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Pelletier JH, Rakkar J, Au AK, Fuhrman DY, Clark RSB, Kochanek PM, Horvat CM. Retrospective Validation of a Computerized Physiologic Equation to Predict Minute Ventilation Needs in Critically Ill Children. Pediatr Crit Care Med 2024; 25:390-395. [PMID: 38329377 PMCID: PMC11065608 DOI: 10.1097/pcc.0000000000003462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
OBJECTIVES Mechanical ventilation (MV) is pervasive among critically ill children. We sought to validate a computerized physiologic equation to predict minute ventilation requirements in children and test its performance against clinician actions in an in silico trial. DESIGN Retrospective, electronic medical record linkage, cohort study. SETTING Quaternary PICU. PATIENTS Patients undergoing invasive MV, serial arterial blood gas (ABG) analysis within 1-6 hours, and pharmacologic neuromuscular blockade (NMB). MEASUREMENTS AND MAIN RESULTS ABG values were filtered to those occurring during periods of NMB. Simultaneous ABG and minute ventilation data were linked to predict serial Pa co2 and pH values using previously published physiologic equations. There were 15,121 included ABGs across 500 encounters among 484 patients, with a median (interquartile range [IQR]) of 20 (10-43) ABGs per encounter at a duration of 3.6 (2.1-4.2) hours. The median (IQR) Pa co2 prediction error was 0.00 (-3.07 to 3.00) mm Hg. In Bland-Altman analysis, the mean error was -0.10 mm Hg (95% CI, -0.21 to 0.01 mm Hg). A nested, in silico trial of ABGs meeting criteria for weaning (respiratory alkalosis) or escalation (respiratory acidosis), compared the performance of recommended ventilator changes versus clinician decisions. There were 1,499 of 15,121 ABGs (9.9%) among 278 of 644 (43.2%) encounters included in the trial. Calculated predictions were favorable to clinician actions in 1124 of 1499 ABGs (75.0%), equivalent to clinician choices in 26 of 1499 ABGs (1.7%), and worse than clinician decisions in 349 of 1499 ABGs (23.3%). Calculated recommendations were favorable to clinician decisions in sensitivity analyses limiting respiratory rate, analyzing only when clinicians made changes, excluding asthma, and excluding acute respiratory distress syndrome. CONCLUSIONS A computerized equation to predict minute ventilation requirements outperformed clinicians' ventilator adjustments in 75% of ABGs from critically ill children in this retrospective analysis. Prospective validation studies are needed.
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Affiliation(s)
- Jonathan H Pelletier
- Division of Critical Care, Department of Pediatrics, Akron Children's Hospital, Akron, OH
| | - Jaskaran Rakkar
- Division of Critical Care, Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ
| | - Alicia K Au
- Division of Critical Care, Department of Pediatrics, Akron Children's Hospital, Akron, OH
- Division of Critical Care, Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ
- Department Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Brain Care Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Division of Health Informatics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Dana Y Fuhrman
- Department Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Robert S B Clark
- Division of Critical Care, Department of Pediatrics, Akron Children's Hospital, Akron, OH
- Division of Critical Care, Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ
- Department Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Brain Care Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Division of Health Informatics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Patrick M Kochanek
- Division of Critical Care, Department of Pediatrics, Akron Children's Hospital, Akron, OH
- Division of Critical Care, Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ
- Department Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Brain Care Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Division of Health Informatics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Christopher M Horvat
- Division of Critical Care, Department of Pediatrics, Akron Children's Hospital, Akron, OH
- Division of Critical Care, Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ
- Department Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Brain Care Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Division of Health Informatics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
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Gist KM, Fuhrman DY, Deep A, Haga T, Demirkol D, Bell MJ, Akcan-Arikan A. Continuous Renal Replacement Therapy: Current State and Future Directions for Worldwide Practice. Pediatr Crit Care Med 2024:00130478-990000000-00325. [PMID: 38511997 DOI: 10.1097/pcc.0000000000003477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Affiliation(s)
- Katja M Gist
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Dana Y Fuhrman
- Department of Pediatrics, Pittsburgh Children's Hospital, University of Pittsburgh College of Medicine, Pittsburgh, PA
| | - Akash Deep
- Intensive Care, Kings College Hospital, London, United Kingdom
| | - Taiki Haga
- Department of Critical Care Medicine, Osaka City General Hospital, Osaka City, Japan
| | - Demet Demirkol
- Department of Pediatrics, Istanbul University, Istanbul, Turkey
| | - Michael J Bell
- Department of Pediatrics, Children's National Medical Center, Washington, DC
| | - Ayse Akcan-Arikan
- Department of Pediatrics, Divisions of Critical Care Medicine and Nephrology, Baylor College of Medicine, Houston, TX
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Stenson EK, Alhamoud I, Alobaidi R, Bottari G, Fernandez S, Fuhrman DY, Guzzi F, Haga T, Kaddourah A, Marinari E, Mohamed T, Morgan C, Mottes T, Neumayr T, Ollberding NJ, Raggi V, Ricci Z, See E, Stanski NL, Zang H, Zangla E, Gist KM. Factors associated with successful liberation from continuous renal replacement therapy in children and young adults: analysis of the worldwide exploration of renal replacement outcomes collaborative in Kidney Disease Registry. Intensive Care Med 2024:10.1007/s00134-024-07336-4. [PMID: 38436726 DOI: 10.1007/s00134-024-07336-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 01/25/2024] [Indexed: 03/05/2024]
Abstract
PURPOSE Continuous renal replacement therapy (CRRT) is used for supportive management of acute kidney injury (AKI) and disorders of fluid balance (FB). Little is known about the predictors of successful liberation in children and young adults. We aimed to identify the factors associated with successful CRRT liberation. METHODS The Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease study is an international multicenter retrospective study (32 centers, 7 nations) conducted from 2015 to 2021 in children and young adults (aged 0-25 years) treated with CRRT for AKI or FB disorders. Patients with previous dialysis dependence, tandem extracorporeal membrane oxygenation use, died within the first 72 h of CRRT initiation, and those who never had liberation attempted were excluded. Patients were categorized based on first liberation attempt: reinstituted (resumption of any dialysis within 72 h) vs. success (no receipt of dialysis for ≥ 72 h). Multivariable logistic regression was used to identify factors associated with successful CRRT liberation. RESULTS A total of 622 patients were included: 287 (46%) had CRRT reinstituted and 335 (54%) were successfully liberated. After adjusting for sepsis at admission and illness severity parameters, several factors were associated with successful liberation, including higher VIS (vasoactive-inotropic score) at CRRT initiation (odds ratio [OR] 1.35 [1.12-1.63]), higher PELOD-2 (pediatric logistic organ dysfunction-2) score at CRRT initiation (OR 1.71 [1.24-2.35]), higher urine output prior to CRRT initiation (OR 1.15 [1.001-1.32]), and shorter CRRT duration (OR 0.19 [0.12-0.28]). CONCLUSIONS Inability to liberate from CRRT was common in this multinational retrospective study. Modifiable and non-modifiable factors were associated with successful liberation. These results may inform the design of future clinical trials to optimize likelihood of CRRT liberation success.
