Nephrotoxin exposure and acute kidney injury in critically ill children undergoing congenital cardiac surgery

Framework for Kidney Health Follow-Up Among Neonates With Critical Cardiac Disease: A Report From the Neonatal Kidney Health Consensus Workshop

Acute kidney injury is common among neonates with critical cardiac disease. Risk factors and associations with kidney-related outcomes are heterogeneous and distinct from other neonates. As survival of children with critical cardiac disease increases to adulthood, the burden of chronic kidney disease is increasing. Thirty percent to 50% of adults with congenital heart disease have impaired kidney function, even in the absence of prior kidney injury episodes. This may be related to the current standardized acute kidney injury criteria, which may not fully capture clinically meaningful kidney injury and long-term kidney health risks. An improved understanding of which neonates with critical cardiac disease should undergo kidney health follow-up is imperative. During the National Institutes of Health-supported Neonatal Kidney Health Consensus Workshop to Address Kidney Health meeting conducted in February 2024, a panel of 51 neonatal nephrology experts focused on at-risk groups: (1) preterm infants, (2) critically ill infants with acute kidney injury, and (3) infants with critical cardiac disease. The critical cardiac disease subgroup, comprising multidisciplinary experts, used a modified Delphi process to achieve consensus on recommendations for kidney health follow-up. In this report, we review available data on kidney health follow-up in critical cardiac disease and summarize the 2 consensus-based recommendations. We introduce novel diagnostic and risk-stratification tools for acute kidney injury diagnosis in neonates with cardiac disease to guide follow-up recommendations. Finally, we identify important knowledge gaps, representing areas of focus for future research. These should be prioritized to understand and improve long-term kidney health in critical cardiac disease.

Association between postoperative ibuprofen exposure and acute kidney injury after pediatric cardiac surgery

BACKGROUND

Acute kidney injury (AKI) is a common complication after pediatric cardiac surgery and is associated with worse outcomes. Ibuprofen is widely used in the perioperative period and can affect kidney function in children. However, the association between ibuprofen exposure and AKI after pediatric cardiac surgery has not been determined yet.

METHODS

In this retrospective cohort study, children undergoing cardiac surgery with cardiopulmonary bypass were studied. Exposure was defined as given ibuprofen in the first 7 days after surgery. Postoperative AKI was diagnosed using the KDIGO criteria. A multivariable Cox regression model was used to assess the association between ibuprofen exposure and postoperative AKI by taking ibuprofen as a time-varying covariate.

RESULTS

Among 1,112 included children, 198 of them (17.8%) experienced AKI. In total, 396 children (35.6%) were exposed to ibuprofen. AKI occurred less frequently among children who were administered ibuprofen than among those who were not (46 of 396 [11.6%] vs. 152 of 716 [21.2%], p < 0.001). Using the Cox regression model accounting for time-varying exposures, ibuprofen treatment was not associated with AKI (adjusted HR, 0.99; 95% CI 0.70-1.39, p = 0.932). This insignificant association was consistent across the sensitivity and subgroup analyses.

CONCLUSIONS

Postoperative ibuprofen exposure in pediatric patients undergoing cardiac surgery was not associated with an increased risk of AKI.

Case report: Challenging kidney transplantation in an adolescent patient with tetralogy of Fallot

Tetralogy of Fallot is the most common cyanotic congenital heart disease. This severe disorder of cardiac physiology can impair renal function and lead to the development of cardiorenal syndrome and eventually to end-stage renal disease. Kidney transplantation may be the best option for renal replacement treatment in patients with tetralogy of Fallot, but only after correcting cardiac abnormalities and optimizing cardiac functions, all of which require a multidisciplinary approach. We report the first case of kidney transplantation in an adolescent patient with tetralogy of Fallot. Our findings confirms that kidney transplantation is a valuable treatment option in selected congenital heart disease cases.

Ketorolac in neonates and infants following congenital heart surgery: a retrospective review

INTRODUCTION

Pain management is essential in the immediate post-surgical period. We sought to describe the ketorolac dose regimen in neonates and infants following cardiac surgery. Secondary outcomes included renal dysfunction, bleeding, and pain management.

METHODS

We performed a single-centre retrospective cohort study of neonates and infants (aged < 12 months) who received ketorolac following cardiac surgery, from November 2020 through November 2021 (inclusive). Ketorolac was administered at 0.5 mg/kg every 6 hours. Safety was defined by absence of a clinically significant decline in renal function (i.e., increase in serum creatinine [SCr] by ≥ 0.3 mg/dL from baseline within 48 hours and/or urine output ≤ 0.5 mL/kg/hour for 6 hours) and absence of clinically significant bleeding defined as major by International Society on Thrombosis and Hemostasis paediatric criteria or Severe/Fatal Bleeding Events by Nellis et al. Efficacy measures included pain scores and opioid utilisation.

RESULTS

Fifty-five patients met eligibility criteria. The median (range) dose and duration of ketorolac administration was 0.5 mg/kg/dose for 48 (6-90) hours. Among all patients, there was not a statistically significant difference observed in median SCr within 48 hours of baseline (p > .9). There were no major or severe bleeding events. The median (range) opioid requirements (morphine intravenous equivalents per kg per day) at 48 hours post-ketorolac initiation was 0.1 (0-0.8) mg/kg/day.

CONCLUSIONS

If validated prospectively, these findings suggest that a ketorolac regimen 0.5 mg/kg/dose every 6 hours in neonates and infants post-cardiac surgery may be safe with regard to renal function and bleeding risk, and effective regarding opioid-sparing capacity.

Ketorolac Dosing and Outcomes in Neonates Following Congenital Heart Surgery: A Retrospective Analysis

BACKGROUND

Pain management is essential for postoperative surgery. Given the association of opioids with adverse outcomes, interest in the use of nonopioid analgesics, such as ketorolac, has increased. Published data on use in neonates are limited.

OBJECTIVES

To describe ketorolac dosing and safety and efficacy outcomes in the first 48 hours postcardiac surgery in neonates.

DESIGN

We performed a single-center retrospective cohort study of neonates (ages < 28 d) who received ketorolac following cardiac surgery from November 2020 to July 2023 (inclusive). The primary safety outcome was a clinically significant decline in renal function, as defined by the composite of an increase in serum creatinine by greater than or equal to 0.3 mg/dL from baseline within 96 hours of ketorolac initiation and urine output less than or equal to 0.5 mL/kg/hr for 6 hours. The secondary safety outcome was clinically significant bleeding, defined as the composite of major bleeding by the International Society on Thrombosis and Hemostasis pediatric criteria and severe/fatal bleeding by the criteria of Nellis et al (2019). Efficacy was measured by opioid utilization based on a standardized pain score-driven analgesia protocol.

INTERVENTIONS

Ketorolac was administered at 0.5 mg/kg every 6 hours as per an institutional clinical management algorithm.

MEASUREMENTS AND MAIN RESULTS

Thirty-nine patients met the eligibility criteria. The median ketorolac dose was 0.5 mg/kg/dose, and median (interquartile range [IQR]) duration of therapy was 48 hours (6-48 hr). No patients experienced a significant decline in renal function, and there were no clinically significant bleeding events. The median (IQR) IV morphine milligram equivalents (MMEs)/kg/d of opioid administration was 0.2 MME/kg/d (0.1-0.25 MME/kg/d) at the time of ketorolac initiation and 0.1 MME/kg/d (0.1-0.2 MME/kg/d) at 48 hours post-ketorolac initiation.

CONCLUSIONS

If validated prospectively, these findings suggest that a ketorolac regimen of 0.5 mg/kg/dose every 6 hours in neonates postcardiac surgery may be safe with regard to renal function and bleeding risk. Additional randomized studies would be needed to determine efficacy with regard to opioid-sparing capacity.

Epidemiology of acute kidney injury in children: a report from the 26th Acute Disease Quality Initiative (ADQI) consensus conference

The nephrology and critical care communities have seen an increase in studies exploring acute kidney injury (AKI) epidemiology in children. As a result, we now know that AKI is highly prevalent in critically ill neonates, children, and young adults. Furthermore, children who develop AKI experience greater morbidity and higher mortality. Yet knowledge gaps still exist that suggest a more comprehensive understanding of AKI will form the foundation for future efforts designed to improve outcomes. In particular, the areas of community acquired AKI, AKI in non-critically ill children, and cohorts from low-middle income countries have not been well studied. Longer-term functional outcomes and patient-centric metrics including social determinants of health, quality of life, and healthcare utilization should be the foci of the next phase of scholarship. Current definitions identify AKI-based upon evidence of dysfunction which serves as a proxy for injury; biomarkers capable of identifying injury as it occurs are likely to more accurately define populations with AKI. Despite the strength of the association, the causal and mechanistic relationships between AKI and poorer outcomes remain inadequately examined. A more robust understanding of the relationship represents a potential to identify therapeutic targets. Once established, a more comprehensive understanding of AKI epidemiology in children will allow investigation of preventive, therapeutic, and quality improvement interventions more effectively.

Challenges in Pharmacovigilance: Variability in the Criteria for Determining Drug-Associated Acute Kidney Injury in Retrospective, Observational Studies

BACKGROUND

Drug-associated acute kidney injury (D-AKI) accounts for 19-26% of acute kidney injury (AKI) events in hospitalized patients and results in outcomes similar to patients with AKI from other etiologies. Diagnosing D-AKI is complex and various criteria have been used.

SUMMARY

To highlight the variability in D-AKI determination, a review was conducted between January 2017 and December 2022 using PubMed. Search terms included adaptations of "drug associated kidney injury" to identify a sampling of literature discussing definitions and criteria for D-AKI evaluation. The search yielded 291 articles that were uploaded to Rayyan, a software tool used to screen and select studies. Retrospective, observational electronic health record (EHR) studies conducted in hospitalized patients were included. The final sample contained 16 studies for data extraction, representing mostly adult populations (n = 13, 81.3%) in noncritical or unspecified inpatient settings (n = 12, 75%). Nine studies (56.3%) utilized the recommended Kidney Disease: Improving Global Outcome guidelines (KDIGO) criteria to define AKI. Baseline creatinine or laboratory criteria for kidney function were provided in 10 studies (62.5%). Eleven studies (68.8%) established a temporal sequence assessment linking nephrotoxin drug exposure to an AKI event, but these criteria were inconsistent among studies using time frames as soon as 3 months prior to AKI.

CONCLUSION

This review highlights the substantial variability in D-AKI criteria in select studies. Minimum expectations about what should be reported and criteria for the elements reported are needed to assure transparency, consistency, and standardization of pharmacovigilance strategies.

Acute Hospital Outcomes for Renal Transplantation in Patients With Moderate or Severe Congenital Heart Disease

Children and adults with congenital heart disease (CHD) are increasingly recognized to be at risk for acute and chronic renal injury. Some of these may progress to the need for renal transplantation. We hypothesized that patients with underlying moderate or severe CHD who undergo renal transplantation will have worse acute hospital outcomes. Using a national administrative database, we queried for admissions aged 0 to 50 years with moderate or severe CHD and renal transplantation and compared these to admissions without CHD. There were 56 admissions for renal transplantation in the CHD group (0.04%) and 26,285 admissions in the group without CHD (0.21%, p<0.001). The CHD group were younger, had a higher proportion of Whites, longer length of stay, higher complication rates, higher in-hospital mortality, and higher costs. In conclusion, although renal transplantation is still relatively uncommon in the CHD population, there is an increasing recognition of severe chronic renal disease in the setting of CHD, making it important to understand the potential implications of these findings.

Management of routine postoperative pain for children undergoing cardiac surgery: a Paediatric Acute Care Cardiology Collaborative Clinical Practice Guideline

BACKGROUND

Pain following surgery for cardiac disease is ubiquitous, and optimal management is important. Despite this, there is large practice variation. To address this, the Paediatric Acute Care Cardiology Collaborative undertook the effort to create this clinical practice guideline.

METHODS

A panel of experts consisting of paediatric cardiologists, advanced practice practitioners, pharmacists, a paediatric cardiothoracic surgeon, and a paediatric cardiac anaesthesiologist was convened. The literature was searched for relevant articles and Collaborative sites submitted centre-specific protocols for postoperative pain management. Using the modified Delphi technique, recommendations were generated and put through iterative Delphi rounds to achieve consensus.

RESULTS

60 recommendations achieved consensus and are included in this guideline. They address guideline use, pain assessment, general considerations, preoperative considerations, intraoperative considerations, regional anaesthesia, opioids, opioid-sparing, non-opioid medications, non-pharmaceutical pain management, and discharge considerations.

CONCLUSIONS

Postoperative pain among children following cardiac surgery is currently an area of significant practice variability despite a large body of literature and the presence of centre-specific protocols. Central to the recommendations included in this guideline is the concept that ideal pain management begins with preoperative counselling and continues through to patient discharge. Overall, the quality of evidence supporting recommendations is low. There is ongoing need for research in this area, particularly in paediatric populations.

Decreases in Nephrotoxic Pain Medications Are Not Associated With Increased Opioid Utilization in Critically Ill Children

OBJECTIVES

Quality improvement initiatives to decrease rates of nephrotoxic medication exposure have reduced rates of acute kidney injury (AKI) in noncritically ill children. The objective of our study was to analyze the implementation of a similar program in critically ill children and to measure important balancing measures including opioid and benzodiazepine exposure.

DESIGN

Prospective quality improvement study.

SETTING

PICU at Children's Hospital Colorado between 2018 and 2020.

PATIENTS

All children admitted to PICU.

INTERVENTIONS

Quality improvement initiative called Nephrotoxic Injury Negated by Just-In-Time Action (NINJA).

MEASUREMENT AND MAIN RESULTS

Eight thousand eight hundred thirty-three PICU patient admissions were included. Mean rates of nephrotoxic medication exposure/1,000 PICU patient days decreased from 46 to 26, whereas rates of nephrotoxic AKI/1,000 PICU patient days did not change. Nonsteroidal anti-inflammatory drug dispenses per 1,000 patient days were reduced from 521 to 456. Similarly, opioid and benzodiazepine exposures per 1,000 patient days were reduced from 812 to 524 and 441 to 227, respectively, during the study observation period.

CONCLUSIONS

The NINJA intervention was efficaciously implemented in our single-center PICU. Nephrotoxic exposure is a modifiable factor that did not inadvertently increase exposure to opioids and benzodiazepines.

Consensus-Based Recommendations on Priority Activities to Address Acute Kidney Injury in Children: A Modified Delphi Consensus Statement

IMPORTANCE

Increasing evidence indicates that acute kidney injury (AKI) occurs frequently in children and young adults and is associated with poor short-term and long-term outcomes. Guidance is required to focus efforts related to expansion of pediatric AKI knowledge.

OBJECTIVE

To develop expert-driven pediatric specific recommendations on needed AKI research, education, practice, and advocacy.

EVIDENCE REVIEW

At the 26th Acute Disease Quality Initiative meeting conducted in November 2021 by 47 multiprofessional international experts in general pediatrics, nephrology, and critical care, the panel focused on 6 areas: (1) epidemiology; (2) diagnostics; (3) fluid overload; (4) kidney support therapies; (5) biology, pharmacology, and nutrition; and (6) education and advocacy. An objective scientific review and distillation of literature through September 2021 was performed of (1) epidemiology, (2) risk assessment and diagnosis, (3) fluid assessment, (4) kidney support and extracorporeal therapies, (5) pathobiology, nutrition, and pharmacology, and (6) education and advocacy. Using an established modified Delphi process based on existing data, workgroups derived consensus statements with recommendations.

FINDINGS

The meeting developed 12 consensus statements and 29 research recommendations. Principal suggestions were to address gaps of knowledge by including data from varying socioeconomic groups, broadening definition of AKI phenotypes, adjudicating fluid balance by disease severity, integrating biopathology of child growth and development, and partnering with families and communities in AKI advocacy.

CONCLUSIONS AND RELEVANCE

Existing evidence across observational study supports further efforts to increase knowledge related to AKI in childhood. Significant gaps of knowledge may be addressed by focused efforts.

Kidney disease and congenital heart disease: Partnership for life

The literature on the relationship between kidney and cardiovascular diseases is continuously expanding. Scientists have elucidated many of the neurohormonal and hemodynamic pathways involved in cardiorenal disease. However, little is known about kidney disease in patients with congenital heart disease. Given advances in the medical and surgical care of this highly complex patient population, survival rates have dramatically improved leading to a higher percentage of adults living with congenital heart disease. Accordingly, a noticeable increase in the prevalence of kidney disease is appreciated in these patients. Some of the main risk factors for developing chronic kidney disease in the adult congenital heart disease population include chronic hypoxia, neurohormonal derangements, intraglomerular hemodynamic changes, prior cardiac surgeries from minimally invasive to open heart surgeries with ischemia, and nephrotoxins. Unfortunately, data regarding the prevalence, pathophysiology, and prognosis of chronic kidney disease in the adult congenital heart disease population remain scarce. This has led to a lack of clear recommendations for evaluating and managing kidney disease in these patients. In this review, we discuss contemporary data on kidney disease in adults with congenital heart disease in addition to some of the gaps in knowledge we face. The article highlights the delicate interaction between disease of the heart and kidneys in these patients, and offers the practitioner tools to more effectively manage this vulnerable population.

Filtering Down to Risks and Solutions: Risk Factors and Stratification After Pediatric Cardiac Surgery

Acute kidney injury after cardiac surgery (CS-AKI) is common in neonatal and pediatric populations and is a risk factor for poor outcomes, such as mortality and increased hospital resource utilization. This review presents a summary of CS-AKI risk factors, integration of biomarkers, and the need to improve risk stratification for targeting future clinical trials. To date, studies examining CS-AKI risk factors cannot be generalized easily owing to variability in patient age, surgical complexity or population, AKI definition, and center-specific practices. However, certain risk associations, such as younger age at surgery, history of prematurity, cardiopulmonary bypass time, and surgical complexity, have been identified across multiple, but not all, studies. CS-AKI appears to have different severity and duration phenotypes, and serum creatinine is limited in its ability to identify CS-AKI early and predict CS-AKI course. Treatment strategies are largely supportive, and efforts are ongoing to use biomarkers and clinical features to risk-stratify patients, which in turn may facilitate differential CS-AKI phenotyping and management with supportive care bundles, clinical decision support techniques, and modulation of modifiable risk factors.

Frequency of Drug Induced Acute Kidney Injury in Pediatric Intensive Care Unit

Background: Acute kidney injury (AKI) is known to complicate one-third of cases in pediatric intensive care units (PICU), and almost one-fourth of these are due to nephrotoxic drugs (NTDs). Although stopping NTDs seems the most obvious option, it is not practically applicable. Many NTDs are the only existing option, and their potential benefits outweigh the risk of drug-induced AKI.

Objectives: To assess the proportion of children receiving NTDs in the PICU and highlight the children who developed AKI.

Methods: A prospective observational study was conducted in the PICU of the National Institute of Child Health, Karachi. All children admitted to the PICU for at least 72 hours not diagnosed with any acute or chronic kidney disease were included. Serum creatinine (SCr) was done at admission and then after 72 hours. Data was entered and analyzed using IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.

Results: Of 99 children, 53 (53.5%) were male. NTD exposure was positive in 97 (97.9%), and 72 (72.7%) had high exposure (≥3 NTDs). Drug-induced AKI was diagnosed in 46 (46.5%). It was significantly related to high SCr even at admission and high NTDs exposure. The mortality rate in the AKI group was 17% compared to 4% in the non-AKI (p=0.02).

Conclusion: Almost half of all PICU admissions were infants. Almost all patients were exposed to NTDs, and three-fourth experienced high exposure. AKI developed in 46% of patients and may be predicted by raised creatinine at the time of admission. Children exposed to ≥3 NTDs had a higher chance of drug-induced AKI.

Nonsteroidal anti-inflammatory drugs associated acute kidney injury in hospitalized children: A systematic review and meta-analysis

INTRODUCTION

Nonsteroidal anti-inflammatory drugs (NSAIDs) are regarded as nephrotoxins. Children commonly use NSAIDs and are susceptible to nephropathy, but the relationship between acute kidney injury (AKI) and use of NSAIDs is not well examined yet.

OBJECTIVE

To evaluate the relationship between AKI and use of NSAIDs in hospitalized pediatric patients who are susceptible to nephropathy.

METHODS

We conducted this systematic review and meta-analysis of observational studies by searching PubMed, Embase, and Cochrane Database for articles published up to June 1, 2020. Reports included involved children (age < 18 years) who used NSAIDs for various reasons and were admitted in the hospital. The main outcome measure was whether AKI occurred, and pooled odds ratio (OR) and 95% confidence intervals (CI) were calculated using generic inverse variance methods.

RESULTS

Seven studies reporting risk of AKI in the hospitalized pediatric patients receiving NSAIDs were included applying a random-effects model. In the hospitalized pediatric population, the pooled OR of AKI for present NSAID exposure was 1.55 (95%CI 1.26-1.92).

CONCLUSIONS

NSAID exposure was associated with an approximate 1.6-fold rise in the odds of developing AKI in hospitalized pediatric patients. Avoidance, cautious use of NSAIDs and further evidence are needed. This study was registered with PROSPERO (identifier: CRD42021219779).

Association of Ibuprofen Prescription With Acute Kidney Injury Among Hospitalized Children in China

IMPORTANCE

Ibuprofen is widely used in children worldwide, especially in those with cancer, fever, or trauma. However, large and high-quality studies of the association between ibuprofen and acute kidney injury (AKI) in children have been lacking.

OBJECTIVE

To examine the association between the use of ibuprofen and the risk of hospital-acquired AKI in hospitalized children in China.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed the cohort of the Epidemiology of AKI in Chinese Hospitalized Patients (EACH) study, a large, multicenter retrospective study of 3 044 023 patients who were admitted to 1 of 25 academic medical centers in China between January 1, 2013, and December 31, 2015. Patient-level data were obtained from the electronic health record system of the participating centers. Hospitalized children aged 1 month to 18 years who had prescriptions and a certain number of serum creatinine (SCr) tests were included. Children with end-stage renal disease, community-acquired AKI, low baseline SCr level (<10 μmol/L), high standardized baseline SCr level (>4 times the sex- and age-specific reference value), or missing diagnosis code were excluded. Data analysis was conducted from January 1, 2020, to August 30, 2020.

EXPOSURES

Exposure to ibuprofen was coded as a time-dependent dichotomous variable.

MAIN OUTCOMES AND MEASURES

Baseline SCr level was calculated for each patient as the mean of all available SCr values between the 30 days prior to admission and the first SCr testing within the first 3 days of hospitalization. Acute kidney injury was defined as an increase in SCr level of 26.5 μmol/L or higher within 48 hours or by 50% or more over the baseline value, according to the Kidney Disease: Improving Global Outcomes guidelines.

RESULTS

Among the 50 420 children (mean [SD] age, 5.0 [5.2] years; 30 640 boys [60.8%]) included in this study, 5526 (11.0%) used ibuprofen and 3476 (6.9%) developed hospital-acquired AKI during hospitalization. Ibuprofen use was associated with a statistically significantly increased risk of hospital-acquired AKI (hazard ratio [HR], 1.23; 95% CI, 1.14-1.34) after adjusting for confounders. Ibuprofen use was associated with a greater hazard in children who had chronic kidney disease vs those without (HR, 2.31 [95% CI, 1.73-3.10] vs 1.19 [95% CI, 1.09-1.29]), required intensive care vs those without this need (HR, 1.47 [95% CI, 1.24-1.75] vs 1.18 [95% CI, 1.07-1.29]), or were older vs younger (>10 years and >1 year to 10 years vs 1 month to 1 year) (HR, 1.64 [95% CI, 1.32-2.05]; 1.36 [95% CI, 1.23-1.52] vs 0.99 [95% CI, 0.86-1.13]). Dose-response analysis suggested that the association of ibuprofen with the risk of hospital-acquired AKI was dose-dependent.

CONCLUSIONS AND RELEVANCE

This study found that ibuprofen was widely used and associated with an increased risk of hospital-acquired AKI in hospitalized children in China. The judicious use of ibuprofen and close monitoring of kidney function in children are needed.

Frequency of Exposure of Nephrotoxic Drugs and Drug-Induced Acute Kidney Injury in Pediatric Intensive Care Unit: A Retrospective Review From a Tertiary Care Centre in Pakistan

Introduction

Acute kidney injury (AKI) is one of the most common problems seen in the pediatric intensive care unit (PICU), with an overall 27% incidence. Besides many other factors, nephrotoxic medications (Nephrotoxins; Ntx) are also responsible for a large proportion of potentially avoidable pediatric AKI, directly accounting for 16% of AKI events.

Objective

To assess potential associations between nephrotoxic drugs and the risk of developing AKI in children admitted in PICU.

Material and methods

This is a retrospective cross-sectional study. Children (aged 1 month - 18 years) admitted to the PICU, with a length of stay >24 hours, were included. AKI was defined as according to KDIGO (Kidney Disease Improving Global Outcomes) criteria. Mild AKI was defined as a rise in creatinine value of 0.3 mg/dl from presenting value at a 24-hour interval. Patients were grouped according to the presence or absence of AKI. All medications administered in the ICU were assessed for nephrotoxicity through a review of adverse reactions mentioned in the Pediatric Dosage Handbook, along with consultation with a clinical pharmacist.

Results

Among 752 patients, the mean age was 4.8 years ± 4.37. There were 57.3% male and 42.7% female children. Among the exposed children, 37.4% received one drug, 32.4% received two drugs and 12.1% had high nephrotoxin exposure. The most commonly used drug was vancomycin (16.8%), as a single Ntx; vancomycin/colistin (12.9%), in dual nephrotoxic combination; and vancomycin/colistin/amphotericin (2.9%) in highly exposed children (i.e., with equal or more than three). Overall, the incidence of AKI was 14.9%.

Conclusion

Nephrotoxins are potentially avoidable risk factors in critically ill children. Whenever a combination of medications is required, it’s advisable to review all medications for better protection of kidneys and preventing of acute kidney injury.

Nephrotoxins and nephrotoxic acute kidney injury

Although the concept of nephrotoxicity has been recognized for more than 80 years, interest in nephrotoxins has intensified dramatically over the past two decades. Much of this attention has rightfully been focused on pharmaceutical agents and iatrogenic harm; however, it is important for providers to recognize that nephrotoxins can be found in naturally occurring substances as well. Although nephrotoxins exist in a myriad of forms, the means by which they induce injury can be organized into a few categories. For most of these agents, regardless of the mechanism, the final common pathway is acute kidney injury (AKI). Unfortunately, therapeutic options are limited and no treatments currently exist to reverse nephrotoxic AKI once it occurs. As a result, current strategies focus on increased awareness, nephrotoxin avoidance, early injury detection, and mitigation of disease severity. The goal of this review is to summarize our current understanding of nephrotoxic mechanisms and the epidemiology of nephrotoxic AKI. Additionally, avoidance and preventative strategies are discussed, screening approaches are suggested, and chronic monitoring recommendations are made.

Cardiopulmonary Bypass and AKI: AKI Is Bad, So Let's Get Beyond the Diagnosis

It is now well-established that AKI is a serious and common complication following cardiopulmonary bypass (CPB) in both children and adults, adverse outcomes may occur in the short term as well as long term, with higher incidence of chronic kidney disease, increased healthcare utilization and higher frequency of cardiovascular events in patients who develop post-CPB AKI. Despite the advances in our understanding of the pathogenesis of the disease and the improvement in diagnostic tools, our therapeutic options have remained suboptimal. There are multiple challenges in designing a clinical therapeutic AKI trial, including a multi-factorial etiology, difficulties with accurate diagnosis of AKI, achievement of adequate study power, and determination of appropriate outcomes. We are often left with "supportive" care. Studies have shown some benefit to AKI bundles, but adherence to bundle guidelines may be suboptimal. Current best practices should include maintenance of adequate renal perfusion pressure and avoidance of fluid overload, with consideration of early renal replacement therapy. Finally, multi-center trials of AKI therapies are crucial to finding treatment for this devastating complication of CPB.