Incidence and outcome of acute kidney injury by the pRIFLE criteria for children receiving extracorporeal membrane oxygenation after heart surgery

Timing of Kidney Replacement Therapy Initiation and Survival During Pediatric Extracorporeal Membrane Oxygenation: An Extracorporeal Life Support Organization Registry Study

To characterize kidney replacement therapy (KRT) and pediatric extracorporeal membrane oxygenation (ECMO) outcomes and to identify the optimal timing of KRT initiation during ECMO associated with increased survival. Observational retrospective cohort study using the Extracorporeal Life Support Organization Registry database in children (0-18 yo) on ECMO from January 1, 2016, to December 31, 2020. Of the 14,318 ECMO runs analyzed, 26% of patients received KRT during ECMO. Patients requiring KRT before ECMO had increased mortality to ECMO decannulation (29% vs. 17%, OR 1.97, P < 0.001) and to hospital discharge (58% vs. 39%, OR 2.16, P < 0.001). Patients requiring KRT during ECMO had an increased mortality to ECMO decannulation (25% vs. 15%, OR 1.85, P < 0.001) and to hospital discharge (56% vs. 34%, OR 2.47, P < 0.001). Multivariable logistic regression demonstrated that the need for KRT during ECMO was an independent predictor for mortality to ECMO decannulation (OR 1.49, P < 0.001) and to hospital discharge (OR 2.02, P < 0.001). Patients initiated on KRT between 24 and 72 hours after cannulation were more likely to survive to ECMO decannulation and showed a trend towards survival to hospital discharge as compared to those initiated before 24 hours and after 72 hours.

Optimizing Outcomes in Extracorporeal Membrane Oxygenation Postcardiotomy in Pediatric Population

Extracorporeal membrane oxygenation (ECMO) is a rapidly emerging advanced life support technique used in cardiorespiratory failure refractory to other treatments. There has been an influx in the number of studies relating to ECMO in recent years, as the technique becomes more popular. However, there are still significant gaps in the literature including complications and their impacts and methods to predict their development. This review evaluates the available literature on the complications of ECMO postcardiotomy in the pediatric population. Areas explored include renal, cardiovascular, hematological, infection, neurological, and hepatic complications. Incidence, risk factors and potential predictors, and scoring systems for the development of these complications have been evaluated.

Factors associated with acute kidney injury in patients undergoing extracorporeal membrane oxygenation: retrospective cohort

OBJECTIVE

To identify factors associated with acute kidney injury in patients undergoing extracorporeal membrane oxygenation.

METHOD

Retrospective cohort study conducted in an adult Intensive Care Unit with patients undergoing extracorporeal membrane oxygenation from 2012 to 2021. The research used the Kidney Disease Improving Global Outcomes as criteria for definition and classification of acute kidney injury. A multiple logistic regression model was developed to analyze the associated factors.

RESULTS

The sample was composed of 122 individuals, of these, 98 developed acute kidney injury (80.3%). In multiple regression, the associated factors found were vasopressin use, Nursing Activities Score, and glomerular filtration rate.

CONCLUSION

The use of vasopressin, the Nursing Activities Score, and the glomerular filtration rate were considered as factors related to the development of acute kidney injury in patients undergoing extracorporeal membrane oxygenation.

Perioperative extracorporeal membrane oxygenation in pediatric congenital heart disease: Chinese expert consensus

BACKGROUND

Congenital heart disease (CHD) is one of the main supportive diseases of extracorporeal membrane oxygenation in children. The management of extracorporeal membrane oxygenation (ECMO) for pediatric CHD faces more severe challenges due to the complex anatomical structure of the heart, special pathophysiology, perioperative complications and various concomitant malformations. The survival rate of ECMO for CHD was significantly lower than other classifications of diseases according to the Extracorporeal Life Support Organization database. This expert consensus aims to improve the survival rate and reduce the morbidity of this patient population by standardizing the clinical strategy.

METHODS

The editing group of this consensus gathered 11 well-known experts in pediatric cardiac surgery and ECMO field in China to develop clinical recommendations formulated on the basis of existing evidences and expert opinions.

RESULTS

The primary concern of ECMO management in the perioperative period of CHD are patient selection, cannulation strategy, pump flow/ventilator parameters/vasoactive drug dosage setting, anticoagulation management, residual lesion screening, fluid and wound management and weaning or transition strategy. Prevention and treatment of complications of bleeding, thromboembolism and brain injury are emphatically discussed here. Special conditions of ECMO management related to the cardiovascular anatomy, haemodynamics and the surgical procedures of common complex CHD should be considered.

