1
|
Dhont E, Van Der Heggen T, Snauwaert E, Willems J, Croubels S, Delanghe J, De Waele JJ, Colman R, Vande Walle J, De Paepe P, De Cock PA. Predictors of augmented renal clearance based on iohexol plasma clearance in critically ill children. Pediatr Nephrol 2024; 39:1607-1616. [PMID: 37994980 DOI: 10.1007/s00467-023-06221-4] [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] [Received: 06/19/2023] [Revised: 10/26/2023] [Accepted: 10/26/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Augmented renal clearance (ARC) holds a risk of subtherapeutic drug concentrations. Knowledge of patient-, disease-, and therapy-related factors associated with ARC would allow predicting which patients would benefit from intensified dosing regimens. This study aimed to identify ARC predictors and to describe ARC time-course in critically ill children, using iohexol plasma clearance (CLiohexol) to measure glomerular filtration rate (GFR). METHODS This is a retrospective analysis of data from the "IOHEXOL" study which validated GFR estimating formulas (eGFR) against CLiohexol. Critically ill children with normal serum creatinine were included, and CLiohexol was performed as soon as possible after pediatric intensive care unit (PICU) admission (CLiohexol1) and repeated (CLiohexol2) after 48-72 h whenever possible. ARC was defined as CLiohexol exceeding normal GFR for age plus two standard deviations. RESULTS Eighty-five patients were included; 57% were postoperative patients. Median CLiohexol1 was 122 mL/min/1.73 m2 (IQR 75-152). Forty patients (47%) expressed ARC on CLiohexol1. Major surgery other than cardiac surgery and eGFR were found as independent predictors of ARC. An eGFR cut-off value of 99 mL/min/1.73 m2 and 140 mL/min/1.73 m2 was suggested to identify ARC in children under and above 2 years, respectively. ARC showed a tendency to persist on CLiohexol2. CONCLUSIONS Our findings raise PICU clinician awareness about increased risk for ARC after major surgery and in patients with eGFR above age-specific thresholds. This knowledge enables identification of patients with an ARC risk profile who would potentially benefit from a dose increase at initiation of treatment to avoid underexposure. TRIAL REGISTRATION ClinicalTrials.gov NCT05179564, registered retrospectively on January 5, 2022.
Collapse
Affiliation(s)
- Evelyn Dhont
- Pediatric Intensive Care Unit, Department of Intensive Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium.
- Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.
| | - Tatjana Van Der Heggen
- Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Evelien Snauwaert
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Department of Pediatric Nephrology, ERKNet Center, Ghent University Hospital, Ghent, Belgium
| | - Jef Willems
- Pediatric Intensive Care Unit, Department of Intensive Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Siska Croubels
- Department of Pathobiology, Pharmacology and Zoological Medicine, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Joris Delanghe
- Department of Diagnostic Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Jan J De Waele
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Roos Colman
- Biostatistics Unit, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Johan Vande Walle
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Department of Pediatric Nephrology, ERKNet Center, Ghent University Hospital, Ghent, Belgium
| | - Peter De Paepe
- Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Pieter A De Cock
- Pediatric Intensive Care Unit, Department of Intensive Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
- Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
| |
Collapse
|
2
|
Dhont E, Van Der Heggen T, De Cock PA. Reply to commenting letter for "Reliability of glomerular filtration rate estimating formulas compared to iohexol plasma clearance in critically ill children" by Smeets et al. Eur J Pediatr 2022; 181:4229-4230. [PMID: 36344705 DOI: 10.1007/s00431-022-04658-7] [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] [Indexed: 11/09/2022]
Affiliation(s)
- Evelyn Dhont
- Department of Pediatric Intensive Care, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium. .,Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.