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Affiliation(s)
- Erin K Stenson
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Issa Alhamoud
- Carver College of Medicine, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | | | | | - Sarah Fernandez
- School of Medicine, Gregorio Marañón University Hospital, Madrid, Spain
| | - Dana Y Fuhrman
- University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | | | - Taiki Haga
- Osaka City General Hospital, Osaka, Japan
| | | | | | - Tahagod Mohamed
- Nationwide Children's Hospital, The Kidney and Urinary Tract Center, The Ohio State University College of Medicine, Columbus, OH, USA
| | | | - Theresa Mottes
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Tara Neumayr
- St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO, USA
| | - Nicholas J Ollberding
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Valeria Raggi
- Bambino Gesù, Children's Hospital, IRCCS, Rome, Italy
| | - Zaccaria Ricci
- Department of Pediatrics, Pediatric Intensive Care Unit, Meyer Children's Hospital, IRCCS, Florence, Italy
| | - Emily See
- Royal Children's Hospital, Murdoch Children's Research Institute, University of Melbourne, Melbourne, VIC, Australia
| | - Natalja L Stanski
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Huaiyu Zang
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Katja M Gist
- St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO, USA
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Fuhrman DY, Stanski NL, Krawczeski CD, Greenberg JH, Arikan AAA, Basu RK, Goldstein SL, Gist KM. A proposed framework for advancing acute kidney injury risk stratification and diagnosis in children: a report from the 26th Acute Disease Quality Initiative (ADQI) conference. Pediatr Nephrol 2024; 39:929-939. [PMID: 37670082 PMCID: PMC10817991 DOI: 10.1007/s00467-023-06133-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 07/24/2023] [Accepted: 08/09/2023] [Indexed: 09/07/2023]
Abstract
Acute kidney injury (AKI) in children is associated with increased morbidity, reduced health-related quality of life, greater resource utilization, and higher mortality. Improvements in the timeliness and precision of AKI diagnosis in children are needed. In this report, we highlight existing, novel, and on-the-horizon diagnostic and risk-stratification tools for pediatric AKI, and outline opportunities for integration into clinical practice. We also summarize pediatric-specific high-risk diagnoses and exposures for AKI, as well as the potential role of real-time risk stratification and clinical decision support to improve outcomes. Lastly, the key characteristics of important pediatric AKI phenotypes will be outlined. Throughout, we identify key knowledge gaps, which represent prioritized areas of focus for future research that will facilitate a comprehensive, timely and personalized approach to pediatric AKI diagnosis and management.
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Affiliation(s)
- Dana Y Fuhrman
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Suite 2000, Pittsburgh, PA, 15224, USA.
- Department of Pediatrics, Division of Nephrology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
| | - Natalja L Stanski
- Department of Pediatrics, Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Catherine D Krawczeski
- Department of Pediatrics, Division of Cardiology, Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA
| | - Jason H Greenberg
- Department of Pediatrics, Division of Nephrology, Yale University Medical Center, New Haven, CT, USA
| | - A Ayse Akcan Arikan
- Department of Pediatrics, Division of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
- Department of Pediatrics, Division of Nephrology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Raj K Basu
- Department of Pediatrics, Division of Critical Care Medicine, Northwestern University Feinberg School of Medicine, Ann & Robert Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Stuart L Goldstein
- Department of Pediatrics, Division of Nephrology & Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Katja M Gist
- Department of Pediatrics, Division of Cardiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Fuhrman DY, Stenson EK, Alhamoud I, Alobaidi R, Bottari G, Fernandez S, Guzzi F, Haga T, Kaddourah A, Marinari E, Mohamed TH, Morgan CJ, Mottes T, Neumayr TM, Ollberding NJ, Raggi V, Ricci Z, See E, Stanski NL, Zang H, Zangla E, Gist KM. Major Adverse Kidney Events in Pediatric Continuous Kidney Replacement Therapy. JAMA Netw Open 2024; 7:e240243. [PMID: 38393726 PMCID: PMC10891477 DOI: 10.1001/jamanetworkopen.2024.0243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/26/2023] [Indexed: 02/25/2024] Open
Abstract
Importance Continuous kidney replacement therapy (CKRT) is increasingly used in youths with critical illness, but little is known about longer-term outcomes, such as persistent kidney dysfunction, continued need for dialysis, or death. Objective To characterize the incidence and risk factors, including liberation patterns, associated with major adverse kidney events 90 days after CKRT initiation (MAKE-90) in children, adolescents, and young adults. Design, Setting, and Participants This international, multicenter cohort study was conducted among patients aged 0 to 25 years from The Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK) registry treated with CKRT for acute kidney injury or fluid overload from 2015 to 2021. Exclusion criteria were dialysis dependence, concurrent extracorporeal membrane oxygenation use, or receipt of CKRT for a different indication. Data were analyzed from May 2 to December 14, 2023. Exposure Patient clinical characteristics and CKRT parameters were assessed. CKRT liberation was classified as successful, reinstituted, or not attempted. Successful liberation was defined as the first attempt at CKRT liberation resulting in 72 hours or more without return to dialysis within 28 days of CKRT initiation. Main Outcomes and Measures MAKE-90, including death or persistent kidney dysfunction (dialysis dependence or ≥25% decline in estimated glomerular filtration rate from baseline), were assessed. Results Among 969 patients treated with CKRT (529 males [54.6%]; median [IQR] age, 8.8 [1.7-15.0] years), 630 patients (65.0%) developed MAKE-90. On multivariable analysis, cardiac comorbidity (adjusted odds ratio [aOR], 1.60; 95% CI, 1.08-2.37), longer duration of intensive care unit admission before CKRT initiation (aOR for 6 days vs 1 day, 1.07; 95% CI, 1.02-1.13), and liberation pattern were associated with MAKE-90. In this analysis, patients who successfully liberated from CKRT within 28 days had lower odds of MAKE-90 compared with patients in whom liberation was attempted and failed (aOR, 0.32; 95% CI, 0.22-0.48) and patients without a liberation attempt (aOR, 0.02; 95% CI, 0.01-0.04). Conclusions and Relevance In this study, MAKE-90 occurred in almost two-thirds of the population and patient-level risk factors associated with MAKE-90 included cardiac comorbidity, time to CKRT initiation, and liberation patterns. These findings highlight the high incidence of adverse outcomes in this population and suggest that future prospective studies are needed to better understand liberation patterns and practices.
