occurred in 1,207 patients (53.8%); 983 of 1,657 in cardiopulmonary bypass patients (59.3%) and 224 of 583 in noncardiopulmonary bypass patients (38.4%). Seven-hundred two (31.3%) had maximum stage 1, 302 (13.5%) stage 2, 203 (9.1%) stage 3; prevalence of cardiac surgery-associated acute kidney injury peaked on postoperative day 1. Cardiac surgery-associated acute kidney injury rates varied greatly (27-86%) across institutions. Preoperative enteral feeding (odds ratio = 0.68; 0.52-0.9) and open sternum (odds ratio = 0.76; 0.61-0.96) were associated with less cardiac surgery-associated acute kidney injury; cardiopulmonary bypass was associated with increased cardiac surgery-associated acute kidney injury (odds ratio = 1.53; 1.01-2.32). Duration of cardiopulmonary bypass was not associated with cardiac surgery-associated acute kidney injury in the cardiopulmonary bypass cohort. Stage 3 cardiac surgery-associated acute kidney injury was independently associated with hospital mortality (odds ratio = 2.44; 1.3-4.61). No cardiac surgery-associated acute kidney injury stage was associated with duration of mechanical ventilation or length of stay. CONCLUSIONS Cardiac surgery-associated acute kidney injury occurs frequently after neonatal cardiac surgery in both cardiopulmonary bypass and noncardiopulmonary bypass patients. Rates vary significantly across hospitals. Only stage 3 cardiac surgery-associated acute kidney injury is associated with mortality. Cardiac surgery-associated acute kidney injury was not associated with any other outcomes. Kidney Disease Improving Global Outcomes criteria may not precisely define a clinically meaningful renal injury phenotype in this population.
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Affiliation(s)
- Jeffrey A Alten
- Division of Pediatric Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - David S Cooper
- Division of Pediatric Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Joshua J Blinder
- Division of Cardiac Critical Care Medicine, Department of Anesthesia/Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - David T Selewski
- Division of Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Sarah Tabbutt
- Department of Pediatrics, University of California San Francisco, Benioff Children's Hospital, San Francisco, CA
| | - Jun Sasaki
- Division of Cardiac Critical Care Medicine, Nicklaus Children's Hospital, Miami, FL
| | - Michael G Gaies
- Department of Pediatrics, Division of Cardiology, C. S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI
| | - Rebecca A Bertrandt
- Division of Critical Care, Department of Pediatrics, Medical College of Wisconsin, Children's Wisconsin, Milwaukee, WI
| | - Andrew H Smith
- Divisions of Cardiology and Critical Care Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | - Garrett Reichle
- Department of Pediatrics, Division of Cardiology, C. S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI
| | - Katja M Gist
- Department of Pediatrics, School of Medicine, University of Colorado, Anschutz Medical Campus, Division of Cardiology, Children's Hospital Colorado, Aurora, CO
| | - Mousumi Banerjee
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
| | - Wenying Zhang
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Kristal M Hock
- Department of Pediatric Cardiology, Section of Cardiac Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Santiago Borasino
- Department of Pediatric Cardiology, Section of Cardiac Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL
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14
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Improving the quality of neonatal acute kidney injury care: neonatal-specific response to the 22nd Acute Disease Quality Initiative (ADQI) conference. J Perinatol 2021; 41:185-195. [PMID: 32892210 DOI: 10.1038/s41372-020-00810-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/03/2020] [Accepted: 08/27/2020] [Indexed: 12/31/2022]
Abstract
With the adoption of standardized neonatal acute kidney injury (AKI) definitions over the past decade and the concomitant surge in research studies, the epidemiology of and risk factors for neonatal AKI have become much better understood. Thus, there is now a need to focus on strategies designed to improve AKI care processes with the goal of reducing the morbidity and mortality associated with neonatal AKI. The 22nd Acute Dialysis/Disease Quality Improvement (ADQI) report provides a framework for such quality improvement in adults at risk for AKI and its sequelae. While many of the concepts can be translated to neonates, there are a number of specific nuances which differ in neonatal AKI care. A group of experts in pediatric nephrology and neonatology came together to provide neonatal-specific responses to each of the 22nd ADQI consensus statements.
