1
|
DeFreitas MJ, Griffin R, Sanderson K, Nada A, Charlton JR, Jetton JG, Kent AL, Guillet R, Askenazi D, Abitbol CL. Maternal Hypertension Disorders and Neonatal Acute Kidney Injury: Results from the AWAKEN Study. Am J Perinatol 2024; 41:649-659. [PMID: 35196719 PMCID: PMC10981551 DOI: 10.1055/a-1780-2249] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE This study aimed to examine the association between maternal hypertension (HTN) exposure and neonatal acute kidney injury (AKI). STUDY DESIGN Retrospective cohort study of 2,162 neonates admitted to 24 neonatal intensive care units (NICUs). Neonates were classified into the following exposure groups: any maternal HTN, chronic maternal HTN, preeclampsia/eclampsia, both, or neither. Demographics, clinical characteristics, and AKI status were compared using Chi-square and analysis of variance. General estimating logistic regression was used to estimate adjusted odds ratios and included a stratified analysis for site of delivery. RESULT Neonates exposed to any maternal HTN disorder had a tendency toward less overall and early AKI. When stratified by inborn versus outborn, exposure to both maternal HTN disorders was associated with a significantly reduced odds of early AKI only in the inborn neonates. CONCLUSION Exposure to maternal HTN, especially preeclampsia/eclampsia superimposed on chronic HTN, was associated with less likelihood of early AKI in the inborn group. KEY POINTS · Maternal HTN is associated with less neonatal AKI.. · Maternal HTN category is variably associated with AKI.. · Inborn status is an important contributor to this association..
Collapse
Affiliation(s)
- Marissa J. DeFreitas
- Department of Pediatrics, Division of Pediatric Nephrology, University of Miami/Holtz Children’s Hospital, Miami, Florida
| | - Russell Griffin
- Department of Epidemiology, University of Alabama Birmingham, Birmingham, Alabama
| | - Keia Sanderson
- Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina, Chapel Hill, North Carolina
| | - Arwa Nada
- Department of Pediatrics, Division of Nephrology & Hypertension Le Bonheur Children’s Hospital, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Jennifer R. Charlton
- Department of Pediatrics, Division of Nephrology, University of Virginia, Charlottesville, Virginia
| | - Jennifer G. Jetton
- Department of Pediatrics, Division of Nephrology, Dialysis and Transplantation, University of Iowa Stead Family Children’s Hospital, Iowa City, Iowa
| | - Alison L. Kent
- Department of Pediatrics, University of Rochester, Rochester, New York
- Department of Pediatrics, Australian National University, ACT, Australia
| | - Ronnie Guillet
- Department of Pediatrics, University of Rochester, Rochester, New York
| | - David Askenazi
- Department of Pediatrics, Division of Nephrology, University of Alabama Birmingham, Birmingham, Alabama
| | - Carolyn L. Abitbol
- Department of Pediatrics, Division of Pediatric Nephrology, University of Miami/Holtz Children’s Hospital, Miami, Florida
| |
Collapse
|
2
|
Gingrich AR, Hagenow AM, Steinbach EJ, Klein JM, Jetton JG, Misurac JM. Acute kidney injury surveillance in the high-risk neonatal population following implementation of creatinine screening protocol. Acta Paediatr 2024; 113:692-699. [PMID: 38084834 DOI: 10.1111/apa.17055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/19/2023] [Accepted: 11/28/2023] [Indexed: 03/12/2024]
Abstract
AIM Acute kidney injury (AKI) in neonates is associated with longer hospital stays and higher mortality rates. However, there is significant variability in prevalence rates of AKI and the true burden is incompletely understood. In November 2020, the University of Iowa Stead Family Children's Hospital Neonatal Intensive Care Unit implemented a creatinine screening protocol to enhance kidney function monitoring. We sought to evaluate adherence to the protocol to determine if increased surveillance led to increased detection of AKI events. METHODS A retrospective chart review was conducted for neonates born at <30 weeks' gestation admitted between 2015 and 2020. We reviewed 100 charts in both the pre (2015-2016) and post (2020-2021) implementation era of the AKI surveillance protocol. AKI was defined according to neonatal modified KDIGO criteria. RESULTS Following implementation of the protocol, neonates were significantly more likely to have creatinine checked (p < 0.001). Serum creatinine was drawn according to protocol guidelines 68% of the time, and 42% of patients (34/82) had an 80% or higher adherence to the protocol. There was a significant increase in detection of AKI in the post-protocol cohort (13/82, incidence of 16%) compared to the pre-protocol cohort (5/83, incidence of 6%), (p = 0.047). CONCLUSION The implementation of a serum creatinine screening protocol increased the frequency of creatinine draws and detection of AKI.
Collapse
Affiliation(s)
| | | | - Emily J Steinbach
- Stead Family Department of Pediatrics, Division of Nephrology, Dialysis, and Transplantation, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Jonathan M Klein
- Stead Family Department of Pediatrics, Division of Neonatology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Jennifer G Jetton
- Department of Pediatrics, Medical College of Wisconsin, Section of Pediatric Nephology, Milwaukee, Wisconsin, USA
| | - Jason M Misurac
- Stead Family Department of Pediatrics, Division of Nephrology, Dialysis, and Transplantation, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| |
Collapse
|
3
|
Segar JL, Jetton JG. Fluid and electrolyte management in the neonate and what can go wrong. Curr Opin Pediatr 2024; 36:198-203. [PMID: 37962361 PMCID: PMC10932865 DOI: 10.1097/mop.0000000000001308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
PURPOSE OF REVIEW This review highlights recent advances in understanding fluid and electrolyte homeostasis during the newborn period, including heightened recognition of fluid overload and acute kidney injury contributing to poor clinical outcomes. Particular attention is given towards the care of extremely preterm infants. RECENT FINDINGS Emerging data demonstrate (i) disproportionally large transepidermal water loss in the extremely preterm population, (ii) the relationship between postnatal weight loss (negative fluid balance) and improved outcomes, (iii) the frequency and negative effects of dysnatremias early in life, (iv) the role of sodium homeostasis in optimizing postnatal growth, and (v) the deleterious effects of fluid overload and acute kidney injury. SUMMARY As clinicians care for an increasing number of preterm infants, understanding progress in approaches to fluid and electrolyte management and avoidance of fluid overload states will improve the care and outcomes of this vulnerable population. Further translational and clinical studies are needed to address remaining knowledge gaps and improve current approaches to fluid and electrolyte management.
Collapse
Affiliation(s)
- Jeffrey L. Segar
- Sections of Neonatology, Department of Pediatrics, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI53226
| | - Jennifer G. Jetton
- Pediatric Nephrology, Department of Pediatrics, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI53226
| |
Collapse
|
4
|
Garg PM, Pittman IA, Ansari MAY, Yen CW, Riddick R, Jetton JG, South AM, Hillegass WB. Gestational age-specific clinical correlates of acute kidney injury in preterm infants with necrotizing enterocolitis. Pediatr Res 2023; 94:2016-2025. [PMID: 37454184 PMCID: PMC10937190 DOI: 10.1038/s41390-023-02736-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 06/02/2023] [Accepted: 06/26/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND To study the gestational age-specific risk factors and outcomes of severe acute kidney injury (AKI) in neonates with necrotizing enterocolitis (NEC). METHODS Retrospective cohort study comparing gestational age (GA)-specific clinical data between infants without severe AKI (stage 0/1 AKI) and those with severe AKI (stages 2 and 3 AKI) stratified by GA ≤27 and >27 weeks. RESULTS Infants with GA ≤27 weeks had double the rate of severe AKI (46.3% vs. 20%). In infants with GA >27 weeks, male sex, outborn, and nephrotoxic medication exposure were associated with severe AKI. On multivariable logistic regression, in infants with GA ≤27 weeks, surgical NEC (OR 35.08 (CI 5.05, 243.73), p < 0.001) and ostomy (OR 6.2(CI 1.29, 29.73), p = 0.027) were associated with significantly higher odds of severe AKI. Surgical NEC infants with GA >27 weeks and severe AKI were significantly more likely to be outborn, have later NEC onset, need dopamine, and have longer hospitalization (158 days [110; 220] vs.75.5 days [38.8; 105]; p = 0.007 than those with non-severe AKI. CONCLUSION In neonates with NEC, surgical intervention was associated with moderate-to-severe AKI in infants with GA ≤27 weeks and with longer hospitalization in infants with GA >27 weeks. IMPACT In both cohorts need for surgery, stoma, cholestasis, and mechanical ventilation were associated with severe AKI; however, the infants with GA <27 weeks had twice the risk of severe AKI than GA >27 weeks group. The longer exposure to nephrotoxic medication and referral need were significant risk factors for AKI in GA >27 weeks group. GA-specific kidney protective and monitoring strategies to prevent AKI and its consequences are needed to improve the clinical outcomes in neonates with NEC. Understanding the risk factors and short- and long-term outcomes unique to different GA groups will help inform those strategies.
Collapse
Affiliation(s)
- Parvesh Mohan Garg
- Department of Pediatrics/Neonatology, Atrium Health Wake Forest Baptist Hospital, Wake Forest University School of Medicine, Winston Salem, NC, USA.