CONCLUSIONS

The consensus could provide a reference for patient selection, management and risk identification of perioperative ECMO in children with CHD. Video abstract (MP4 104726 kb).

Epidemiology of Acute Kidney Injury After Neonatal Cardiac Surgery: A Report From the Multicenter Neonatal and Pediatric Heart and Renal Outcomes Network

OBJECTIVES

Cardiac surgery-associated acute kidney injury occurs commonly following congenital heart surgery and is associated with adverse outcomes. This study represents the first multicenter study of neonatal cardiac surgery-associated acute kidney injury. We aimed to describe the epidemiology, including perioperative predictors and associated outcomes of this important complication.

DESIGN

This Neonatal and Pediatric Heart and Renal Outcomes Network study is a multicenter, retrospective cohort study of consecutive neonates less than 30 days. Neonatal modification of The Kidney Disease Improving Global Outcomes criteria was used. Associations between cardiac surgery-associated acute kidney injury stage and outcomes (mortality, length of stay, and duration of mechanical ventilation) were assessed through multivariable regression.

SETTING

Twenty-two hospitals participating in Pediatric Cardiac Critical Care Consortium.

PATIENTS

Twenty-two-thousand forty neonates who underwent major cardiac surgery from September 2015 to January 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Cardiac surgery-associated acute kidney injury occurred in 1,207 patients (53.8%); 983 of 1,657 in cardiopulmonary bypass patients (59.3%) and 224 of 583 in noncardiopulmonary bypass patients (38.4%). Seven-hundred two (31.3%) had maximum stage 1, 302 (13.5%) stage 2, 203 (9.1%) stage 3; prevalence of cardiac surgery-associated acute kidney injury peaked on postoperative day 1. Cardiac surgery-associated acute kidney injury rates varied greatly (27-86%) across institutions. Preoperative enteral feeding (odds ratio = 0.68; 0.52-0.9) and open sternum (odds ratio = 0.76; 0.61-0.96) were associated with less cardiac surgery-associated acute kidney injury; cardiopulmonary bypass was associated with increased cardiac surgery-associated acute kidney injury (odds ratio = 1.53; 1.01-2.32). Duration of cardiopulmonary bypass was not associated with cardiac surgery-associated acute kidney injury in the cardiopulmonary bypass cohort. Stage 3 cardiac surgery-associated acute kidney injury was independently associated with hospital mortality (odds ratio = 2.44; 1.3-4.61). No cardiac surgery-associated acute kidney injury stage was associated with duration of mechanical ventilation or length of stay.

CONCLUSIONS

Cardiac surgery-associated acute kidney injury occurs frequently after neonatal cardiac surgery in both cardiopulmonary bypass and noncardiopulmonary bypass patients. Rates vary significantly across hospitals. Only stage 3 cardiac surgery-associated acute kidney injury is associated with mortality. Cardiac surgery-associated acute kidney injury was not associated with any other outcomes. Kidney Disease Improving Global Outcomes criteria may not precisely define a clinically meaningful renal injury phenotype in this population.

Acute Kidney Injury, Fluid Overload, and Renal Replacement Therapy Differ by Underlying Diagnosis in Neonatal Extracorporeal Support and Impact Mortality Disparately

INTRODUCTION

We aimed to characterize acute kidney injury (AKI), fluid overload (FO), and renal replacement therapy (RRT) utilization by diagnostic categories and examine associations between these complications and mortality by category.

METHODS

To test our hypotheses, we conducted a retrospective multicenter, cohort study including 446 neonates (categories: 209 with cardiac disease, 114 with congenital diaphragmatic hernia [CDH], 123 with respiratory disease) requiring extracorporeal membrane oxygenation (ECMO) between January 1, 2007, and December 31, 2011.

RESULTS

AKI, FO, and RRT each varied by diagnostic category. AKI and RRT receipt were most common in those neonates with cardiac disease. Subjects with CDH had highest peak %FO (51% vs. 28% cardiac vs. 32% respiratory; p < 0.01). Hospital survival was 55% and varied by diagnostic category (45% cardiac vs. 48% CDH vs. 79% respiratory; p < 0.001). A significant interaction suggested risk of mortality differed by diagnostic category in the presence or absence of AKI. In its absence, diagnosis of CDH (vs. respiratory disease) (OR 3.04, 95% CL 1.14-8.11) independently predicted mortality. In all categories, peak %FO (OR 1.20, 95% CL 1.11-1.30) and RRT receipt (OR 2.12, 95% CL 1.20-3.73) were independently associated with mortality.

