Outcome of pediatric acute kidney injury: a multicenter prospective cohort study

Acute kidney injury in hospitalized children with proteinuria: A multicenter retrospective analysis

BACKGROUND AND OBJECTIVE

Acute kidney injury (AKI) is a common complication in hospitalized pediatric patients. Previous studies focused on adults found that proteinuria detected during an admission urinalysis is fit to serve as an indicator for AKI and associated clinical outcomes. The objective of this study is to evaluate if proteinuria on the first day of hospital services in hospitalized children is associated with AKI, need for renal replacement therapy, shock and/or antibiotic use, critical care services, and all-cause mortality at 30 days, hypothesizing that it is associated with these outcomes.

METHODS

This is a retrospective cohort study using TriNetX electronic health record data of patients 2 to 18 years of age who underwent urinalysis laboratory testing on hospital admission, had three subsequent days of hospital or critical care services billing codes and creatinine laboratory values, and no pre-existing renal-related complex chronic condition. This study evaluated for the frequency, odds, and severity of AKI as defined by Kidney Disease: Improving Global Outcomes modified criteria and assessed for associated clinical outcomes.

RESULTS

This study included 971 pediatric subjects [435 (44.7%) with proteinuria]. Proteinuria on the first day of hospital services was associated with an increased odds for higher severity AKI on any day of hospitalization (odds ratio [OR] 2.41, CI 1.8-3.23, p<0.001), need for renal replacement therapy (OR 4.58, CI 1.69-12.4, p = 0.001), shock and/or antibiotic use (OR 1.34, CI 1.03-1.75, p = 0.033), and all-cause mortality at 30 days post-admission (OR 10.0, CI 1.25-80.5, p = 0.013).

CONCLUSION

Children with proteinuria on the first day of hospital care services may have an increased odds of higher severity AKI, need for renal replacement therapy, shock and/or antibiotic use, and all-cause mortality at 30 days post-admission, with no significant association found for critical care services, mechanical intubation, or inotrope or vasopressor use.

Acute Kidney Injury: Definition, Management, and Promising Therapeutic Target

Acute kidney injury (AKI) is caused by a sudden loss of renal function, resulting in the build-up of waste products and a significant increase in mortality and morbidity. It is commonly diagnosed in critically ill patients, with its occurrence estimated at up to 50% in patients hospitalized in the intensive critical unit. Despite ongoing efforts, the death rate associated with AKI has remained high over the past half-century. Thus, it is critical to investigate novel therapy options for preventing the epidemic. Many studies have found that inflammation and Toll-like receptor-4 (TLR-4) activation have a significant role in the pathogenesis of AKI. Noteworthy, challenges in the search for efficient pharmacological therapy for AKI have arisen due to the multifaceted origin and complexity of the clinical history of people with the disease. This article focuses on kidney injury's epidemiology, risk factors, and pathophysiological processes. Specifically, it focuses on the role of TLRs especially type 4 in disease development.

The renal angina index accurately predicts low risk of developing severe acute kidney injury among children admitted to a low-resource pediatric intensive care unit

BACKGROUND

Acute kidney injury (AKI) increases the risk of adverse outcomes. The renal angina index (RAI) has previously been used to predict patients at risk of developing severe AKI (sAKI).

METHOD

This single-centre prospective observational study aimed to assess the prevalence of sAKI in PICU as the primary outcome and the duration of mechanical ventilation and PICU stay, RRT need, and mortality as secondary outcomes. The utility of the RAI in predicting day 3 sAKI was also assessed. We enrolled 122 patients aged 1 month to 16 years whose baseline characteristics were collected via questionnaire. RAI was calculated on day 0 with a score of ≥8 being considered positive. sAKI was defined as KDIGO stages 2 and 3.

RESULTS

sAKI prevalence was 14.8% and its development was associated with longer duration of mechanical ventilation (p = 0.001) and higher mortality (p = 0.011). A positive Day 0 RAI predicted day 3 sAKI with sensitivity 55.6%, specificity 85.6%, PPV 40.0%, NPV 91.8%, and AUC of 0.77. Exclusion of children older than 5 years improved RAI performance (sensitivity 72.7%, specificity 88.0%, PPV 57.1%, NPV 93.6%, AUC 0.80). A modified RAI based on local AKI risk factors had equivalent performance to RAI (Z - score 0.78 (CI -0.077-0.033), p = 0.435) with sensitivity 72.2%, specificity 80.8%, PPV 39.4%, NPV 94.4% and AUC 0.80.

CONCLUSION

The RAI can be an effective tool in ruling out sAKI in patients and a modification of RAI based on population-based risk factors improves the test's sensitivity and NPV.

Pharmacokinetics in Critically Ill Children with Acute Kidney Injury

Acute kidney injury (AKI) is a commonly encountered comorbidity in critically ill children. The coexistence of AKI disturbs drug pharmacokinetics and pharmacodynamics, leading to clinically significant consequences. This can complicate an already critical clinical scenario by causing potential underdosing or overdosing giving way to possible therapeutic failures and adverse reactions. Current available studies offer little guidance to help maneuver such complex dosing regimens and decision-making in pediatric patients as most of them are done on heterogeneous groups of adult populations. Though there are some studies on drug dosing during continuous renal replacement therapy (CRRT), their utility is in question because of the recent advances in CRRT technology. Our review aims to discuss the principles of pharmacokinetics pertinent for honing the existing practices of drug dosing in critically ill children with AKI, and the various complexities and intricate challenges involved. This in turn will provide a framework to help enable caretakers to tailor dosing regimens in complex clinical setups with further ease and precision.

A Retrospective Analysis of Risk Factors and Impact of Acute Kidney Injury in Critically Ill Children

BACKGROUND

Acute kidney injury (AKI) is a serious clinical condition in critically ill children and is associated with worse outcomes. A few pediatric studies focused on the risk factors of AKI. We aimed to identify the incidence, risk factors, and outcomes of AKI in the pediatric intensive care unit (PICU).

PATIENTS AND METHODS

All the patients admitted to PICU over a period of 20 months were included. We compared both groups the risk factors between AKI and non-AKI.

RESULTS

A total of 63 patients (17.5%) of the 360 patients developed AKI during PICU stay. The presence of comorbidity, diagnosis of sepsis, increased PRISM III score, and positive renal angina index were found to be risk factors for AKI on admission. Thrombocytopenia, multiple organ failure syndrome, the requirement of mechanical ventilation, use of inotropic drugs, intravenous iodinated contrast media, and exposure to an increased number of nephrotoxic drugs were independent risk factors during the hospital stay. The patients with AKI had a lower renal function on discharge and had worse overall survival.

