Association of Urinary Albumin:Creatinine Ratio with Outcome of Children with Sepsis

Sex Differences in Pediatric Sepsis Mortality: A Systematic Review and Meta-Analysis

OBJECTIVES

Pediatric sepsis remains a leading cause of childhood mortality worldwide. Sex differences have been shown to modify risk factors, treatment, and outcome of various diseases, and adult studies revealed sex differences in pathophysiological responses to septic shock. We aimed to perform a systematic review and meta-analysis on the association of sex with outcomes in hospitalized children with sepsis.

DATA SOURCES

Medline and Embase databases were searched for studies of children < 18 years with sepsis published between January 01, 2005, and March 31, 2022.

STUDY SELECTION

We included cohort studies, and randomized controlled trials in children greater than or equal to 37-week-old postconception to 18 years which included sepsis, severe sepsis or septic shock, and mortality as an outcome.

DATA EXTRACTION

Study characteristics, patient demographics, and illness severity scores were extracted from eligible articles. Random-effects meta-analysis was performed.

DATA SYNTHESIS

We screened 14,791 studies, with 912 full-text reviews and inclusion of 124 studies. The total population involved 426,163 patients, of which 47% (201,438) were girls. Meta-regression showed moderate evidence for a higher mortality in boys compared with girls. The estimated risk difference of mortality between boys and girls with all types of sepsis was -0.005 (95% CI, -0.0099 to -0.00001; p = 0.049), indicating slightly higher mortality for boys. When including the World Bank income level as a moderator, the effect was -0.008 (95% CI, -0.013 to -0.002; p = 0.005).

CONCLUSIONS

This large systematic review and meta-analysis on sex differences in pediatric sepsis mortality showed moderate evidence for a higher sepsis mortality in boys compared with girls. The effect persisted when adjusting for country's income level.

Elevated serum albumin-to-creatinine ratio as a protective factor on clinical outcomes among critically ill patients with sepsis: a retrospective study

Background

The aim of this study was to examine the prognostic significance of serum albumin-to-creatinine ratio (ACR) in critically ill patients with sepsis.

Methods

This retrospective study analyzed sepsis cases admitted to the Affiliated Hospital of Jiangsu University between January 2015 and November 2023. The patients were divided into four groups based on their ACR upon admission to the intensive care unit (ICU). Laboratory data were collected at the time of ICU admission, and the primary outcome measure was in-hospital all-cause mortality. Kaplan-Meier survival curves were generated to illustrate the differences in 30-/60-day mortality among the various groups. Multivariate Cox regression models and restricted cubic splines (RCS) were utilized to explore the association between ACR and all-cause mortality in sepsis patients. Subgroup analyses were conducted to examine the impact of other covariates on the relationship between ACR and all-cause mortality.

Results

A total of 1,123 eligible patients were included in the study, with a median ACR of 0.169. The in-hospital mortality rate was 33.7%, the ICU mortality rate was 31.9%, and the 30-day mortality rate was 28.1%. Kaplan-Meier survival analysis demonstrated that patients with higher ACR had a significantly lower risk of 30-/60-day mortality (log-rank p < 0.001). Multivariable Cox proportional hazards analyses revealed that ACR was an independent predictor of in-hospital death (HR: 0.454, 95% CI 0.271-0.761, p = 0.003), ICU death (HR: 0.498, 95% CI 0.293-0.847, p = 0.010), and 30-day death (HR: 0.399, 95% CI 0.218-0.730, p = 0.003). For each 1-unit increase in ACR, there was a 1.203-fold decrease in the risk of death during the hospital stay. The RCS curve illustrated a non-linear negative correlation between ACR and in-hospital mortality (p for non-linear =0.018), ICU mortality (p for non-linear =0.005), and 30-day mortality (p for non-linear =0.006). Sensitivity analysis indicated consistent effect sizes and directions in different subgroups, confirming the stability of the results.

Conclusion

Low ACR levels were identified as independent risk factors associated with increased in-hospital, ICU, and 30-day mortality in sepsis patients. ACR can serve as a significant predictor of the clinical outcome of sepsis.

Reporting of Social Determinants of Health in Pediatric Sepsis Studies

OBJECTIVE

Standardized, consistent reporting of social determinants of health (SDOH) in studies on children with sepsis would allow for: 1) understanding the association of SDOH with illness severity and outcomes, 2) comparing populations and extrapolating study results, and 3) identification of potentially modifiable socioeconomic factors for policy makers. We, therefore, sought to determine how frequently data on SDOH were reported, which factors were collected and how these factors were defined in studies of sepsis in children.