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15
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Li D, Niu Z, Huang Q, Sheng W, Wang T. A meta-analysis of the incidence rate of postoperative acute kidney injury in patients with congenital heart disease. BMC Nephrol 2020; 21:350. [PMID: 32807107 PMCID: PMC7433101 DOI: 10.1186/s12882-020-02005-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 08/03/2020] [Indexed: 01/07/2023] Open
Abstract
Background Acute kidney injury (AKI) is a common complication of cardiac surgery. However, the incidence rate of AKI in patients with congenital heart disease (CHD) greatly varies between reports owing to the different definitions used for AKI. Therefore, this study was designed as a meta-analysis aimed at summarizing the incidence rate of AKI in patients with congenital heart disease (CHD) on the basis of different AKI criteria. Methods Studies published till April 24, 2020, on the incidence rate of AKI in patients with CHD, were retrieved from electronic databases and printed literature. To pool data from the included studies, the effect size, a combined statistics, was chosen and presented with the incidence rate and 95% confidence interval (CI). Heterogeneity was evaluated using I2 statistics and Cochran Q test. The incidence rates obtained from the subgroup analysis according to study location, type of surgery, type of cohort, age, and AKI criteria) were also evaluated to determine the correlation of AKI with these factors. Publication bias was estimated using the Egger test. Results Thirty studies, comprising 9925 patients with AKI who had CHD, were included. Overall, the pooled incidence rate of AKI in the patients with CHD was 38.4% (95% CI, 32.0–44.7%). However, the incidence rate was not significantly affected by gender, study location, type of surgery, type of cohort, and AKI criteria. Moreover, age was significantly associated with the incidence of AKI, and the incidence rate was higher in the patients aged < 1 month than in those aged 1 month to 18 years, < 18 years, and ≥ 18 years (P < 0.05). Conclusions In this study, the estimated incidence rate of AKI in patients with CHD was 38.4% and may be influenced by age. These findings highlight the importance of further investigation of the specific causes of and effective preventive measures for AKI.
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Affiliation(s)
- Dandan Li
- Department of Environmental Health, Qingdao Centers for Disease Control and Prevention, Qingdao, 266033, Shandong, China
| | - Zhaozhuo Niu
- Department of Cardiovascular Surgery, Qingdao Municipal Hospital, No. 5 Donghai Middle Road, Shinan District, Qingdao, 266000, Shandong, China
| | - Qiang Huang
- Department of Cardiovascular Surgery, Qingdao Municipal Hospital, No. 5 Donghai Middle Road, Shinan District, Qingdao, 266000, Shandong, China
| | - Wei Sheng
- Department of Cardiovascular Surgery, Qingdao Municipal Hospital, No. 5 Donghai Middle Road, Shinan District, Qingdao, 266000, Shandong, China
| | - Tianyi Wang
- Department of Cardiovascular Surgery, Qingdao Municipal Hospital, No. 5 Donghai Middle Road, Shinan District, Qingdao, 266000, Shandong, China.
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16
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The role of serum cystatin C level in detection of early onset kidney injury after coronary artery bypass surgery. JOURNAL OF SURGERY AND MEDICINE 2020. [DOI: 10.28982/josam.758803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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17
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Houska NM, Schwartz LI. The Year in Review: Anesthesia for Congenital Heart Disease 2019. Semin Cardiothorac Vasc Anesth 2020; 24:175-186. [DOI: 10.1177/1089253220920476] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
This review focuses on the literature published from January 2019 to February 2020 that is of interest to anesthesiologists taking care of children and adults with congenital heart disease. Five themes are addressed during this time period, and 59 peer-reviewed articles are discussed.