CONCLUSIONS

AKI is prevalent and multifactorial in critically sick children. The risk factors of AKI may be present on admission and during the hospital stay. AKI is related to prolonged mechanical ventilation days, longer PICU stays, and a higher mortality rate. Based on the presented results early prediction of AKI and consequent modification of nephrotoxic medication may generate positive effects on the outcome of critically ill children.

Long-term Health Care Utilization and Associated Costs After Dialysis-Treated Acute Kidney Injury in Children

RATIONALE & OBJECTIVE

Acute kidney injury (AKI) is common among hospitalized children and is associated with increased hospital length of stay and costs. However, there are limited data on postdischarge health care utilization after AKI hospitalization. Our objectives were to evaluate health care utilization and physician follow-up patterns after dialysis-treated AKI in a pediatric population.

STUDY DESIGN

Retrospective cohort study, using provincial health administrative databases.

SETTING & PARTICIPANTS

All children (0-18 years) hospitalized between 1996 and 2017 in Ontario, Canada. Excluded individuals comprised non-Ontario residents; those with metabolic disorders or poisoning; and those who received dialysis or kidney transplant before admission, a kidney transplant by 104 days after discharge, or were receiving dialysis 76-104 days from dialysis start date.

EXPOSURE

Episodes of dialysis-treated AKI, identified using validated health administrative codes. AKI survivors were matched to 4 hospitalized controls without dialysis-treated AKI by age, sex, and admission year.

OUTCOME

Our primary outcome was postdischarge hospitalizations, emergency department visits, and outpatient physician visits. Secondary outcomes included outpatient visits by physician type and composite health care costs.

ANALYTICAL APPROACH

Proportions with≥1 event and rates (per 1,000 person-years). Total and median composite health care costs. Adjusted rate ratios using negative binomial regression models.

RESULTS

We included 1,688 pediatric dialysis-treated AKI survivors and 6,752 matched controls. Dialysis-treated AKI survivors had higher rehospitalization and emergency department visit rates during the analyzed follow-up periods (0-1, 0-5, and 0-10 years postdischarge, and throughout follow-up), and higher outpatient visit rates in the 0-1-year follow-up period. The overall adjusted rate ratio for rehospitalization was 1.46 (95% CI, 1.25-1.69; P<0.0001) and for outpatient visits was 1.16 (95% CI, 1.09-1.23; P=0.01). Dialysis-treated AKI survivors also had higher health care costs. Nephrologist follow-up was infrequent among dialysis-treated AKI survivors (18.6% by 1 year postdischarge).

LIMITATIONS

Potential miscoding of study exposures or outcomes. Residual uncontrolled confounding. Data for health care costs and emergency department visits was unavailable before 2006 and 2001, respectively.

CONCLUSIONS

Dialysis-treated AKI survivors had greater postdischarge health care utilization and costs versus hospitalized controls. Strategies are needed to improve follow-up care for children after dialysis-treated AKI to prevent long-term complications.

Neutrophil Gelatinase-Associated Lipocalin as a Predictor of Acute Kidney Injury in Children With Shock: A Prospective Study

BACKGROUND

The current definition of acute kidney injury (AKI) is based on serum creatinine (SrCr) and urine output, limited by delayed identification of such patients. Plasma neutrophil gelatinase-associated lipocalin (NGAL) is considered an early diagnostic and highly predictive biomarker of AKI.

OBJECTIVE

To determine the diagnostic accuracy of NGAL for AKI compared with creatinine clearance for early detection of AKI in children with shock receiving inotropic support.

METHODS

Critically ill children requiring inotropic support in the pediatric intensive care unit were enrolled prospectively. SrCr and NGAL values were obtained three times at six, 12, and 48 hours after vasopressor initiation. Patients with AKI were defined as having loss of >25% renal function based on creatinine clearance within 48 hours. NGAL level of more than 150 ng/dl was suggestive of the diagnosis of AKI. Receiver operator characteristic curves were generated for NGAL and SrCr to compare the predictive ability of both at 0, 12, and 48 hours of starting vasopressor support.  Results: A total of 94 patients were enrolled. The mean age was 43±50.95 months. Most common primary diagnoses were related to the cardiovascular system (46%). Twenty-nine patients (31%) died during the hospital stay. Thirty-four patients (36%) developed AKI within 48 hours following shock. The area under the curve (AUC) for NGAL at a cutoff of 150 ng/ml was 0.70, 0.74, and 0.73 at six-hour, 12-hour, and 48-hour follow-up, respectively. NGAL had a sensitivity of 85.3% and specificity of 50% at 0 hours of follow-up for diagnosis of AKI.

CONCLUSION

Serum NGAL has better sensitivity and AUC compared to SrCr for early diagnosis of AKI in children admitted with shock.

Prediction of acute kidney injury, sepsis and mortality in children with urinary CXCL10

BACKGROUND

To determine the associations of urinary CXC motif chemokine 10 (uCXCL10) with AKI, sepsis and pediatric intensive care unit (PICU) mortality in critically ill children, as well as its predictive value for the aforementioned issues.

METHODS

Urinary CXCL10 levels were serially measured in 342 critically ill children during the first week after PICU admission. AKI diagnosis was based on the criteria of KDIGO. Sepsis was diagnosed according to the surviving sepsis campaign's international guidelines for children.

RESULTS

Fifty-two (15.2%) children developed AKI, 132 (38.6%) were diagnosed with sepsis, and 30 (12.3%) died during the PICU stay. Both the initial and peak values of uCXCL10 remained independently associated with AKI, sepsis, septic AKI and PICU mortality. The AUCs of the initial uCXCL10 for predicting AKI, sepsis, septic AKI and PICU mortality were 0.63 (0.53-0.72), 0.62 (0.56-0.68), 0.75 (0.64-0.87) and 0.77 (0.68-0.86), respectively. The AUCs for prediction by using peak uCXCL10 were as follows: AKI 0.65 (0.56-0.75), sepsis 0.63 (0.57-0.69), septic AKI 0.76 (0.65-0.87) and PICU mortality 0.84 (0.76-0.91).

CONCLUSIONS

Urinary CXCL10 is independently associated with AKI and sepsis and may be a potential indicator of septic AKI and PICU mortality in critically ill children.

