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Banigan MA, Keim G, Traynor D, Yehya N, Lindell RB, Fitzgerald JC. Association of continuous kidney replacement therapy timing and mortality in critically ill children. Pediatr Nephrol 2024; 39:2217-2226. [PMID: 38396090 DOI: 10.1007/s00467-024-06320-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 02/04/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common complication of critical illness and associated with high morbidity and mortality. Optimal timing of continuous kidney replacement therapy (CKRT) in children is unknown. We aimed to measure the association between timing of initiation and mortality. METHODS This is a single-center retrospective cohort study of pediatric patients receiving CKRT from 2013 to 2019. The primary exposure, time to CKRT initiation, was measured from onset of stage 3 AKI during hospitalization (defined using Kidney Disease: Improving Global Outcomes creatinine and urine output criteria) and analyzed as both a continuous and categorical variable. The primary outcome was ICU mortality. RESULTS Ninety-nine patients met criteria for analysis. Overall mortality was 39% (39/99). Median time from stage 3 AKI onset to CKRT initiation was 1.5 days in survivors and 5.5 days in nonsurvivors (p < 0.001). In multivariable analysis, increased time to CKRT initiation was independently associated with mortality [OR 1.02 per hour (95% CI 1.01-1.04), p < 0.001]. Longer time to CKRT initiation was associated with higher odds of mortality in ascending time intervals. Patients started on CKRT > 2 days compared to < 2 days after stage 3 AKI onset had higher mortality (65% vs. 5%, p < 0.001), longer median ICU length of stay (25 vs. 12 d, p < 0.001), longer median CKRT duration (11 vs. 5 d, p < 0.001), and fewer AKI-free days (0 vs. 14 d, p < 0.001). CONCLUSIONS Longer time to initiation of CKRT after development of severe AKI is independently associated with mortality. Consideration of early CKRT in this high-risk population may be a strategy to reduce mortality and improve recovery of kidney function. However, there remains significant heterogeneity in the definition of early versus late initiation and the optimal timing of CKRT remains unknown.
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Affiliation(s)
- Maureen A Banigan
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Garrett Keim
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Danielle Traynor
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nadir Yehya
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Robert B Lindell
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Julie C Fitzgerald
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Li L, Zhou T, Lu Y, Chen J, Lei Y, Wu Q, Arnold J, Becich MJ, Bisyuk Y, Blecker S, Chrischilles E, Christakis DA, Geary CR, Jhaveri R, Lenert L, Liu M, Mirhaji P, Morizono H, Mosa ASM, Onder AM, Patel R, Smoyer WE, Taylor BW, Williams DA, Dixon BP, Flynn JT, Gluck C, Harshman LA, Mitsnefes MM, Modi ZJ, Pan CG, Patel HP, Verghese PS, Forrest CB, Denburg MR, Chen Y. Post-acute and Chronic Kidney Function Outcomes of COVID-19 in Children and Adolescents: An EHR Cohort Study from the RECOVER Initiative. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.06.25.24309488. [PMID: 38978683 PMCID: PMC11230320 DOI: 10.1101/2024.06.25.24309488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
We investigated the risks of post-acute and chronic adverse kidney outcomes of SARS-CoV-2 infection in the pediatric population via a retrospective cohort study using data from the RECOVER program. We included 1,864,637 children and adolescents under 21 from 19 children's hospitals and health institutions in the US with at least six months of follow-up time between March 2020 and May 2023. We divided the patients into three strata: patients with pre-existing chronic kidney disease (CKD), patients with acute kidney injury (AKI) during the acute phase (within 28 days) of SARS-CoV-2 infection, and patients without pre-existing CKD or AKI. We defined a set of adverse kidney outcomes for each stratum and examined the outcomes within the post-acute and chronic phases after SARS-CoV-2 infection. In each stratum, compared with the non-infected group, patients with COVID-19 had a higher risk of adverse kidney outcomes. For patients without pre-existing CKD, there were increased risks of CKD stage 2+ (HR 1.20; 95% CI: 1.13-1.28) and CKD stage 3+ (HR 1.35; 95% CI: 1.15-1.59) during the post-acute phase (28 days to 365 days) after SARS-CoV-2 infection. Within the post-acute phase of SARS-CoV-2 infection, children and adolescents with pre-existing CKD and those who experienced AKI were at increased risk of progression to a composite outcome defined by at least 50% decline in estimated glomerular filtration rate (eGFR), eGFR <15 mL/min/1.73m2, End Stage Kidney Disease diagnosis, dialysis, or transplant.