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Affiliation(s)
- Nicholas M. Houska
- Children’s Hospital Colorado, Aurora, CO, USA
- University of Colorado, Aurora, CO, USA
| | - Lawrence I. Schwartz
- Children’s Hospital Colorado, Aurora, CO, USA
- University of Colorado, Aurora, CO, USA
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18
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Ali F, Khan MK, Mirza B, Qureshi S, Abbas Q. Acute Kidney Injury after Congenital Heart Disease Surgery: A Single-Center Experience in a Low- to Middle-Income Country. Cureus 2020; 12:e7727. [PMID: 32432005 PMCID: PMC7234068 DOI: 10.7759/cureus.7727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Acute kidney injury (AKI) is a commonly recognized clinical problem after congenital heart disease (CHD) surgery. Increased perioperative morbidity, development of chronic kidney disease, and increased mortality are the major concerns. We investigated frequency, risk factors, and outcomes of AKI after CHD surgery at our hospital. Methods This study was a retrospective analytic review conducted from January 2013 to October 2016 on patients aged between 1 month and 45 years who underwent cardiopulmonary bypass (CPB) for CHD surgery. The modified Kidney Disease Improving Global Outcomes criteria based on serum creatinine value was adopted to diagnose AKI. We assessed AKI frequency and its staging, and outcomes as AKI resolution, length of stay, and mortality. Stages II and III (plasma creatinine level two or more times the baseline) were labeled as severe AKI. Univariate and multivariate logistic regression analyses were conducted, and results were reported as mean with standard deviation and as frequencies with percentage. Odds ratios (ORs) with 95% confidence intervals (CIs) were reported for factors associated with the development of AKI. Results Of the 840 patients who underwent CHD surgery, 237 (28%) developed AKI. AKI stages II1 and III were seen in 101 (42%) and 103 (43%) patients, respectively. Prolonged CPB time > 120 minutes (adjusted OR [AOR]: 1.87; 95% CI: 1.22-2.88; p = 0.004) and hemoglobin > 16 gm/dL (AOR: 1.80; 95% CI: 1.16-2.78; p = 0.008) were associated with the development of AKI on multivariate analysis. AKI resolved spontaneously in 222 (94%) patients, and 10 (4%) patients who developed AKI died. Conclusions Most patients with AKI showed spontaneous resolution. Prolonged CPB time and increased hemoglobin were found to be significant risk factors. Our study found spontaneous resolution of AKI in most cases. However, preplanning and careful monitoring in patients with expected prolonged CPB time and increased baseline hemoglobin can prevent and identify AKI at an early stage.
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Affiliation(s)
- Fatima Ali
- Pediatrics and Child Health, Aga Khan University Hospital, Karachi, PAK
| | - Misha Khalid Khan
- Pediatrics and Child Health, Aga Khan University Hospital, Karachi, PAK
| | - Bilal Mirza
- Pediatrics and Child Health, Aga Khan University Hospital, Karachi, PAK
| | - Sonia Qureshi
- Pediatrics and Child Health, Aga Khan University Hospital, Karachi, PAK
| | - Qalab Abbas
- Pediatrics and Child Health, Aga Khan University Hospital, Karachi, PAK
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19
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Pettit KA, Schreiter NA, Lushaj EB, Hermsen JL, Wilhelm M, Mahon ACR, Nelson KL, DeGrave JJ, Marka N, Anagnostopoulos PV. Prophylactic Peritoneal Drainage is Associated with Improved Fluid Output after Congenital Heart Surgery. Pediatr Cardiol 2020; 41:1704-1713. [PMID: 32734528 PMCID: PMC7391225 DOI: 10.1007/s00246-020-02431-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 07/22/2020] [Indexed: 11/24/2022]
Abstract
Infants undergoing congenital heart surgery (CHS) with cardiopulmonary bypass (CPB) are at risk of acute kidney injury (AKI) and fluid overload. We hypothesized that placement of a passive peritoneal drain (PPD) can improve postoperative fluid output in such infants. We analyzed 115 consecutive patients, age birth to 60 days, admitted to the PICU after CHS with CPB between 2012 and 2018. Patients who needed postoperative ECMO were excluded. Linear and logistic regression models compared postoperative fluid balances, diuretics administration, AKI, vasoactive-inotropic scores (VIS), time intubated, and length of stay after adjusting for pre/operative predictors including STAT category, bypass time, age, weight, and open chest status. PPD patients had higher STAT category (p = 0.001), longer CPB times (p = 0.001), and higher VIS on POD 1-3 (p ≤ 0.005 daily). PPD patients also had higher AKI rates (p = 0.01) that did not reach significance in multivariable modeling. There were no postoperative deaths. Postoperative hours of intubation, hospital length of stay, and POD 1-5 fluid intake did not differ between groups. Over POD 1-5, PPD use accounted for 48.8 mL/kg increased fluid output (95% CI [2.2, 95.4], p = 0.043) and 3.41 mg/kg less furosemide administered (95% CI [1.69, 5.14], p < 0.001). No PPD complications were observed. Although PPD placement did not affect end-outcomes, it was used in higher acuity patients. PPD placement is associated with improved fluid output despite lower diuretic administration and may be a useful postoperative fluid management adjunct in some complex CHS patients.