DISCUSSION/CONCLUSIONS

Physiologically distinct ECMO diagnoses warrant individualized treatment strategies given variable incidence and effects of AKI, FO, and RRT by category on mortality.

Clinical Characteristics and Outcomes of Children With Extracorporeal Membrane Oxygenation in a Developing Country: An 11-Year Single-Center Experience

Introduction: Extracorporeal Membrane Oxygenation (ECMO) is a lifesaving procedure for patients with refractory cardiac or respiratory failure. The indications for ECMO are growing, and it is increasingly being used to support cardiopulmonary failure in children. However, the risks and benefits of ECMO should be weighed before deploying it on the patients. The objectives of this study were to identify the mortality risk factors and to determine the ECMO outcomes. Methods: The retrospective chart reviews were done for all patients aged 1 day-20 years old receiving ECMO between January 2010 and December 2020. Results: Seventy patients were enrolled in the study. The median age was 31.3 months. The incidence of VA and VV ECMO was 85.7 and 14.3%, respectively. The most common indication for ECMO was the failure to wean off cardiopulmonary bypass after cardiac surgery. Pre-existing acute kidney injury (OR 4.23; 95% CI 1.34-13.32, p = 0.014) and delayed enteral feeding (OR 3.85, 95% CI 1.23-12.02, p = 0.020), and coagulopathy (OD 12.64; 95% CI 1.13-141.13, p = 0.039) were associated with the higher rate of mortality. The rates of ECMO survival and survival to discharge were 70 and 50%, respectively. Conclusion: ECMO is the lifesaving tool for critically ill pediatric patients. Pre-existing acute kidney injury, delayed enteral feeding, and coagulopathy were the potential risk factors associated with poor outcomes in children receiving ECMO. However, ECMO setup can be done successfully in a developing country.

Extracardiac Complications in Intensive Care Units after Surgical Repair for Congenital Heart Disease: Imaging Review with a Focus on Ultrasound and Radiography

Pediatric patients show various extracardiac complications after cardiovascular surgery, and radiography and ultrasound are routinely performed in the intensive care unit to detect and evaluate these complications. This review presents images of these complications, sonographic approach, and timing of occurrence that are categorized based on their extracardiac locations and include complications pertaining to the central nervous system, mediastinum, thorax and lung parenchyma, diaphragm, liver and biliary system, and kidney along with pleural effusion and iatrogenic complications. This pictorial review will make it easier for medical doctors in intensive care units to identify and manage various extracardiac complications in pediatric patients after cardiovascular surgery.

Risk Factors for Developing Severe Acute Kidney Injury in Adult Patients With Refractory Postcardiotomy Cardiogenic Shock Receiving Venoarterial Extracorporeal Membrane Oxygenation

OBJECTIVES

Postcardiotomy cardiogenic shock occurs in 2-6% of patients undergoing cardiac surgery, and 1% of cardiac surgery patients will require mechanical circulatory support using venoarterial extracorporeal membrane oxygenation. Acute kidney injury is a frequent complication in this population and negatively impacts the survival. We aimed to determine whether the timing of extracorporeal membrane oxygenation implantation influences the renal prognosis of these patients.

DESIGN

Retrospective observational cohort study between January 2013 and December 2016.

SETTING

An 18-bed surgical ICU in a university hospital.