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Affiliation(s)
- Dana Y. Fuhrman
- University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Erin K. Stenson
- Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora
| | - Issa Alhamoud
- University of Iowa Stead Family Children’s Hospital, Carver College of Medicine, Iowa City
| | | | | | - Sarah Fernandez
- Gregorio Marañón University Hospital, School of Medicine, Madrid, Spain
| | | | - Taiki Haga
- Osaka City General Hospital, Osaka, Japan
| | - Ahmad Kaddourah
- Sidra Medicine, Doha, Qatar
- Weill Cornell Medical College, Ar-Rayyan, Qatar
| | | | - Tahagod H. Mohamed
- Nationwide Children’s Hospital, The Heart Center, The Ohio State University College of Medicine, Columbus
| | | | - Theresa Mottes
- Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Tara M. Neumayr
- Washington University School of Medicine, St Louis Children’s Hospital, St Louis, Missouri
| | - Nicholas J. Ollberding
- Cincinnati Children’s Hospital Medical Center; University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Valeria Raggi
- Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | | | - Emily See
- Royal Children’s Hospital, University of Melbourne, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
| | - Natalja L. Stanski
- Cincinnati Children’s Hospital Medical Center; University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Huaiyu Zang
- Cincinnati Children’s Hospital Medical Center; University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Katja M. Gist
- Cincinnati Children’s Hospital Medical Center; University of Cincinnati College of Medicine, Cincinnati, Ohio
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Scioscia A, Rakkar J, Pelletier JH, Ghassemzadeh R, Hamilton MF, Fuhrman DY. Virtual Learning Improves Attendance for Critical Care Education During the COVID-19 Pandemic. J Pediatr Intensive Care 2023; 12:325-329. [PMID: 37970144 PMCID: PMC10631843 DOI: 10.1055/s-0041-1735868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 08/03/2021] [Indexed: 10/20/2022] Open
Abstract
The COVID-19 pandemic has pushed medical educators and learners to adapt to virtual learning (VL) in an expedited manner. The effect of VL for critical care education has not yet been evaluated. In a quantitative analysis of survey data and attendance records, we sought to determine the association of VL with conference attendance and work-life balance. Attending physicians, fellows, and advanced practice providers (APP) at a pediatric critical care department at a quaternary children's hospital participated in the study. Attendance records were obtained before and after the adaption of a VL platform. In addition, an electronic, anonymous survey to evaluate current satisfaction and the strengths and weaknesses of VL as well as its impact on work-life balance was administered. In total, 31 learners (17 attending physicians, 13 fellows, and 1 APP) completed the survey. A total of 83.9% (26/31) of participants were satisfied, and 77.4% (24/31) found VL to be similar or more engaging than non-VL. However, 6.5% (2/31) of learners reported difficulty in using the new platform, 87% (27/31) of participants supported VL as an effective learning tool, and 83.3% (25/30) reported a positive impact on work-life balance. Additionally, median monthly conference attendance increased significantly from 85 to 114 attendees per month ( p < 0.05). Our results suggest that a virtual model has advantages for overall attendance and work-life balance. We anticipate VL will continue to be an integral part of medical education. Future work evaluating the impact of VL on interdepartmental and interinstitutional collaborations is needed.
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Affiliation(s)
- Andrea Scioscia
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Jaskaran Rakkar
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Jonathan H. Pelletier
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Rod Ghassemzadeh
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Melinda F. Hamilton
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Dana Y. Fuhrman
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States
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Fuhrman DY, Gist KM, Akcan-Arikan A. Current practices in pediatric continuous kidney replacement therapy: a systematic review-guided multinational modified Delphi consensus study. Pediatr Nephrol 2023; 38:2817-2826. [PMID: 36625932 PMCID: PMC11069347 DOI: 10.1007/s00467-022-05864-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/25/2022] [Accepted: 12/14/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Continuous kidney replacement therapy (CKRT) has become an integral part of the care of critically ill children. However, uncertainty exists regarding the current state of how CKRT is prescribed and delivered in children. The main objective of this study was to identify the current practices for pediatric CKRT. METHODS We conducted a systematic review of the literature from 2012 to 2022 to identify data regarding CKRT timing of initiation, dosing, anticoagulation, fluid removal, and quality monitoring. Using this data, we then performed a two-round modified Delphi process using a multinational internet-assisted survey of prescribers of CKRT. RESULTS The survey was constructed using 172 articles that met inclusion criteria (12% of studies were pediatric focused). A total of 147 and 126 practitioners completed the survey in rounds 1 and 2, respectively. Participants represented Europe (9.5-11.6%) and North America including pediatric intensivists, nephrologists, and advance practice providers. Consensus (defined as a ≥ 75% participant response of "sometimes" or "always") was achieved for 26 statements. There was consensus in the practices of CKRT initiation, dosing, method of anticoagulation, and fluid removal. In contrast, there appears to be greater variability in the methods used for monitoring anticoagulation and the quality of the delivered treatment. CONCLUSIONS Our study results suggest that the current state of pediatric CKRT practice is reflective of the literature over the last 10 years, which is largely based on the care of adult patients. This data provides a framework to study best practices to further improve outcomes for children receiving CKRT. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Dana Y Fuhrman
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
- Department of Pediatrics, Division of Nephrology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
- University of Pittsburgh Children's Hospital of Pittsburgh, 4401 Penn Avenue, Suite 2000, Pittsburgh, PA, 15224, USA.
| | - Katja M Gist
- Department of Pediatrics, Division of Cardiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ayse Akcan-Arikan
- Department of Pediatrics, Division of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
- Department of Pediatrics, Division of Nephrology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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Menon S, Krallman KA, Arikan AA, Fuhrman DY, Gorga SM, Mottes T, Ollberding N, Ricci Z, Stanski NL, Selewski DT, Soranno DE, Zappitelli M, Zang H, Gist KM. Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK). Kidney Int Rep 2023; 8:1542-1552. [PMID: 37547524 PMCID: PMC10403688 DOI: 10.1016/j.ekir.2023.05.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 05/17/2023] [Accepted: 05/28/2023] [Indexed: 08/08/2023] Open
Abstract
Introduction Continuous renal replacement therapy (CRRT) is used for the symptomatic management of acute kidney injury (AKI) and fluid overload (FO). Contemporary reports on pediatric CRRT are small and single center in design. Large international studies evaluating CRRT practice and outcomes are lacking. Herein, we describe the design of a multinational collaborative. Methods The Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK) is an international collaborative of pediatric specialists whose mission is to improve short- and long-term outcomes of children treated with CRRT. The aims of this multicenter retrospective study are to describe the epidemiology, liberation patterns, association of fluid balance and timing of CRRT initiation, and CRRT prescription with outcomes. Results We included children (n = 996, 0-25 years) admitted to an intensive care unit (ICU) and treated with CRRT for AKI or FO at 32 centers (in 7 countries) from 2018 to 2021. Demographics and clinical characteristics before CRRT initiation, during the first 7 days of both CRRT, and liberation were collected. Outcomes include the following: (i) major adverse kidney events at 90 days (mortality, dialysis dependence, and persistent kidney dysfunction), and (ii) functional outcomes (functional stats scale). Conclusion The retrospective WE-ROCK study represents the largest international registry of children receiving CRRT for AKI or FO. It will serve as a broad and invaluable resource for the field of pediatric critical care nephrology that will improve our understanding of practice heterogeneity and the association of CRRT with clinical and patient-centered outcomes. This will generate preliminary data for future interventional trials in this area.
