Cardiac Catheterization and Postoperative Acute Kidney Failure in Congenital Heart Pediatric Patients

Echocardiogram-Guided Balloon Valvuloplasty of the Aortic Valve in Neonates and Infants Reduces Contrast Exposure with Maintained Efficacy and Less Aortic Regurgitation

Balloon aortic valvuloplasty (BAV) is performed in children with significant aortic stenosis (AS). Traditionally, contrast angiography measures the annulus and assesses aortic regurgitation (AR) after each dilation. Echocardiographic guidance is hypothesized to reduce contrast and radiation exposure, without compromising efficacy or safety. Patients < 10 kg undergoing BAV from 2013 to 2022 were retrospectively investigated. Agreement between echocardiographic and angiographic annulus measurements was assessed. Echocardiogram-guided (eBAV) and traditional angiogram-guided (tBAV) outcomes were compared controlling for weight, critical AS, and other congenital heart disease (CHD). Twelve eBAV and 19 tBAV procedures were performed. The median age was 33 days, median weight was 4.3 kg, 7 patients (23%) had critical AS, and 9 patients (29%) had other CHD. Annulus measurements by intraprocedural echocardiography and angiography displayed excellent correlation (ICC 0.95, p < 0.001). eBAV patients received less contrast (0.5 vs 3.5 ml/kg, p < 0.01). Five recent eBAV procedures were performed contrast free. Radiation exposure was not statistically different between the eBAV and tBAV groups (155 vs 313 µGy·M2, p = 0.12). One eBAV patient (8%) and 3 tBAV patients (16%, p = 0.62) experienced serious adverse events. Technical success (gradient < 35 mmHg and increase in AR by ≤ 1 grade) occurred in 11 eBAV patients (92%) and 16 tBAV patients (84%, p = 0.22). AR increased in 2 eBAV patients (17%) and 8 tBAV patients (44%, p = 0.02). eBAV was associated with similar efficacy and significantly lower contrast exposure and risk of aortic regurgitation. There was strong agreement between aortic valve annulus measurements by intraprocedural echocardiography and angiography, ultimately permitting contrast free BAV.

Renal Function After Transcatheter Piccolo Patent Ductus Arteriosus Closure With Contrast Angiography in Extremely Premature Infants

Transcatheter patent ductus arteriosus (PDA) device closure is increasingly performed in extremely premature infants. Contrast angiography improves the procedural safety and effectiveness by precise anatomic delineation. Contrast nephropathy is a concern in clinically ill premature infants, especially with the presence of renal insufficiency. We hypothesized that the benefit of transcatheter PDA closure outweighs the harm of contrast nephropathy in extremely premature infants. A total of 160 infants underwent successful transcatheter (n = 59) and surgical (n = 101) PDA closure at a median age of 26 (7 to 78) days. The surgical group had a lower procedural weight (870 vs 960 g, p = 0.014). In the transcatheter group, serum creatinine decreased from 0.48 to 0.45 mg/100 ml at 24 hours (p = 0.003, n = 59) and decreased further to 0.37 mg/100 ml at 5 to 7 days after closure (p <0.001). Median contrast amount was 1.9 ml/kg (0.6 to 6.1). In 8 infants with pre-existing renal insufficiency who underwent transcatheter closure, serum creatine significantly improved from 1.44 to 1.36 mg/100 ml at 24 hours and 0.79 mg/100 ml at 5 to 7 days after closure (p <0.001). There was no difference in improvement of serum creatinine between transcatheter and surgical closure groups. In conclusion, despite the use of contrast, serum creatinine significantly improved with transcatheter PDA closure even in infants with pre-existing renal insufficiency. Contrast angiography should not be discouraged for transcatheter PDA closure because of the concern for contrast nephropathy in extremely premature infants.