IMPACT

Urinary CXC motif chemokine 10 (uCXCL10), as an inflammatory mediator, has been proposed to be a biomarker for AKI in a specific setting. AKI biomarkers are often susceptible to confounding factors, limiting their utility as a specific biomarker, especially in heterogeneous population. This study revealed that uCXCL10 levels are independently associated with increased risk for AKI, sepsis, septic AKI and PICU mortality. A higher uCXCL10 may be predictive of septic AKI and PICU mortality in critically ill children.

Trajectory of kidney recovery in pediatric patients requiring continuous kidney replacement therapy for acute kidney injury

BACKGROUND

Acute kidney injury (AKI) is commonly seen in the PICU and is associated with poor short-term and long-term outcomes, especially in patients who required continuous kidney replacement therapy (CKRT). However, as the trajectory of kidney recovery in these patients remain uncertain, determination of the timing to convert to permanent kidney replacement therapy (KRT) remains a major challenge. We aimed to examine the frequency and timing of kidney recovery in pediatric AKI survivors that required CKRT.

METHODS

We performed a retrospective study of patients under 18 years old who received CKRT for AKI in a tertiary-care PICU over 6 years. Primary outcomes were the rate of KRT withdrawal due to kidney recovery and KRT-dependent days for those who survived to hospital discharge. Secondary outcomes were all-cause mortality, dialysis dependence, and occurrences of estimated glomerular filtration rate (eGFR) < 90 mL/min/1.73m² and eGFR < 60 mL/min/1.73m² one year after initiation of the index CKRT in survivors.

RESULTS

Thirty-nine patients were included. Of the 28 children who survived to hospital discharge, 26 (93%) withdrew from dialysis due to kidney recovery, all within 30 days. Twenty-three patients were followed up. One had died, five had an eGFR of 60 mL/min/1.73m² or more but less than 90 mL/min/1.73m², and two had an eGFR < 60 mL/min/1.73m², of which one required peritoneal dialysis.

CONCLUSIONS

Over 90% of the survivors withdrew CKRT within 30 days. However, the frequency of abnormal eGFR one year after initiation of CKRT in survivors exceeded 30% and supports the recommendation of post-AKI follow-up.

Risk factors and outcomes associated with acute kidney injury following extracardiac total cavopulmonary connection: a retrospective observational study

BACKGROUND

Total cavopulmonary connection (TCPC) is an important operation for the treatment of complex congenital heart disease. Epidemiology and outcomes for pediatric patients with acute kidney injury (AKI) following extracardiac TCPC have not been well documented. This study investigates the prevalence, risk factors, and outcomes of AKI in children after extracardiac TCPC surgery.

METHODS

We retrospectively evaluated patients (age at surgery <18 years) who underwent extracardiac TCPC surgery between January 2008 and January 2020 in the Pediatric Cardiac Surgical Center of Fuwai Hospital, Beijing, China. AKI was defined according to the pediatric-modified risk, injury, failure, loss of function, and end-stage renal disease criteria.

RESULTS

A total of 377 pediatric patients were included in this study; 123 patients (32.6%) had some degree of AKI. Among the patients with AKI, 101 (82.1%) were diagnosed with AKI-risk (AKI-R), while 22 (17.9%) were diagnosed with acute kidney injury/failure (AKI/F) (16 with AKI, and 6 with AKF). Preoperative estimated creatinine clearance (OR: 1.039, 95% CI: 1.024-1.055, P<0.001), neutrophil-to-lymphocyte ratio (OR: 1.208, 95% CI: 1.128-1.294, P<0.001), and renal perfusion pressure (OR: 0.962, 95% CI: 0.938-0.986, P=0.002) on postoperative day (POD) 0 were significantly associated with AKI after TCPC. Having previously undergone a bidirectional Glenn was significantly associated with the severity of postoperative AKI (OR: 0.253, 95% CI: 0.088-0.731, P=0.011). Furthermore, AKI was associated with prolonged mechanical ventilation time, prolonged intensive care unit stay, and composite adverse outcome. Compared with non-AKI patients, the 10-year survival rate of patients with severe AKI was significantly lower (95.5% vs. 65.9%, P=0.009).

CONCLUSIONS

Although the incidence of AKI was high in patients undergoing TCPC surgery, most cases were AKI-R. Severe AKI was significantly associated with early adverse outcomes and poor long-term survival.

Diagnostic accuracy of renal angina index alone or in combination with biomarkers for predicting acute kidney injury in children

Early recognition of patients at risk for severe acute kidney injury (AKI) by renal angina index (RAI) may help in the early institution of preventive measures. Objective was to evaluate performance of RAI alone or in combination with biomarkers in predicting severe AKI (KDIGO stage 2 and 3 or equivalent) and receipt of kidney replacement therapy (KRT) in critically ill children. We searched PubMed, EMBASE, Web of Sciences, and CENTRAL for studies published till May 2021. Search terms included acute kidney injury, pediatrics, adolescent, renal angina index, and biomarker. Proceedings of relevant conferences and references of included studies were also scrutinized. Two reviewers independently assessed the study eligibility. Cohort and cross-sectional studies evaluating the diagnostic performance of RAI in predicting AKI or receipt of KRT in children were included. Eligible participants were the children less than 18 years with RAI assessment on day 0 ofadmission. We followed PRISMA-DTA guidelines and used the QUADAS-2 tool for quality assessment. A bivariate model for meta-analysis was used to calculate the summary estimates of diagnostic parameters. Major outcomes were the diagnostic accuracy of RAI (≥ 8) alone or with biomarkers in predicting severe AKI and KRT receipt. Diagnostic accuracy was reported using summary sensitivity, specificity, and area under the curve (AUC). Overall, 22 studies (24 reports, 14,001 participants) were included. RAI ≥ 8 on day 0 has summary sensitivity, specificity, and AUC of 0.86 (95% CI, 0.77-0.92), 0.77 (0.68-0.83), and 0.88 (0.85-0.91) respectively for prediction of severe AKI on day 3. In comparison, a combination of RAI and urinary neutrophil gelatinase-associated lipocalin (NGAL) showed summary sensitivity, specificity, and AUC of 0.76 (0.62-0.85), 0.89 (0.74-0.96), and 0.87 (0.84-0.90) respectively for predicting severe AKI. The sensitivity, specificity, and AUC of RAI for predicting receipt of KRT were 0.82 (0.71-0.90), 0.74 (0.66-0.81), and 0.85 (0.81-0.88) respectively. In meta-regression, only the study setting (sepsis vs. heterogenous) was associated with heterogeneity. We observed substantial heterogeneity among eligible studies. Five studies had concerns in patient selection, and seven studies also had applicability concerns in patient selection for this review. Moderate certainty evidence showed that RAI ≥ 8 has good predicting ability in recognizing children at risk of severe AKI and receipt of KRT. The combination of urinary NGAL and RAI further improves the predicting ability (low-certainty evidence). Further studies are required on the context-driven assessment of novel biomarkers in the early prediction of AKI in RAI-positive children. Systematic review registration number: CRD4202122268. A higher resolution version of the Graphical abstract is available as Supplementary information.