DATA SOURCES AND SELECTION

We reviewed 106 articles (published between 2005 and 2020) utilized in a recent systematic review on physiologic criteria for pediatric sepsis.

DATA EXTRACTION

Data were extracted by two reviewers on variables that fell within the World Health Organization's SDOH categories.

DATA SYNTHESIS

SDOH were not the primary outcome in any of the included studies. Seventeen percent of articles (18/106) did not report on any SDOH, and a further 36.8% (39/106) only reported on gender/sex. Of the remaining 46.2% of articles, the most reported SDOH categories were preadmission nutritional status (35.8%, 38/106) and race/ethnicity (18.9%, 20/106). However, no two studies used the same definition of the variables reported within each of these categories. Six studies reported on socioeconomic status (3.8%, 6/106), including two from upper-middle-income and four from lower middle-income countries. Only three studies reported on parental education levels (2.8%, 3/106). No study reported on parental job security or structural conflict.

CONCLUSIONS

We found overall low reporting of SDOH and marked variability in categorizations and definitions of SDOH variables. Consistent and standardized reporting of SDOH in pediatric sepsis studies is needed to understand the role these factors play in the development and severity of sepsis, to compare and extrapolate study results between settings and to implement policies aimed at improving socioeconomic conditions related to sepsis.

Criteria for Pediatric Sepsis-A Systematic Review and Meta-Analysis by the Pediatric Sepsis Definition Taskforce

OBJECTIVE

To determine the associations of demographic, clinical, laboratory, organ dysfunction, and illness severity variable values with: 1) sepsis, severe sepsis, or septic shock in children with infection and 2) multiple organ dysfunction or death in children with sepsis, severe sepsis, or septic shock.

DATA SOURCES

MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched from January 1, 2004, and November 16, 2020.

STUDY SELECTION

Case-control studies, cohort studies, and randomized controlled trials in children greater than or equal to 37-week-old postconception to 18 years with suspected or confirmed infection, which included the terms "sepsis," "septicemia," or "septic shock" in the title or abstract.

DATA EXTRACTION

Study characteristics, patient demographics, clinical signs or interventions, laboratory values, organ dysfunction measures, and illness severity scores were extracted from eligible articles. Random-effects meta-analysis was performed.

DATA SYNTHESIS

One hundred and six studies met eligibility criteria of which 81 were included in the meta-analysis. Sixteen studies (9,629 patients) provided data for the sepsis, severe sepsis, or septic shock outcome and 71 studies (154,674 patients) for the mortality outcome. In children with infection, decreased level of consciousness and higher Pediatric Risk of Mortality scores were associated with sepsis/severe sepsis. In children with sepsis/severe sepsis/septic shock, chronic conditions, oncologic diagnosis, use of vasoactive/inotropic agents, mechanical ventilation, serum lactate, platelet count, fibrinogen, procalcitonin, multi-organ dysfunction syndrome, Pediatric Logistic Organ Dysfunction score, Pediatric Index of Mortality-3, and Pediatric Risk of Mortality score each demonstrated significant and consistent associations with mortality. Pooled mortality rates varied among high-, upper middle-, and lower middle-income countries for patients with sepsis, severe sepsis, and septic shock (p < 0.0001).

CONCLUSIONS

Strong associations of several markers of organ dysfunction with the outcomes of interest among infected and septic children support their inclusion in the data validation phase of the Pediatric Sepsis Definition Taskforce.