Contrast media exposure in the perioperative period confers no additional risk of acute kidney injury in infants and young children undergoing cardiac surgery with cardiopulmonary bypass

BACKGROUND

Recently, there has been an interest in the temporal relationship between contrast exposure (CM) and cardiac surgery suggesting that a "double hit" on the kidney function in close succession increases the risk of acute kidney injury (AKI) after cardiac surgery. However, data from young children is limited. The purpose of this study was to retrospectively evaluate the effects of preoperative CM exposure on postoperative AKI in infant and young children patients and to further analyze the influence of exposure time interval.

METHODS

Patients (age ≤ 3 years) who underwent diagnostic imaging within 14 days before on-pump cardiac surgery between 1 May 2017 and 31 May 2018 in Fuwai Hospital, Beijing, were analyzed. Kidney outcome was assessed according to Kidney Disease: Improving Global Outcomes creatinine-based criteria.

RESULTS

One thousand four hundred pediatric patients (192 CM and 1,248 non-CM) were identified. Postoperative AKI occurred in 57 (29.7%) of the 192 patients who were exposed to CM. Following propensity score adjustment, no difference in risk for AKI was observed between the CM and non-CM groups (RR 1.142, 95% CI 0.916-1.424; P = 0.264). Multivariable logistic regression of the CM group indicated that independent predictors of postoperative AKI were lower weight, lower preoperative creatinine level, and longer CPB duration. Time interval between CM exposure and on-pump cardiac surgery was not significantly associated with increased risk of AKI (OR 0.853, 95% CI 0.265~2.747; P = 0.790).

CONCLUSIONS

For pediatric patients who are soon to undergo on-pump cardiac procedures, there appears to be no need to hesitate in performing the diagnostic imaging investigations requiring CM, or delay CPB after CM exposure. These patients may benefit from increased diagnostic utility without increasing their risk of postoperative AKI.

Cardiorenal Syndrome

Cardiorenal syndrome (CRS) describes a specific acute and chronic clinical picture in which the heart or the kidney are primarily dysfunctioning and secondarily affect each other. CRS is divided into five classes: acute and chronic CRS, acute and chronic renocardiac syndromes, and secondary dysfunction of heart and kidneys. This article specifically details the classification and the epidemiology, some risk factors, and the pathophysiology of CRS. Some emerging aspects of CRS are also discussed, such as CRS in patients with end-stage heart failure, with mechanical ventricular assistance, and after heart transplantation. Finally, some aspects of pediatric CRS are detailed.

Exposure to contrast media in the perioperative period confers no additional risk of acute kidney injury in surgical patients

Background

Iodinated contrast media (CM) used in angiography and computed tomography (CT) scans is an important cause of acute kidney injury (AKI) in hospitalized patients undergoing surgery. Contrast-induced nephropathy leads to AKI soon after CM administration. The aim of the study was to determine whether the timing of contrast media exposure related to diagnostic imaging during the immediate perioperative period influences the risk of post-operative AKI.

Methods

All patients aged 18 years or above who underwent diagnostic imaging within 7 days of non-cardiac surgery between 1 January 2003 and 31 December 2013 in the Tayside region of Scotland, UK were included in the analysis. The primary outcome of AKI was defined using the Kidney Disease: Improving Global Outcomes creatinine-based criteria. Multiple logistic regressions were performed to identify predictors for AKI.

Results

Of 9300 patients, 6224 were exposed to CM in the immediate perioperative period and 3076 were not. Post-operative AKI occurred in 678 (10.9%) of the 6224 patients who were exposed to CM. On multiple logistic regression, independent predictors of post-operative AKI were increasing age, male gender, lower baseline renal function and treatment with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Timing of CM exposure did not affect risk of developing AKI, odds ratio 0.972 (95% confidence interval 0.935-1.010), P = 0.146.

Conclusions

For patients who have either just had or are soon to undergo general surgical procedures there appears to be no need to limit CT scan quality by avoiding the administration of CM. These patients may benefit from the increased diagnostic utility of contrast-enhanced CT scans without increasing their risk of perioperative AKI.

Kidney injury biomarkers after cardiac angiography in children with congenital heart disease

OBJECTIVE

This study aims to investigate the changes in renal function and levels of urinary biomarkers before and after cardiac angiography in children with congenital heart disease (CHD).

SETTING

Children with CHD are at a risk for kidney injury during contrast exposure in cardiac angiography.

OUTCOME MEASURES

We measured urinary protein, albumin, N-acetyl-β-D-glucosaminidase (NAG), β2-microglobulin (BMG), and liver-type fatty acid-binding protein (L-FABP) levels, as well as serum creatinine and cystatin C levels, before and after cardiac angiography in 33 children with CHD.

RESULTS

No significant decrease was noted in either the creatinine-based or cystatin C-based estimated glomerular filtration rate at 24 hours after angiography compared with that before angiography. Urinary protein, NAG, BMG, and L-FABP levels were significantly increased at 24 hours after angiography, all of which returned to baseline levels at more than 7 days after angiography. An increase in urinary level of protein, albumin, NAG, or BMG was mostly associated with increased urinary L-FABP level. An increase in both urinary BMG and L-FABP, but not that in urinary L-FABP alone, was associated with increased levels of urinary protein and NAG, as well as the greater dose of contrast media.

CONCLUSIONS

Transient increases of kidney injury biomarkers following cardiac angiography are not necessarily associated with the impairment of renal function in a short time period; however, the increase in urinary protein, albumin, NAG, or BMG level may indicate greater stresses to the kidneys than the increase in urinary L-FABP alone in children with CHD.

Prevention of Acute Kidney Injury in Children Undergoing Cardiac Surgery: A Narrative Review

Children undergoing cardiac surgery are at risk of developing acute kidney injury (AKI). Preventing cardiac surgery-associated AKI (CS-AKI) is important as it is associated with increased early- and long-term mortality and morbidity. Targeting modifiable risk factors (eg, avoiding poor renal perfusion, nephrotoxic drugs, and fluid overload) reduces the risk of CS-AKI. There is currently no strong evidence for the routine use of pharmacological approaches (eg, aminophylline, dexmedetomidine, fenoldopam, and steroids) to prevent CS-AKI. There is robust evidence to support the role of early peritoneal dialysis as a nonpharmacologic approach to prevent CS-AKI.

Acute kidney injury following first-stage palliation in hypoplastic left heart syndrome: hybrid versus Norwood palliation

OBJECTIVE

The aim of this study was to evaluate the prevalence of acute kidney injury after first-stage surgical palliation in patients with a single ventricle and to explore associated risk factors and outcomes. Design and patients This single-centre retrospective study included neonates who underwent either Norwood or Hybrid procedure from 2008 to 2015 for a single ventricle. Postoperative acute kidney injury was defined using the paediatric risk, injury, failure, loss, end-stage renal disease (pRIFLE), criteria within 72 hours of the procedure. Main results Our cohort (n=48) underwent surgical palliation at a mean (SD) age of 12 (11) days. Postoperative acute kidney injury was diagnosed in 14 (29%) patients. The prevalence of acute kidney injury in the Hybrid group was 16% and 53% in the Norwood group. Infants who developed acute kidney injury underwent surgery at younger ages [6 (5-10) versus 10 (8-16) days, p=0.016], and had a higher peak lactate level in the initial 24 hours [5.9 (4.2-9.1) versus 3.4 (2.4-6.7), p=0.007]. Norwood procedure was significantly associated with acute kidney injury [odds ratio 11.7 (95% confidence interval 1.3-101.9), p=0.03]. ICU stay [38 (21-84) versus 16 (6-45) days, p=0.038] and time to extubation [204 (120-606) versus 72 (26-234) hours, p=0.014] were longer in those with acute kidney injury. The two patients who developed early postoperative renal failure as per pRIFLE died before discharge from associated comorbidities.

