The Kidney in Critical Cardiac Disease: Proceedings From the 10th International Conference of the Pediatric Cardiac Intensive Care Society

A Comparison of Perinatal Circulatory Transition in Critical Right and Left Heart Obstructive Lesions

BACKGROUND

During perinatal transition in hypoplastic left heart syndrome (HLHS), reduced systemic blood flow (Qs) and cerebral blood flow and increased pulmonary blood flow (Qp) are observed, contributing to hemodynamic instability. The aim of the present study was to explore whether similar or discordant perinatal changes occur in critical pulmonary outflow tract obstruction (POFO) compared with HLHS and healthy control subjects.

METHODS

Echocardiography was prospectively performed at 36 to 39 gestational weeks and then serially from 6 to 96 hours after birth, before cardiac intervention. Combined cardiac output (CCO), superior vena cava (SVC) flow rate, Qs and Qp, and resistance indices (RIs) in the middle cerebral artery (MCA), celiac artery, and superior mesenteric artery were compared among the three groups.

RESULTS

In fetal POFO (n = 19) and HLHS (n = 31), CCO was comparable with that in control subjects (n = 21) because of elevated stroke volume, but CCO in POFO was lower compared with HLHS (P < .01). Compared with control subjects, POFO CCO was lower at 6 hours after delivery but comparable at 24 to 96 hours. In contrast, from 6 to 96 hours, the HLHS group had higher CCO than POFO and control subjects. Compared with control subjects, both neonates with POFO and those with HLHS had lower Qs and SVC flow (POFO at 24 hours, P < .001; HLHS 6-hour Qs and 6- to 24-hour SVC flow). Compared with control subjects, Qp was increased in POFO at 48 to 96 hours (P < .05) and in HLHS at all time points (P < .001). Compared with fetal MCA RI, postnatal MCA RI was acutely higher in both POFO and HLHS, whereas in control subjects, it tended to decrease postnatally. Celiac artery RI and superior mesenteric artery pulsatility index were higher in POFO and HLHS from 6 to 48 hours vs control subjects.

CONCLUSIONS

POFO and HLHS demonstrate divergent acute hemodynamic changes in the early neonatal period, with early decreased CCO in POFO and increased CCO in HLHS. Both demonstrate early compromise in Qs and SVC (cerebral flow) and ongoing altered splanchnic flow.

Association of Preoperative Diuretic Use With Early Acute Kidney Injury in Infants With Biventricular Hearts Following Cardiac Surgery

Background Diuretics are used to manage congestive heart failure in infants with congenital heart disease. Adult data indicate that preoperative diuretic use increases the risk of cardiac surgery associated acute kidney injury (CS-AKI). We have sought to understand if preoperative diuretics in infants increases the risk of CS-AKI. Methods and Results This is a single-center retrospective study of infants (1-12 months) who had CS requiring cardiopulmonary bypass between 2013 and 2018. The diagnosis and severity of CS-AKI was defined according to the Kidney Disease Improving Global Outcomes guidelines. Three hundred patients were included (mean 6 months, SD 2.4, range 1.2-12.9 months). A total of 149 (49.7%) patients were diagnosed with CS-AKI (stage 1: 80 [54%], stage 2: 57 [38%], stage 3: 12 [8%]). Logistic regression analysis showed preoperative diuretics were not associated with CS-AKI (odds ratio [OR], 0.79; 95% CI, 0.43-1.44; P=0.45). A diagnosis of tetralogy of Fallot was an independent risk factor for CS-AKI (OR, 3.49; 95% CI, 1.33-9.1, P=0.01). A diagnosis of tetralogy of Fallot (OR, 3.6; 95% CI, 1.28-10.22; P=0.02) and longer cardiopulmonary bypass (OR, 1.01; 95% CI, 1.0-1.02; P=0.04) time are risk factors for moderate to severe CS-AKI. Conclusions Preoperative diuretic use does not contribute to the risk of CS-AKI in infants early after surgery. A diagnosis of tetralogy of Fallot was the only risk factor for CS-AKI identified using multivariate analysis in our cohort. Furthermore, a diagnosis of tetralogy of Fallot and longer cardiopulmonary bypass time are risk factors for moderate to severe CS-AKI.

Post-operative Renal Failure, Shunt Type and Mortality after Norwood Palliation

BACKGROUND

The Single Ventricle Reconstruction (SVR) trial demonstrated increased risk of death or heart transplant one year post-Norwood in subjects randomized to Blalock-Taussig shunts (mBTS) compared to right ventricle-to-pulmonary artery (RV-PA) shunts. We used the SVR public use database to evaluate incidence and risk factors for post-operative renal failure and relationships between renal failure, shunt type and outcomes post-Norwood.

METHODS

Post-operative renal failure was defined a-priori as a 3-fold rise in creatinine from baseline, or dialysis use, within 7 days of Norwood. We used multivariate logistic regression to evaluate risk factors for post-operative renal failure and Cox hazard regression to determine the association between post-operative renal failure and one-year post-Norwood mortality.

RESULTS

Overall, post-operative renal failure occurred in 8.4% (46/544) with risk factors including receipt of a mBTS (aOR 3.3, p=0.02), low center volume (aOR 2.7, p=0.005), presence of ≥2 pre-op complications (aOR 4.0, p<0.001), low birth weight (aOR 3.2, p=0.002), post-operative heart block (aOR 8.5, p=0.001), and delayed sternal closure (aOR 5.3, p=0.026). Renal failure was an independent risk factor for one-year mortality (aHR 1.9, p=0.019). Assessing interaction by shunt type, mortality risk associated with renal failure was greatest in the RV-PA shunt group (aHR 3.3 versus RV-PA shunt without renal failure, p=0.001), but was also increased in the mBTS group (aHR 1.9, p=0.03).