Lesión renal aguda en el paciente pediátrico: revisión integrativa

Introducción: La lesión renal aguda se ha convertido en una complicación común en los niños hospitalizados, especialmente cuando están en una situación clínica crítica. Objetivo: Conocer y sintetizar la bibliografía científica más actualizada sobre la lesión renal aguda en la población pediátrica. Metodología: Estudio descriptivo de revisión integrativa. La búsqueda de artículos se ha realizado en las bases de datos Pubmed, Scopus y Google Scholar. La estrategia de búsqueda se estableció con los siguientes términos MeSH: ”acute kidney injury”, “children” y “pediatric”. La calidad metodológica se realizó mediante la escala STROBE. Resultados: Se incluyeron 35 artículos, 19 de diseño observacional retrospectivo, 12 observacionales prospectivos, 3 revisiones bibliográficas y 1 estudio cualitativo. No hay variables sociodemográficas destacables que impliquen mayor probabilidad de presentar lesión renal aguda. Tanto la etiología como los factores de riesgo son muy variables. La lesión renal aguda se asocia a mayor número de complicaciones y estancia hospitalaria. No hay evidencia de cuidados enfermeros en la lesión renal aguda en pacientes pediátricos. Conclusiones: Se observa una falta de homogeneidad en los criterios de definición, incidencia, etiología, factores de riesgo y de tratamiento en los pacientes pediátricos con lesión renal aguda, y escasez de artículos originales de investigación. La lesión renal aguda pediátrica se asocia a mayor mortalidad, morbilidad, mayor estancia hospitalaria y mayor duración de la ventilación mecánica. El papel de enfermería en el manejo del tratamiento conservador y de las terapias de reemplazo renal de este cuadro, es fundamental en la supervivencia de estos pacientes.

Acute kidney injury in the pediatric intensive care unit: outpatient follow-up

BACKGROUND

Few studies have characterized follow-up after pediatric acute kidney injury (AKI). Our aim was to describe outpatient AKI follow-up after pediatric intensive care unit (PICU) admission.

METHODS

Two-center retrospective cohort study (0-18 years; PICU survivors (2003-2005); noncardiac surgery; and no baseline kidney disease). Provincial administrative databases were used to determine outcomes.

EXPOSURE

AKI (KDIGO (Kidney Disease: Improving Global Outcomes) definitions).

OUTCOMES

post-discharge nephrology, family physician, pediatrician, and non-nephrology specialist visits. Regression was used to evaluate factors associated with the presence of nephrology follow-up (Cox) and the number of nephrology and family physician or pediatrician visits (Poisson), among AKI survivors.

RESULTS

Of n = 2041, 355 (17%) had any AKI; 64/355 (18%) had nephrology; 198 (56%) had family physician or pediatrician; and 338 (95%) had family physician, pediatrician, or non-nephrology specialist follow-up by 1 year post discharge. Only 44/142 (31%) stage 2-3 AKI patients had nephrology follow-up by 1 year. Inpatient nephrology consult (adjusted hazard ratio (aHR) 7.76 [95% confidence interval (CI) 4.89-12.30]), kidney admission diagnosis (aHR 4.26 [2.21-8.18]), and AKI non-recovery by discharge (aHR 2.65 [1.55-4.55]) were associated with 1-year nephrology follow-up among any AKI survivors.

CONCLUSIONS

Nephrology follow-up after AKI was uncommon, but nearly all AKI survivors had follow-up with non-nephrologist physicians. This suggests that AKI follow-up knowledge translation strategies for non-nephrology providers should be a priority.

IMPACT

Pediatric AKI survivors have high long-term rates of chronic kidney disease (CKD) and hypertension, justifying regular kidney health surveillance after AKI. However, there is limited pediatric data on follow-up after AKI, including the factors associated with nephrology referral and extent of non-nephrology follow-up. We found that only one-fifth of all AKI survivors and one-third of severe AKI (stage 2-3) survivors have nephrology follow-up within 1 year post discharge. However, 95% are seen by a family physician, pediatrician, or non-nephrology specialist within 1 year post discharge. This suggests that knowledge translation strategies for AKI follow-up should be targeted at non-nephrology healthcare providers.

Risk factors and occurrence of chronic kidney disease following acute kidney injury in Children

Background

Chronic kidney disease (CKD) is an irreversible progressive condition with diverse etiologies among which acute kidney injury (AKI) is increasingly being recognized as an important one.

Methods

This was a prospective observational study of pediatric intensive care unit (PICU) patients admitted with different etiologies, at a tertiary care hospital for children in Kashmir India, between October 2018 and September 2020. AKI was defined as an increase in absolute serum creatinine (SCr) ≥0.3 mg/dL or by a percentage increase in SCr 50% and/or by a decrease in urine output to <0.5 mL/kg/h for >6 hours (h). Besides analysis of AKI and associated PICU mortality, post-AKI patients after discharge were kept on follow-up for complete 1 year.

Results

From 119 enrolled patients with AKI with no preexisting risk factors, 5.6% (n = 8/119) developed CKD. The AKI-associated mortality rate after 48 h of PICU stay was 13.4% (n = 16/119). At time of discharge from hospital, elevated blood pressure (BP) (n = 5/8) and subnephrotic proteinuria (n = 3/8) were the statistically significant sequels of AKI (P value <0.001) for progression to CKD. After 3 months of follow-up, elevated BP (n = 7/8) and subnephrotic proteinuria (n = 3/8) were significantly associated with progression to CKD at 1 year (P < 0.005).

Conclusions

Occurrence of CKD after an attack of AKI was not uncommon and the risk of long-term consequences in the form of hypertension, proteinuria, and CKD is significant, which may be much higher than observed. It is prudent that all post-AKI PICU discharged patients must be monitored for the long-term consequences of AKI.

Assessment of the renal angina index for the prediction of acute kidney injury in patients admitted to a European pediatric intensive care unit

BACKGROUND

Acute kidney injury (AKI) is associated with worse outcomes and increased morbidity and mortality in pediatric intensive care unit (PICU) patients. The renal angina index (RAI) has been proposed as an early prediction tool for AKI development.