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Affiliation(s)
- Kevin A. Pettit
- Department of Pediatrics, The American Family Children’s Hospital, University of Wisconsin Hospital and Clinics, 1675 Highland Ave, Madison, WI 53792 USA
| | - Nicholas A. Schreiter
- School of Medicine and Public Health, The American Family Children’s Hospital, University of Wisconsin Hospital and Clinics, 1675 Highland Ave, Madison, WI 53792 USA
| | - Entela B. Lushaj
- Division of Cardiothoracic Surgery, Department of Surgery, The American Family Children’s Hospital, University of Wisconsin Hospital and Clinics, 1675 Highland Ave, Madison, WI 53792 USA
| | - Joshua L. Hermsen
- Division of Cardiothoracic Surgery, Department of Surgery, The American Family Children’s Hospital, University of Wisconsin Hospital and Clinics, 1675 Highland Ave, Madison, WI 53792 USA
| | - Michael Wilhelm
- Department of Pediatrics, The American Family Children’s Hospital, University of Wisconsin Hospital and Clinics, 1675 Highland Ave, Madison, WI 53792 USA
| | - Allison C. Redpath Mahon
- Department of Pediatrics, The American Family Children’s Hospital, University of Wisconsin Hospital and Clinics, 1675 Highland Ave, Madison, WI 53792 USA
| | - Kari L. Nelson
- Division of Cardiothoracic Surgery, Department of Surgery, The American Family Children’s Hospital, University of Wisconsin Hospital and Clinics, 1675 Highland Ave, Madison, WI 53792 USA
| | - Joshua J. DeGrave
- School of Pharmacy, The American Family Children’s Hospital, University of Wisconsin Hospital and Clinics, 1675 Highland Ave, Madison, WI 53792 USA
| | - Nicholas Marka
- Division of Cardiothoracic Surgery, Department of Surgery, The American Family Children’s Hospital, University of Wisconsin Hospital and Clinics, 1675 Highland Ave, Madison, WI 53792 USA
| | - Petros V. Anagnostopoulos
- Division of Cardiothoracic Surgery, Department of Surgery, The American Family Children’s Hospital, University of Wisconsin Hospital and Clinics, 1675 Highland Ave, Madison, WI 53792 USA ,University of Wisconsin Department of Surgery Clinical Science Center, 600 Highland Ave, Madison, WI 53792 USA
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20
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Harer MW, Chock VY. Renal Tissue Oxygenation Monitoring-An Opportunity to Improve Kidney Outcomes in the Vulnerable Neonatal Population. Front Pediatr 2020; 8:241. [PMID: 32528917 PMCID: PMC7247835 DOI: 10.3389/fped.2020.00241] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 04/20/2020] [Indexed: 12/12/2022] Open
Abstract
Adequate oxygenation of the kidney is of critical importance in the neonate. Non-invasive monitoring of renal tissue oxygenation using near-infrared spectroscopy (NIRS) is a promising bedside strategy for early detection of circulatory impairment as well as recognition of specific renal injury. As a diagnostic tool, renal NIRS monitoring may allow for earlier interventions to prevent or reduce injury in various clinical scenarios in the neonatal intensive care unit. Multiple studies utilizing NIRS monitoring in preterm and term infants have provided renal tissue oxygenation values at different time points during neonatal hospitalization, and have correlated measures with ultrasound and Doppler flow data. With the establishment of normal values, studies have utilized renal tissue oxygenation monitoring in preterm neonates to predict a hemodynamically significant patent ductus arteriosus, to assess response to potentially nephrotoxic medications, to identify infants with sepsis, and to describe changes after red blood cell transfusions. Other neonatal populations being investigated with renal NIRS monitoring include growth restricted infants, those requiring delivery room resuscitation, infants with congenital heart disease, and neonates undergoing extracorporeal membrane oxygenation. Furthermore, as the recognition of acute kidney injury (AKI) and its associated morbidity and mortality in neonates has increased over the last decade, alternative methods are being investigated to diagnose AKI before changes in serum creatinine or urine output occur. Studies have utilized renal NIRS monitoring to diagnose AKI in specific populations, including neonates with hypoxic ischemic encephalopathy after birth asphyxia and in infants after cardiac bypass surgery. The use of renal tissue oxygenation monitoring to improve renal outcomes has yet to be established, but results of studies published to date suggest that it holds significant promise to function as a real time, early indicator of poor renal perfusion that may help with development of specific treatment protocols to prevent or decrease the severity of AKI.