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS, USA.
| | - Isabella A Pittman
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Md Abu Yusuf Ansari
- Department of Data Sciences, University of Mississippi Medical Center, Jackson, MS, USA
| | - Chin Wen Yen
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Robbin Riddick
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Jennifer G Jetton
- Section of Pediatric Nephrology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Andrew M South
- Department of Pediatrics-Section of Nephrology, Brenner Children's, Wake Forest University School of Medicine, Winston Salem, NC, USA
| | - William B Hillegass
- Department of Data Sciences, University of Mississippi Medical Center, Jackson, MS, USA
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| |
Collapse
|
5
|
Pettit KA, Selewski DT, Askenazi DJ, Basu RK, Bridges BC, Cooper DS, Fleming GM, Gien J, Gorga SM, Jetton JG, King EC, Steflik HJ, Paden ML, Sahay RD, Zappitelli M, Gist KM. Synergistic association of fluid overload and acute kidney injury on outcomes in pediatric cardiac ECMO: a retrospective analysis of the KIDMO database. Pediatr Nephrol 2023; 38:1343-1353. [PMID: 35943578 DOI: 10.1007/s00467-022-05708-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 07/25/2022] [Accepted: 07/26/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) and fluid overload (FO) are associated with poor outcomes in children receiving extracorporeal membrane oxygenation (ECMO). Our objective is to evaluate the impact of AKI and FO on pediatric patients receiving ECMO for cardiac pathology. METHODS We performed a secondary analysis of the six-center Kidney Interventions During Extracorporeal Membrane Oxygenation (KIDMO) database, including only children who underwent ECMO for cardiac pathology. AKI was defined using Kidney Disease: Improving Global Outcomes (KDIGO) creatinine criteria. FO was defined as < 10% (FO-) vs. ≥ 10% (FO +) and was evaluated at ECMO initiation, peak during ECMO, and ECMO discontinuation. Primary outcomes were mortality and length of stay (LOS). RESULTS Data from 191 patients were included. Non-survivors (56%) were more likely to be FO + than survivors at peak ECMO fluid status and ECMO discontinuation. There was a significant interaction between AKI and FO. In the presence of AKI, the adjusted odds of mortality for FO + was 4.79 times greater than FO- (95% CI: 1.52-15.12, p = 0.01). In the presence of FO + , the adjusted odds of mortality for AKI + was 2.7 times higher than AKI- [95%CI: 1.10-6.60; p = 0.03]. Peak FO + was associated with a 55% adjusted relative increase in LOS [95%CI: 1.07-2.26, p = 0.02]. CONCLUSIONS The association of peak FO + with mortality is present only in the presence of AKI + . Similarly, AKI + is associated with mortality only in the presence of peak FO + . FO + was associated with LOS. Studies targeting fluid management have the potential to improve LOS and mortality outcomes. A higher resolution version of the Graphical abstract is available as Supplementary information.
Collapse
Affiliation(s)
- Kevin A Pettit
- Department of Pediatrics, Children's Hospital of Colorado, University of Colorado Anschutz Medical Campus, 13123 E 16th Ave, B100, Aurora, CO, 80045, USA.
| | - David T Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - David J Askenazi
- Department of Pediatrics, University of Alabama Birmingham, Birmingham, AL, USA
| | - Rajit K Basu
- Division of Critical Care Medicine, Lurie Children's Hospital, Chicago, IL, USA
| | - Brian C Bridges
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - David S Cooper
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Geoffrey M Fleming
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Jason Gien
- Department of Pediatrics, Children's Hospital of Colorado, University of Colorado Anschutz Medical Campus, 13123 E 16th Ave, B100, Aurora, CO, 80045, USA
| | - Stephen M Gorga
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jennifer G Jetton
- Divison of Nephrology, Dialysis and Transplantation, Stead Family Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, IO, USA
| | - Eileen C King
- Divison of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Heidi J Steflik
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Matthew L Paden
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Rashmi D Sahay
- Divison of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Michael Zappitelli
- Department of Pediatrics, Toronto Hospital for Sick Children, Toronto Canada and McGill University Health Centre, Montreal, Canada
| | - Katja M Gist
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| |
Collapse
|
6
|
Mohamed TH, Morgan J, Mottes TA, Askenazi D, Jetton JG, Menon S. Kidney support for babies: building a comprehensive and integrated neonatal kidney support therapy program. Pediatr Nephrol 2022:10.1007/s00467-022-05768-y. [PMID: 36227440 DOI: 10.1007/s00467-022-05768-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 08/01/2022] [Accepted: 09/08/2022] [Indexed: 11/26/2022]
Abstract
Kidney support therapy (KST), previously referred to as Renal Replacement Therapy, is utilized to treat children and adults with severe acute kidney injury (AKI), fluid overload, inborn errors of metabolism, and kidney failure. Several forms of KST are available including peritoneal dialysis (PD), intermittent hemodialysis (iHD), and continuous kidney support therapy (CKST). Traditionally, extracorporeal KST (CKST and iHD) in neonates has had unique challenges related to small patient size, lack of neonatal-specific devices, and risk of hemodynamic instability due to large extracorporeal circuit volume relative to patient total blood volume. Thus, PD has been the most commonly used modality in infants, followed by CKST and iHD. In recent years, CKST machines designed for small children and novel filters with smaller extracorporeal circuit volumes have emerged and are being used in many centers to provide neonatal KST for toxin removal and to achieve fluid and electrolyte homeostasis, increasing the options available for this unique and vulnerable group. These new treatment options create a dramatic paradigm shift with recalibration of the benefit: risk equation. Renewed focus on the infrastructure required to deliver neonatal KST safely and effectively is essential, especially in programs/units that do not traditionally provide KST to neonates. Building and implementing a neonatal KST program requires an expert multidisciplinary team with strong institutional support. In this review, we first describe the available neonatal KST modalities including newer neonatal and infant-specific platforms. Then, we describe the steps needed to develop and sustain a neonatal KST team, including recommendations for provider and nursing staff training. Finally, we describe how quality improvement initiatives can be integrated into programs.
Collapse
Affiliation(s)
- Tahagod H Mohamed
- Division of Nephrology and Hypertension, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA.
- The Kidney and Urinary Tract Center, Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH, 430205, USA.
| | - Jolyn Morgan
- The Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Theresa A Mottes
- Division of Nephrology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - David Askenazi
- Pediatric and Infant Center for Acute Nephrology, Division of Pediatric Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jennifer G Jetton
- Section of Nephrology, Medical College of Wisconsin/Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Shina Menon
- Division of Pediatric Nephrology, Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, WA, USA
| |
Collapse
|
7
|
Goldstein SL, Akcan-Arikan A, Alobaidi R, Askenazi DJ, Bagshaw SM, Barhight M, Barreto E, Bayrakci B, Bignall ONR, Bjornstad E, Brophy PD, Chanchlani R, Charlton JR, Conroy AL, Deep A, Devarajan P, Dolan K, Fuhrman DY, Gist KM, Gorga SM, Greenberg JH, Hasson D, Ulrich EH, Iyengar A, Jetton JG, Krawczeski C, Meigs L, Menon S, Morgan J, Morgan CJ, Mottes T, Neumayr TM, Ricci Z, Selewski D, Soranno DE, Starr M, Stanski NL, Sutherland SM, Symons J, Tavares MS, Vega MW, Zappitelli M, Ronco C, Mehta RL, Kellum J, Ostermann M, Basu RK. Consensus-Based Recommendations on Priority Activities to Address Acute Kidney Injury in Children: A Modified Delphi Consensus Statement. JAMA Netw Open 2022; 5:e2229442. [PMID: 36178697 PMCID: PMC9756303 DOI: 10.1001/jamanetworkopen.2022.29442] [Citation(s) in RCA: 59] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE Increasing evidence indicates that acute kidney injury (AKI) occurs frequently in children and young adults and is associated with poor short-term and long-term outcomes. Guidance is required to focus efforts related to expansion of pediatric AKI knowledge. OBJECTIVE To develop expert-driven pediatric specific recommendations on needed AKI research, education, practice, and advocacy. EVIDENCE REVIEW At the 26th Acute Disease Quality Initiative meeting conducted in November 2021 by 47 multiprofessional international experts in general pediatrics, nephrology, and critical care, the panel focused on 6 areas: (1) epidemiology; (2) diagnostics; (3) fluid overload; (4) kidney support therapies; (5) biology, pharmacology, and nutrition; and (6) education and advocacy. An objective scientific review and distillation of literature through September 2021 was performed of (1) epidemiology, (2) risk assessment and diagnosis, (3) fluid assessment, (4) kidney support and extracorporeal therapies, (5) pathobiology, nutrition, and pharmacology, and (6) education and advocacy. Using an established modified Delphi process based on existing data, workgroups derived consensus statements with recommendations. FINDINGS The meeting developed 12 consensus statements and 29 research recommendations. Principal suggestions were to address gaps of knowledge by including data from varying socioeconomic groups, broadening definition of AKI phenotypes, adjudicating fluid balance by disease severity, integrating biopathology of child growth and development, and partnering with families and communities in AKI advocacy. CONCLUSIONS AND RELEVANCE Existing evidence across observational study supports further efforts to increase knowledge related to AKI in childhood. Significant gaps of knowledge may be addressed by focused efforts.