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Affiliation(s)
- Lu Li
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
- The Graduate Group in Applied Mathematics and Computational Science, School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, USA
| | - Ting Zhou
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
| | - Yiwen Lu
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
- The Graduate Group in Applied Mathematics and Computational Science, School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, USA
| | - Jiajie Chen
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
| | - Yuqing Lei
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
| | - Qiong Wu
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
| | - Jonathan Arnold
- Division of General Internal Medicine, University of Pittsburgh School of Medicine
| | - Michael J. Becich
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Yuriy Bisyuk
- Office of Research, University Medical Center New Orleans, New Orleans, LA
| | - Saul Blecker
- Department of Population Health, NYU Grossman School of Medicine
| | | | - Dimitri A Christakis
- Center for Child Health, Behavior and Development, Seattle Children’s Research Institute, Seattle, WA 98105, USA
| | - Carol Reynolds Geary
- Department of Pathology, Microbiology, and Immunology, University of Nebraska Medical Center, Omaha, NE
| | - Ravi Jhaveri
- Division of Infectious Diseases, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Leslie Lenert
- Biomedical Informatics Center, Medical University of South Carolina
| | - Mei Liu
- Department of Health Outcomes and Biomedical Informatics, University of Florida, College of Medicine
| | - Parsa Mirhaji
- Albert Einstein College of Medicine, Bronx, NY 10461
| | - Hiroki Morizono
- Center for Genetic Medicine Research, Children’s National Hospital, Washington DC
| | | | - Ali Mirza Onder
- Division of Pediatric Nephrology, Nemours Children’s Hospital, Wilmington, DE
| | - Ruby Patel
- Division of Pediatric Nephrology, Stanford Medicine Children’s Health, Palo Alto, CA
| | - William E. Smoyer
- Center for Clinical and Translational Research, Nationwide Children’s Hospital, Department of Pediatrics, The Ohio State University
| | - Bradley W. Taylor
- Clinical and Translational Science Institute, The Medical College of Wisconsin, Milwaukee, WI 53226
| | | | - Bradley P. Dixon
- Renal Section, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | | | - Caroline Gluck
- Nemours Children’s Health, Division of Pediatric Nephrology, Wilmington, DE
| | | | - Mark M Mitsnefes
- Cincinnati Children’s Hospital medical Center and University of Cincinnati
| | - Zubin J. Modi
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor
- Division of Pediatric Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor
| | - Cynthia G. Pan
- Department of Pediatrics, Section of Nephrology, Medical College of Wisconsin
| | - Hiren P. Patel
- Nationwide Children’s Hospital
- Ohio State University College of Medicine
| | - Priya S. Verghese
- Ann & Robert H Lurie Children’s Hospital
- Northwestern University, Feinberg School of Medicine
| | - Christopher B. Forrest
- Applied Clinical Research Center, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michelle R. Denburg
- Division of Pediatric Nephrology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics and Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Yong Chen
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
- The Graduate Group in Applied Mathematics and Computational Science, School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, USA
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McNicholas B, Akcan Arikan A, Ostermann M. Quality of life after acute kidney injury. Curr Opin Crit Care 2023; 29:566-579. [PMID: 37861184 DOI: 10.1097/mcc.0000000000001090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
PURPOSE OF REVIEW Deciphering the effect of acute kidney injury (AKI) during critical illness on long-term quality of life versus the impact of conditions that brought on critical illness is difficult. RECENT FINDINGS Reports on patient-centred outcomes such as health-related quality of life (HRQOL) have provided insight into the long-lasting impact of critical illness complicated by AKI. However, these data stem from observational studies and randomized controlled trials, which have been heterogeneous in their patient population, timing, instruments used for assessment and reporting. Recent studies have corroborated these findings including lack of effect of renal replacement therapy compared to severe AKI on outcomes and worse physical compared to cognitive dysfunction. SUMMARY In adults, more deficits in physical than mental health domains are found in survivors of AKI in critical care, whereas memory deficits and learning impairments have been noted in children. Further study is needed to understand and develop interventions that preserve or enhance the quality of life for individual patients who survive AKI following critical illness, across all ages.