OBJECTIVES

The objective was to evaluate outcomes of RAI-positive patients and to compare RAI performance with traditional AKI markers across different patient groups (medical/post-surgical). This was an observational retrospective study. All children admitted to a tertiary hospital PICU over a 3-year period were included. Electronic medical records were reviewed. Day 1 RAI was calculated, as was the presence and staging of day 3 AKI.

RESULTS

A total of 593 patients were included; 56% were male, the mean age was 55 months, and 17% had a positive RAI. This was associated with day 3 AKI development and worse outcomes, such as greater need for kidney replacement therapy, longer duration of mechanical ventilation, vasoactive support and PICU stay, and higher mortality. For all-stage kidney injury, RAI presented a sensitivity of 87.5% and a specificity of 88.1%. Prediction of day 3 all-stage AKI by RAI had an AUC=0.878; its performance increased for severe AKI (AUC = 0.93). RAI was superior to serum creatinine increase and KDIGO AKI staging on day 1 in predicting severe AKI development. The performance remained high irrespective of the type of admission.

CONCLUSIONS

The RAI is a simple and inexpensive tool that can be used with medical and post-surgical PICU patients to predict AKI development and anticipate complications, allowing for the adoption of preventive measures.

Long-Term Kidney Outcomes Following Dialysis-Treated Childhood Acute Kidney Injury: A Population-Based Cohort Study

BACKGROUND

AKI is common during pediatric hospitalizations and associated with adverse short-term outcomes. However, long-term outcomes among survivors of pediatric AKI who received dialysis remain uncertain.

METHODS

To determine the long-term risk of kidney failure (defined as receipt of chronic dialysis or kidney transplant) or death over a 22-year period for pediatric survivors of dialysis-treated AKI, we used province-wide health administrative databases to perform a retrospective cohort study of all neonates and children (aged 0-18 years) hospitalized in Ontario, Canada, from April 1, 1996, to March 31, 2017, who survived a dialysis-treated AKI episode. Each AKI survivor was matched to four hospitalized pediatric comparators without dialysis-treated AKI, on the basis of age, sex, and admission year. We reported the incidence of each outcome and performed Cox proportional hazards regression analyses, adjusting for relevant covariates.

RESULTS

We identified 1688 pediatric dialysis-treated AKI survivors (median age 5 years) and 6752 matched comparators. Among AKI survivors, 53.7% underwent mechanical ventilation and 33.6% had cardiac surgery. During a median 9.6-year follow-up, AKI survivors were at significantly increased risk of a composite outcome of kidney failure or death versus comparators. Death occurred in 113 (6.7%) AKI survivors, 44 (2.6%) developed kidney failure, 174 (12.1%) developed hypertension, 213 (13.1%) developed CKD, and 237 (14.0%) had subsequent AKI. AKI survivors had significantly higher risks of developing CKD and hypertension versus comparators. Risks were greatest in the first year after discharge and gradually decreased over time.

CONCLUSIONS

Survivors of pediatric dialysis-treated AKI are at higher long-term risks of kidney failure, death, CKD, and hypertension, compared with a matched hospitalized cohort.

Acute kidney injury in pediatric patients hospitalized with acute COVID-19 and multisystem inflammatory syndrome in children associated with COVID-19

This study describes the incidence, associated clinical characteristics and outcomes of acute kidney injury in a pediatric cohort with COVID-19 and Multisystem Inflammatory Syndrome in Children (MIS-C). We performed a retrospective study of patients 18 years of age and under admitted to four New York hospitals in the Northwell Health System interned during the height of the COVID-19 pandemic, between March 9 and August 13, 2020. Acute kidney injury was defined and staged according to Kidney Disease: Improving Global Outcomes criteria. The cohort included 152 patients; 97 acute-COVID-19 and 55 with MIS-C associated with COVID-19. Acute kidney injury occurred in 8 with acute-COVID-19 and in 10 with MIS-C. Acute kidney injury, in unadjusted models, was associated with a lower serum albumin level (odds ratio 0.17; 95% confidence interval 0.07, 0.39) and higher white blood cell counts (odds ratio 1.11; 95% confidence interval 1.04, 1.2). Patients with MIS-C and acute kidney injury had significantly greater rates of systolic dysfunction, compared to those without (80% vs 49%). In unadjusted models, patients with acute kidney injury had 8.4 days longer hospitalizations compared to patients without acute kidney injury (95% confidence interval, 4.4-6.7). Acute kidney injury in acute-COVID-19 and MIS-C may be related to inflammation and/or dehydration. Further research in larger pediatric cohorts is needed to better characterize risk factors for acute kidney injury in acute-COVID-19 and with MIS-C consequent to COVID-19.

Acute kidney injury: epidemiology and course in critically ill children

BACKGROUND

Acute kidney injury (AKI) is a major cause of morbidity and mortality in critically ill children. The aim of this paper was to describe the prevalence and course of AKI in critically ill children and to compare different AKI classification criteria.

METHODS

We conducted a retrospective observational study in our multi-disciplinary Pediatric Intensive Care Unit (ICU) from January 2015 to December 2018. All patients from birth to 16 years of age who were admitted to the pediatric ICU were included. The Kidney Disease Improving Global Outcomes (KDIGO) definition was considered as the reference standard. We compared the incidence data assessed by KDIGO, pediatric risk, injury, failure, loss of kidney function and end- stage renal disease (pRIFLE) and pediatric reference change value optimised for AKI (pROCK).

RESULTS

Out of 7505 patients, 9.2% developed AKI by KDIGO criteria. The majority (59.8%) presented with stage 1 AKI. Recovery from AKI was observed in 70.4% of patients within 7 days from diagnosis. Both pRIFLE and pROCK were less sensitive compared to KDIGO criteria for the classification of AKI. Patients who met all three-KDIGO, pRIFLE and pROCK criteria had a high mortality rate (35.0%).

CONCLUSION

Close to one in ten patients admitted to the pediatric ICU met AKI criteria according to KDIGO. In about 30% of patients, AKI persisted beyond 7 days. Follow-up of patients with persistent kidney function reduction at hospital discharge is needed to reveal the long-term morbidity due to AKI in the pediatric ICU.

Acute kidney injury in children with COVID-19: a retrospective study

Background

Acute kidney injury (AKI) is a complication of coronavirus disease 2019 (COVID-19). The reported incidence of AKI, however, varies among studies. We aimed to evaluate the incidence of AKI and its association with mortality and morbidity in children infected with severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV-2) who required hospital admission.