Collapse
Affiliation(s)
- Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ayse Akcan-Arikan
- Division of Critical Care Medicine and Nephrology, Texas Children's Hospital, Baylor College of Medicine, Houston
| | - Rashid Alobaidi
- Alberta Health Sciences University, Edmonton, Alberta, Canada
| | | | - Sean M Bagshaw
- Alberta Health Sciences University, Edmonton, Alberta, Canada
| | - Matthew Barhight
- Ann & Robert Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | | | - Benan Bayrakci
- Department of Pediatric Intensive Care Medicine, Life Support Center, Hacettepe University, Ankara, Turkey
| | | | | | - Patrick D Brophy
- Golisano Children's Hospital, Rochester University Medical Center, Rochester, New York
| | | | | | | | - Akash Deep
- King's College London, London, United Kingdom
| | - Prasad Devarajan
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kristin Dolan
- Mercy Children's Hospital Kansas City, Kansas City, Missouri
| | - Dana Y Fuhrman
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Katja M Gist
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Stephen M Gorga
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor
| | | | - Denise Hasson
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Arpana Iyengar
- St John's Academy of Health Sciences, Bangalore, Karnataka, India
| | | | | | - Leslie Meigs
- Stead Family Children's Hospital, The University of Iowa, Iowa City
| | - Shina Menon
- Seattle Children's Hospital, Seattle, Washington
| | - Jolyn Morgan
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Theresa Mottes
- Ann & Robert Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | - Tara M Neumayr
- Washington University School of Medicine, St Louis, Missouri
| | | | | | | | - Michelle Starr
- Riley Children's Hospital, Indiana University, Bloomington
| | - Natalja L Stanski
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Scott M Sutherland
- Lucille Packard Children's Hospital, Stanford University, Stanford, California
| | | | | | - Molly Wong Vega
- Division of Nephrology, Texas Children's Hospital, Baylor College of Medicine, Houston
| | | | - Claudio Ronco
- Universiti di Padova, San Bartolo Hospital, Vicenza, Italy
| | | | - John Kellum
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Rajit K Basu
- Ann & Robert Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | | |
Collapse
|
8
|
Chmielewski J, Chaudhry PM, Harer MW, Menon S, South AM, Chappell A, Griffin R, Askenazi D, Jetton J, Starr MC, Selewski DT, Sarkar S, Kent A, Fletcher J, Abitbol CL, DeFreitas M, Duara S, Charlton JR, Swanson JR, Guillet R, D’Angio C, Mian A, Rademacher E, Mhanna MJ, Raina R, Kumar D, Jetton JG, Brophy PD, Colaizy TT, Klein JM, Arikan AA, Rhee CJ, Goldstein SL, Nathan AT, Kupferman JC, Bhutada A, Rastogi S, Bonachea E, Ingraham S, Mahan J, Nada A, Cole FS, Davis TK, Dower J, Milner L, Smith A, Fuloria M, Reidy K, Kaskel FJ, Soranno DE, Gien J, Gist KM, Chishti AS, Hanna MH, Hingorani S, Juul S, Wong CS, Joseph C, DuPont T, Ohls R, Staples A, Rohatgi S, Sethi SK, Wazir S, Khokhar S, Perazzo S, Ray PE, Revenis M, Mammen C, Synnes A, Wintermark P, Zappitelli M, Woroniecki R, Sridhar S. Documentation of acute kidney injury at discharge from the neonatal intensive care unit and role of nephrology consultation. J Perinatol 2022; 42:930-936. [PMID: 35676535 PMCID: PMC9280854 DOI: 10.1038/s41372-022-01424-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 04/29/2022] [Accepted: 05/27/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To investigate whether NICU discharge summaries documented neonatal AKI and estimate if nephrology consultation mediated this association. STUDY DESIGN Secondary analysis of AWAKEN multicenter retrospective cohort. EXPOSURES AKI severity and diagnostic criteria. OUTCOME AKI documentation on NICU discharge summaries using multivariable logistic regression to estimate associations and test for causal mediation. RESULTS Among 605 neonates with AKI, 13% had documented AKI. Those with documented AKI were more likely to have severe AKI (70.5% vs. 51%, p < 0.001) and SCr-only AKI (76.9% vs. 50.1%, p = 0.04). Nephrology consultation mediated 78.0% (95% CL 46.5-109.4%) of the total effect of AKI severity and 82.8% (95% CL 70.3-95.3%) of the total effect of AKI diagnostic criteria on documentation. CONCLUSION We report a low prevalence of AKI documentation at NICU discharge. AKI severity and SCr-only AKI increased odds of AKI documentation. Nephrology consultation mediated the associations of AKI severity and diagnostic criteria with documentation.
Collapse
Affiliation(s)
- Jennifer Chmielewski
- Department of Pediatrics, Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Paulomi M. Chaudhry
- Department of Pediatrics, Division of Neonatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Matthew W. Harer
- Department of Pediatrics, Division of Neonatology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Shina Menon
- Division of Nephrology, University of Washington and Seattle Children’s Hospital, Seattle, WA, USA
| | - Andrew M. South
- Department of Pediatrics, Section of Nephrology, Brenner Children’s, Wake Forest School of Medicine, Winston Salem, NC, USA.,Division of Public Health Sciences, Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Ashley Chappell
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Russell Griffin
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David Askenazi
- Department of Pediatrics, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jennifer Jetton
- Division of Nephrology, Dialysis and Transplantation, Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Michelle C. Starr
- Department of Pediatrics, Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA.,Pediatric and Adolescent Comparative Effectiveness Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA.,Correspondence and requests for materials should be addressed to Michelle C. Starr.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Gist KM, Misfeldt A, Sahay RD, Gorga SM, Askenazi DJ, Bridges BC, Paden ML, Zappitelli M, Gien J, Basu RK, Jetton JG, Murphy HJ, King E, Fleming GM, Selewski DT, Cooper DS. Acute Kidney Injury and Fluid Overload in Pediatric Extracorporeal Cardio-Pulmonary Resuscitation: A Multicenter Retrospective Cohort Study. ASAIO J 2022; 68:956-963. [PMID: 34643574 DOI: 10.1097/mat.0000000000001601] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Acute kidney injury (AKI) and fluid overload (FO) are common complications of extracorporeal membrane oxygenation (ECMO). The purpose of this study was to characterize AKI and FO in children receiving extracorporeal cardiopulmonary resuscitation (eCPR). We performed a multicenter retrospective study of children who received eCPR. AKI was assessed during ECMO and FO defined as <10% [FO-] vs. ≥10% [FO+] evaluated at ECMO initiation and discontinuation. A composite exposure, defined by a four-group discrete phenotypic classification [FO-/AKI-, FO-/AKI+, FO+/AKI-, FO+/AKI+] was also evaluated. Primary outcome was mortality and hospital length of stay (LOS) among survivors. 131 patients (median age 29 days (IQR:9, 242 days); 51% men and 82% with underlying cardiac disease) were included. 45.8% survived hospital discharge. FO+ at ECMO discontinuation, but not AKI was associated with mortality [aOR=2.3; 95% CI: 1.07-4.91]. LOS for FO+ patients was twice as long as FO- patients, irrespective of AKI status [(FO+/AKI+ (60 days; IQR: 49-83) vs. FO-/AKI+ (30 days, IQR: 19-48 days); P = 0.01]. FO+ at ECMO initiation and discontinuation was associated with an adjusted 66% and 50% longer length of stay respectively. Prospective studies that target timing and strategy of fluid management, including its removal in children receiving ECPR are greatly needed.
Collapse
Affiliation(s)
- Katja M Gist
- From the Department of Pediatrics, Children's Hospital of Colorado University of Colorado Anschutz Medical Campus Aurora, Colorado
| | - Andrew Misfeldt
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Rashmi D Sahay
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Stephen M Gorga
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan
| | - David J Askenazi
- Department of Pediatrics, University of Alabama Birmingham, Birmingham, Alabama
| | - Brian C Bridges
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Matthew L Paden
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Michael Zappitelli
- Department of Pediatrics, Toronto Hospital for Sick Children, Toronto, Canada and McGill University Health Centre, Montreal, Canada
| | - Jason Gien
- From the Department of Pediatrics, Children's Hospital of Colorado University of Colorado Anschutz Medical Campus Aurora, Colorado
| | - Rajit K Basu
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jennifer G Jetton
- Division of Nephrology, Dialysis and Transplantation, Stead Family Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, Iowa
| | - Heidi J Murphy
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Eileen King
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Geoffrey M Fleming
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
- Deceased
| | - David T Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - David S Cooper
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| |
Collapse
|
10
|
Segar J, Jetton JG. Diuretic use, acute kidney injury, and premature infants: the call for evidence-based guidelines. Pediatr Nephrol 2021; 36:3807-3811. [PMID: 34258644 DOI: 10.1007/s00467-021-05201-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 06/23/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Jeffrey Segar
- Departments of Pediatrics and Physiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jennifer G Jetton
- Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA, USA.
| |
Collapse
|
11
|
Starr MC, Charlton JR, Guillet R, Reidy K, Tipple TE, Jetton JG, Kent AL, Abitbol CL, Ambalavanan N, Mhanna MJ, Askenazi DJ, Selewski DT, Harer MW. Advances in Neonatal Acute Kidney Injury. Pediatrics 2021; 148:peds.2021-051220. [PMID: 34599008 DOI: 10.1542/peds.2021-051220] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/13/2021] [Indexed: 01/14/2023] Open
Abstract
In this state-of-the-art review, we highlight the major advances over the last 5 years in neonatal acute kidney injury (AKI). Large multicenter studies reveal that neonatal AKI is common and independently associated with increased morbidity and mortality. The natural course of neonatal AKI, along with the risk factors, mitigation strategies, and the role of AKI on short- and long-term outcomes, is becoming clearer. Specific progress has been made in identifying potential preventive strategies for AKI, such as the use of caffeine in premature neonates, theophylline in neonates with hypoxic-ischemic encephalopathy, and nephrotoxic medication monitoring programs. New evidence highlights the importance of the kidney in "crosstalk" between other organs and how AKI likely plays a critical role in other organ development and injury, such as intraventricular hemorrhage and lung disease. New technology has resulted in advancement in prevention and improvements in the current management in neonates with severe AKI. With specific continuous renal replacement therapy machines designed for neonates, this therapy is now available and is being used with increasing frequency in NICUs. Moving forward, biomarkers, such as urinary neutrophil gelatinase-associated lipocalin, and other new technologies, such as monitoring of renal tissue oxygenation and nephron counting, will likely play an increased role in identification of AKI and those most vulnerable for chronic kidney disease. Future research needs to be focused on determining the optimal follow-up strategy for neonates with a history of AKI to detect chronic kidney disease.