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Affiliation(s)
- Shina Menon
- Department of Pediatrics, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, Washington, USA
| | - Kelli A. Krallman
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Ayse A. Arikan
- Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Dana Y. Fuhrman
- Department of Pediatrics, Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Stephen M. Gorga
- Department of Pediatrics, University of Michigan Medical School, C.S. Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - Theresa Mottes
- Department of Pediatrics, Anne and Robert Lurie Children’s Hospital, Northwestern University School of Medicine, Chicago, Illinois, USA
| | - Nicholas Ollberding
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Zaccaria Ricci
- Department of Pediatrics, Meyer University Hospital, University of Florence, Florence, Italy
| | - Natalja L. Stanski
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - David T. Selewski
- Department of Pediatrics, Children’s Hospital of South Carolina, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Danielle E. Soranno
- Department of Pediatrics and Bioengineering, Indiana University, Riley Children’s Hospital, Indianapolis, Indiana
| | - Michael Zappitelli
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Huaiyu Zang
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Katja M. Gist
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Fuhrman DY, Thadani S, Hanson C, Carcillo JA, Kellum JA, Park HJ, Lu L, Kim-Campbell N, Horvat CM, Arikan AA. Therapeutic Plasma Exchange Is Associated With Improved Major Adverse Kidney Events in Children and Young Adults With Thrombocytopenia at the Time of Continuous Kidney Replacement Therapy Initiation. Crit Care Explor 2023; 5:e0891. [PMID: 37066071 PMCID: PMC10097539 DOI: 10.1097/cce.0000000000000891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2023] Open
Abstract
Therapeutic plasma exchange (TPE) has been shown to improve organ dysfunction and survival in patients with thrombotic microangiopathy and thrombocytopenia associated with multiple organ failure. There are no known therapies for the prevention of major adverse kidney events after continuous kidney replacement therapy (CKRT). The primary objective of this study was to evaluate the effect of TPE on the rate of adverse kidney events in children and young adults with thrombocytopenia at the time of CKRT initiation. DESIGN Retrospective cohort. SETTING Two large quaternary care pediatric hospitals. PATIENTS All patients less than or equal to 26 years old who received CKRT between 2014 and 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We defined thrombocytopenia as a platelet count less than or equal to 100,000 (cell/mm3) at the time of CKRT initiation. We ascertained major adverse kidney events at 90 days (MAKE90) after CKRT initiation as the composite of death, need for kidney replacement therapy, or a greater than or equal to 25% decline in estimated glomerular filtration rate from baseline. We performed multivariable logistic regression and propensity score weighting to analyze the relationship between the use of TPE and MAKE90. After excluding patients with a diagnosis of thrombotic thrombocytopenia purpura and atypical hemolytic uremic syndrome (n = 6) and with thrombocytopenia due to a chronic illness (n = 2), 284 of 413 total patients (68.8%) had thrombocytopenia at CKRT initiation (51% female). Of the patients with thrombocytopenia, the median (interquartile range) age was 69 months (13-128 mo). MAKE90 occurred in 69.0% and 41.5% received TPE. The use of TPE was independently associated with reduced MAKE90 by multivariable analysis (odds ratio [OR], 0.35; 95% CI, 0.20-0.60) and by propensity score weighting (adjusted OR, 0.31; 95% CI, 0.16-0.59). CONCLUSIONS Thrombocytopenia is common in children and young adults at CKRT initiation and is associated with increased MAKE90. In this subset of patients, our data show benefit of TPE in reducing the rate of MAKE90.
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Affiliation(s)
- Dana Y Fuhrman
- Department of Critical Care Medicine, Division of Pediatric Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
- Department of Pediatrics, Division of Nephrology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
- The Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Sameer Thadani
- Department of Pediatrics, Division of Nephrology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Claire Hanson
- Department of Critical Care Medicine, Division of Pediatric Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, Division of Pediatric Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
- The Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - John A Kellum
- The Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Hyun Jung Park
- Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Liling Lu
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA
| | - Nahmah Kim-Campbell
- Department of Critical Care Medicine, Division of Pediatric Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Christopher M Horvat
- Department of Critical Care Medicine, Division of Pediatric Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
- Department of Pediatrics, Division of Health Informatics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Ayse Akcan Arikan
- Department of Pediatrics, Division of Nephrology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
- Department of Pediatrics, Division of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
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10
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Gist KM, Fuhrman DY, Akcan-Arikan A. Standardizing Care in Pediatric Continuous Kidney Replacement Therapy-Can We Reach Consensus Without Adequate Evidence? JAMA Netw Open 2022; 5:e2246909. [PMID: 36520442 DOI: 10.1001/jamanetworkopen.2022.46909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Katja M Gist
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Dana Y Fuhrman
- UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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11
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Pelletier JH, Au AK, Fuhrman DY, Marroquin OC, Suresh S, Clark RSB, Kochanek PM, Horvat CM. Healthcare Use in the Year Following Bronchiolitis Hospitalization. Hosp Pediatr 2022; 12:937-949. [PMID: 36281706 PMCID: PMC9946196 DOI: 10.1542/hpeds.2022-006657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
OBJECTIVES Healthcare utilization after bronchiolitis hospitalization is incompletely understood. We aimed to characterize readmissions and outpatient visits within 1 year after hospital discharge. METHODS Retrospective multicenter observational cohort study of children under 24-months old admitted with bronchiolitis between January 1, 2010 and December 12, 2019 to the Pediatric Health Information Systems database. A single-center nested subset using linked electronic health records allowed analysis of outpatient visits. RESULTS There were 308 306 admissions for bronchiolitis among 271 115 patients across 47 hospitals between 2010-2019. The percent of patients readmitted within 30 days after discharge was 6.0% (16 167 of 271 115), and 17.8% (48 332 of 271 115) of patients were readmitted within 1 year. 22.9% (16 919 of 74 001) of patients admitted to an ICU and 26.8% (7865 of 29 378) of patients undergoing mechanical ventilation were readmitted within 1 year. There were 1438 patients with outpatient healthcare data available. There were a median (interquartile range) of 9 (6-13) outpatient visits per patient within 1 year after discharge. Outpatient healthcare use increased for 4 months following bronchiolitis hospitalization compared with previously reported age-matched controls. Higher income, white race, commercial insurance, complex chronic conditions, ICU admission, and mechanical ventilation were associated with higher outpatient utilization. Higher quartiles of outpatient use were associated with readmission for bronchiolitis and all-cause readmissions. CONCLUSIONS Readmissions in the year after bronchiolitis hospitalization are common, and outpatient healthcare use is increased for 4 months following discharge. Prospective study is needed to track long-term outcomes of infants with bronchiolitis.
