Quality of life after acute kidney injury McNicholas, Bairbre; Akcan Arikan, Ayse; Ostermann, Marlies
Current opinion in critical care,
12/2023, Volume:
29, Issue:
6
Journal Article
Deciphering the effect of acute kidney injury (AKI) during critical illness on long-term quality of life versus the impact of conditions that brought on critical illness is difficult.
Reports on ...patient-centred outcomes such as health-related quality of life (HRQOL) have provided insight into the long-lasting impact of critical illness complicated by AKI. However, these data stem from observational studies and randomized controlled trials, which have been heterogeneous in their patient population, timing, instruments used for assessment and reporting. Recent studies have corroborated these findings including lack of effect of renal replacement therapy compared to severe AKI on outcomes and worse physical compared to cognitive dysfunction.
In adults, more deficits in physical than mental health domains are found in survivors of AKI in critical care, whereas memory deficits and learning impairments have been noted in children. Further study is needed to understand and develop interventions that preserve or enhance the quality of life for individual patients who survive AKI following critical illness, across all ages.
Background
The objectives of the study are to describe tandem therapeutic plasma exchange (TPE) and continuous kidney replacement therapy (CKRT) patients’ outcomes in a large institution.
Methods
We ...reviewed pediatric patients receiving tandem TPE and CKRT from 2013 to 2016. Over the study period, 63 discrete patients received tandem TPE and CKRT for a total of 378 TPE procedures on 1676 days on CKRT.
Results
Patient age ranged from newborn to 19 years old with weights ranging from 2.31 to 112.3 kg (17 patients were < 10 kg and less than 1 year old). All procedures were completed in intensive care units (ICU) as CKRT can only be done in this environment. All treatments completed successfully; majority of patients (90%) developed hypocalcemia though none were symptomatic. Case mortality rate was 40%. Disease severity scores at ICU admission were higher and time to TPE and CKRT start was longer in the deceased group.
Conclusions
As a conclusion, though complications including hypocalcemia are common with tandem TPE and CKRT in pediatrics, patients remained asymptomatic. Such treatments have to be carefully planned with interdisciplinary teams to address indications, technicalities, and complications.
This retrospective study included pediatric intensive care unit patients receiving continuous veno-venous hemodiafiltration (CVVHDF) being treated with cefepime. The free drug concentration above one ...time the MIC (
>1×MIC) and four times a presumed MIC (
>4×MIC) of 8 μg/ml were calculated. Four patients received doses ranging from 48 to 64 mg/kg of body weight every 6 to 12 h. Three patients achieved 100%
>1×MIC, with the fourth patient achieving 98%
>1×MIC. Therapeutic drug monitoring should be considered for critically ill patients receiving cefepime on CVVHDF.
Objective To investigate the impact of an early emergency department (ED) protocol-driven resuscitation (septic shock protocol SSP) on the incidence of acute kidney injury (AKI). Study design This ...was a retrospective pediatric cohort with clinical sepsis admitted to the pediatric intensive care unit (PICU) from the ED before (2009, PRE) and after (2010, POST) implementation of the SSP. AKI was defined by pRIFLE (pediatric version of the Risk of renal dysfunction; Injury to kidney; Failure of kidney function; Loss of kidney function, End-stage renal disease creatinine criteria). Results A total of 202 patients (PRE, n = 98; POST, n = 104) were included (53% male, mean age 7.7 ± 5.6 years, mean Pediatric Logistic Organ Dysfunction PELOD 8.9 ± 12.7, mean Pediatric Risk of Mortality score 5.3 ± 13.9). There were no differences in demographics or illness severity between the PRE and POST groups. POST was associated with decreased AKI (54% vs 29%, P < .001), renal-replacement therapy (4 vs 0, P = .04), PICU, and hospital lengths of stay (LOS) (1.9 ± 2.3 vs 4.5 ± 7.6, P < .01; 6.3 ± 5.1 vs 15.3 ± 16.9, P < .001, respectively), and mortality (10% vs 3%, P = .037). The SSP was independently associated with decreased AKI when we controlled for age, sex, and PELOD (OR 0.27, CI 0.13-0.56). In multivariate analyses, the SSP was independently associated with shorter PICU and hospital LOS when we controlled for AKI and PELOD ( P = .02, P < .001, respectively). Conclusion A protocol-driven implementation of a resuscitation bundle in the pediatric ED decreased AKI and need for renal-replacement therapy, as well as PICU and hospital LOS and mortality.