Collapse
Affiliation(s)
- Michelle C Starr
- Division of Pediatric Nephrology, Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, Indiana
| | - Jennifer R Charlton
- Division of Nephrology, Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Ronnie Guillet
- Division of Neonatology, Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, New York
| | - Kimberly Reidy
- Division of Pediatric Nephrology, Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
| | - Trent E Tipple
- Section of Neonatal-Perinatal Medicine, Department of Pediatrics, College of Medicine, The University of Oklahoma, Oklahoma City, Oklahoma
| | - Jennifer G Jetton
- Division of Nephrology, Dialysis, and Transplantation, Stead Family Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, Iowa
| | - Alison L Kent
- Division of Neonatology, Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, New York.,College of Health and Medicine, The Australian National University, Canberra, Australia Capitol Territory, Australia
| | - Carolyn L Abitbol
- Division of Pediatric Nephrology, Department of Pediatrics, Miller School of Medicine, University of Miami and Holtz Children's Hospital, Miami, Florida
| | | | - Maroun J Mhanna
- Department of Pediatrics, Louisiana State University Shreveport, Shreveport, Louisiana
| | - David J Askenazi
- Nephrology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - David T Selewski
- Division of Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | | | | |
Collapse
|
12
|
Stanford AH, Reyes M, Rios DR, Giesinger RE, Jetton JG, Bischoff AR, McNamara PJ. Safety, Feasibility, and Impact of Enalapril on Cardiorespiratory Physiology and Health in Preterm Infants with Systemic Hypertension and Left Ventricular Diastolic Dysfunction. J Clin Med 2021; 10:jcm10194519. [PMID: 34640535 PMCID: PMC8509219 DOI: 10.3390/jcm10194519] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 09/23/2021] [Accepted: 09/25/2021] [Indexed: 11/16/2022] Open
Abstract
Neonatal hypertension has been increasingly recognized in premature infants with bronchopulmonary dysplasia (BPD); of note, a sub-population of these infants may have impaired left ventricular (LV) diastolic function, warranting timely treatment to minimize long term repercussions. In this case series, enalapril, an angiotensin-converting enzyme (ACE) inhibitor, was started in neonates with systemic hypertension and echocardiography signs of LV diastolic dysfunction. A total of 11 patients were included with birth weight of 785 ± 239 grams and gestational age of 25.3 (24, 26.1) weeks. Blood pressure improvement was noticed within 2 weeks of treatment. Improvement in LV diastolic function indices were observed with a reduction in Isovolumic Relaxation Time (IVRT) from 63.1 ± 7.2 to 50.9 ± 7.4 msec and improvement in the left atrium size indexed to aorta (LA:Ao) from1.73 (1.43, 1.88) to 1.23 (1.07, 1.29). Neonatal systemic hypertension is often underappreciated in ex-preterm infants and may be associated with important maladaptive cardiac changes with long term implications. It is biologically plausible that identifying and treating LV diastolic dysfunction in neonates with systemic hypertension may have a positive modulator effect on cardiovascular health in childhood and beyond.
Collapse
Affiliation(s)
- Amy H. Stanford
- Division of Neonatology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA; (A.H.S.); (M.R.); (D.R.R.); (R.E.G.); (A.R.B.)
| | - Melanie Reyes
- Division of Neonatology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA; (A.H.S.); (M.R.); (D.R.R.); (R.E.G.); (A.R.B.)
| | - Danielle R. Rios
- Division of Neonatology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA; (A.H.S.); (M.R.); (D.R.R.); (R.E.G.); (A.R.B.)
| | - Regan E. Giesinger
- Division of Neonatology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA; (A.H.S.); (M.R.); (D.R.R.); (R.E.G.); (A.R.B.)
| | - Jennifer G. Jetton
- Division of Pediatric Nephrology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA;
| | - Adrianne R. Bischoff
- Division of Neonatology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA; (A.H.S.); (M.R.); (D.R.R.); (R.E.G.); (A.R.B.)
| | - Patrick J. McNamara
- Division of Neonatology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA; (A.H.S.); (M.R.); (D.R.R.); (R.E.G.); (A.R.B.)
- Department of Internal Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA
- Correspondence: ; Tel.: +1-319-467-7435
| |
Collapse
|
13
|
Abstract
The study of neonatal acute kidney injury (AKI) has transitioned from small, single-center studies to the development of a large, multicenter cohort. The scope of research has expanded from assessment of incidence and mortality to analysis of more specific risk factors, novel urinary biomarkers, interplay between AKI and other organ systems, impact of fluid overload, and quality improvement efforts. The intensification has occurred through collaboration between the neonatology and nephrology communities. This review discusses 2 case scenarios to illustrate the clinical presentation of neonatal AKI, important risk factors, and approaches to minimize AKI events and adverse long-term outcomes.
Collapse
Affiliation(s)
- Keegan J Kavanaugh
- Stead Family Department of Pediatrics, University of Iowa, 200 Hawkins Drive, 2015-26 BT, Iowa City, IA 52241, USA
| | - Jennifer G Jetton
- Division of Pediatric Nephrology, Dialysis, and Transplantation, Stead Family Department of Pediatrics, University of Iowa, 200 Hawkins Drive, 2029 BT, Iowa City, IA 52241, USA.
| | - Alison L Kent
- Division of Neonatology, Golisano Children's Hospital, University of Rochester School of Medicine, 601 Elmwood Avenue, Box 651, Rochester, NY 14642, USA; College of Health and Medicine, Australian National University, Canberra, Australian Capital Territory 2601, Australia. https://twitter.com/Aussiekidney
| |
Collapse
|
14
|
Selewski DT, Askenazi DJ, Kashani K, Basu RK, Gist KM, Harer MW, Jetton JG, Sutherland SM, Zappitelli M, Ronco C, Goldstein SL, Mottes TA. Quality improvement goals for pediatric acute kidney injury: pediatric applications of the 22nd Acute Disease Quality Initiative (ADQI) conference. Pediatr Nephrol 2021; 36:733-746. [PMID: 33433708 DOI: 10.1007/s00467-020-04828-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 09/24/2020] [Accepted: 10/15/2020] [Indexed: 02/07/2023]
Affiliation(s)
- David T Selewski
- Department of Pediatric, Medical University of South Carolina, 96 Jonathan Lucas St, CSB 428 MSC 608, Charleston, SC, 29425, USA.
| | - David J Askenazi
- Department of Pediatrics, University of Alabama Birmingham, Birmingham, AL, USA
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rajit K Basu
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Katja M Gist
- Department of Pediatrics, Children's Hospital of Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Matthew W Harer
- Division of Neonatology, Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Jennifer G Jetton
- Division of Nephrology, Dialysis, and Transplantation, Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Scott M Sutherland
- Department of Pediatrics, Division of Nephrology, Stanford University, Stanford, CA, USA
| | - Michael Zappitelli
- Department of Pediatrics, Toronto Hospital for Sick Children, Toronto, Canada
| | - Claudio Ronco
- Department of Medicine, Department. Nephrology Dialysis & Transplantation, International Renal Research Institute, San Bortolo Hospital, University of Padova, Vicenza, Italy
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | |
Collapse
|
15
|
Murphy HJ, Gien J, Sahay R, King E, Selewski DT, Bridges BC, Cooper DS, Fleming GM, Paden ML, Zappitelli M, Gist KM, Basu RK, Jetton JG, Askenazi D. Acute Kidney Injury, Fluid Overload, and Renal Replacement Therapy Differ by Underlying Diagnosis in Neonatal Extracorporeal Support and Impact Mortality Disparately. Blood Purif 2021; 50:808-817. [PMID: 33461205 DOI: 10.1159/000512538] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 10/23/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION We aimed to characterize acute kidney injury (AKI), fluid overload (FO), and renal replacement therapy (RRT) utilization by diagnostic categories and examine associations between these complications and mortality by category. METHODS To test our hypotheses, we conducted a retrospective multicenter, cohort study including 446 neonates (categories: 209 with cardiac disease, 114 with congenital diaphragmatic hernia [CDH], 123 with respiratory disease) requiring extracorporeal membrane oxygenation (ECMO) between January 1, 2007, and December 31, 2011. RESULTS AKI, FO, and RRT each varied by diagnostic category. AKI and RRT receipt were most common in those neonates with cardiac disease. Subjects with CDH had highest peak %FO (51% vs. 28% cardiac vs. 32% respiratory; p < 0.01). Hospital survival was 55% and varied by diagnostic category (45% cardiac vs. 48% CDH vs. 79% respiratory; p < 0.001). A significant interaction suggested risk of mortality differed by diagnostic category in the presence or absence of AKI. In its absence, diagnosis of CDH (vs. respiratory disease) (OR 3.04, 95% CL 1.14-8.11) independently predicted mortality. In all categories, peak %FO (OR 1.20, 95% CL 1.11-1.30) and RRT receipt (OR 2.12, 95% CL 1.20-3.73) were independently associated with mortality. DISCUSSION/CONCLUSIONS Physiologically distinct ECMO diagnoses warrant individualized treatment strategies given variable incidence and effects of AKI, FO, and RRT by category on mortality.
Collapse
Affiliation(s)
- Heidi J Murphy
- Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA,
| | - Jason Gien
- Pediatrics, University of Colorado, Denver, Colorado, USA
| | - Rashmi Sahay
- Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Eileen King
- Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - David T Selewski
- Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Brian C Bridges
- Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - David S Cooper
- Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Geoffrey M Fleming
- Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | | | - Michael Zappitelli
- Pediatrics, Toronto Hospital for Sick Children, Toronto, Ontario, Canada
| | - Katja M Gist
- Pediatrics, University of Colorado, Denver, Colorado, USA
| | - Rajit K Basu
- Pediatrics, Emory University, Atlanta, Georgia, USA
| | | | - David Askenazi
- Pediatrics, University of Alabama Birmingham, Birmingham, Alabama, USA
| |
Collapse
|
16
|
Rutledge A, Murphy HJ, Harer MW, Jetton JG. Fluid Balance in the Critically Ill Child Section: "How Bad Is Fluid in Neonates?". Front Pediatr 2021; 9:651458. [PMID: 33959572 PMCID: PMC8093499 DOI: 10.3389/fped.2021.651458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 03/15/2021] [Indexed: 12/16/2022] Open
Abstract
Fluid overload (FO) in neonates is understudied, and its management requires nuanced care and an understanding of the complexity of neonatal fluid dynamics. Recent studies suggest neonates are susceptible to developing FO, and neonatal fluid balance is impacted by multiple factors including functional renal immaturity in the newborn period, physiologic postnatal diuresis and weight loss, and pathologies that require fluid administration. FO also has a deleterious impact on other organ systems, particularly the lung, and appears to impact survival. However, assessing fluid balance in the postnatal period can be challenging, particularly in extremely low birth weight infants (ELBWs), given the confounding role of maternal serum creatinine (Scr), physiologic weight changes, insensible losses that can be difficult to quantify, and difficulty in obtaining accurate intake and output measurements given mixed diaper output. Although significant FO may be an indication for kidney replacement therapy (KRT) in older children and adults, KRT may not be technically feasible in the smallest infants and much remains to be learned about optimal KRT utilization in neonates. This article, though not a meta-analysis or systematic review, presents a comprehensive review of the current evidence describing the effects of FO on outcomes in neonates and highlights areas where additional research is needed.
Collapse
Affiliation(s)
- Austin Rutledge
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - Heidi J Murphy
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - Matthew W Harer
- Department of Pediatrics (Neonatology), University of Wisconsin, Madison, WI, United States
| | - Jennifer G Jetton
- Stead Family Department of Pediatrics (Nephrology), University of Iowa Health Care, Iowa City, IA, United States
| |
Collapse
|
17
|
Murphy HJ, Thomas B, Van Wyk B, Tierney SB, Selewski DT, Jetton JG. Nephrotoxic medications and acute kidney injury risk factors in the neonatal intensive care unit: clinical challenges for neonatologists and nephrologists. Pediatr Nephrol 2020; 35:2077-2088. [PMID: 31605211 DOI: 10.1007/s00467-019-04350-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 08/21/2019] [Accepted: 09/02/2019] [Indexed: 02/07/2023]
Abstract
Neonatal acute kidney injury (AKI) is common. Critically ill neonates are at risk for AKI for many reasons including the severity of their underlying illnesses, prematurity, and nephrotoxic medications. In this educational review, we highlight four clinical scenarios in which both the illness itself and the medications indicated for their treatment are risk factors for AKI: sepsis, perinatal asphyxia, patent ductus arteriosus, and necrotizing enterocolitis. We review the available evidence regarding medications commonly used in the neonatal period with known nephrotoxic potential, including gentamicin, acyclovir, indomethacin, vancomycin, piperacillin-tazobactam, and amphotericin. We aim to illustrate the complexity of decision-making involved for both neonatologists and pediatric nephrologists when managing infants with these conditions and advocate for ongoing multidisciplinary collaboration in the development of better AKI surveillance protocols and AKI mitigation strategies to improve care for these vulnerable patients.
Collapse
Affiliation(s)
- Heidi J Murphy
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Brady Thomas
- Stead Family Department of Pediatrics, Division of Neonatology, University of Iowa, Iowa City, IA, USA
| | - Brynna Van Wyk
- Stead Family Department of Pediatrics, Division of Nephrology, Dialysis, and Transplantation, University of Iowa, 200 Hawkins Drive, 2027 BT, Iowa City, IA, 52241, USA
| | - Sarah B Tierney
- Department of Pharmaceutical Care, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - David T Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Jennifer G Jetton
- Stead Family Department of Pediatrics, Division of Nephrology, Dialysis, and Transplantation, University of Iowa, 200 Hawkins Drive, 2027 BT, Iowa City, IA, 52241, USA.
| |
Collapse
|
18
|
Thomas CP, Freese ME, Ounda A, Jetton JG, Holida M, Noureddine L, Smith RJ. Correction: Initial experience from a renal genetics clinic demonstrates a distinct role in patient management. Genet Med 2020; 23:2017-2019. [PMID: 33024316 PMCID: PMC8486658 DOI: 10.1038/s41436-020-01000-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Christie P Thomas
- Departments of Internal Medicine, University of Iowa, Iowa City, IA, USA. .,Departments of Pediatrics, University of Iowa, Iowa City, IA, USA. .,Veterans Affairs Medical Center, Iowa City, IA, USA.
| | - Margaret E Freese
- Departments of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - Agnes Ounda
- Departments of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | | | - Myrl Holida
- Departments of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Lama Noureddine
- Departments of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - Richard J Smith
- Departments of Internal Medicine, University of Iowa, Iowa City, IA, USA.,Departments of Pediatrics, University of Iowa, Iowa City, IA, USA.,The Iowa Institute of Human Genetics, University of Iowa, Iowa City, IA, USA
| |
Collapse
|
19
|
Steinbach EJ, Monga V, Furqan M, Laux DE, Zepeda-Orozco D, Jetton JG, Saunders D, Dunlap N, Curtis A, Fairbanks R, Bell S, Anderson CM, Beardsley RA, Holmlund J, Spitz D, Allen BG. Effects of GC4419 (avasopasem manganese) on chronic kidney disease in head and neck cancer patients treated with radiation and cisplatin. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.12071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
12071 Background: Nephrotoxicity is a major complication of platinum-based chemotherapy and ranges in incidence from 31-68%. The effects of platinum-based chemotherapeutics on long-term renal outcomes (chronic kidney disease, CKD) profoundly affect morbidity and mortality. Concurrent chemoradiotherapy (CRT) including cisplatin is standard for locally advanced squamous cell head and neck cancer (HNC) but is accompanied by the risk of CKD. In a randomized, multi-center, placebo-controlled Phase 2b trial ( NCT02508389 ) of GC4419 (avasopasem manganese) in HNC patients receiving CRT, avasopasem reduced the duration, incidence, and severity of severe oral mucositis (Anderson et al, JCO 2019). Avasopasem did not appear to alter the safety profile of CRT in that trial, including incidence of adverse events of kidney injury or azotemia. Methods: Pre- and post-treatment markers of kidney function including blood urea nitrogen (BUN), serum creatinine (sCr), and estimated glomerular filtration rate (eGFR) were retrospectively evaluated for a subset of 52 of the trial patients who received 3 cycles x 100 mg/m2 cisplatin plus placebo or 30 or 90 mg of avasopasem intravenously prior to RT, and 7 comparator patients who received the same CRT outside the study. Kidney function was evaluated between 3- and 24-months post-completion of cisplatin-radiation therapy by two-way analysis of variance (ANOVA) as defined by the Kidney Disease Improving Global Outcomes (KDIGO) CKD staging. Results: Baseline patient characteristics were skewed towards a male population but were balanced across all treatment arms with regards to baseline kidney function (comparator + placebo, n = 19; 30 mg GC4419, n = 18; 90 mg GC4419, n = 15). Treatment with 90 mg GC4419 demonstrated normal BUN values (10-20 mg/dL) at 3, 6, and 18 months and normal sCr values (0.6-1.2 mg/dL) between 3 and 24 months as compared to the placebo arm + comparator group, which exhibited statistically elevated BUN and sCr (p < 0.05). Treatment with 90 mg GC4419 also demonstrated significantly higher eGFR between 3 and 24 months post-chemoradiation (p < 0.05) compared to the placebo arm + comparator group. 90 mg GC4419 treatment significantly reduced the incidence of CKD compared to the placebo arm and comparator group, as determined by fold change in sCr values and eGFR measurements < 60 mL/min (stage G3a/b, G4, or G5 CKD). Conclusions: Avasopasem has the potential to reduce the incidence and severity of CKD in patients receiving cisplatin therapy. Clinical trial information: NCT02508389 .
Collapse
Affiliation(s)
| | - Varun Monga
- University of Iowa Hospitals and Clinics, Iowa City, IA
| | | | | | | | - Jennifer G. Jetton
- University of Iowa Stead Family Children's Hospital, Division of Nephrology, Dialysis, and Transplantation, Iowa City, IA
| | - Deborah Saunders
- Northeast Cancer Centre, Health Sciences North, Sudbury, ON, Canada
| | - Neal Dunlap
- University of Louisville, James Graham Brown Cancer Center, Louisville, KY
| | | | | | | | | | | | | | - Douglas Spitz
- University of Iowa Hospitals and Clinics, Holden Comprehensive Cancer Center, Iowa City, IA
| | | |
Collapse
|
20
|
Gorga SM, Sahay RD, Askenazi DJ, Bridges BC, Cooper DS, Paden ML, Zappitelli M, Gist KM, Gien J, Basu RK, Jetton JG, Murphy HJ, King E, Fleming GM, Selewski DT. Fluid overload and fluid removal in pediatric patients on extracorporeal membrane oxygenation requiring continuous renal replacement therapy: a multicenter retrospective cohort study. Pediatr Nephrol 2020; 35:871-882. [PMID: 31953749 PMCID: PMC7517652 DOI: 10.1007/s00467-019-04468-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 12/09/2019] [Accepted: 12/20/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The aim of this study was to characterize continuous renal replacement therapy (CRRT) utilization on extracorporeal membrane oxygenation (ECMO) and to determine the association of both fluid overload (FO) at CRRT initiation and fluid removal during CRRT with mortality in a large multicenter cohort. METHODS Retrospective chart review of all children < 18 years of age concurrently treated with ECMO and CRRT from January 1, 2007, to December 31, 2011, at six tertiary care children's hospital. Children treated with hemodialysis or peritoneal dialysis were excluded from the FO analysis. MEASUREMENTS AND MAIN RESULTS A total of 756 of the 1009 children supported with ECMO during the study period had complete FO data. Of these, 357 (47.2%) received either CRRT or were treated with an in-line filter and thus entered into the final analysis. Survival to ECMO decannulation was 66.4% and survival to hospital discharge was 44.3%. CRRT initiation occurred at median of 1 day (IQR 0, 2) after ECMO initiation. Median FO at CRRT initiation was 20.1% (IQR 5, 40) and was significantly lower in ECMO survivors vs. non-survivors (15.3% vs. 30.5% p = 0.005) and in hospital survivors vs. non-survivors (13.5% vs. 25.9%, p = 0.004). Median FO at CRRT discontinuation was significantly lower in ECMO survivors (23% vs. 37.6% p = 0.002) and hospital survivors vs. non-survivors (22.6% vs. 36.1%, p = 0.002). In ECMO survivors, after adjusting for pH at CRRT initiation, non-renal complications, ECMO mode, support type, center, patient age and AKI, FO at CRRT initiation (p = 0.01), and FO at CRRT discontinuation (p = 0.0002) were independently associated with duration of ECMO. In a similar multivariable analysis, FO at CRRT initiation (adjusted adds ratio [aOR] 1.09, 95% CI 1.00-1.18, p = 0.045) and at CRRT discontinuation (aOR 1.11, 95% CI 1.03-1.19, p = 0.01) were independently associated with hospital mortality. CONCLUSIONS In a multicenter pediatric ECMO cohort, this study demonstrates that severe FO was very common at CRRT initiation. We found an independent association between the degree of FO at CRRT initiation with adverse outcomes including mortality and increased duration of ECMO support. The results suggest that intervening prior to the development of significant FO may be a clinical therapeutic target and warrants further evaluation.
Collapse
Affiliation(s)
- Stephen M Gorga
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Rashmi D Sahay
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - David J Askenazi
- Department of Pediatrics, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Brian C Bridges
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - David S Cooper
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Matthew L Paden
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael Zappitelli
- Department of Pediatrics, Toronto Hospital for Sick Children, Toronto, Canada and McGill University Health Centre, Montreal, Canada
| | - Katja M Gist
- Department of Pediatrics, Children's Hospital of Colorado University of Colorado Anschutz Medical Campus Aurora, Aurora, CO, USA
| | - Jason Gien
- Department of Pediatrics, Children's Hospital of Colorado University of Colorado Anschutz Medical Campus Aurora, Aurora, CO, USA
| | - Rajit K Basu
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Jennifer G Jetton
- Division of Nephrology, Dialysis and Transplantation, Stead Family Department of Pediatrics, University of Iowa Children's Hospital, Iowa City, IA, USA
| | - Heidi J Murphy
- Department of Pediatric, Medical University of South Carolina, Charleston, SC, USA
| | - Eileen King
- Department of Pediatrics, University of Alabama Birmingham, Birmingham, Alabama, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Geoffrey M Fleming
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - David T Selewski
- Department of Pediatric, Medical University of South Carolina, Charleston, SC, USA.
| |
Collapse
|
21
|
Subramani AV, Lockwood GM, Jetton JG, Dhungana N, Sato TS. Pediatric idiopathic retroperitoneal fibrosis. Radiol Case Rep 2019; 14:459-462. [PMID: 30740191 PMCID: PMC6357545 DOI: 10.1016/j.radcr.2019.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 01/09/2019] [Accepted: 01/13/2019] [Indexed: 10/29/2022] Open
Abstract
Retroperitoneal fibrosis (RPF) is a very rare disease that is even more rare in the pediatric population. Even less common are idiopathic pediatric cases of retroperitoneal fibrosis, with a majority of reported pediatric retroperitoneal fibrosis cases being associated with secondary etiologies. We present an 11-year-old Caucasian female that was diagnosed with idiopathic retroperitoneal fibrosis using magnetic resonance imaging (MRI) to work-up severe bilateral hydronephrosis that was identified with retroperitoneal ultrasound. Given the uncommon nature of this serious condition, we present this case to illustrate the importance for physicians to include retroperitoneal fibrosis in the differential diagnosis of a pediatric patient presenting with obstructive urinary findings and understand the utility of using MRI to diagnosis and monitor this disease.
Collapse
Affiliation(s)
- Ashwin V Subramani
- Roy J. and Lucille A. Carver College of Medicine, 01334C PFP, 200 Hawkins Drive, Iowa City, IA 52242, US
| | - Gina M Lockwood
- University of Iowa Hospitals and Clinics, Department of Urology, 3240 RCP, 200 Hawkins Drive, Iowa City, IA 52242, US
| | - Jennifer G Jetton
- University of Iowa Hospitals and Clinics, Department of Pediatrics, 2027 BT, 200 Hawkins Drive, Iowa City, IA 52242, US
| | - Neha Dhungana
- University of Iowa Hospitals and Clinics, Department of Pathology, 5223 RCP, 200 Hawkins Drive, Iowa City, IA 52242, US
| | - T Shawn Sato
- University of Iowa Hospitals and Clinics, Department of Radiology, 3889 JPP, 200 Hawkins Drive, Iowa City, IA 52242, US
| |
Collapse
|
22
|
Harshman LA, Lee-Son K, Jetton JG. Vitamin and trace element deficiencies in the pediatric dialysis patient. Pediatr Nephrol 2018; 33:1133-1143. [PMID: 28752387 PMCID: PMC5787050 DOI: 10.1007/s00467-017-3751-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 06/02/2017] [Accepted: 06/02/2017] [Indexed: 02/06/2023]
Abstract
Pediatric dialysis patients are at risk of nutritional illness secondary to deficiencies in water-soluble vitamins and trace elements. Unlike 25-OH vitamin D, most other vitamins and trace elements are not routinely monitored in the blood and, consequently, the detection of any deficiency may not occur until significant complications develop. Causes of vitamin and trace element deficiency in patients on maintenance dialysis patient are multifactorial, ranging from diminished nutritional intake to altered metabolism as well as dialysate-driven losses of water-soluble vitamins and select trace elements. In this review we summarize the nutritional sources of key water-soluble vitamins and trace elements with a focus on the biological roles and clinical manifestations of their respective deficiency to augment awareness of potential nutritional illness in pediatric patients receiving maintenance dialysis. The limited pediatric data on the topic of clearance of water-soluble vitamins and trace elements by individual dialysis modality are reviewed, including a brief discussion on clearance of water-soluble vitamins and trace elements with continuous renal replacement therapy.
Collapse
Affiliation(s)
- Lyndsay A Harshman
- Stead Family Department of Pediatrics, Division of Nephrology, Dialysis & Transplantation, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA.
- Stead Family Department of Pediatrics, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 4037 Boyd Tower, Iowa City, IA, 52242-1053, USA.
| | - Kathy Lee-Son
- Stead Family Department of Pediatrics, Division of Nephrology, Dialysis & Transplantation, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - Jennifer G Jetton
- Stead Family Department of Pediatrics, Division of Nephrology, Dialysis & Transplantation, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| |
Collapse
|
23
|
Affiliation(s)
- John P Lee
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Michael Tansey
- Divisions of Pediatric Endocrinology, University of Iowa Stead Family Children’s Hospital, Iowa City, IA
| | - Jennifer G Jetton
- Divisions of Pediatric Nephrology, Dialysis, and Transplantation, University of Iowa Stead Family Children’s Hospital, Iowa City, IA
| | - Matthew D Krasowski
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA
| |
Collapse
|
24
|
Misurac JM, VanDeVoorde RG, Kallash M, Iorember FM, Luckritz KE, Rheault MN, Jetton JG, Turman MA, Kapur G, Twombley KE, Hashmat S, Weaver DJ, Leiser JD, Nailescu C. Immunogenicity of Augmented Compared With Standard Dose Hepatitis B Vaccine in Pediatric Patients on Dialysis: a Midwest Pediatric Nephrology Consortium Study. Clin J Am Soc Nephrol 2017; 12:772-778. [PMID: 28270432 PMCID: PMC5477206 DOI: 10.2215/cjn.04750416] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 01/30/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Patients on maintenance dialysis have a higher risk of unresponsiveness to hepatitis B vaccination and loss of hepatitis B immunity. Adult guidelines recommend augmented dosing (40 mcg/dose), resulting in improved response in adults. We sought to determine whether children on dialysis mount a similar antibody response when given standard or augmented dosing of hepatitis B vaccine. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This is a retrospective review of patients on dialysis aged <19 years from May 1, 2008 to May 1, 2013 at 12 pediatric dialysis units. Hepatitis B surface antibody (HBsAb) titers ≥10 mIU/ml were defined as protective. RESULTS A total of 187 out of 417 patients received one or more hepatitis B vaccine boosters. The median age was 13 years; the cohort was 57% boys and 59% white. Booster dose or HBsAb titers were missing in 17 patients. Conversion to protective HBsAb titers was achieved in 135 out of 170 patients (79%) after their first single-dose booster or multidose booster series. In patients receiving a single-dose booster, the response rate was 53% (nine out of 17) after a 10 mcg dose, 86% (65 out of 76) after a 20 mcg dose, and 65% (17 out of 26) after a 40 mcg hepatitis B vaccine dose. In patients receiving a multidose booster series, the response rate was 95% (19 out of 20) after a 10 mcg/dose series, 83% (20 out of 24) after a 20 mcg/dose series, and 71% (five out of seven) after a 40 mcg/dose series. Patients receiving a multidose booster series had a response rate of 86% (44 out of 51), compared with 76% (91 out of 119) in patients receiving a single-dose booster (P=0.21). Twenty-seven patients received more than one single-dose booster or multidose series, and 26 out of 27 (96%) eventually gained immunity after receiving one to three additional single-dose boosters or multidose booster series. CONCLUSIONS There was no clear gradient of increasing seroconversion rate with increasing vaccine dose in this cohort of pediatric patients on dialysis.
Collapse
Affiliation(s)
- Jason M Misurac
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Abstract
Both acute kidney injury (AKI) and chronic kidney disease (CKD) are seen more frequently in the neonatal intensive care unit (NICU) as advances in supportive care improve the survival of critically ill infants as well as those with severe, congenital kidney and urinary tract anomalies. Many aspects of the infant's care, including fluid balance, electrolyte and mineral homeostasis, acid-base balance, and growth and nutrition require close monitoring by and collaboration among neonatologists, nephrologists, dieticians, and pharmacologists. This educational review summarizes the therapies widely used for neonates with AKI and CKD. Use of these therapies is extrapolated from data in older children and adults or based on clinical experience and case series. There is a critical need for more research on the use of therapies in infants with kidney disease as well as for the development of drug delivery systems and preparations scaled more appropriately for these small patients.
Collapse
Affiliation(s)
- Jennifer G Jetton
- Division of Nephrology, Dialysis and Transplantation, Stead Family Department of Pediatrics, University of Iowa Children's Hospital, Iowa City, IA, USA.
| | - Mark Sorenson
- Department of Pharmaceutical Care, University of Iowa Children's Hospital, Iowa City, IA, USA
| |
Collapse
|
26
|
|
27
|
Jetton JG, Guillet R, Askenazi DJ, Dill L, Jacobs J, Kent AL, Selewski DT, Abitbol CL, Kaskel FJ, Mhanna MJ, Ambalavanan N, Charlton JR. Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates: Design of a Retrospective Cohort Study. Front Pediatr 2016; 4:68. [PMID: 27486571 PMCID: PMC4950470 DOI: 10.3389/fped.2016.00068] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 06/20/2016] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Acute kidney injury (AKI) affects ~30% of hospitalized neonates. Critical to advancing our understanding of neonatal AKI is collaborative research among neonatologists and nephrologists. The Neonatal Kidney Collaborative (NKC) is an international, multidisciplinary group dedicated to investigating neonatal AKI. The AWAKEN study (Assessment of Worldwide Acute Kidney injury Epidemiology in Neonates) was designed to describe the epidemiology of neonatal AKI, validate the definition of neonatal AKI, identify primary risk factors for neonatal AKI, and investigate the contribution of fluid management to AKI events and short-term outcomes. METHODS AND ANALYSIS The NKC was established with at least one pediatric nephrologist and neonatologist from 24 institutions in 4 countries (USA, Canada, Australia, and India). A Steering Committee and four subcommittees were created. The database subcommittee oversaw the development of the web-based database (MediData Rave™) that captured all NICU admissions from 1/1/14 to 3/31/14. Inclusion and exclusion criteria were applied to eliminate neonates with a low likelihood of AKI. Data collection included: (1) baseline demographic information; (2) daily physiologic parameters and care received during the first week of life; (3) weekly "snapshots"; (4) discharge information including growth parameters, final diagnoses, discharge medications, and need for renal replacement therapy; and (5) all serum creatinine values. ETHICS AND DISSEMINATION AWAKEN was proposed as human subjects research. The study design allowed for a waiver of informed consent/parental permission. NKC investigators will disseminate data through peer-reviewed publications and educational conferences. DISCUSSION The purpose of this publication is to describe the formation of the NKC, the establishment of the AWAKEN cohort and database, future directions, and a few "lessons learned." The AWAKEN database includes ~325 unique variables and >4 million discrete data points. AWAKEN will be the largest, most inclusive neonatal AKI study to date. In addition to validating the neonatal AKI definition and identifying risk factors for AKI, this study will uncover variations in practice patterns related to fluid provision, renal function monitoring, and involvement of pediatric nephrologists during hospitalization. The AWAKEN study will position the NKC to achieve the long-term goal of improving the lives, health, and well-being of newborns at risk for kidney disease.
Collapse
Affiliation(s)
- Jennifer G Jetton
- Stead Family Department of Pediatrics, Division of Nephrology, Dialysis and Transplantation, University of Iowa Children's Hospital , Iowa City, IA , USA
| | - Ronnie Guillet
- Department of Pediatrics, Division of Neonatology, University of Rochester Medical Center , Rochester, NY , USA
| | - David J Askenazi
- Department of Pediatrics, Division of Nephrology, University of Alabama at Birmingham , Birmingham, AL , USA
| | - Lynn Dill
- Department of Pediatrics, Division of Nephrology, University of Alabama at Birmingham , Birmingham, AL , USA
| | - Judd Jacobs
- Data Management Center, Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH , USA
| | - Alison L Kent
- Department of Neonatology, Centenary Hospital for Women and Children, Canberra Hospital, Australian National University Medical School , Canberra, ACT , Australia
| | - David T Selewski
- Department of Pediatrics and Communicable Diseases, Division of Nephrology, C.S. Mott Children's Hospital, University of Michigan , Ann Arbor, MI , USA
| | - Carolyn L Abitbol
- Department of Pediatrics, Division of Nephrology, Holtz Children's Hospital, University of Miami , Miami, FL , USA
| | - Fredrick J Kaskel
- Department of Pediatrics, Division of Nephrology, Children's Hospital at Montefiore, Albert Einstein , Bronx, NY , USA
| | - Maroun J Mhanna
- Department of Pediatrics, Division of Neonatology, MetroHealth Medical Center, Case Western Reserve University , Cleveland, OH , USA
| | - Namasivayam Ambalavanan
- Department of Pediatrics, Division of Neonatology, University of Alabama at Birmingham , Birmingham, AL , USA
| | - Jennifer R Charlton
- Department of Pediatrics, Division of Nephrology, University of Virginia , Charlottesville, VA , USA
| | | |
Collapse
|
28
|
Lee-Son K, Jetton JG. AKI and Genetics: Evolving Concepts in the Genetics of Acute Kidney Injury: Implications for Pediatric AKI. J Pediatr Genet 2015; 5:61-8. [PMID: 27617143 DOI: 10.1055/s-0035-1557112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 05/21/2015] [Indexed: 12/21/2022]
Abstract
In spite of recent advances in the field of acute kidney injury (AKI) research, morbidity and mortality remain high for AKI sufferers. The study of genetic influences in AKI pathways is an evolving field with potential for improving outcomes through the identification of risk and protective factors at the individual level that may in turn allow for the development of rational therapeutic interventions. Studies of single nucleotide polymorphisms, individual susceptibility to nephrotoxic medications, and epigenetic factors comprise a growing body of research in this area. While promising, this field is still only emerging, with a small number of studies in humans and very little data in pediatric patients.
Collapse
Affiliation(s)
- Kathy Lee-Son
- Division of Pediatric Nephrology, Dialysis, and Transplantation, University of Iowa Children's Hospital, Iowa City, Iowa, United States
| | - Jennifer G Jetton
- Division of Pediatric Nephrology, Dialysis, and Transplantation, University of Iowa Children's Hospital, Iowa City, Iowa, United States
| |
Collapse
|
29
|
Abstract
In recent years, there have been significant advancements in our understanding of acute kidney injury (AKI) and its impact on outcomes across medicine. Research based on single-center cohorts suggests that neonatal AKI is very common and associated with poor outcomes. In this state-of-the-art review on neonatal AKI, we highlight the unique aspects of neonatal renal physiology, definition, risk factors, epidemiology, outcomes, evaluation, and management of AKI in neonates. The changes in renal function with gestational and chronologic age are described. We put forth and describe the neonatal modified Kidney Diseases: Improving Global Outcomes AKI criteria and provide the rationale for its use as the standardized definition of neonatal AKI. We discuss risk factors for neonatal AKI and suggest which patient populations may warrant closer surveillance, including neonates <1500 g, infants who experience perinatal asphyxia, near term/ term infants with low Apgar scores, those treated with extracorporeal membrane oxygenation, and those requiring cardiac surgery. We provide recommendations for the evaluation and treatment of these patients, including medications and renal replacement therapies. We discuss the need for long-term follow-up of neonates with AKI to identify those children who will go on to develop chronic kidney disease. This review highlights the deficits in our understanding of neonatal AKI that require further investigation. In an effort to begin to address these needs, the Neonatal Kidney Collaborative was formed in 2014 with the goal of better understanding neonatal AKI, beginning to answer critical questions, and improving outcomes in these vulnerable populations.
Collapse
Affiliation(s)
- David T Selewski
- Division of Nephrology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Jennifer R Charlton
- Division of Nephrology, Department of Pediatrics, University of Virginia, Charlottesville, Virginia;
| | - Jennifer G Jetton
- Division of Nephrology, Dialysis and Transplantation, Stead Family Department of Pediatrics, University of Iowa Children's Hospital, Iowa City, Iowa
| | - Ronnie Guillet
- Division of Neonatology, Department of Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Maroun J Mhanna
- Division of Neonatology, Department of Pediatrics, Case Western Reserve University at MetroHealth Medical Center, Cleveland, Ohio
| | - David J Askenazi
- Division of Nephrology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama; and
| | - Alison L Kent
- Department of Neonatology, Centenary Hospital for Women and Children, Canberra Hospital, Australian Capital Territory, Australia
| |
Collapse
|
30
|
Harshman LA, Muff-Luett M, Neuberger ML, Dagle JM, Shilyansky J, Nester CM, Brophy PD, Jetton JG. Peritoneal dialysis in an extremely low-birth-weight infant with acute kidney injury. Clin Kidney J 2014; 7:582-5. [PMID: 25859376 PMCID: PMC4389134 DOI: 10.1093/ckj/sfu095] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 08/15/2014] [Indexed: 11/13/2022] Open
Abstract
Critically ill neonates are at high risk for acute kidney injury (AKI). Renal supportive therapy (RST) can be an important tool for supporting critically ill neonates with AKI, particularly in cases of oliguria and fluid overload. There are few reports of RST for management of oligo-anuric AKI in the extremely low-birth-weight infant weighing <1000 g. We report successful provision of peritoneal dialysis (PD) to an 830-g neonate with oligo-anuric AKI through adaptation of a standard pediatric acute PD catheter.
Collapse
Affiliation(s)
- Lyndsay A Harshman
- Stead Family Department of Pediatrics, Division of Pediatric Nephrology , University of Iowa Children's Hospital , Iowa City, IA , USA
| | - Melissa Muff-Luett
- Stead Family Department of Pediatrics, Division of Pediatric Nephrology , University of Iowa Children's Hospital , Iowa City, IA , USA
| | - Mary L Neuberger
- Stead Family Department of Pediatrics, Division of Pediatric Nephrology , University of Iowa Children's Hospital , Iowa City, IA , USA
| | - John M Dagle
- Stead Family Department of Pediatrics, Division of Neonatology , University of Iowa Children's Hospital , Iowa, City , IA , USA
| | - Joel Shilyansky
- Department of Surgery, Division of Pediatric Surgery , University of Iowa Carver College of Medicine , Iowa City , IA , USA
| | - Carla M Nester
- Stead Family Department of Pediatrics, Division of Pediatric Nephrology , University of Iowa Children's Hospital , Iowa City, IA , USA
| | - Patrick D Brophy
- Stead Family Department of Pediatrics, Division of Pediatric Nephrology , University of Iowa Children's Hospital , Iowa City, IA , USA
| | - Jennifer G Jetton
- Stead Family Department of Pediatrics, Division of Pediatric Nephrology , University of Iowa Children's Hospital , Iowa City, IA , USA
| |
Collapse
|
31
|
Abstract
BACKGROUND An obstacle to the successful classification of attention deficit hyperactivity disorder (ADHD) is the frequently reported co-morbidity between ADHD and conduct disorder (CD). Prior work suggested that from a familial perspective, ADHD children with CD may be aetiologically distinct from those without CD. METHODS Using family study methodology and three longitudinal assessments over 4 years, we tested hypotheses about patterns of familial association between ADHD, CD, oppositional defiant disorder (ODD) and adult antisocial personality disorder (ASPD). RESULTS At the 4-year follow-up, there were 34 children with lifetime diagnoses of ADHD + CD, 59 with ADHD + ODD and 33 with ADHD only. These were compared with 92 non-ADHD, non-CD, non-ODD control probands. Familial risk analysis revealed the following: (1) relatives of each ADHD proband subgroup were at significantly greater risk for ADHD and ODD than relatives of normal controls; (2) rates of CD and ASPD were elevated among relatives of ADHD + CD probands only; (3) the co-aggregation of ADHD and the antisocial disorders could not be accounted for by marriages between ADHD and antisocial spouses; and (4) both ADHD and antisocial disorders occurred in the same relatives more often than expected by chance alone. CONCLUSIONS These findings suggest that ADHD with and without antisocial disorders may be aetiologically distinct disorders and provide evidence for the nosologic validity of ICD-10 hyperkinetic conduct disorder.
Collapse
Affiliation(s)
- S V Faraone
- Massachusetts General Hospital, Department of Psychiatry, Harvard Medical School, Massachusetts Mental Health Center, Brockton, USA
| | | | | | | |
Collapse
|
32
|
Biederman J, Wilens T, Mick E, Faraone SV, Weber W, Curtis S, Thornell A, Pfister K, Jetton JG, Soriano J. Is ADHD a risk factor for psychoactive substance use disorders? Findings from a four-year prospective follow-up study. J Am Acad Child Adolesc Psychiatry 1997; 36:21-9. [PMID: 9000777 DOI: 10.1097/00004583-199701000-00013] [Citation(s) in RCA: 282] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate whether attention-deficit hyperactivity disorder (ADHD) is a risk factor for psychoactive substance use disorders (PSUD), attending to issues of psychiatric comorbidity, family history, and adversity. METHOD Using assessments from multiple domains, the authors examined 140 ADHD and 120 normal control subjects at baseline and 4 years later. Drug and alcohol abuse and dependence were operationally defined. RESULTS No differences were detected in the rates of alcohol or drug abuse or dependence or in the rates of abuse of individual substances between the groups; both ADHD and control probands had a 15% rate of PSUD. Conduct and bipolar disorders predicted PSUD, independently of ADHD status. Family history of substance dependence and antisocial disorders was associated with PSUD in controls but less clearly so in ADHD probands. Family history of ADHD was not associated with risk for PSUD. ADHD probands had a significantly shorter time period between the onsets of abuse and dependence compared with controls (1.2 years versus 3 years, p < .01). CONCLUSIONS Adolescents with and without ADHD had a similar risk for PSUD that was mediated by conduct and bipolar disorder. Since the risk for PSUD has been shown to be elevated in adults with ADHD when compared with controls, a sharp increase in PSUD is to be expected in grown-up ADHD children during the transition from adolescence to adulthood.
Collapse
Affiliation(s)
- J Biederman
- Pediatric Psychopharmacology Unit, Massachusetts General Hospital, Boston 02114, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Biederman J, Faraone SV, Milberger S, Jetton JG, Chen L, Mick E, Greene RW, Russell RL. Is childhood oppositional defiant disorder a precursor to adolescent conduct disorder? Findings from a four-year follow-up study of children with ADHD. J Am Acad Child Adolesc Psychiatry 1996; 35:1193-204. [PMID: 8824063 DOI: 10.1097/00004583-199609000-00017] [Citation(s) in RCA: 187] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the overlap between attention-deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD), addressing whether ODD is subsyndromal form of conduct disorder (CD) and, if so, whether it is a precursor or prodrome syndrome of CD. METHOD Assessments from multiple domains were used to examine 140 children with ADHD and 120 normal controls at baseline and 4 years later. RESULTS Of children who had ADHD at baseline, 65% had comorbid ODD and 22% had CD. Among those with ODD, 32% had comorbid CD. All but one child with CD also had ODD that preceded the onset of CD by several years. ODD+CD children had more severe symptoms of ODD, more comorbid psychiatric disorders, lower Global Assessment of Functioning Scale scores, more bipolar disorder, and more abnormal Child Behavior Checklist clinical scale scores compared with ADHD children with non-CD ODD and those without ODD or CD. In addition, ODD without CD at baseline assessment in childhood did not increase the risk for CD at the 4-year follow-up, by midadolescence. CONCLUSIONS Two subtypes of ODD associated with ADHD were identified: one that is prodromal to CD and another that is subsyndromal to CD but not likely to progress into CD in later years. These ODD subtypes have different correlates, course, and outcome.
Collapse
Affiliation(s)
- J Biederman
- Pediatric Psychopharmacology Unit, Psychiatry Service, Massachusetts General Hospital, Boston 02114, USA
| | | | | | | | | | | | | | | |
Collapse
|