The Glomerular Endothelium Restricts Albumin Filtration

Inflammatory activation and/or dysfunction of the glomerular endothelium triggers proteinuria in many systemic and localized vascular disorders. Among them are the thrombotic microangiopathies, many forms of glomerulonephritis, and acute inflammatory episodes like sepsis and COVID-19 illness. Another example is the chronic endothelial dysfunction that develops in cardiovascular disease and in metabolic disorders like diabetes. While the glomerular endothelium is a porous sieve that filters prodigious amounts of water and small solutes, it also bars the bulk of albumin and large plasma proteins from passing into the glomerular filtrate. This endothelial barrier function is ascribed predominantly to the endothelial glycocalyx with its endothelial surface layer, that together form a relatively thick, mucinous coat composed of glycosaminoglycans, proteoglycans, glycolipids, sialomucins and other glycoproteins, as well as secreted and circulating proteins. The glycocalyx/endothelial surface layer not only covers the glomerular endothelium; it extends into the endothelial fenestrae. Some glycocalyx components span or are attached to the apical endothelial cell plasma membrane and form the formal glycocalyx. Other components, including small proteoglycans and circulating proteins like albumin and orosomucoid, form the endothelial surface layer and are bound to the glycocalyx due to weak intermolecular interactions. Indeed, bound plasma albumin is a major constituent of the endothelial surface layer and contributes to its barrier function. A role for glomerular endothelial cells in the barrier of the glomerular capillary wall to protein filtration has been demonstrated by many elegant studies. However, it can only be fully understood in the context of other components, including the glomerular basement membrane, the podocytes and reabsorption of proteins by tubule epithelial cells. Discovery of the precise mechanisms that lead to glycocalyx/endothelial surface layer disruption within glomerular capillaries will hopefully lead to pharmacological interventions that specifically target this important structure.

Urine Albumin-Creatinine ratio is associated with prognosis in patients with diabetic foot osteomyelitis

AIMS

We aimed to explore the association between albuminuria and clinical outcomes in patients with diabetic foot osteomyelitis (DFO).

METHODS

This is an observational retrospective study and a total of 202 inpatients with DFO were eligible for inclusion in our study. Based on urine albumin-creatinine ratio (UACR), the patients were divided into three groups: normoalbuminuria group, microalbuminuria group and macroalbuminuria group. The data collected include demographics data, laboratory data, clinical diagnostic data, diabetic foot examination and clinical visit data. The association was then evaluated between albuminuria and all-cause mortality, major cardiovascular adverse events (MACE) and mixed endpoint events.

RESULTS

The mean age was 60.3 years, 62.9% were male and 45.05% were urinary protein-positive. The incidence rates of all-cause mortality, MACE and mixed endpoint events related to elevated UACR were significantly increased in patients with DFO (all P for trend < 0.01). After adjusting for confounders, compared with normoalbuminuria group, the risk of all-cause mortality, MACE and mixed endpoint events in the microalbuminuria group increased by 81.8%, 135.4% and 136.4%, respectively. The risk of all-cause mortality, MACE and mixed endpoint events in the macroalbuminuria group increased by 246.2%, 145.1% and 252.3%, respectively. The population attributable risk percentage (PAR%) suggested that 50.16% of all-cause mortality, 47.85% of MACE and 59.11% of mixed endpoint events could be attributed to the elevated UACR. Meanwhile, compared with normoalbuminuria, those with microalbuminuria or macroalbuminuria have lower apoA1 and ABI, higher SCr and higher incidence rate of CHD, hindfoot infection and severe infection (all P < 0.05).

CONCLUSIONS

In patients with DFO, the UACR level is associated with all-cause mortality, MACE and mixed endpoint events and elevated UACR levels increase the risk of all-cause mortality, MACE and mixed endpoint events.

Comparison of urine albumin creatinine ratio with the pediatric index of mortality 2 score for prediction of pediatric intensive care unit outcomes

Background

Predicting morbidity and mortality in a pediatric intensive care unit (PICU) is of extreme importance to make precise decisions for better outcomes.

Aim

We compared the urine albumin creatinine ratio (ACR) with the established PICU score, pediatric index of mortality 2 (PIM 2) for predicting PICU outcomes.

Methods

This cross-sectional study enrolled 67 patients admitted to PICU with systemic inflammatory response syndrome. Urine ACR was estimated on admission, and PIM 2 score was calculated. ACR was compared with PIM 2 for PICU outcome measures: the need for inotropes, development of multiple organ dysfunction syndrome (MODS), duration of PICU stay, and survival.

Results

Microalbuminuria was found in 77.6% of patients with a median ACR of 80 mg/g. ACR showed a significant association with the need for inotropes (p < 0.001), MODS (p = 0.001), and significant correlation to PICU stay (p 0.001, rho = 0.361). The area under the receiver operating characteristic curve for ACR (0.798) was comparable to that of PIM 2 (0.896). The cutoff value of ACR derived to predict mortality was 110 mg/g. The study subjects were divided into 2 groups: below cutoff and above the cutoff. Outcome variables, inotrope use, MODS, mortality, and PICU stay compared between these subgroups, were statistically significant.

Conclusion

ACR is a good predictor of PICU outcomes and is comparable to PIM 2 for mortality prediction.