Cirrhotic cardiomyopathy (CCM), a comorbidity of end‐stage cirrhotic liver disease, remains uncharacterized in children, largely because of a lack of an established pediatric definition. The aim of ...this retrospective cohort analysis is to derive objective two‐dimensional echocardiographic (2DE) criteria to define CCM associated with biliary atresia (BA), or BA‐CCM, and correlate presence of BA‐CCM with liver transplant (LT) outcomes in this population. Using receiver operating characteristic (ROC) curve analysis, optimal cut‐off values for left ventricular (LV) geometrical parameters that were highly sensitive and specific for the primary outcomes: A composite of serious adverse events (CSAE) and peritransplant death were determined. These results were used to propose a working definition for BA‐CCM: (1) LV mass index (LVMI) ≥95 g/m2.7 or (2) relative wall thickness of LV ≥0.42. Applying these criteria, BA‐CCM was found in 34 of 69 (49%) patients with BA listed for LT and was associated with increased multiorgan dysfunction, mechanical and vasopressor support, and longer intensive care unit (ICU) and hospital stays. BA‐CCM was present in all 4 waitlist deaths, 7 posttransplant deaths, and 20 patients with a CSAE (P < 0.01). On multivariable regression analysis, BA‐CCM remained independently associated with both death and a CSAE (P < 0.01). Utilizing ROC analysis, LVMI was found to be a stronger predictor for adverse outcomes compared with current well‐established markers, including Pediatric End‐Stage Liver Disease (PELD) score. Conclusion: BA‐CCM is highly sensitive and specific for morbidity and mortality in children with BA listed for LT. 2DE screening for BA‐CCM may provide pertinent clinical information for prioritization and optimal peritransplant management of these children.
Assessment of acute kidney injury (AKI) in septic patients remains imprecise. In adults, the classification of septic patients by clinical AKI phenotypes (severity and timing) demonstrates unique ...associations with patient outcome vs. broadly defined AKI.
In a multinational prospective observational study, AKI diagnosis in critically ill septic children was stratified by duration (transient vs. persistent) and severity (mild vs. severe by creatinine change and urine output). The outcomes of interest were mortality and intensive care unit resource complexity at 28 days.
Seven hundred and fifty-seven septic children were studied (male 52.7%, age 4.6 years (1.5-11.9)). Mortality (overall 12.1%) was different between severe AKI and mild AKI (18.3 vs. 4.4%, p < 0.001) as well as intensive care unit (ICU) complexity (overall 34.5%, 45 vs. 21.7%, p < 0.001). Patients with Persistent AKI had fewer ICU-free days (17 (7, 21) vs. 24 (17, 26), p < 0.001) and higher ICU complexity (52.8 vs. 22.9%, p = 0.002) than transient AKI, even after exclusion of patients with early mortality. AKI phenotypes incorporating temporal and severity data correlate with unique survival (range 4.4-21.6%) and ICU-free days (range of 15-25 days) CONCLUSIONS: The outcome of septic children with AKI changes by clinical phenotype. Our findings underscore the importance of prognostic enrichment in sepsis and AKI for the purpose of trial design and patient management.
Although AKI occurs commonly in patients with sepsis (S-AKI), outcomes for children with S-AKI varies based on the severity and timing of the AKI. Existing S-AKI pediatric data utilize a broad singular definition of kidney injury. Increasing the precision of AKI classification results in a new understanding of how S-AKI associates with patient outcome. A refined classification of S-AKI identifies subgroups of children, making possible a targeted and a personalized medicine approach to S-AKI study and management.
The most appropriate vancomycin dosing strategy in pediatric patients weighing ≥70 kg (weight based versus non-weight based) to achieve an area under the concentration-time curve (AUC) of ≥400 ...mg·liter/h and a trough concentration of <20 mg/liter is not known. Population pharmacokinetic analysis determined that dosing of vancomycin should be weight based using fat-free mass, with appropriate adjustment for kidney dysfunction.