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Affiliation(s)
| | - Alicia K Au
- Departments of Critical Care Medicine
- Pediatrics
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Brain Care Institute
| | | | - Oscar C Marroquin
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Srinivasan Suresh
- Division of Health Informatics, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh; Pittsburgh, Pennsylvania
- Division Emergency Medicine, Department of Pediatrics, University of Pittsburgh and University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert S B Clark
- Departments of Critical Care Medicine
- Pediatrics
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Brain Care Institute
| | - Patrick M Kochanek
- Departments of Critical Care Medicine
- Pediatrics
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Brain Care Institute
| | - Christopher M Horvat
- Departments of Critical Care Medicine
- Pediatrics
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Brain Care Institute
- Division of Health Informatics, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh; Pittsburgh, Pennsylvania
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12
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Goldstein SL, Akcan-Arikan A, Alobaidi R, Askenazi DJ, Bagshaw SM, Barhight M, Barreto E, Bayrakci B, Bignall ONR, Bjornstad E, Brophy PD, Chanchlani R, Charlton JR, Conroy AL, Deep A, Devarajan P, Dolan K, Fuhrman DY, Gist KM, Gorga SM, Greenberg JH, Hasson D, Ulrich EH, Iyengar A, Jetton JG, Krawczeski C, Meigs L, Menon S, Morgan J, Morgan CJ, Mottes T, Neumayr TM, Ricci Z, Selewski D, Soranno DE, Starr M, Stanski NL, Sutherland SM, Symons J, Tavares MS, Vega MW, Zappitelli M, Ronco C, Mehta RL, Kellum J, Ostermann M, Basu RK. Consensus-Based Recommendations on Priority Activities to Address Acute Kidney Injury in Children: A Modified Delphi Consensus Statement. JAMA Netw Open 2022; 5:e2229442. [PMID: 36178697 PMCID: PMC9756303 DOI: 10.1001/jamanetworkopen.2022.29442] [Citation(s) in RCA: 59] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ayse Akcan-Arikan
- Division of Critical Care Medicine and Nephrology, Texas Children's Hospital, Baylor College of Medicine, Houston
| | - Rashid Alobaidi
- Alberta Health Sciences University, Edmonton, Alberta, Canada
| | | | - Sean M Bagshaw
- Alberta Health Sciences University, Edmonton, Alberta, Canada
| | - Matthew Barhight
- Ann & Robert Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | | | - Benan Bayrakci
- Department of Pediatric Intensive Care Medicine, Life Support Center, Hacettepe University, Ankara, Turkey
| | | | | | - Patrick D Brophy
- Golisano Children's Hospital, Rochester University Medical Center, Rochester, New York
| | | | | | | | - Akash Deep
- King's College London, London, United Kingdom
| | - Prasad Devarajan
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kristin Dolan
- Mercy Children's Hospital Kansas City, Kansas City, Missouri
| | - Dana Y Fuhrman
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Katja M Gist
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Stephen M Gorga
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor
| | | | - Denise Hasson
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Arpana Iyengar
- St John's Academy of Health Sciences, Bangalore, Karnataka, India
| | | | | | - Leslie Meigs
- Stead Family Children's Hospital, The University of Iowa, Iowa City
| | - Shina Menon
- Seattle Children's Hospital, Seattle, Washington
| | - Jolyn Morgan
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Theresa Mottes
- Ann & Robert Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | - Tara M Neumayr
- Washington University School of Medicine, St Louis, Missouri
| | | | | | | | - Michelle Starr
- Riley Children's Hospital, Indiana University, Bloomington
| | - Natalja L Stanski
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Scott M Sutherland
- Lucille Packard Children's Hospital, Stanford University, Stanford, California
| | | | | | - Molly Wong Vega
- Division of Nephrology, Texas Children's Hospital, Baylor College of Medicine, Houston
| | | | - Claudio Ronco
- Universiti di Padova, San Bartolo Hospital, Vicenza, Italy
| | | | - John Kellum
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Rajit K Basu
- Ann & Robert Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
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13
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Husain-Syed F, Emlet DR, Wilhelm J, Danesi TH, Ferrari F, Bezerra P, Lopez-Giacoman S, Villa G, Tello K, Birk HW, Seeger W, Giavarina D, Salvador L, Fuhrman DY, Kellum JA, Ronco C. Effects of preoperative high-oral protein loading on short- and long-term renal outcomes following cardiac surgery: a cohort study. J Transl Med 2022; 20:204. [PMID: 35538495 PMCID: PMC9092825 DOI: 10.1186/s12967-022-03410-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 04/24/2022] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Post-cardiac surgery acute kidney injury (AKI) is associated with increased mortality. A high-protein meal enhances the renal blood flow and glomerular filtration rate (GFR) and might protect the kidneys from acute ischemic insults. Hence, we assessed the effect of a preoperative high-oral protein load on post-cardiac surgery renal function and used experimental models to elucidate mechanisms by which protein might stimulate kidney-protective effects. METHODS The prospective "Preoperative Renal Functional Reserve Predicts Risk of AKI after Cardiac Operation" study follow-up was extended to postoperative 12 months for 109 patients. A 1:2 ratio propensity score matching method was used to identify a control group (n = 214) to comparatively evaluate the effects of a preoperative protein load and standard care. The primary endpoints were AKI development and postoperative estimated GFR (eGFR) loss at 3 and 12 months. We also assessed the secretion of tissue inhibitor of metalloproteases-2 (TIMP-2) and insulin-like growth factor-binding protein 7 (IGFBP7), biomarkers implicated in mediating kidney-protective mechanisms in human kidney tubular cells that we exposed to varying protein concentrations. RESULTS The AKI rate did not differ between the protein loading and control groups (13.6 vs. 12.3%; p = 0.5). However, the mean eGFR loss was lower in the former after 3 months (0.1 [95% CI - 1.4, - 1.7] vs. - 3.3 [95% CI - 4.4, - 2.2] ml/min/1.73 m2) and 12 months (- 2.7 [95% CI - 4.2, - 1.2] vs - 10.2 [95% CI - 11.3, - 9.1] ml/min/1.73 m2; p < 0.001 for both). On stratification based on AKI development, the eGFR loss after 12 months was also found to be lower in the former (- 8.0 [95% CI - 14.1, - 1.9] vs. - 18.6 [95% CI - 23.3, - 14.0] ml/min/1.73 m2; p = 0.008). A dose-response analysis of the protein treatment of the primary human proximal and distal tubule epithelial cells in culture showed significantly increased IGFBP7 and TIMP-2 expression. CONCLUSIONS A preoperative high-oral protein load did not reduce AKI development but was associated with greater renal function preservation in patients with and without AKI at 12 months post-cardiac surgery. The potential mechanisms of action by which protein loading may induce a kidney-protective response might include cell cycle inhibition of renal tubular epithelial cells. Clinical trial registration ClinicalTrials.gov: NCT03102541 (retrospectively registered on April 5, 2017) and ClinicalTrials.gov: NCT03092947 (retrospectively registered on March 28, 2017).