CONCLUSIONS

Post-operative renal failure is common after Norwood and is independently associated with mortality. Although renal failure is more common after mBTS, the highest mortality risk with renal failure occurs after RV-PA shunt.

Hybrid Blood Purification Therapy Based on Camel Nanoantibody Immunoadsorbent on Patients with Chronic Renal Failure in Nephrology Department

This paper proposes a study on the effect of hybrid blood purification therapy based on camel nanoantibody immunoadsorbent on chronic renal failure patients in nephrology department. In this paper, the hybrid blood purification therapy based on camel nanoantibody immunoadsorbent was applied to patients with chronic renal failure, and the curative effect of the patients was studied. In order to highlight the effect, a control group was set up for comparison. In this paper, the clearance effect of small molecule toxin, middle molecular toxin, and dialysis adequacy was analyzed. This study found that the average dialysis adequacy of the control group was 1.23% and that of the experimental group was 1.26%. The dialysis adequacy of the experimental group was significantly better than that of the control group. In addition, the clearance effect of small and medium molecular toxins in the experimental group was significantly better than that in the control group. It can be seen that the hybrid blood purification therapy based on camel nanoantibody immunoadsorbent is effective in the treatment of chronic renal failure patients in the department of nephrology. Therefore, it is of great value to apply camel nanoantibody in the clinical treatment of renal failure.

Changing the terminology from kidney replacement therapy to kidney support therapy

Kidney replacement therapy (KRT) is a common supportive treatment for renal dysfunction, especially acute kidney injury. However, critically ill or immunosuppressed patients with renal dysfunction often have dysfunction in other organs as well. To improve patient outcomes, clinicians began to initiate kidney replacement therapy in situations where nonrenal conditions may lead to acute kidney injury, such as septic shock, hematopoietic stem cell transplantation, veno-occlusive renal disease, cardiopulmonary bypass, chemotherapy, tumor lysis syndrome, hyperammonemia, and various others. In this review, we discuss the use of various modes of kidney replacement therapy in treating renal and nonrenal complications to illustrate why kidney support therapy is a more appropriate terminology than kidney replacement therapy.

Are My Pediatric Patients at Increased Risk of Developing Chronic Kidney Disease?

Chronic kidney disease (CKD) is an underrecognized and often undiagnosed cause of morbidity and mortality. Many children and adolescents are at increased risk of developing CKD as they mature and age, secondary to conditions commonly cared for by pediatric health professionals. Prematurity, diabetes mellitus, hypertension, congenital heart disease, sickle cell disease and trait, severe obesity, cancer chemotherapy, other drug toxicities, and systemic situations that may cause acute kidney injury such as sepsis or extracorporeal membrane oxygenation therapy predispose to potential CKD. Clinicians should be aware of these conditions in order to screen for CKD, choose non-nephrotoxic treatments for these children whenever possible, and treat or refer those who have early signs of CKD.

Prevention and possible mechanism of a purified Laminaria japonica polysaccharide on adriamycin-induced acute kidney injury in mice

The present work aims to investigate the effects and underlying mechanism of a homogeneous Laminaria japonica polysaccharide (LJP61A) on acute kidney injury (AKI) in mice. According to the results of biochemical and pathological analysis, we concluded that LJP61A could protect kidney from the damage of adriamycin in AKI mice. Compared to the model group, the mRNA level of cytokines (TNF-α, IL-1β and MCP-1) and protein level of mesenchymal markers demsin were decrease by the treatment of LJP61A while the protein levels of podocyte structure markers (Nephrin and WT-1) were increased. Moreover, the adriamycin-induced enhancement of phosphor-p65, phosphor-p38, phosphor-ERK1/2 and phosphor-JNK in the kidney of AKI mice were significantly suppressed by LJP61A. Similar variation was observed in the mRNA and protein levels of TGF-β1 and Smad3. These results suggested that LJP61A prevented acute kidney injury possibly via regulating TGF-β1-mediated Smad3, MAPKs and NF-κB signaling pathways.

Acute Kidney Injury and Fluid Overload in Pediatric Cardiac Surgery

PURPOSE OF REVIEW

Acute kidney injury (AKI) and fluid overload affect a large number of children undergoing cardiac surgery, and confers an increased risk for adverse complications and outcomes including death. Survivors of AKI suffer long-term sequelae. The purpose of this narrative review is to discuss the short and long-term impact of cardiac surgery associated AKI and fluid overload, currently available tools for diagnosis and risk stratification, existing management strategies, and future management considerations.

RECENT FINDINGS

Improved risk stratification, diagnostic prediction tools and clinically available early markers of tubular injury have the ability to improve AKI-associated outcomes. One of the major challenges in diagnosing AKI is the diagnostic imprecision in serum creatinine, which is impacted by a variety of factors unrelated to renal disease. In addition, many of the pharmacologic interventions for either AKI prevention or treatment have failed to show any benefit, while peritoneal dialysis catheters, either for passive drainage or prophylactic dialysis may be able to mitigate the detrimental effects of fluid overload.

SUMMARY

Until novel risk stratification and diagnostics tools are integrated into routine practice, supportive care will continue to be the mainstay of therapy for those affected by AKI and fluid overload after pediatric cardiac surgery. A viable series of preventative measures can be taken to mitigate the risk and severity of AKI and fluid overload following cardiac surgery, and improve care.