| | - Tatjana Van Der Heggen
- Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Pieter A De Cock
- Department of Pediatric Intensive Care, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium.,Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.,Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
| |
Collapse
|
3
|
Dhont E, Windels C, Snauwaert E, Van Der Heggen T, de Jaeger A, Dhondt L, Delanghe J, Croubels S, Walle JV, De Paepe P, De Cock PA. Reliability of glomerular filtration rate estimating formulas compared to iohexol plasma clearance in critically ill children. Eur J Pediatr 2022; 181:3851-3866. [PMID: 36053381 DOI: 10.1007/s00431-022-04570-0] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 07/14/2022] [Accepted: 07/18/2022] [Indexed: 11/30/2022]
Abstract
UNLABELLED Accurate renal function assessment is crucial to guide intensive care decision-making and drug dosing. Estimates of glomerular filtration rate (eGFR) are routinely used in critically ill children; however, these formulas were never evaluated against measured GFR (mGFR) in this population. We aimed to assess the reliability of common eGFR formulas compared to iohexol plasma clearance (CLiohexol) in a pediatric intensive care (PICU) population. Secondary outcomes were the prevalence of acute kidney injury (AKI) (by pRIFLE criteria) and augmented renal clearance (ARC) (defined as standard GFR for age + 2 standard deviations (SD)) within 48 h after admission based on mGFR and eGFR by the revised Schwartz formula and the difference between these two methods to diagnose AKI and ARC. In children, between 0 and 15 years of age, without chronic renal disease, GFR was measured by CLiohexol and estimated using 26 formulas based on creatinine (Scr), cystatine C (CysC), and betatrace protein (BTP), early after PICU admission. eGFR and mGFR results were compared for the entire study population and in subgroups according to age, using Bland-Altman analysis with calculation of bias, precision, and accuracy expressed as percentage of eGFR results within 30% (P30) and 10% (P10) of mGFR. CLiohexol was measured in 98 patients. Mean CLiohexol (± SD) was 115 ± 54 ml/min/1.73m2. Most eGFR formulas showed overestimation of mGFR with large bias and poor precision reflected by wide limits of agreement (LoA). Bias was larger with CysC- and BTP-based formulas compared to Scr-based formulas. In the entire study population, none of the eGFR formulas showed the minimal desired P30 > 75%. The widely used revised Schwartz formula overestimated mGFR with a high percentage bias of - 18 ± 51% (95% confidence interval (CI) - 29; - 9), poor precision with 95% LoA from - 120 to 84% and insufficient accuracy reflected by P30 of only 51% (95% CI 41; 61), and P10 of 21% (95% CI 13; 66) in the overall population. Although performance of Scr-based formulas was worst in children below 1 month of age, exclusion of neonates and younger children did not result in improved agreement and accuracy. Based on mGFR, prevalence of AKI and ARC within 48 h was 17% and 45% of patients, respectively. There was poor agreement between revised Schwartz formula and mGFR to diagnose AKI (kappa value of 0.342, p < 0.001; sensitivity of 30%, 95% CI 5; 20%) and ARC (kappa value of 0.342, p < 0.001; sensitivity of 70%, 95% CI 33; 58). CONCLUSION In this proof-of-concept study, eGFR formulas were found to be largely inaccurate in the PICU population. Clinicians should therefore use these formulas with caution to guide drug dosing and therapeutic interventions in critically ill children. More research in subgroup populations is warranted to conclude on generalizability of these study findings. CLINICALTRIALS gov NCT05179564, registered retrospectively on January 5, 2022. WHAT IS KNOWN • Both acute kidney injury and augmented renal clearance may be present in PICU patients and warrant adaptation of therapy, including drug dosing. • Biomarker-based eGFR formulas are widely used for GFR assessment in critically ill children, although endogenous filtration biomarkers have important limitations in PICU patients and eGFR formulas have never been validated against measured GFR in this population. WHAT IS NEW • eGFR formulas were found to be largely inaccurate in the PICU population when compared to measured GFR by iohexol clearance. Clinicians should therefore use these formulas with caution to guide drug dosing and therapeutic interventions in critically ill children. • Iohexol plasma clearance could be considered an alternative for accurate GFR assessment in PICU patients.
Collapse
Affiliation(s)
- Evelyn Dhont
- Department of Pediatric Intensive Care, Pediatric Intensive Care 1K12D, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium.
- Faculty of Medicine and Health Sciences, Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium.
| | - Charlotte Windels
- Department of General Practice and Primary Health Care, Ghent University, Ghent, Belgium
| | - Evelien Snauwaert
- Department of Pediatric Nephrology, Ghent University Hospital, Ghent, Belgium
| | - Tatjana Van Der Heggen
- Faculty of Medicine and Health Sciences, Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
| | - Annick de Jaeger
- Department of Pediatric Intensive Care, Pediatric Intensive Care 1K12D, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Laura Dhondt
- Faculty of Veterinary Medicine, Department of Pathobiology, Pharmacology and Zoological Medicine, Ghent University, Ghent, Belgium
| | - Joris Delanghe
- Faculty of Medicine and Health Sciences, Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| | - Siska Croubels
- Faculty of Veterinary Medicine, Department of Pathobiology, Pharmacology and Zoological Medicine, Ghent University, Ghent, Belgium
| | - Johan Vande Walle
- Department of Pediatric Nephrology, Ghent University Hospital, Ghent, Belgium
| | - Peter De Paepe
- Faculty of Medicine and Health Sciences, Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
| | - Pieter A De Cock
- Department of Pediatric Intensive Care, Pediatric Intensive Care 1K12D, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
- Faculty of Medicine and Health Sciences, Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
| |
Collapse
|
4
|
Dhont E, Van Der Heggen T, De Jaeger A, Vande Walle J, De Paepe P, De Cock PA. Augmented renal clearance in pediatric intensive care: are we undertreating our sickest patients? Pediatr Nephrol 2020; 35:25-39. [PMID: 30374606 DOI: 10.1007/s00467-018-4120-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [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: 05/30/2018] [Revised: 10/04/2018] [Accepted: 10/16/2018] [Indexed: 10/28/2022]
Abstract
Many critically ill patients display a supraphysiological renal function with enhanced renal perfusion and glomerular hyperfiltration. This phenomenon described as augmented renal clearance (ARC) may result in enhanced drug elimination through renal excretion mechanisms. Augmented renal clearance seems to be triggered by systemic inflammation and therapeutic interventions in intensive care. There is growing evidence that ARC is not restricted to the adult intensive care population, but is also prevalent in critically ill children. Augmented renal clearance is often overlooked due to the lack of reliable methods to assess renal function in critically ill children. Standard equations to calculate glomerular filtration rate (GFR) are developed for patients who have a steady-state creatinine production and a stable renal function. Those formulas are not reliable in critically ill patients with acutely changing GFR and tend to underestimate true GFR in patients with ARC. Tools for real-time, continuous, and non-invasive measurement of fluctuating GFR are most needed to identify changes in kidney function during critical illness and therapeutic interventions. Such devices are currently being validated and hold a strong potential to become the standard of practice. In the meantime, urinary creatinine clearance is considered the most reliable method to detect ARC in critically ill patients. Augmented renal clearance is clearly associated with subtherapeutic antimicrobial concentrations and subsequent therapeutic failure. This warrants the need for adjusted dosing regimens to optimize pharmacokinetic and pharmacodynamic target attainment. This review aims to summarize current knowledge on ARC in critically ill children, to give insight into its possible pathophysiological mechanism, to evaluate screening methods for ARC in the pediatric intensive care population, and to illustrate the effect of ARC on drug exposure, therapeutic efficacy, and clinical outcome.