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Affiliation(s)
- Faeq Husain-Syed
- grid.416303.30000 0004 1758 2035Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza, San Bortolo Hospital, Via Rodolfi, 37, 36100 Vicenza, Italy ,grid.411067.50000 0000 8584 9230Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus-Liebig-University Giessen, Klinikstrasse 33, 35392 Giessen, Germany
| | - David R. Emlet
- grid.21925.3d0000 0004 1936 9000Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA 15261 USA
| | - Jochen Wilhelm
- grid.8664.c0000 0001 2165 8627Institute for Lung Health, Justus-Liebig-University Giessen, Ludwigstrasse 23, 35390 Giessen, Germany
| | - Tommaso Hinna Danesi
- grid.416303.30000 0004 1758 2035Department of Cardiac Surgery, San Bortolo Hospital, Via Rodolfi, 37, 36100 Vicenza, Italy ,grid.24827.3b0000 0001 2179 9593Division of Cardiac Surgery, Department of Surgery, College of Medicine, University of Cincinnaci, 231 Albert Sabin Way, Cincinnati, OH 45267-0558 USA
| | - Fiorenza Ferrari
- grid.416303.30000 0004 1758 2035Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza, San Bortolo Hospital, Via Rodolfi, 37, 36100 Vicenza, Italy ,grid.419425.f0000 0004 1760 3027Intensive Care Unit, I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, 27100 Pavia, Italy
| | - Pércia Bezerra
- grid.416303.30000 0004 1758 2035Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza, San Bortolo Hospital, Via Rodolfi, 37, 36100 Vicenza, Italy
| | - Salvador Lopez-Giacoman
- grid.416303.30000 0004 1758 2035Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza, San Bortolo Hospital, Via Rodolfi, 37, 36100 Vicenza, Italy
| | - Gianluca Villa
- grid.416303.30000 0004 1758 2035Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza, San Bortolo Hospital, Via Rodolfi, 37, 36100 Vicenza, Italy ,grid.8404.80000 0004 1757 2304Department of Health Science, Section of Anesthesiology and Intensive Care, University of Florence, Piazza San Marco, 4, 50121 Florence, Italy
| | - Khodr Tello
- grid.411067.50000 0000 8584 9230Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus-Liebig-University Giessen, Klinikstrasse 33, 35392 Giessen, Germany ,grid.8664.c0000 0001 2165 8627Member of the German Centre for Lung Research, Universities of Giessen and Marburg Lung Centre, Klinikstrasse 33, 35392 Giessen, Germany
| | - Horst-Walter Birk
- grid.411067.50000 0000 8584 9230Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus-Liebig-University Giessen, Klinikstrasse 33, 35392 Giessen, Germany
| | - Werner Seeger
- grid.411067.50000 0000 8584 9230Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus-Liebig-University Giessen, Klinikstrasse 33, 35392 Giessen, Germany ,grid.8664.c0000 0001 2165 8627Member of the German Centre for Lung Research, Universities of Giessen and Marburg Lung Centre, Klinikstrasse 33, 35392 Giessen, Germany ,grid.418032.c0000 0004 0491 220XDepartment of Lung Development and Remodelling, Max Planck Institute for Heart and Lung Research, Ludwigstrasse 43, 61231 Bad Nauheim, Germany
| | - Davide Giavarina
- grid.416303.30000 0004 1758 2035Department of Clinical Chemistry and Hematology Laboratory, San Bortolo Hospital, Via Rodolfi, 37, 36100 Vicenza, Italy
| | - Loris Salvador
- grid.416303.30000 0004 1758 2035Department of Cardiac Surgery, San Bortolo Hospital, Via Rodolfi, 37, 36100 Vicenza, Italy
| | - Dana Y. Fuhrman
- grid.21925.3d0000 0004 1936 9000Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA 15261 USA ,grid.412689.00000 0001 0650 7433Departments of Critical Care Medicine and Pediatrics, Children’s Hospital of University of Pittsburgh Medical Center, One Children’s Hospital Way, 4401 Penn Ave, Pittsburgh, PA 15224 USA
| | - John A. Kellum
- grid.21925.3d0000 0004 1936 9000Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA 15261 USA
| | - Claudio Ronco
- grid.416303.30000 0004 1758 2035Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza, San Bortolo Hospital, Via Rodolfi, 37, 36100 Vicenza, Italy ,grid.5608.b0000 0004 1757 3470Department of Medicine (DIMED), Università di Padova, Via Giustiniani, 2, 35128 Padua, Italy
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14
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Foglia MJ, Pelletier JH, Bayir H, Fleck A, Konyk L, McSteen C, Fisher D, Fuhrman DY. Tandem Therapeutic Plasma Exchange Reduces Continuous Renal Replacement Therapy Downtime. Blood Purif 2022; 51:523-530. [PMID: 34515068 PMCID: PMC8885923 DOI: 10.1159/000518348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 07/06/2021] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Continuous renal replacement therapy (CRRT) has become a primary treatment of severe acute kidney injury in children admitted to the intensive care unit. CRRT "downtime" (when the circuit is not active) can represent a significant portion of the prescribed treatment time and adversely affects clearance. The objective of this study was to evaluate factors associated with CRRT "downtime" and to determine whether instituting a tandem therapeutic plasma exchange (TPE) protocol could significantly and robustly decrease circuit downtime in patients receiving both therapies. METHODS This is a retrospective cohort study of 116 patients undergoing CRRT in the pediatric, neonatal, or cardiac ICU at UPMC Children's Hospital of Pittsburgh from January 2014 to July 2020. We performed multivariable logistic regression to determine factors associated with CRRT downtime. We instituted a tandem TPE protocol whereby TPE and CRRT could run in parallel without pausing CRRT in April 2018. We analyzed the effect of the protocol change by plotting downtime for patients undergoing CRRT and TPE on a run chart. The effect of initiating tandem TPE on downtime was assessed by special cause variation. RESULTS For 108/139 (77.7%) sessions with downtime data available, the median (IQR) percentage of downtime was 6.2% (1.7-12.7%). Multivariable logistic regression showed that TPE was significantly associated with CRRT downtime (p = 0.003), and that age, sex, race, catheter size, and anticoagulation were not. For patients undergoing TPE, the median (IQR) percentage of downtime was 14.7% (10.5-26%) and 3.4% (1.3-4.9%) before and after initiation of tandem TPE, respectively (p < 0.001). The difference in downtime percentage met criteria for special cause variation. CONCLUSIONS Interruptions for TPE increase CRRT downtime. Tandem TPE significantly reduces CRRT downtime in patients undergoing both procedures concomitantly.
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Affiliation(s)
- Matthew J. Foglia
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan H. Pelletier
- Division of Pediatric Critical Care, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Hülya Bayir
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA,Division of Pediatric Critical Care, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA,Pediatric CRRT Program, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA,Children’s Neuroscience Institute, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Annette Fleck
- Division of Pediatric Critical Care, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA,Pediatric CRRT Program, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Leslie Konyk
- Division of Pediatric Critical Care, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA,Pediatric CRRT Program, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Coleen McSteen
- Division of Pediatric Critical Care, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA,Pediatric CRRT Program, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Dawn Fisher
- Division of Pediatric Critical Care, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA,Pediatric CRRT Program, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Dana Y. Fuhrman
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA,Division of Pediatric Critical Care, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA,Pediatric CRRT Program, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
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15
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Pande CK, Smith MB, Soranno DE, Gist KM, Fuhrman DY, Dolan K, Conroy AL, Akcan-Arikan A. The Neglected Price of Pediatric Acute Kidney Injury: Non-renal Implications. Front Pediatr 2022; 10:893993. [PMID: 35844733 PMCID: PMC9279899 DOI: 10.3389/fped.2022.893993] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 05/23/2022] [Indexed: 01/03/2023] Open
Abstract
Preclinical models and emerging translational data suggest that acute kidney injury (AKI) has far reaching effects on all other major organ systems in the body. Common in critically ill children and adults, AKI is independently associated with worse short and long term morbidity, as well as mortality, in these vulnerable populations. Evidence exists in adult populations regarding the impact AKI has on life course. Recently, non-renal organ effects of AKI have been highlighted in pediatric AKI survivors. Given the unique pediatric considerations related to somatic growth and neurodevelopmental consequences, pediatric AKI has the potential to fundamentally alter life course outcomes. In this article, we highlight the challenging and complex interplay between AKI and the brain, heart, lungs, immune system, growth, functional status, and longitudinal outcomes. Specifically, we discuss the biologic basis for how AKI may contribute to neurologic injury and neurodevelopment, cardiac dysfunction, acute lung injury, immunoparalysis and increased risk of infections, diminished somatic growth, worsened functional status and health related quality of life, and finally the impact on young adult health and life course outcomes.
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Affiliation(s)
- Chetna K Pande
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Mallory B Smith
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA, United States.,Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA, United States
| | - Danielle E Soranno
- Section of Nephrology, Departments of Pediatrics, Bioengineering and Medicine, University of Colorado, Aurora, CO, United States
| | - Katja M Gist
- Division of Cardiology, Department of Pediatrics, Cioncinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH, United States
| | - Dana Y Fuhrman
- Division of Critical Care Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States.,Division of Nephrology, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Kristin Dolan
- Division of Critical Care Medicine, Department of Pediatrics, University of Missouri Kansas City, Children's Mercy Hospital, Kansas City, MO, United States
| | - Andrea L Conroy
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Ayse Akcan-Arikan
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States.,Division of Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
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Pelletier JH, Rakkar J, Simon D, Au AK, Fuhrman DY, Clark RS, Kochanek PM, Horvat CM. Association between pediatric TBI mortality and median family income in the United States: A retrospective cohort study. Lancet Reg Health Am 2022; 5. [PMID: 35252952 PMCID: PMC8896657 DOI: 10.1016/j.lana.2021.100164] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND There are regional disparities in pediatric traumatic brain injury (TBI) mortality across the United States, but the factors underlying these differences are unclear. METHODS We performed a retrospective cross-sectional analysis of the Pediatric Health Information System database including inpatient hospital encounters for children less than 18 years old with a primary diagnosis of TBI between 2010-2019. FINDINGS Lower median family income was associated with pediatric TBI mortality. Encounters from zip-codes with a median family income of <$20,000 had a 3.1% (29/950) mortality, as opposed to 1.3% (29/2,267) mortality for zip-codes with a median family income of >$80,000 (p = 0.00096). In multivariable logistic regression, every $10,000 of income was associated with an odds ratio of mortality of 0.94 (95% confidence interval 0.90 - 0.98). 82.5% (397/481) of ballistic TBI injuries were caused by a firearm. Lower income was associated with a higher proportion of ballistic TBI injuries (2.5% [24/950] for <$20,000 versus 0.3% [7/2,267] for >$80,000, p < 0.0001). In multivariable logistic regression, ballistic TBI injuries were associated with an odds ratio of mortality of 5.19 (95% confidence interval 4.00 - 6.73). United States regional variation in pediatric TBI mortality was linearly associated with the percentage of ballistic TBI (adjusted r-squared 0.59, p = 0.0097). INTERPRETATION Children from lower income zip-codes are more likely to sustain a ballistic TBI, and more likely to die. Further work is necessary to determine causal factors underlying these associations and to design interventions that prevent these injuries and/or improve outcomes.
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Affiliation(s)
- Jonathan H. Pelletier
- Department Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jaskaran Rakkar
- Department Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Dennis Simon
- Department Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Brain Care Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alicia K. Au
- Department Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Brain Care Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Dana Y. Fuhrman
- Department Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Robert S.B. Clark
- Department Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Brain Care Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Patrick M. Kochanek
- Department Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Brain Care Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Christopher M. Horvat
- Department Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Brain Care Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Division of Health Informatics, UPMC Children's Hospital of Pittsburgh; Pittsburgh, PA, USA
- Corresponding Author: Christopher Horvat, Division of Pediatric Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA 15224, United States. +1 412-692-5298.
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17
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Bembea MM, Agus M, Akcan-Arikan A, Alexander P, Basu R, Bennett TD, Bohn D, Brandão LR, Brown AM, Carcillo JA, Checchia P, Cholette J, Cheifetz IM, Cornell T, Doctor A, Eckerle M, Erickson S, Farris RW, Faustino EVS, Fitzgerald JC, Fuhrman DY, Giuliano JS, Guilliams K, Gaies M, Gorga SM, Hall M, Hanson SJ, Hartman M, Hassinger AB, Irving SY, Jeffries H, Jouvet P, Kannan S, Karam O, Khemani RG, Niranjan K, Lacroix J, Laussen P, Leclerc F, Lee JH, Leteurtre S, Lobner K, McKiernan PJ, Menon K, Monagle P, Muszynski JA, Odetola F, Parker R, Pathan N, Pierce RW, Pineda J, Prince JM, Robinson KA, Rowan CM, Ryerson LM, Sanchez-Pinto LN, Schlapbach LJ, Selewski DT, Shekerdemian LS, Simon D, Smith LS, Squires JE, Squires RH, Sutherland SM, Ouellette Y, Spaeder MC, Srinivasan V, Steiner ME, Tasker RC, Thiagarajan R, Thomas N, Tissieres P, Traube C, Tucci M, Typpo KV, Wainwright MS, Ward SL, Watson RS, Weiss S, Whitney J, Willson D, Wynn JL, Yeyha N, Zimmerman JJ. Pediatric Organ Dysfunction Information Update Mandate (PODIUM) Contemporary Organ Dysfunction Criteria: Executive Summary. Pediatrics 2022; 149:S1-S12. [PMID: 34970673 PMCID: PMC9599725 DOI: 10.1542/peds.2021-052888b] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/24/2021] [Indexed: 01/20/2023] Open
Abstract
Prior criteria for organ dysfunction in critically ill children were based mainly on expert opinion. We convened the Pediatric Organ Dysfunction Information Update Mandate (PODIUM) expert panel to summarize data characterizing single and multiple organ dysfunction and to derive contemporary criteria for pediatric organ dysfunction. The panel was composed of 88 members representing 47 institutions and 7 countries. We conducted systematic reviews of the literature to derive evidence-based criteria for single organ dysfunction for neurologic, cardiovascular, respiratory, gastrointestinal, acute liver, renal, hematologic, coagulation, endocrine, endothelial, and immune system dysfunction. We searched PubMed and Embase from January 1992 to January 2020. Study identification was accomplished using a combination of medical subject headings terms and keywords related to concepts of pediatric organ dysfunction. Electronic searches were performed by medical librarians. Studies were eligible for inclusion if the authors reported original data collected in critically ill children; evaluated performance characteristics of scoring tools or clinical assessments for organ dysfunction; and assessed a patient-centered, clinically meaningful outcome. Data were abstracted from each included study into an electronic data extraction form. Risk of bias was assessed using the Quality in Prognosis Studies tool. Consensus was achieved for a final set of 43 criteria for pediatric organ dysfunction through iterative voting and discussion. Although the PODIUM criteria for organ dysfunction were limited by available evidence and will require validation, they provide a contemporary foundation for researchers to identify and study single and multiple organ dysfunction in critically ill children.
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Affiliation(s)
- Melania M. Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael Agus
- Division of Medical Critical Care, Boston Children’s Hospital, Harvard Medical School, Boston Children’s Hospital, Boston, MA
| | - Ayse Akcan-Arikan
- Department of Pediatrics, Sections of Critical Care and Nephrology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
| | - Peta Alexander
- Department of Cardiology, Boston Children’s Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Rajit Basu
- Division of Pediatric Critical Care, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Tellen D. Bennett
- Sections of Informatics and Data Science and Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
| | - Desmond Bohn
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto
| | - Leonardo R. Brandão
- Division of Hematology-Oncology, Department of Paediatrics, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Ann-Marie Brown
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA
| | - Joseph A. Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - Paul Checchia
- Section of Critical Care Medicine, Department of Pediatrics, Texas Children’s Hospital and Baylor College of Medicine, Houston, TX
| | - Jill Cholette
- Department of Pediatrics, University of Rochester Golisano Children’s Hospital, Rochester, NY
| | - Ira M. Cheifetz
- Department of Pediatrics, Rainbow Babies and Children’s Hospital, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Timothy Cornell
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children’s Hospital Stanford, Palo Alto, CA
| | - Allan Doctor
- University of Maryland School of Medicine, Center for Blood Oxygen Transport and Hemostasis
| | - Michelle Eckerle
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati OH USA and Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati OH
| | - Simon Erickson
- Department of Paediatric Critical Care; Perth Children’s Hospital and University of Western Australia; Perth, Western Australia, Australia
| | - Reid W.D. Farris
- Department of Pediatrics, University of Washington and Seattle Children’s Hospital; Seattle, WA
| | - E. Vincent S. Faustino
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Yale School of Medicine, New Haven CT
| | - Julie C. Fitzgerald
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Dana Y. Fuhrman
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - John S. Giuliano
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Kristin Guilliams
- Department of Neurology, Division of Pediatric and Development Neurology, Department of Pediatrics, Division of Pediatric Critical Care Medicine, Washington University School of Medicine, St. Louis, MI
| | - Michael Gaies
- Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | | | - Mark Hall
- Division of Critical Care Medicine, Department of Pediatrics, The Ohio State University College of Medicine, Nationwide Children’s Hospital, Columbus, OH
| | - Sheila J. Hanson
- Department of Pediatrics, Critical Care Section, Medical College of Wisconsin/Children’s Wisconsin, Milwaukee, WI
| | - Mary Hartman
- Department of Pediatrics, Washington University, St. Louis, MO
| | - Amanda B. Hassinger
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, John R. Oishei Children’s Hospital, Buffalo, NY
| | - Sharon Y. Irving
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA
| | - Howard Jeffries
- Department of Pediatrics, University of Washington School of Medicine, Seattle WA
| | - Philippe Jouvet
- Department of Paediatrics; Sainte-Justine Hospital and University of Montreal; Montreal, Québec, Canada
| | - Sujatha Kannan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Oliver Karam
- Division of Pediatric Critical Care Medicine, Children’s Hospital of Richmond at VCU, Richmond, VA
| | - Robinder G. Khemani
- Department of Anesthesiology and Critical Care Medicine; Children’s Hospital Los Angeles and University of Southern California Keck School of Medicine; Los Angeles, CA
| | - Kissoon Niranjan
- Division of Critical Care, Department of Pediatrics, University of British Columbia and BC Children’s Hospital
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Centre Hospitalier Universitaire de Sainte-Justine, Université de Montreal, Canada
| | - Peter Laussen
- Department of Cardiology, Boston Children’s Hospital and Department of Anesthesia, Harvard Medical School, Boston, MA
| | - Francis Leclerc
- Univ. Lille, CHU Lille, ULR 2694 - METRICS : Évaluation des technologies de santé et des pratiques médicales, F-59000 Lille, France
| | - Jan Hau Lee
- Children’s Intensive Care Unit, KK Women’s and Children’s Hospital, and, Duke-NUS Medical School, Singapore
| | - Stephane Leteurtre
- Univ. Lille, CHU Lille, ULR 2694 - METRICS : Évaluation des technologies de santé et des pratiques médicales, F-59000 Lille, France
| | - Katie Lobner
- Welch Medical Library, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Patrick J. McKiernan
- Division of Gastroenterology, Hepatology, and Nutrition, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Kusum Menon
- Division of Pediatric Critical Care, Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Paul Monagle
- Department of Clinical Haematology, Royal Children’s Hospital, Victoria, Australia, and Haematology Research, Murdoch Children’s Research Institute, Victoria, Australia
| | - Jennifer A. Muszynski
- Division of Critical Care Medicine, Department of Pediatrics, The Ohio State University College of Medicine, Nationwide Children’s Hospital, Columbus, OH
| | | | - Robert Parker
- Department of Pediatrics (Emeritus), Hematology/Oncology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY
| | - Nazima Pathan
- Department of Paediatrics, University of Cambridge; Clinical Research Associate, Kings College, Cambridge, UK
| | - Richard W. Pierce
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Jose Pineda
- Department of Anesthesiology and Critical Care Medicine; Children’s Hospital Los Angeles and University of Southern California Keck School of Medicine; Los Angeles, CA
| | - Jose M. Prince
- Department of Surgery and Pediatrics, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Karen A. Robinson
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Courtney M. Rowan
- Department of Pediatrics, Division of Pediatric Critical Care; Indiana University School of Medicine and Riley Hospital for Children; Indianapolis, IN
| | | | - L. Nelson Sanchez-Pinto
- Departments of Pediatrics (Critical Care) and Preventive Medicine (Health & Biomedical Informatics), Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Luregn J Schlapbach
- Pediatric and Neonatal Intensive Care Unit, Children`s Research Center, University Children`s Hospital Zurich, Zurich, Switzerland
| | - David T. Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Lara S. Shekerdemian
- Section of Critical Care Medicine, Department of Pediatrics, Texas Children’s Hospital and Baylor College of Medicine, Houston, TX
| | - Dennis Simon
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - Lincoln S. Smith
- Department of Pediatrics, University of Washington and Seattle Children’s Hospital; Seattle, WA
| | - James E. Squires
- Division of Gastroenterology, Hepatology, and Nutrition, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Robert H. Squires
- Division of Gastroenterology, Hepatology, and Nutrition, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Scott M. Sutherland
- Department of Pediatrics, Division of Nephrology, Stanford University School of Medicine, Stanford, CA
| | - Yves Ouellette
- Division of Critical Care Medicine, Department of Pediatrics, Mayo Clinic, Rochester, MN
| | | | - Vijay Srinivasan
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Marie E. Steiner
- Department of Pediatrics, Critical Care Medicine & Hematology, University of Minnesota, Minneapolis, MN
| | - Robert C. Tasker
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston MA
| | - Ravi Thiagarajan
- Department of Cardiology, Boston Children’s Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Neal Thomas
- Department of Pediatrics and Public Health Science, Division of Pediatric Critical Care Medicine; Penn State Hershey Children’s Hospital; Hershey, PA
| | - Pierre Tissieres
- Pediatric Intensive Care, AP-HP Paris Saclay University, Le Kremlin-Bicêtre, France
| | - Chani Traube
- Department of Pediatrics, Division of Critical Care Medicine, Weill Cornell Medical College, NY
| | - Marisa Tucci
- Division of Pediatric Critical Care Medicine, Centre Hospitalier Universitaire de Sainte-Justine, Université de Montreal, Canada
| | - Katri V. Typpo
- Department of Pediatrics and the Steele Children’s Research Center, University of Arizona College of Medicine, Tucson, AZ
| | - Mark S. Wainwright
- Department of Neurology, Division of Pediatric Neurology, University of Washington, Seattle, WA
| | - Shan L. Ward
- Department of Pediatrics, Division of Critical Care, UCSF Benioff Children’s Hospitals, San Francisco and Oakland, CA
| | - R. Scott Watson
- Department of Pediatrics, University of Washington and Seattle Children’s Hospital; Seattle, WA
| | - Scott Weiss
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Jane Whitney
- Division of Medical Critical Care, Boston Children’s Hospital, Harvard Medical School, Boston Children’s Hospital, Boston, MA
| | - Doug Willson
- Division of Pediatric Critical Care Medicine, Children’s Hospital of Richmond at VCU, Richmond, VA
| | - James L. Wynn
- Department of Pediatrics and Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, