Most children with serious acute illness do not have underlying chronic conditions. This prospective study involving patients in pediatric intensive care units showed that acute kidney injury is ...common and is associated with poor outcomes, including increased mortality.
Epidemiologic studies involving adults have shown that acute kidney injury is associated with increased mortality, prolonged mechanical ventilation, and prolonged length of stay in intensive care units (ICUs).
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A multinational, prospective study involving 1802 adults
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initiated the use of Kidney Disease: Improving Global Outcomes (KDIGO) guidelines to describe the epidemiology of acute kidney injury; the guidelines
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define and stage acute kidney injury according to the plasma creatinine level and urine output (Table S1 in the Supplementary Appendix, available with the full text of this article at NEJM.org). That study showed graded associations between the severity of acute kidney injury and . . .
Abstract Background Increases in serum creatinine (ΔSCr) from baseline signify acute kidney injury (AKI) but offer little granular information regarding its characteristics. The 10th Consensus ...Conference of the Acute Dialysis Quality Initiative (ADQI) suggested that combining AKI biomarkers would provide better precision for AKI course prognostication. Objectives This study investigated the value of combining a functional damage biomarker (plasma cystatin C pCysC) with a tubular damage biomarker (urine neutrophil gelatinase-associated lipocalin uNGAL), forming a composite biomarker for prediction of discrete characteristics of AKI. Methods Data from 345 children after cardiopulmonary bypass (CPB) were analyzed. Severe AKI was defined as Kidney Disease Global Outcomes Initiative stages 2 to 3 (≥100% ΔSCr) within 7 days of CPB. Persistent AKI lasted >2 days. SCr in reversible AKI returned to baseline ≤48 h after CPB. The composite of uNGAL (>200 ng/mg urine Cr = positive +) and pCysC (>0.8 mg/l = positive +), uNGAL+/pCysC+, measured 2 h after CPB initiation, was compared to ΔSCr increases of ≥50% for correlation with AKI characteristics by using predictive probabilities, likelihood ratios (LR), and area under the curve receiver operating curve (AUC-ROC) values. Results Severe AKI occurred in 18% of patients. The composite uNGAL+/pCysC+ demonstrated a greater likelihood than ΔSCr for severe AKI (+LR: 34.2 13.0:94.0 vs. 3.8 1.9:7.2) and persistent AKI (+LR: 15.6 8.8:27.5 versus 4.5 2.3:8.8). In AKI patients, the uNGAL−/pCysC+ composite was superior to ΔSCr for prediction of transient AKI. Biomarker composites carried greater probability for specific outcomes than ΔSCr strata. Conclusions Composites of functional and tubular damage biomarkers are superior to ΔSCr for predicting discrete characteristics of AKI.
Maintenance intravenous fluids (IVFs) are used to provide critical supportive care for children who are acutely ill. IVFs are required if sufficient fluids cannot be provided by using enteral ...administration for reasons such as gastrointestinal illness, respiratory compromise, neurologic impairment, a perioperative state, or being moribund from an acute or chronic illness. Despite the common use of maintenance IVFs, there is high variability in fluid prescribing practices and a lack of guidelines for fluid composition administration and electrolyte monitoring. The administration of hypotonic IVFs has been the standard in pediatrics. Concerns have been raised that this approach results in a high incidence of hyponatremia and that isotonic IVFs could prevent the development of hyponatremia. Our goal in this guideline is to provide an evidence-based approach for choosing the tonicity of maintenance IVFs in most patients from 28 days to 18 years of age who require maintenance IVFs. This guideline applies to children in surgical (postoperative) and medical acute-care settings, including critical care and the general inpatient ward. Patients with neurosurgical disorders, congenital or acquired cardiac disease, hepatic disease, cancer, renal dysfunction, diabetes insipidus, voluminous watery diarrhea, or severe burns; neonates who are younger than 28 days old or in the NICU; and adolescents older than 18 years old are excluded. We specifically address the tonicity of maintenance IVFs in children.The Key Action Statement of the subcommittee is as follows:
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IMPORTANCE: After initial resuscitation, critically ill children may accumulate fluid and develop fluid overload. Accruing evidence suggests that fluid overload contributes to greater complexity of ...care and worse outcomes. OBJECTIVE: To describe the methods to measure fluid balance, define fluid overload, and evaluate the association between fluid balance and outcomes in critically ill children. DATA SOURCES: Systematic search of MEDLINE, EMBASE, Cochrane Library, trial registries, and selected gray literature from inception to March 2017. STUDY SELECTION: Studies of children admitted to pediatric intensive care units that described fluid balance or fluid overload and reported outcomes of interest were included. No language restrictions were applied. DATA EXTRACTION AND SYNTHESIS: All stages were conducted independently by 2 reviewers. Data extracted included study characteristics, population, fluid metrics, and outcomes. Risk of bias was assessed using the Newcastle-Ottawa Scale. Narrative description of fluid assessment methods and fluid overload definitions was done. When feasible, pooled analyses were performed using random-effects models. MAIN OUTCOMES AND MEASURES: Mortality was the primary outcome. Secondary outcomes included treatment intensity, organ failure, and resource use. RESULTS: A total of 44 studies (7507 children) were included in this systematic review and meta-analysis. Of those, 27 (61%) were retrospective cohort studies, 13 (30%) were prospective cohort studies, 3 (7%) were case-control studies, and 1 study (2%) was a secondary analysis of a randomized trial. The proportion of children with fluid overload varied by case mix and fluid overload definition (median, 33%; range, 10%-83%). Fluid overload, however defined, was associated with increased in-hospital mortality (17 studies n = 2853; odds ratio OR, 4.34 95% CI, 3.01-6.26; I2 = 61%). Survivors had lower percentage fluid overload than nonsurvivors (22 studies n = 2848; mean difference, −5.62 95% CI, −7.28 to −3.97; I2 = 76%). After adjustment for illness severity, there was a 6% increase in odds of mortality for every 1% increase in percentage fluid overload (11 studies n = 3200; adjusted OR, 1.06 95% CI, 1.03-1.10; I2 = 66%). Fluid overload was associated with increased risk for prolonged mechanical ventilation (>48 hours) (3 studies n = 631; OR, 2.14 95% CI, 1.25-3.66; I2 = 0%) and acute kidney injury (7 studies n = 1833; OR, 2.36 95% CI, 1.27-4.38; I2 = 78%). CONCLUSIONS AND RELEVANCE: Fluid overload is common and is associated with substantial morbidity and mortality in critically ill children. Additional research should now ideally focus on interventions aimed to mitigate the potential for harm associated with fluid overload.
Sepsis-associated acute kidney injury Alobaidi, Rashid; Basu, Rajit K; Goldstein, Stuart L ...
Seminars in nephrology
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Journal Article
Recenzirano
Odprti dostop
Acute kidney injury (AKI) is an epidemic problem. Sepsis has long been recognized as a foremost precipitant of AKI. Sepsis-associated AKI (SA-AKI) portends a high burden of morbidity and mortality in ...both children and adults with critical illness. Although our understanding of its pathophysiology is incomplete, SA-AKI likely represents a distinct subset of AKI contributed to by a unique constellation of hemodynamic, inflammatory, and immune mechanisms. SA-AKI poses significant clinical challenges for clinicians. To date, no singular effective therapy has been developed to alter the natural history of SA-AKI. Rather, current strategies to alleviate poor outcomes focus on clinical risk identification, early detection of injury, modifying clinician behavior to avoid harm, early appropriate antimicrobial therapy, and surveillance among survivors for the longer-term sequelae of kidney damage. Recent evidence has confirmed that patients no longer die with AKI, but from AKI. To improve the care and outcomes for sufferers of SA-AKI, clinicians need a robust appreciation for its epidemiology and current best-evidence strategies for prevention and treatment.
Reliable prediction of severe acute kidney injury (AKI) has the potential to optimize treatment. Here we operationalized the empiric concept of renal angina with a renal angina index (RAI) and ...determined the predictive performance of RAI. This was assessed on admission to the pediatric intensive care unit, for subsequent severe AKI (over 200% rise in serum creatinine) 72h later (Day-3 AKI). In a multicenter four cohort appraisal (one derivation and three validation), incidence rates for a Day 0 RAI of 8 or more were 15–68% and Day-3 AKI was 13–21%. In all cohorts, Day-3 AKI rates were higher in patients with an RAI of 8 or more with the area under the curve of RAI for predicting Day-3 AKI of 0.74–0.81. An RAI under 8 had high negative predictive values (92–99%) for Day-3 AKI. RAI outperformed traditional markers of pediatric severity of illness (Pediatric Risk of Mortality-II) and AKI risk factors alone for prediction of Day-3 AKI. Additionally, the RAI outperformed all KDIGO stages for prediction of Day-3 AKI. Thus, we operationalized the renal angina concept by deriving and validating the RAI for prediction of subsequent severe AKI. The RAI provides a clinically feasible and applicable methodology to identify critically ill children at risk of severe AKI lasting beyond functional injury. The RAI may potentially reduce capricious AKI biomarker use by identifying patients in whom further testing would be most beneficial.
Abstract
Acute kidney injury (AKI) remains a common clinical syndrome associated with increased morbidity and mortality. In the last several years there have been several advances in the ...identification of patients at increased risk for AKI through the use of traditional and newer functional and damage biomarkers of AKI. This article will specifically focus on the impact of biomarkers of AKI on individual patient care, focusing predominantly on the markers with the most expansive breadth of study in patients and reported literature evidence. Several studies have demonstrated that close monitoring of widely available biomarkers such as serum creatinine and urine output is strongly associated with improved patient outcomes. An integrated approach to these biomarkers used in context with patient risk factors (identifiable using electronic health record monitoring) and with tests of renal reserve may guide implementation and targeting of care bundles to optimize patient care. Besides traditional functional markers, biochemical injury biomarkers have been increasingly utilized in clinical trials both as a measure of kidney injury as well as a trigger to initiate other treatment options (e.g. care bundles and novel therapies). As the novel measures are becoming globally available, the clinical implementation of hospital-based real-time biomarker measurements involves a multidisciplinary approach. This literature review discusses the data evidence supporting both the strengths and limitations in the clinical implementation of biomarkers based on the authors’ collective clinical experiences and opinions.
The use of kidney support therapy (KST) for use in managing patients with acute kidney injury (AKI) has expanded greatly in the last several decades. The growing use of KST modalities in children, ...and now in neonates, has been associated with opportunities for education, clinical research, clinical practice improvements, and outcomes research. A multitude of controversies exist in the field of pediatric KST—many of which are shared by adult critical care nephrology practice. Simultaneously, pediatric KST has led the way to a burgeoning exploration of the importance of fluid overload as it relates to KST initiation and management and also with quality improvement. In this review, we will explore and describe the paradigms contained with pediatric KST used to support children with AKI. In addition to the governing principles related to the mechanics of KST, we will describe the novel aspects of newer support machines and ethical considerations of KST provision. Anticoagulation, dose, and modality will be discussed as well as priming procedures for special considerations. The utilization of KST across pediatric populations represents the next frontier of critical care nephrology.
Acute kidney injury (AKI) is prevalent in critically ill patients and associated with poor outcomes. Current AKI diagnostics— changes to serum creatinine (SCr) and urine output— are imprecise. ...Integration of injury biomarkers with SCr may improve diagnostic precision.
We performed a secondary analysis of a study of critically ill children. Measurements of urine neutrophil gelatinase-associated lipocalin (uNGAL) and SCr samples from ICU admission facilitated the creation of four groups for comparison, based on elevation of SCr from baseline and reference NGAL cut-off value: uNGAL-/SCr-, uNGAL+/SCr-, uNGAL-/SCr + and uNGAL+/SCr+. The primary outcome assessed was AKI severity on Day 3.
178 children were studied. Compared to uNGAL-/SCr-, uNGAL+/SCr- patients had increased risk for all-stage Day 3 AKI (≥ KDIGO stage 1) (OR 3.83, 1.3–11.3, p = .025). Compared to uNGAL-/SCr+, uNGAL+/SCr + patients had increased risk for severe Day 3 AKI (≥ KDIGO stage 2) (OR 12, 1.4–102, p = .018). The only patients to suffer all-stage Day 3 AKI and mortality were uNGAL+ (3.2% uNGAL+/SCr-; 6.5% uNGAL+/SCr+).
Unique biomarker combinations on admission are predictive of distinct Day 3 AKI severity phenotypes. These classifications may enable a more personalized approach to the early management of AKI. Expanded study in larger populations is warranted.
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•Current diagnostics for acute kidney injury are imprecise.•Integration of biomarkers with serum creatinine may improve diagnostic precision.•Increased urinary NGAL identifies patients likely to have persistent kidney injury.•Low urinary NGAL predicts reversible kidney injury.•Use of biomarkers may permit a personalized and proactive approach to management.
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