CONCLUSIONS

Acute kidney injury occurs in a third of the patients with single ventricle after surgical palliation but is mostly transient. Norwood, compared with Hybrid procedure, is a risk factor for postoperative acute kidney injury, which, in turn, is associated with longer ICU stay and time to extubation.

Contrast media-induced nephropathy: how has Italy contributed in the past 30 years? A systematic review

Background and objective

The use of contrast media in Italy has exponentially increased in the past 3 decades. However, it is unknown whether there has been an increase in clinical research evaluating the risks associated with contrast media usage, especially regarding contrast-induced nephropathy. To fill this gap in knowledge, we performed a systematic review.

Study eligibility criteria

Meta-analyses, observational studies, and clinical trials assessing contrast media-induced nephropathy as the safety outcome, in which at least one author was affiliated with an Italian university/health care structure, were eligble.

Data sources

Ovid MEDLINE, Ovid Embase, Cochrane Methodology Register, and Web of Science were screened.

Participants

Men and women exposed to contrast media.

Results

In total, 60 original articles were retrieved with an incremental trend between 1990 and 2017. Cohort studies were the most common study design represented. In total, 45 of 60 (75.0%) studies were monocenter studies and 41 of 60 (68.3%) received no funding. In all, 91.7% of studies disclosed no conflicts of interest and 81.7% had no external collaboration. Most of the studies provided a level of evidence of III-2 (32/60; 53.3%) and II (23/60; 38.3%). In total, 50 of 60 studies (83.3%) were published in a scientific journal ranked in the first quartile of their subject area.

Conclusion

There was an increased number of studies evaluating contrast-induced nephropathy in Italy during the last three decades. These studies covered procedures to prevent contrast-induced nephropathy or aimed to identify risk factors, biomarkers, and scores, and their related prognosis.

Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Fluid Management

OBJECTIVE

In this Consensus Statement, we review the etiology and pathophysiology of fluid disturbances in critically ill children with cardiac disease. Clinical tools used to recognize pathologic fluid states are summarized, as are the mechanisms of action of many drugs aimed at optimal fluid management.

DATA SOURCES

The expertise of the authors and a review of the medical literature were used as data sources.

DATA SYNTHESIS

The authors synthesized the data in the literature in order to present clinical tools used to recognize pathologic fluid states. For each drug, the physiologic rationale, mechanism of action, and pharmacokinetics are synthesized, and the evidence in the literature to support the therapy is discussed.

CONCLUSIONS

Fluid management is challenging in critically ill pediatric cardiac patients. A myriad of causes may be contributory, including intrinsic myocardial dysfunction with its associated neuroendocrine response, renal dysfunction with oliguria, and systemic inflammation with resulting endothelial dysfunction. The development of fluid overload has been associated with adverse outcomes, including acute kidney injury, prolonged mechanical ventilation, increased vasoactive support, prolonged hospital length of stay, and mortality. An in-depth understanding of the many factors that influence volume status is necessary to guide optimal management.

Urinary 8-Hydroxy-2'-Deoxyguanosine: A Biomarker for Radiation-Induced Oxidative DNA Damage in Pediatric Cardiac Catheterization

OBJECTIVE

To determine the utility of urinary 8-hydroxy-2'-deoxyguanosine (8-OHdG) as a sensitive biomarker for radiation-induced cellular DNA damage in children undergoing cardiac catheterization.

STUDY DESIGN

We enrolled pediatric patients with congenital heart diseases requiring cardiac catheterization in conjunction with healthy children and children under sedation as control. Demographic, clinical, laboratory and invasive hemodynamic data, urinary 8-OHdG levels, and radiation exposure measurements were collected prospectively.

RESULTS

Nineteen patients, 10 healthy children and 9 children under sedation, were studied. In 19 patients who underwent cardiac catheterization, the median level of 8-OHdG in urine obtained at 24-48 hours after the procedure was significantly higher than at baseline (44.0 vs 17.3 ng/mg creatinine, P = .0001). Furthermore, the urinary 8-OHdG level after the procedure increased in 18 of the 19 study subjects. In contrast, there was no significant difference in 8-OHdG levels between the 2 spot urine samples obtained at arbitrary intervals of 24-48 hours in 10 healthy children (P = .7213), and at baseline and 24-48 hours following echocardiography in 9 children under sedation (P = .1097). Stepwise multiple regression analysis revealed that the cumulative air kerma during the cardiac catheterization was the variable which was strongly and significantly associated with the ratio of post- to precardiac catheterization urinary 8-OHdG levels among the evaluated variables (R(2) = 0.7179, F = 11.0256, P = .0007).

CONCLUSIONS

Urinary 8-OHdG could be a useful biomarker for radiation-induced cellular DNA damage in children undergoing diagnostic cardiac catheterization.

Acute kidney injury after using contrast during cardiac catheterization in children with heart disease

Acute kidney injury (AKI) is closely associated with the mortality of hospitalized patients and long-term development of chronic kidney disease, especially in children. The purpose of our study was to assess the evidence of contrast-induced AKI after cardiac catheterization in children with heart disease and evaluate the clinical usefulness of candidate biomarkers in AKI. A total of 26 children undergoing cardiac catheterization due to various heart diseases were selected and urine and blood samples were taken at 0 hr, 6 hr, 24 hr, and 48 hr after cardiac catheterization. Until 48 hr after cardiac catheterization, there was no significant increase in serum creatinine level in all patients. Unlike urine kidney injury molecule-1, IL-18 and neutrophil gelatinase-associated lipocalin, urine liver-type fatty acid-binding protein (L-FABP) level showed biphasic pattern and the significant difference in the levels of urine L-FABP between 24 and 48 hr. We suggest that urine L-FABP can be one of the useful biomarkers to detect subclinical AKI developed by the contrast before cardiac surgery.

The Year in Review

Congenital cardiac anesthesiology is a young and rapidly growing subspecialty. It embraces a large spectrum of congenital and acquired heart diseases, which now affect the entire life span of patients from “cradle to grave.” One of the challenges faced by congenital cardiac anesthesiologists is reading the large amount of relevant literature from the fields of cardiology, cardiac surgery, intensive care medicine, and anesthesiology. This review highlights some of the current themes in the literature during the past year.

Incidence of acute kidney injury following cardiac catheterization prior to cardiopulmonary bypass in children

OBJECTIVES

To determine whether contrast administration was a risk factor for development of acute kidney injury (AKI) in cyanotic congenital heart disease (CHD) patients undergoing cardiopulmonary bypass (CPB).

BACKGROUND

AKI following CPB or contrast administration is well described. In previous studies, administration of contrast prior to CPB has been shown to increase the risk of AKI. Chronic cyanosis leads to glomerular damage and dysfunction, thus potentially placing this population at increased risk of developing AKI following contrast administration prior to CPB.

METHODS

One hundred twenty-two patients with cyanotic CHD undergoing preoperative cardiac catheterization (PCC) and subsequent CPB at Children's Medical Center of Dallas from January 1, 2007 until November 30, 2010 were identified, looking specifically at bi-directional Glenn (BDG) anastomoses and Fontan procedures. One hundred thirteen patients undergoing PCC ≤ 48 hr prior to and > 5 days prior to CPB were included. Occurrence of AKI following CPB was the primary outcome variable.

RESULTS

Logistic regression analysis revealed pre-catheterization serum creatinine was a risk factor for post-CPB AKI (P < 0.001) in both Fontan and BDG patients. All other variables were not significantly associated with the development of AKI in either BDG or Fontan patients. Length of stay (hospital or ICU) was not different among the groups regardless of the occurrence of AKI.

CONCLUSIONS

In this study of cyanotic CHD patients, contrast administration within 48 hr prior to CPB was not an additional risk factor for the development of AKI.