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Affiliation(s)
- Bairbre McNicholas
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital
- School of Medicine, University of Galway, Galway, Ireland
| | - Ayse Akcan Arikan
- Department of Pediatrics, Divisions of Critical Care Medicine and Nephrology, Baylor College of Medicine, Houston, Texas, USA
| | - Marlies Ostermann
- King's College London, Guy's & St Thomas' Hospital, Department of Critical Care, Westminster Bridge Road, London, UK
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Stanski NL, Basu RK, Cvijanovich NZ, Fitzgerald JC, Bigham MT, Jain PN, Schwarz AJ, Lutfi R, Thomas NJ, Baines T, Haileselassie B, Weiss SL, Atreya MR, Lautz AJ, Zingarelli B, Standage SW, Kaplan J, Chawla LS, Goldstein SL. External validation of the modified sepsis renal angina index for prediction of severe acute kidney injury in children with septic shock. Crit Care 2023; 27:463. [PMID: 38017578 PMCID: PMC10683237 DOI: 10.1186/s13054-023-04746-6] [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: 10/05/2023] [Accepted: 11/18/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Acute kidney injury (AKI) occurs commonly in pediatric septic shock and increases morbidity and mortality. Early identification of high-risk patients can facilitate targeted intervention to improve outcomes. We previously modified the renal angina index (RAI), a validated AKI prediction tool, to improve specificity in this population (sRAI). Here, we prospectively assess sRAI performance in a separate cohort. METHODS A secondary analysis of a prospective, multicenter, observational study of children with septic shock admitted to the pediatric intensive care unit from 1/2019 to 12/2022. The primary outcome was severe AKI (≥ KDIGO Stage 2) on Day 3 (D3 severe AKI), and we compared predictive performance of the sRAI (calculated on Day 1) to the original RAI and serum creatinine elevation above baseline (D1 SCr > Baseline +). Original renal angina fulfillment (RAI +) was defined as RAI ≥ 8; sepsis renal angina fulfillment (sRAI +) was defined as RAI ≥ 20 or RAI 8 to < 20 with platelets < 150 × 103/µL. RESULTS Among 363 patients, 79 (22%) developed D3 severe AKI. One hundred forty (39%) were sRAI + , 195 (54%) RAI + , and 253 (70%) D1 SCr > Baseline + . Compared to sRAI-, sRAI + had higher risk of D3 severe AKI (RR 8.9, 95%CI 5-16, p < 0.001), kidney replacement therapy (KRT) (RR 18, 95%CI 6.6-49, p < 0.001), and mortality (RR 2.5, 95%CI 1.2-5.5, p = 0.013). sRAI predicted D3 severe AKI with an AUROC of 0.86 (95%CI 0.82-0.90), with greater specificity (74%) than D1 SCr > Baseline (36%) and RAI + (58%). On multivariable regression, sRAI + retained associations with D3 severe AKI (aOR 4.5, 95%CI 2.0-10.2, p < 0.001) and need for KRT (aOR 5.6, 95%CI 1.5-21.5, p = 0.01). CONCLUSIONS Prediction of severe AKI in pediatric septic shock is important to improve outcomes, allocate resources, and inform enrollment in clinical trials examining potential disease-modifying therapies. The sRAI affords more accurate and specific prediction than context-free SCr elevation or the original RAI in this population.