PATIENTS

A total of 4,796 consecutive adult patients who underwent cardiac surgery were included in the study, and 347 (7.2%) were assisted with venoarterial extracorporeal membrane oxygenation for refractory postcardiotomy cardiogenic shock. The patients who died during the first 48 hours after venoarterial extracorporeal membrane oxygenation implantation were excluded. The complete-case analysis included 257 patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the occurrence, within 10 days following the venoarterial extracorporeal membrane oxygenation implantation, of a stage 3 acute kidney injury defined by the Kidney Disease: Improving Global Outcomes group. One hundred sixty-nine patients (65.7%) presented with a Kidney Disease: Improving Global Outcomes stage 3 acute kidney injury; 14 patients (5.4%) died before the end of the follow-up period, without developing the primary outcome. Ninety-two percent of patients with Kidney Disease: Improving Global Outcomes 3 acute kidney injury received renal replacement therapy, for a median duration of 7 days (3-16 d). Late implantation of venoarterial extracorporeal membrane oxygenation was independently associated with an increased risk of Kidney Disease: Improving Global Outcomes stage 3 acute kidney injury (odds ratio, 2.81 [95% CI, 1.31-6.07]; p = 0.008). The other factors associated with Kidney Disease: Improving Global Outcomes stage 3 acute kidney injury were preoperative left ventricular ejection fraction (odds ratio, 1.03 [95% CI, 1.01-1.05]; p = 0.007), intraoperative plasma transfusion (odds ratio, 1.13 [95% CI, 1.02-1.26]; p = 0.022), increased bilirubinemia level (odds ratio, 1.013 [95% CI, 1.001-1.026]; p = 0.032), and increased creatinine levels (odds ratio, 1.012 [95% CI, 1.006-1.018]; p < 0.001) on the day of implantation.

CONCLUSIONS

Significant kidney dysfunction is particularly frequent in patients with refractory postcardiotomy cardiogenic shock assisted with venoarterial extracorporeal membrane oxygenation. Early implantation of extracorporeal membrane oxygenation may help prevent acute kidney injury.

Acute Kidney Injury in Pediatric Patients on Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-analysis

Background: Acute kidney injury (AKI) is a well-established complication of extra-corporal membrane oxygenation (ECMO) in the adult population. The data in the pediatric and neonatal population is still limited. Moreover, the mortality risk of AKI among pediatric patients requiring ECMO remains unclear. Thus, this meta-analysis aims to assess the incidence of AKI, AKI requiring renal replacement therapy and AKI associated mortality in pediatric/neonatal patients requiring ECMO. Methods: A literature search was performed utilizing MEDLINE, EMBASE, and the Cochrane Database from inception through June 2019. We included studies that evaluated the incidence of AKI, severe AKI requiring renal replacement therapy (RRT) and the risk of mortality among pediatric patients on ECMO with AKI. Random-effects meta-analysis was used to calculate the pooled incidence of AKI and the odds ratios (OR) for mortality. Results: 13 studies with 3523 pediatric patients on ECMO were identified. Pooled incidence of AKI and AKI requiring RRT were 61.9% (95% confidence interval (CI): 39.0-80.4%) and 40.9% (95%CI: 31.2-51.4%), respectively. A meta-analysis limited to studies with standard AKI definitions showed a pooled estimated AKI incidence of 69.2% (95%CI: 59.7-77.3%). Compared with patients without AKI, those with AKI and AKI requiring RRT while on ECMO were associated with increased hospital mortality ORs of 1.70 (95% CI, 1.38-2.10) and 3.64 (95% CI: 2.02-6.55), respectively. Conclusions: The estimated incidence of AKI and severe AKI requiring RRT in pediatric patients receiving ECMO are high at 61.9% and 40.9%, respectively. AKI among pediatric patients on ECMO is significantly associated with reduced patient survival.

Acute kidney injury after pediatric cardiac surgery

Acute kidney injury (AKI) is a common complication of pediatric cardiac surgery and is associated with increased morbidity and mortality. Literature of AKI after pediatric cardiac surgery is comprehensively reviewed in terms of incidence, risk factors, biomarkers, treatment and prognosis. The novel RIFLE (pediatric RIFLE for pediatrics), Acute Kidney Injury Network (AKIN) and Kidney Disease Improving Global Outcomes (KDIGO) criteria have brought about unified diagnostic standards and comparable results for AKI after cardiac surgery. Numerous risk factors, either renal or extrarenal, can be responsible for the development of AKI after cardiac surgery, with low cardiac output syndrome being the most pronounced predictor. Early fluid overload is also crucial for the occurrence of AKI and prognosis in pediatric patients. Three sensitive biomarkers, neutrophil gelatinase-associated lipocalin, cystatin C (CysC) and liver fatty acid-binding protein, are regarded as the earliest (increase at 2-4 h), and another two, kidney injury molecule-1 and interleukin-18 represent the intermediate respondents (increase at 6-12 h after surgery). To ameliorate the cardiopulmonary bypass techniques, improve renal perfusion and eradicate the causative risk factors are imperative for the prevention of AKI in pediatric patients. The early and intermediate biomarkers are helpful for an early judgment of occurrence of postoperative AKI. Improved survival has been achieved by prevention, renal support and modifications of hemofiltration techniques. Further development is anticipated in small children.