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Affiliation(s)
- Matthew W Harer
- Division of Neonatology, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Valerie Y Chock
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, United States
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21
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Kidney Disease: Improving Global Outcomes in neonates with acute kidney injury after cardiac surgery. Clin Exp Nephrol 2019; 24:167-173. [PMID: 31677063 DOI: 10.1007/s10157-019-01805-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 10/15/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) after cardiac surgery (CS-AKI) in children with congenital heart disease is a serious complication closely associated with high morbidity and mortality. Kidney Disease: Improving Global Outcomes (KDIGO) AKI staging demonstrates high sensitivity for detecting AKI and predicting associated in-hospital mortality. However, neonatal-modified KDIGO criteria (n-KDIGO), recently introduced as a standard diagnostic tool, for CS-AKI have not been fully validated. Here, we evaluated the incidence of risk factors and postoperative outcomes of neonatal CS-AKI. METHODS We retrospectively studied 114 consecutive neonates who underwent cardiac surgery at the Kagoshima University Hospital. CS-AKI was classified using the n-KDIGO criteria. Risk adjustment in congenital heart surgery (RACHS-1) score was used to predict the complexity-adjusted mortality and % fluid overload (%FO) was used to monitor fluid balance in pediatric cardiac surgery. RESULTS Among 81 patients, neonatal CS-AKI occurred in 57 (70.4%) patients according to n-KDIGO criteria. Of these, 28 (34.6%) patients reached n-KDIGO 1, 17 (21.0%) reached n-KDIGO 2, and 12 (14.8%) reached n-KDIGO 3. Patients with CS-AKI had significantly higher vasoactive-inotropic score levels, longer operative times, and higher %FO than patients without CS-AKI. Notably, increased duration of cardiopulmonary bypass times and %FO were risk factors for the development of neonatal CS-AKI. The n-KDIGO-based severe AKI grade had higher risk of in-hospital mortality; however, the n-KDIGO-based mild AKI grade was not associated with any postoperative outcomes. CONCLUSIONS CS-AKI based on n-KDIGO criteria is common in neonates and is closely associated with higher mortality, especially in patients with severe CS-AKI.
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The Effect of Levosimendan Versus Milrinone on the Occurrence Rate of Acute Kidney Injury Following Congenital Heart Surgery in Infants: A Randomized Clinical Trial. Pediatr Crit Care Med 2019; 20:947-956. [PMID: 31274775 DOI: 10.1097/pcc.0000000000002017] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVES It has been shown that, in contrast to other inotropic agents, levosimendan improves glomerular filtration rate after adult cardiac surgery. The aim of this study was to investigate the efficacy of levosimendan, compared with milrinone, in preventing acute kidney dysfunction in infants after open-heart surgery with cardiopulmonary bypass. DESIGN Two-center, double-blinded, prospective, randomized clinical trial. SETTING The study was performed in two tertiary pediatric centers, one in Sweden (Gothenburg) and one in Finland (Helsinki). PATIENTS Infants between 1 and 12 months old, diagnosed with Tetralogy of Fallot, complete atrioventricular septal defect or nonrestrictive ventricular septal defect, undergoing total corrective cardiac surgery with cardiopulmonary bypass. INTERVENTIONS Seventy-two infants were randomized to receive a perioperative infusion of levosimendan (0.1 µg/kg/min) or milrinone (0.4 µg/kg/min). The infusion was initiated at the start of cardiopulmonary bypass and continued for 26 hours. MEASUREMENTS AND MAIN RESULTS The primary outcome variable was the absolute value of serum creatinine data on postoperative day 1. Secondary outcomes included the following: 1) acute kidney injury according to the serum creatinine criteria of the Kidney Diseases: Improving Global Outcomes; 2) acute kidney injury with serum creatinine corrected for fluid balance; 3) plasma neutrophil gelatinase-associated lipocalin; 4) cystatin C; 5) urea; 6) lactate; 7) hemodynamic variables; 8) use of diuretics in the PICU; 9) need of dialysis; 10) length of ventilator therapy; and 11) length of PICU stays. There was no significant difference in postoperative serum creatinine between the treatment groups over time (p = 0.65). The occurrence rate of acute kidney injury within 48 hours was 46.9% in the levosimendan group and 39.5% in the milrinone group (p = 0.70). There were no significant differences in other secondary outcome variables between the groups. CONCLUSIONS Levosimendan compared with milrinone did not reduce the occurrence rate of acute kidney injury in infants after total corrective heart surgery for atrioventricular septal defect, ventricular septal defect, or Tetralogy of Fallot.