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Affiliation(s)
- Natalja L Stanski
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave MLC 2005, Cincinnati, OH, 45229, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA.
| | - Rajit K Basu
- Division of Critical Care Medicine, Ann & Robert Lurie Children's Hospital of Chicago, Northwestern University, 225 E. Chicago Ave, Chicago, IL, 60611, USA
| | | | - Julie C Fitzgerald
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Michael T Bigham
- Akron Children's Hospital, 214 W Bowery St., Akron, OH, 44308, USA
| | - Parag N Jain
- Texas Children's Hospital and Baylor College of Medicine, 6621 Fannin Street, Houston, TX, 77030, USA
| | - Adam J Schwarz
- Children's Hospital of Orange County, 1201 W La Veta Ave, Orange, CA, 92868, USA
| | - Riad Lutfi
- Riley Hospital for Children, 705 Riley Hospital Drive, Indianapolis, IN, 46202, USA
| | - Neal J Thomas
- Penn State Health Children's Hospital, 600 University Drive, Hershey, PA, 17033, USA
| | - Torrey Baines
- University of Florida Health Shands Children's Hospital, 1600 South West Archer Rd, Gainesville, FL, 32608, USA
| | | | - Scott L Weiss
- Nemours Children's Health, 1600 Rockland Rd, Wilmington, DE, 19803, USA
| | - Mihir R Atreya
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave MLC 2005, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA
| | - Andrew J Lautz
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave MLC 2005, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA
| | - Basilia Zingarelli
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave MLC 2005, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA
| | - Stephen W Standage
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave MLC 2005, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA
| | - Jennifer Kaplan
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave MLC 2005, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA
| | - Lakhmir S Chawla
- Department of Medicine, Veterans Affairs Medical Center San Diego, 3350 La Jolla Village Drive, San Diego, CA, 92161, USA
| | - Stuart L Goldstein
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
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5
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Strong AE, Zee J, Fulchiero R, Kilbaugh TJ, Connelly J, Makeneni S, Campos D, Laskin BL, Denburg MR. Intravascular Hemolysis and AKI in Children Undergoing Extracorporeal Membrane Oxygenation. KIDNEY360 2023; 4:1536-1544. [PMID: 37853572 PMCID: PMC10695640 DOI: 10.34067/kid.0000000000000253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 08/21/2023] [Indexed: 10/20/2023]
Abstract
Key Points The incidence of AKI while undergoing ECMO in pediatric patients is high and independently increases mortality. Laboratory markers consistent with intravascular hemolysis increase the hazard of a composite outcome of AKI or RRT while undergoing ECMO. Further research into appropriate monitoring or treatment of ECMO-associated hemolysis may lead to important interventions to prevent AKI. Background AKI is common in patients requiring extracorporeal membrane oxygenation (ECMO), with a variety of proposed mechanisms. We sought to describe the effect of laboratory evidence of ECMO-associated intravascular hemolysis on AKI and RRT. Methods This retrospective cohort study included patients treated with ECMO at a single center over 10 years. The primary outcome was a composite of time to RRT or AKI (by creatinine-based Kidney Disease Improving Global Outcomes criteria) after ECMO start. Serum creatinine closest to ECMO start time was considered the pre-ECMO baseline and used to determine abnormal kidney function at ECMO start. The patient's subsequent creatinine values were used to identify AKI on ECMO. Multivariable cause-specific Cox proportional hazards models were used to assess the effect of separate markers of intravascular hemolysis on the time to the composite outcome after controlling for confounders. Results Five hundred and one children were evaluated with a median age 1.2 years, 56% male. Four separate multivariable models, each with a different marker of hemolysis (plasma-free hemoglobin, lactate dehydrogenase (LDH), minimum platelet count, and minimum daily hemoglobin), were used to examine the effect on the composite outcome of AKI/RRT. An elevated plasma-free hemoglobin, the most specific of these hemolysis markers, demonstrated an almost three-fold higher adjusted hazard for the composite outcome (hazard ratio [HR], 2.9; P value < 0.01; 95% confidence interval [CI], 1.4 to 5.6). Elevated LDH was associated with an adjusted HR of 3.1 (P value < 0.01; 95% CI, 1.7 to 5.5). Effect estimates were also pronounced in a composite outcome of only more severe AKI, stage 2+ AKI/RRT: HR 6.6 (P value < 0.01; 95% CI, 3.3 to 13.2) for plasma-free hemoglobin and 2.8 (P value < 0.01; 95% CI, 1.5 to 5.6) for LDH. Conclusions Laboratory findings consistent with intravascular hemolysis on ECMO were independently associated with a higher hazard of a composite outcome of AKI/RRT in children undergoing ECMO.