Pediatric liver failure patients frequently develop multiple organ failure and require continuous renal replacement therapy (CRRT) as part of supportive therapy in the pediatric intensive care unit. ...While many centers employ no anticoagulation for fear of bleeding complications, balanced coagulation disturbance predisposes these patients to clotting as well as bleeding, making maintenance of longer circuit life to deliver adequate dialysis clearance challenging. Regional citrate anticoagulation (RCA) is an attractive option as it avoids systemic anticoagulation, but since citrate metabolism is impaired in liver failure, concerns about toxicity has limited its use. Pediatric data on RCA with liver failure is very scarce. We aimed to establish safety and efficacy of RCA in pediatric liver failure patients on CRRT. Retrospective review of pediatric patients with liver failure receiving CRRT over 30 months. Demographic data and CRRT related data were collected by chart review. Citrate accumulation (CA) was defined as total calcium (mg/dl) /ionized calcium (mmol/L) ratio >2.5 for > 48 hours. Efficacy was assessed by filter life. Safety was assessed by frequency of adverse events ((AEs) defined as bleeding, hemodynamic instability, arrhythmias). Fifty-one patients (median age 3.5 (IQR 0.75-14.2) years) received 861 CRRT days; 70% experienced at least one episode of CA, only 37% were recorded as such in the medical record. AE rate was 93/1000 CRRT days and did not differ between CA days and others. Median filter life was 66 hours (IQR 29-74); 63% filters lasted longer than 48 hrs. Though common, CA was not associated with increased AEs on in pediatric liver failure patients on CRRT receiving RCA. Filter life was adequate. RCA appears an effective anticoagulation for CRRT in pediatric liver failure. Application of a structured definition would increase recognition of CA to allow timely intervention.
Background
The primary objective was to evaluate associations between perioperative clinical variables and postoperative hemodynamic indices after HT with the development of severe AKI. The secondary ...objective was to evaluate associations between UOP or creatinine as AKI indicators and morbidity after HT.
Methods
Retrospective study of all patients who underwent HT 1/2016‐11/2019 at a quaternary pediatric institution. Severe AKI was defined as KDIGO stage 2 or higher.
Results
Of 94 HT patients, 73 met inclusion criteria; 45% of patients developed severe AKI. In univariate analysis, non‐Hispanic Black race, preoperative AKI, longer CPB duration, lower weight, and peak lactate within 12 h post‐HT were associated with severe AKI. CVP ≤12 h post‐HT had a quadratic relationship, rather than linear, with severe AKI. PPV >18% was significantly associated with severe AKI but equated to noncontiguous 10 min of high variation over a 12‐h period, and thus was deemed not clinically significant. In multivariate analysis, Black race, longer CPB duration, and higher CVP remained associated with severe AKI (c: 0.84, 95% CI 0.73–0.92). Severe AKI per creatinine, but not UOP criteria, was associated with longer duration of ventilation (p = .012) and longer intensive care unit length of stay (p = .003).
Conclusions
In pediatric HT patients, non‐Hispanic Black race, longer CPB time, and higher postoperative CVP ≤12 h post‐HT were associated with severe AKI. AKI based on creatinine, not UOP, was associated with postoperative HT morbidity.
The use of mechanical circulatory support (MCS) therapies in children with medically refractory cardiac failure has increased over the past two decades. With the growing experience and expertise, MCS ...is currently offered as a bridge to recovery or heart transplantation and in some cases even as destination therapy. Acute kidney injury (AKI) is common in patients with end-stage heart failure (ESHF). When severe AKI develops requiring kidney replacement therapy (KRT), these patients present unique challenges for the pediatric nephrology team. The use of KRT has not been adequately described in children with ESHF on the newer MCS. We also present original case series data from our center experience. The purpose of this review is to familiarize the reader with the current MCS technologies, approach to their selection, how they interact when combined with current KRT circuits, and distinguish similarities and differences. We will attempt to highlight the distinctive features of each technology, specifically focusing on growing trends in use of continuous-flow ventricular assist devices (CF-VAD) as it poses additional challenges to the pediatric nephrologist.
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