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Another Outcome Lost to the Benefits of Levosimendan? Pediatr Crit Care Med 2019; 20:992-994. [PMID: 31580276 DOI: 10.1097/pcc.0000000000002019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Liu H, Zheng SQ, Qian SC, He HH, Xue JR. Haematocrit differences modify the association of cardiopulmonary bypass reoxygenation with acute kidney injury after paediatric Tetralogy of Fallot repair. Perfusion 2019; 35:284-289. [PMID: 31480951 DOI: 10.1177/0267659119871777] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Little is known regarding the potential impact of haematocrit differences in the association between cardiopulmonary bypass reoxygenation and acute kidney injury following Tetralogy of Fallot repair. METHODS We investigated the association of perfusate oxygenation during aortic occlusion associated with acute kidney injury between 204 normal and 248 higher haematocrit children with Tetralogy of Fallot, aged 1 month-18 years, who were surgically repaired in 2012-2018. Normal and higher haematocrit children were defined as having a preoperative haematocrit within and above age- and sex-specific reference intervals, respectively. Acute kidney injury was determined as a binary variable according to the Kidney Disease Improving Global Outcomes criteria. RESULTS After adjusting for baseline and clinical covariates, a significant interaction between the haematocrit and continuous perfusate oxygenation on acute kidney injury was found (pinteraction = 0.049): a higher perfusate oxygenation was associated with a greater acute kidney injury risk among higher haematocrit children (adjusted odds ratio = 1.50, 95% confidence interval = [1.02, 2.22] per SD, p = 0.038) but not among normal haematocrit children (adjusted odds ratio = 0.91, 95% confidence interval = [0.51, 1.63] per SD, p = 0.73). After a similar adjustment, there was a marginal interaction between tertiles of perfusate oxygenation and haematocrit on acute kidney injury (pinteraction = 0.09): the middle and top tertiles of perfusate oxygenation were associated with a trend towards increased acute kidney injury risks among higher haematocrit children (adjusted odds ratio = 1.69, 95% confidence interval = [0.61, 4.66]; adjusted odds ratio = 2.25, 95% confidence interval = [0.84, 5.99], respectively) but not among normal haematocrit children (adjusted odds ratio = 1.16, 95% confidence interval = [0.46, 2.94]; adjusted odds ratio = 0.45, 95% confidence interval = [0.15, 1.36], respectively) compared with the bottom tertile. CONCLUSION Preoperative haematocrit differences significantly modify the association of perfusate oxygenation with acute kidney injury, highlighting differential control of reoxygenation for different haematocrit children with Tetralogy of Fallot in the management of cardiopulmonary bypass.
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Affiliation(s)
- Hong Liu
- Graduate School, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Si-Qiang Zheng
- Graduate School, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Si-Chong Qian
- Department of Cardiovascular Surgery and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Huang-He He
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jin-Rong Xue
- Department of Cardiovascular Surgery and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Shao L, Xue FS, Yang H. Risk factors of acute kidney injury after pediatric cardiac surgery. Acta Anaesthesiol Scand 2019; 63:274-275. [PMID: 30238449 DOI: 10.1111/aas.13264] [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]
Affiliation(s)
- Liujiazi Shao
- Department of Anesthesiology; Beijing Friendship Hospital; Capital Medical University; Beijing China
| | - Fu Shan Xue
- Department of Anesthesiology; Beijing Friendship Hospital; Capital Medical University; Beijing China
| | - He Yang
- Department of Anesthesiology; Beijing Friendship Hospital; Capital Medical University; Beijing China
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