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Affiliation(s)
- Amy E. Strong
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Division of Nephrology, University of Iowa Stead Family Children's Hospital, Iowa City, Iowa
| | - Jarcy Zee
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania
| | - Rosanna Fulchiero
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Todd J. Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- ECMO Center at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - James Connelly
- ECMO Center at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Spandana Makeneni
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania
| | - Diego Campos
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Benjamin L. Laskin
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michelle R. Denburg
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Stanski NL, Pode Shakked N, Zhang B, Cvijanovich NZ, Fitzgerald JC, Jain PN, Schwarz AJ, Nowak J, Weiss SL, Allen GL, Thomas NJ, Haileselassie B, Goldstein SL. Serum renin and prorenin concentrations predict severe persistent acute kidney injury and mortality in pediatric septic shock. Pediatr Nephrol 2023; 38:3099-3108. [PMID: 36939916 PMCID: PMC10588759 DOI: 10.1007/s00467-023-05930-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/24/2023] [Accepted: 02/24/2023] [Indexed: 03/21/2023]
Abstract
BACKGROUND Studies in critically ill adults demonstrate associations between serum renin concentrations (a proposed surrogate for renin-angiotensin-aldosterone system dysregulation) and poor outcomes, but data in critically ill children are lacking. We assessed serum renin + prorenin concentrations in children with septic shock to determine their predictive ability for acute kidney injury (AKI) and mortality. METHODS We conducted a secondary analysis of a multicenter observational study of children aged 1 week to 18 years admitted to 14 pediatric intensive care units (PICUs) with septic shock and residual serum available for renin + prorenin measurement. Primary outcomes were development of severe persistent AKI (≥ KDIGO stage 2 for ≥ 48 h) in the first week and 28-day mortality. RESULTS Among 233 patients, day 1 median renin + prorenin concentration was 3436 pg/ml (IQR 1452-6567). Forty-two (18%) developed severe persistent AKI and 32 (14%) died. Day 1 serum renin + prorenin predicted severe persistent AKI with an AUROC of 0.75 (95% CI 0.66-0.84, p < 0.0001; optimal cutoff 6769 pg/ml) and mortality with an AUROC of 0.79 (95% CI 0.69-0.89, p < 0.0001; optimal cutoff 6521 pg/ml). Day 3/day 1 (D3:D1) renin + prorenin ratio had an AUROC of 0.73 (95% CI 0.63-0.84, p < 0.001) for mortality. On multivariable regression, day 1 renin + prorenin > optimal cutoff retained associations with severe persistent AKI (aOR 6.8, 95% CI 3.0-15.8, p < 0.001) and mortality (aOR 6.9, 95% CI 2.2-20.9, p < 0.001). Similarly, D3:D1 renin + prorenin > optimal cutoff was associated with mortality (aOR 7.6, 95% CI 2.5-23.4, p < 0.001). CONCLUSIONS Children with septic shock have very elevated serum renin + prorenin concentrations on PICU admission, and these concentrations, as well as their trend over the first 72 h, predict severe persistent AKI and mortality. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Natalja L Stanski
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA.
| | - Naomi Pode Shakked
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Bin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | | | - Julie C Fitzgerald
- The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Parag N Jain
- Texas Children's Hospital and Baylor College of Medicine, 6621 Fannin Street, Houston, TX, 77030, USA
| | - Adam J Schwarz
- Children's Hospital of Orange County, 1201 W La Veta Ave, Orange, CA, 92868, USA
| | - Jeffrey Nowak
- Children's Minnesota, 2525 Chicago Ave, Minneapolis, MN, 55404, USA
| | - Scott L Weiss
- The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Geoffrey L Allen
- Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Neal J Thomas
- Penn State Health Children's Hospital, 600 University Dr, Hershey, PA, 17033, USA
| | | | - Stuart L Goldstein
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA
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7
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Dixon CG, Thadani S, Fitzgerald JC, Akcan-Arikan A, Yehya N. Fluid Overload Precedes and Masks Cryptic Kidney Injury in Pediatric Acute Respiratory Distress Syndrome. Crit Care Med 2023; 51:765-774. [PMID: 36939256 PMCID: PMC10214878 DOI: 10.1097/ccm.0000000000005836] [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] [Indexed: 03/21/2023]
Abstract
OBJECTIVES Given the complex interrelatedness of fluid overload (FO), creatinine, acute kidney injury (AKI), and clinical outcomes, the association of AKI with poor outcomes in critically ill children may be underestimated due to definitions used. We aimed to disentangle these temporal relationships in a large cohort of children with acute respiratory distress syndrome (ARDS). DESIGN Retrospective cohort study. SETTING Quaternary care PICU. PATIENTS Seven hundred twenty intubated children with ARDS between 2011 and 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Daily fluid balance, urine output (UOP), and creatinine for days 1-7 of ARDS were retrospectively abstracted. A subset of patients had angiopoietin 2 (ANGPT2) quantified on days 1, 3, and 7. Patients were classified as AKI by Kidney Disease Improving Global Outcomes (KDIGO) stage 2/3 then grouped by timing of AKI onset (early if days 1-3 of ARDS, late if days 4-7 of ARDS, persistent if both) for comparison of PICU mortality and ventilator-free days (VFDs). A final category of "Cryptic AKI" was used to identify subjects who met KDIGO stage 2/3 criteria only when creatinine was adjusted for FO. Outcomes were compared between those who had Cryptic AKI identified by FO-adjusted creatinine versus those who had no AKI. Conventionally defined AKI occurred in 26% of patients (early 10%, late 3%, persistent 13%). AKI was associated with higher mortality and fewer VFDs, with no differences according to timing of onset. The Cryptic AKI group (6% of those labeled no AKI) had higher mortality and fewer VFDs than patients who did not meet AKI with FO-adjusted creatinine. FO, FO-adjusted creatinine, and ANGPT2 increased 1 day prior to meeting AKI criteria in the late AKI group. CONCLUSIONS AKI was associated with higher mortality and fewer VFDs in pediatric ARDS, irrespective of timing. FO-adjusted creatinine captures a group of patients with Cryptic AKI with outcomes approaching those who meet AKI by traditional criteria. Increases in FO, FO-adjusted creatinine, and ANGPT2 occur prior to meeting conventional AKI criteria.
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Affiliation(s)
- Celeste G. Dixon
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Medical Center, Washington, District of Columbia
| | - Sameer Thadani
- Divisions of Critical Care Medicine and Nephrology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Julie C. Fitzgerald
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Ayse Akcan-Arikan
- Divisions of Critical Care Medicine and Nephrology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Nadir Yehya
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Role of fluid status markers as risk factors for suboptimal vancomycin concentration during continuous infusion in neonates: an observational study. Eur J Pediatr 2022; 181:2935-2942. [PMID: 35581390 DOI: 10.1007/s00431-022-04500-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 05/04/2022] [Accepted: 05/06/2022] [Indexed: 11/03/2022]
Abstract
UNLABELLED Vancomycin is widely used in neonatal sepsis but proportion of newborn reaching recommended concentration is variable. Fluid status impact on vancomycin level remains understudied. We aimed to study fluid factors impacting vancomycin concentration at 24 h of treatment. We performed a prospective and retrospective observational monocentric study of NICU patients requiring a vancomycin treatment. We used a continuous infusion protocol, with age-appropriate loading and maintenance doses. Vancomycin target serum concentration after 24 h (C24h) was above 20 mg/L. Demographic, infections, and organ failure variables were analyzed as potential predictors of C24h. Over the study period, 70 infective episodes in 52 patients were included. At treatment initiation, the median post-natal age was 12.5 days (IQR 7-23), post menstrual age 30 weeks (IQR 28-35), and median weight 1140 g (IQR 835-1722). Germs isolated were mainly gram-positive with 73.5% being coagulase-negative Staphylococci. Median C24h was 18.7 mg/L (IQR 15.4-22.4). Overall, 41 (58.6%) treatments had a C24h < 20 mg/L. After multivariate analysis, higher creatinine level (OR 1.03 (95% CI 1.002-1.06)) was associated with C24h ≥ 20 mg/L; weight gain the day before infection (OR 0.21 (95% CI 0.05-0.79)) and positive biomarkers of inflammation (OR 0.22 (0.05-0.94)) were associated with C24h < 20 mg/L. CONCLUSION Vancomycin C24h was underdosed in 60% of patients and factors linked to changes in vancomycin pharmacokinetic such as volume of distribution and clearance, linked to creatinine level, inflammation, or weight gain, were identified. WHAT IS KNOWN • Adjustment of vancomycin regimen remains difficult due to inter- and intra-individual variability of vancomycin pharmacokinetics. • Impact of fluid status on vancomycin concentration in critically ill neonates is incompletely studied. WHAT IS NEW • Proportion of patients with adequate vancomycin concentration using a target adapted to nosocomial gram-positive bacteria MIC is low. • We confirmed the role of creatinine level and report two new factors associated with low vancomycin concentration: presence of systemic inflammation and weight gain.
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Risk Factors for Sepsis-Associated Acute Kidney Injury in the PICU: A Retrospective Cohort Study. Pediatr Crit Care Med 2022; 23:e366-e370. [PMID: 35435886 DOI: 10.1097/pcc.0000000000002957] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Acute kidney injury (AKI), particularly of greater severity and longer duration, is associated with increased morbidity and mortality in the pediatric population. AKI frequently occurs during sepsis, yet the knowledge of risk factors for sepsis-associated AKI in the PICU is limited. We aimed to identify risk factors for AKI that develops or persists after 72 hours from sepsis recognition in pediatric patients with severe sepsis. DESIGN Retrospective cohort study. SETTING PICU at an academic, tertiary-care center. PATIENTS Children greater than 1 month and less than or equal to 18 years with severe sepsis in the combined cardiac and medical/surgical PICU between December 1, 2013, and December 31, 2020, at the University of Virginia Children's Hospital. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The cohort included 124 patients with severe sepsis with 33 patients (27%) who were postcardiac surgery with cardiopulmonary bypass. AKI was defined by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. The primary outcome was severe AKI, defined as KDIGO stage 2 or 3 AKI present at any point between days 3 and 7 after sepsis recognition. Severe AKI was present in 25 patients (20%). Factors independently associated with severe AKI were maximum vasoactive-inotropic score (VIS) within 48 hours after sepsis recognition and fluid overload. The presence of severe AKI was associated with increased inhospital mortality. CONCLUSIONS In children with severe sepsis, the degree of hemodynamic support as measured by the VIS and the presence of fluid overload may identify patients at increased risk of developing severe AKI.
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