Collapse
Affiliation(s)
- Evelyn Dhont
- Department of Pediatric Intensive Care, Ghent University Hospital, Ghent, Belgium. .,Pediatric Intensive Care 1K12D, Ghent University Hospital, Heymanslaan 10, 9000, Ghent, Belgium.
| | | | - Annick De Jaeger
- Department of Pediatric Intensive Care, Ghent University Hospital, Ghent, Belgium
| | - Johan Vande Walle
- Department of Pediatrics, Ghent University Hospital, Ghent, Belgium.,Department of Pediatric Nephrology, Ghent University Hospital, Ghent, Belgium
| | - Peter De Paepe
- Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
| | - Pieter A De Cock
- Department of Pediatric Intensive Care, Ghent University Hospital, Ghent, Belgium.,Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium.,Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
| |
Collapse
|
5
|
Van Der Heggen T, Dhont E, Peperstraete H, Delanghe JR, Vande Walle J, De Paepe P, De Cock PA. Augmented renal clearance: a common condition in critically ill children. Pediatr Nephrol 2019; 34:1099-1106. [PMID: 30778827 DOI: 10.1007/s00467-019-04205-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [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: 08/28/2018] [Revised: 01/20/2019] [Accepted: 01/21/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Augmented renal clearance (ARC), an increase in kidney function with enhanced elimination of circulating solute, has been increasingly recognized in critically ill adults. In a pediatric intensive care setting, data are scarce. The primary objective of this study was to investigate the prevalence of ARC in critically ill children. Secondary objectives included a risk factor analysis for the development of ARC and a comparison of two methods for assessment of renal function. METHODS In 105 critically ill children between 1 month and 15 years of age, glomerular filtration rate (GFR) was measured by means of a daily 24-h creatinine clearance (24 h ClCr) and compared to an estimated GFR using the revised Schwartz formula. Logistic regression analysis was used to identify risk factors for ARC. RESULTS Overall, 67% of patients expressed ARC and the proportion of ARC patients decreased during consecutive days. ARC patients had a median ClCr of 142.2 ml/min/1.73m2 (IQR 47.1). Male gender and antibiotic treatment were independently associated with the occurrence of ARC. The revised Schwartz formula seems less appropriate for ARC detection. CONCLUSIONS A large proportion of critically ill children develop ARC during their stay at the intensive care unit. Clinicians should be cautious when using Schwartz formula to detect ARC. Our findings require confirmation from large study cohorts and investigation of the relationship with clinical outcome.
Collapse
Affiliation(s)
- Tatjana Van Der Heggen
- Department of Pediatrics, Ghent University Hospital, 3K12D, Corneel Heymanslaan 10, 9000, Ghent, Belgium.
- Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium.
| | - Evelyn Dhont
- Department of Pediatrics, Ghent University Hospital, 3K12D, Corneel Heymanslaan 10, 9000, Ghent, Belgium
- Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
- Department of Pediatric Intensive Care, Ghent University Hospital, Ghent, Belgium
| | | | - Joris R Delanghe
- Department of Laboratory Medicine, Ghent University, Ghent, Belgium
| | - Johan Vande Walle
- Department of Pediatrics, Ghent University Hospital, 3K12D, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Peter De Paepe
- Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
| | - Pieter A De Cock
- Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
- Department of Pediatric Intensive Care, Ghent University Hospital, Ghent, Belgium
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
| |
Collapse
|
6
|
Couvreur T, Hallaert G, Van Der Heggen T, Baert E, Dewaele F, Kalala Okito JP, Vanhauwaert D, Deruytter M, Van Roost D, Caemaert J. Endoscopic Treatment of Temporal Arachnoid Cysts in 34 Patients. World Neurosurg 2015; 84:734-40. [DOI: 10.1016/j.wneu.2015.04.053] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Revised: 04/22/2015] [Accepted: 04/22/2015] [Indexed: 10/23/2022]
|