Methods

This was a multicenter retrospective cohort study from three tertiary centers, which included children with confirmed COVID-19. All children were evaluated for AKI using the Kidney Disease Improving Global Outcomes (KDIGO) definition and staging.

Results

Of 89 children included, 19 (21 %) developed AKI (52.6 % stage I). A high renal angina index score was correlated with severity of AKI. Also, multisystem inflammatory syndrome in children (MIS-C) was increased in children with AKI compared to those with normal kidney function (15 % vs. 1.5 %). Patients with AKI had significantly more pediatric intensive care admissions (PICU) (32 % vs. 2.8 %, p < 0.001) and mortality (42 % vs. 0 %, p < 0.001). However, AKI was not associated with prolonged hospitalization (58 % vs. 40 %, p = 0.163) or development of MIS-C (10.5 % vs. 1.4 %, p = 0.051). No patient in the AKI group required renal replacement therapy. Residual renal impairment at discharge occurred in 9 % of patients. This was significantly influenced by the presence of comorbidities, hypotension, hypoxia, heart failure, acute respiratory distress, hypernatremia, abnormal liver profile, high C-reactive protein, and positive blood culture.

Conclusions

AKI occurred in one-fifth of children with SARS-CoV-2 infection requiring hospital admission, with one-third of those requiring PICU. AKI was associated with increased morbidity and mortality, and residual renal impairment at time of discharge.

Serum Creatinine Monitoring After Acute Kidney Injury in the PICU

OBJECTIVES

It is unknown whether children with acute kidney injury during PICU admission have kidney function monitored after discharge. Objectives: 1) describe postdischarge serum creatinine monitoring after PICU acute kidney injury and 2) determine factors associated with postdischarge serum creatinine monitoring.

DESIGN

Secondary analysis of longitudinal cohort study data.

SETTING

Two PICUs in Montreal and Edmonton, Canada.

PATIENTS

Children (0-18 yr old) surviving PICU admission greater than or equal to 2 days from 2005 to 2011. Exclusions: postcardiac surgery and prior kidney disease. Exposure: acute kidney injury by Kidney Disease: Improving Global Outcomes serum creatinine definition.

INTERVENTIONS

None.

MEASUREMENTS

Primary outcome: postdischarge serum creatinine measured by 90 days, 1 year, and 5-7 years.

SECONDARY OUTCOMES

Healthcare events and nephrology follow-up.

ANALYSIS

Proportions with outcomes; logistic regression to evaluate factors associated with the primary outcome. Kaplan-Meier analysis of time to serum creatinine measurement and healthcare events.

MAIN RESULTS

Of n = 277, 69 (25%) had acute kidney injury; 29/69 (42%), 34/69 (49%), and 51/69 (74%) had serum creatinine measured by 90 days, 1 year, and 5-7 year postdischarge, respectively. Acute kidney injury survivors were more likely to have serum creatinine measured versus nonacute kidney injury survivors at all time points (p ≤ 0.01). Factors associated with 90-day serum creatinine measurement were inpatient nephrology consultation (unadjusted odds ratio [95% CI], 14.9 [1.7-127.0]), stage 2-3 acute kidney injury (adjusted odds ratio, 3.4 [1.1-10.2]), and oncologic admission diagnosis (adjusted odds ratio, 10.0 [1.1-93.5]). A higher proportion of acute kidney injury versus nonacute kidney injury survivors were readmitted by 90 days (25 [36%] vs 44 [21%]; p = 0.01) and 1 year (33 [38%] vs 70 [34%]; p = 0.04). Of 24 acute kidney injury survivors diagnosed with chronic kidney disease or hypertension at 5-7 year follow-up, 16 (67%) had serum creatinine measurement and three (13%) had nephrology follow-up postdischarge.

CONCLUSIONS

Half of PICU acute kidney injury survivors have serum creatinine measured within 1-year postdischarge and follow-up is suboptimal for children developing long-term kidney sequelae. Knowledge translation strategies should emphasize the importance of serum creatinine monitoring after childhood acute kidney injury.

Impact of Acute Kidney Injury on Critically Ill Children and Neonates

Acute kidney injury (AKI) is a clinical syndrome that manifests as an abrupt impairment of kidney function. AKI is common in critically ill pediatric patients admitted to the pediatric intensive care units. AKI is a deleterious complication in critically ill children as it is associated with increased morbidity and mortality. This review provides an overview of the incidence, morbidity, and mortality of AKI in critically ill children in general and specific cohorts such as post-cardiac surgeries, sepsis, critically ill neonates, and post stem cell transplantation.

Prediction of Acute Kidney Injury on Admission to Pediatric Intensive Care

OBJECTIVES

Up to 37% of children admitted to the PICU develop acute kidney injury as defined by Kidney Disease: Improving Global Outcomes criteria. We describe the prevalence of acute kidney injury in a mixed pediatric intensive care cohort using this criteria. As tools to stratify patients at risk of acute kidney injury on PICU admission are lacking, we explored the variables at admission and day 1 that might predict the development of acute kidney injury.

DESIGN

Single-center retrospective observational study.

SETTING

Thirty-six-bed surgical/medical tertiary PICU.

PATIENTS

Children from birth to less than or equal to 16 years old admitted between 2015 and 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Clinical data were extracted from the PICU clinical information system. Patients with baseline creatinine at admission greater than 20 micromol/L above the calculated normal creatinine level were classified as "high risk of acute kidney injury." Models were created to predict acute kidney injury at admission and on day 1. Out of the 7,505 children admitted during the study period, 738 patients (9.8%) were classified as high risk of acute kidney injury at admission and 690 (9.2%) developed acute kidney injury during PICU admission. Compared to Kidney Disease: Improving Global Outcomes criteria as the reference standard, high risk of acute kidney injury had a lower sensitivity and higher specificity compared with renal angina index greater than or equal to 8 on day 1. For the admission model, the adjusted odds ratio of developing acute kidney injury for high risk of acute kidney injury was 4.2 (95% CI, 3.3-5.2). The adjusted odds ratio in the noncardiac cohort for high risk of acute kidney injury was 7.3 (95% CI, 5.5-9.7). For the day 1 model, odds ratios for high risk of acute kidney injury and renal angina index greater than or equal to 8 were 3.3 (95% CI, 2.6-4.2) and 3.1 (95% CI, 2.4-3.8), respectively.

CONCLUSIONS

The relationship between high risk of acute kidney injury and acute kidney injury needs further evaluation. High risk of acute kidney injury performed better in the noncardiac cohort.

Acute renal failure in children. Multicenter prospective cohort study in medium-complexity intensive care units from the Colombian southeast

BACKGROUND

Acute kidney injury is frequent in critically ill children; however, it varies in causality and epidemiology according to the level of patient care complexity. A multicenter prospective cohort study was conducted in four medium-complexity pediatric intensive care units from the Colombian southeast aimed to estimate the clinical prognosis of patients with diagnosis of acute kidney injury.

METHODS

We included children >28 days and <18 years of age, who were admitted with diagnosis of acute kidney injury classified by Kidney Disease Improving Global Outcomes (KDIGO), during the period from January to December 2017. Severe acute kidney injury was defined as stage 2 and stage 3 classifications. Maximum KDIGO was evaluated during the hospital stay and follow up. Length of hospital stay, use of mechanical ventilation and vasoactive drugs, use of renal replacement therapy, and mortality were assessed until discharge.

RESULTS

Prevalence at admission of acute kidney injury was 5.2% (95%CI 4.3% to 6.2%). It was found that 71% of the patients had their maximum KDIGO on day one; an increment in the maximum stage of acute kidney injury increased the pediatric intensive care unit stay. Patients with maximum KDIGO 3 were associated with greater use of mechanical ventilation (47%), compared with maximum KDIGO 2 (37%) and maximum KDIGO 1 (16%). Eight patients with maximum KDIGO 2 and 14 with maximum KDIGO 3 required renal replacement therapy. Mortality was at 11.8% (95%CI 6.4% to 19.4%).

CONCLUSION

Acute kidney injury, established and classified according to KDIGO as severe and its maximum stage, was associated with worse clinical outcomes; early therapeutic efforts should focus on preventing the progression to severe stages.

Acute kidney injury without previous renal disease in critical care unit

BACKGROUND

Acute kidney injury (AKI) is common in hospitalized and critically ill children. Apart from primary kidney disease, etiologies of AKI are usually related to systemic disease and nephrotoxic insult. This study examines the incidence, characteristics, and mortality risks of AKI in critically ill children without primary renal disease or previously known chronic kidney disease.

METHODS

A retrospective cohort study was conducted of patients aged 1-18 years, diagnosed with AKI (excluding severe glomerulonephritis and previously known chronic kidney disease) in pediatric intensive care units between 2013 and 2016. Acute kidney injury was defined according to the Kidney Disease Improving Global Outcomes classifications. Cox proportional hazards regression analysis was employed to assess the relationship between the risk factors and mortality.

RESULTS

Of 1,377 pediatric intensive care unit patients, 253 (18.4%) developed AKI and only 169 (12.3%) who did not have previously known renal disease were included. Of these 169 AKI patients, the mean age was 8.1 ± 4.7 years; 88 (52.1%) patients were male; and 60 (35.5%) patients had AKI stage 3. The most common etiologies of AKI were sepsis (76.9%) and shock (64.5%). Fifty-three (31.4%) of those patients died during admission. The risk factors for death were the need for mechanical ventilation (adjusted hazard ratio, 17.82; 95% CI, 2.41-132.06) and AKI stage 3 (adjusted hazard ratio, 2.32; 95% CI, 1.07-5.00).

CONCLUSIONS

Acute kidney injury in critically ill children without previously known renal disease was approximately two-thirds of the overall incidence. The risk factors of in-hospital death were the use of mechanical ventilation, and AKI stage 3.

Impact of acute kidney injury and nephrotoxic exposure on hospital length of stay

OBJECTIVE

Acute kidney injury (AKI) is a common occurrence among hospitalized children and leads to increased mortality and prolonged length of stay (LOS) in critically ill patients. Few studies have examined the impact of AKI on LOS for common pediatric conditions. We hypothesized that a diagnosis of AKI would be associated with a longer hospital LOS and increased exposure to nephrotoxic medications for all patients.

PATIENTS AND METHODS

We performed a multicenter retrospective cross-sectional analysis of 34 children's hospitals in the Pediatric Health Information System (PHIS) database from 1/2009 through 12/2013. Patients were grouped based on primary discharge diagnosis, number of days spent in an intensive care unit, and assignment of a secondary diagnostic code for AKI. Median LOS was compared among different patient groupings. Exposure to commonly used nephrotoxic medications was collected for each admission.

RESULTS

A total of 588,884 admissions from 423,337 patients were included in the analysis. The median LOS among non-critically ill patients with and without AKI was 5 days [95% CI 3-10] versus 2 days [95% CI 1-4], respectively. Among critically ill patients, median LOS for those with and without AKI was 12 days [95% CI 7-20] versus 4 days [95% CI 2-7], respectively. Patients who developed AKI were more likely to have significant nephrotoxic exposure.

CONCLUSIONS

Development of AKI was associated with longer hospital length of stay and increased nephrotoxic medication exposure for all diagnostic categories. Non-critically ill children with AKI were hospitalized the same length or longer than critically ill children without AKI.

Association Between Furosemide Exposure and Clinical Outcomes in a Retrospective Cohort of Critically Ill Children

Furosemide is commonly prescribed in critically ill patients to increase the urine output and prevent fluid overload (FO) and acute kidney injury (AKI), but not supported by conclusive evidence. There remain conflicting findings on whether furosemide associates with AKI and adverse outcomes. Information on the impact of furosemide on adverse outcomes in a general population of pediatric intensive care unit (PICU) is limited. The aim of the cohort study was to investigate the associations of furosemide with AKI and clinical outcomes in critically ill children. Study Design: We retrospectively reviewed a cohort of 456 critically ill children consecutively admitted to PICU from January to December 2016. The exposure of interest was the use of furosemide in the first week after admission. FO was defined as ≥5% of daily fluid accumulation, and mean FO was considered significant when mean daily fluid accumulation during the first week was ≥5%. The primary outcomes were AKI in the first week after admission and mortality during PICU stay. AKI diagnosis was based on Kidney Disease: Improving Global Outcomes criteria with both serum creatinine and urine output. Results: Furosemide exposure occurred in 43.4% of all patients (n = 456) and 49.3% of those who developed FO (n = 150) in the first week after admission. Patients who were exposed to furosemide had significantly less degree of mean daily fluid accumulation than those who were not (1.10 [-0.33 to 2.61%] vs. 2.00 [0.54-3.70%], P < 0.001). There was no difference in the occurrence of AKI between patients who did and did not receive furosemide (22 of 198 [11.1%] vs. 36 of 258 [14.0%], P = 0.397). The mortality rate was 15.4% (70 of 456), and death occurred more frequently among patients who received furosemide than among those who did not (21.7 vs. 10.5%, P = 0.002). Furosemide exposure was associated with increased odds for mortality in a multivariate logistic regression model adjusted for body weight, gender, illness severity assessed by PRISM III score, the presence of mean FO, and AKI stage [adjusted odds ratio (AOR) 1.95; 95%CI, 1.08-3.52; P = 0.026]. Conclusion: Exposure to furosemide might be associated with increased risk for mortality, but not AKI, in critically ill children.

Acute kidney injury risk-based screening in pediatric inpatients: a pragmatic randomized trial

BACKGROUND

Pediatric acute kidney injury (AKI) is common and associated with increased morbidity, mortality, and length of stay. We performed a pragmatic randomized trial testing the hypothesis that AKI risk alerts increase AKI screening.

METHODS

All intensive care and ward admissions of children aged 28 days through 21 years without chronic kidney disease from 12/6/2016 to 11/1/2017 were included. The intervention alert displayed if calculated AKI risk was > 50% and no serum creatinine (SCr) was ordered within 24 h. The primary outcome was SCr testing within 48 h of AKI risk > 50%.

RESULTS

Among intensive care admissions, 973/1909 (51%) were randomized to the intervention. Among those at risk, more SCr tests were ordered for the intervention group than for controls (418/606, 69% vs. 361/597, 60%, p = 0.002). AKI incidence and severity were the same in intervention and control groups. Among ward admissions, 5492/10997 (50%) were randomized to the intervention, and there were no differences between groups in SCr testing, AKI incidence, or severity of AKI.

CONCLUSIONS

Alerts based on real-time prediction of AKI risk increased screening rates in intensive care but not pediatric ward settings. Pragmatic clinical trials provide the opportunity to assess clinical decision support and potentially eliminate ineffective alerts.

Predictors of mortality after admission to pediatric intensive care unit in oncohematologic patients without history of hematopoietic stem cell transplantation: A single-center experience

BACKGROUND

Pediatric oncohematologic patients are a high-risk population for clinical deterioration that might require pediatric intensive care unit (PICU) admission. Several studies have described outcomes and mortality predictors for patients post hematopoietic stem cell transplantation (HSCT), but fewer data exist regarding the category of non-HSCT patients.

PROCEDURE

All oncohematologic non-HSCT patients ≤18 years requiring PICU admission from 1998 to 2015 in our tertiary-care academic hospital were retrospectively evaluated by means of the pediatric hematology-oncology unit database and the Italian PICUs data network database. We assessed the relation between demographic and clinical characteristics and 90-day mortality after PICU admission.

RESULTS

Of 3750 hospitalized oncohematologic patients, 3238 were non-HSCT and 63 (2%) of them were admitted to the PICU. Patients were mainly affected by hematological malignancies (70%) and mostly were in the induction-therapy phase. The main reasons for admission were respiratory failure (40%), sepsis (25%), and seizures (16%). The median PICU stay was 5 days (range 1-107). The mortality rate at PICU discharge was 30%, and at 90 days it was 35%. Fifty-five percent of deaths happened in the first 2 days of the PICU stay. Cardiac arrest (P = .007), presence of disseminated intravascular coagulation (DIC, P = .007), and acute kidney injury (AKI) at PICU admission (P < .001) and during PICU stay (P = .021) were significant predictors of mortality in the multivariate analysis. Respiratory failure and mechanical ventilation were not associated with mortality.

CONCLUSIONS

A relatively small percentage of non-HSCT patients required PICU admission, but the mortality rate was still high. Hemodynamic instability, DIC, and AKI, but not respiratory failure, were significant predictors of mortality.

Short-term outcome associated with disease severity and electrolyte abnormalities among critically ill children with acute kidney injury

Background

Acute kidney injury (AKI) in critically ill children is associated with increased mortality and morbidity. In this study we evaluated the effect of AKI severity on the incidence of short-term mortality and morbidity.

Methods

Multicenter prospective cohort study was conducted over two years period. We used the Kidney Disease Improving Global Outcomes (KDIGO) to diagnose and stage AKI.

Results

A total of 511 out of 1367 included children (37.4%; 95% CI: 34.8–40.0) were diagnosed with AKI. They were categorized into three KDIGO stages: stage I (mild) in 47.5% (95% CI: 43.2–52.0), stage II (moderate) in 32.8% (95% CI: 28.8–37.1) and stage III (severe) in 19.7% (95% CI: 16.4–23.5). Stage II and III AKI had higher risk of mortality and longer length of stay (LOS) in hospital.

Children with stage III AKI were more likely to require mechanical ventilation, referral to pediatric nephrology and discharge with abnormal creatinine level (above 100 uml\L).

Hypervolemia, hypocalcemia, anemia, and acidosis were found to be independent risk factors of mortality.

Conclusion

The extent of severity of AKI is directly associated with increased mortality, LOS and short-term morbidity.

Hemodynamic impact of the connection to continuous renal replacement therapy in critically ill children

BACKGROUND

Continuous renal replacement therapy (CRRT) is the treatment of choice for critically ill children with acute kidney injury. Hypotension after starting CRRT is frequent but very few studies have analyzed its incidence and clinical relevance.

METHODS

A prospective, observational study was performed including critically ill children treated with CRRT between 2010 and 2014. Hemodynamic data and connection characteristics were collected before, during, and 60 min after CRRT circuit connection. Hypotension with the connection was defined as a decrease in > 20% of the mean arterial pressure from baseline or when intravenous fluid resuscitation or an increase in vasopressors was required.

RESULTS

One hundred sixty-one connections in 36 children (median age 18.8 months) were analyzed. Twenty-eight patients (77.8%) were in the postoperative period of cardiac surgery, 94% had mechanical ventilation, and 86.1% had vasopressors. The heparinized circuit priming solution was discarded in 8.7% and infused to the patient in 18% of the connections. The circuit was re-primed in the remaining 73.3% using albumin (79.3%), red blood cells (4.5%), or another crystalloid solution without heparin (16.2%). Hypotension occurred in 49.7% of the connections a median of 5 min after the beginning of the therapy. Fluid resuscitation was required in 38.5% and the dose of vasopressors was increased in 12.4% of the connections. There was no relationship between hypotension and age or weight. Re-priming the circuit with albumin reduced the incidence of hypotension from 71.4 to 44.6% (p = 0.004).

CONCLUSIONS

Hypotension after the connection to CRRT is very frequent in critically ill children. Re-priming the circuit with albumin could improve hemodynamics during connection.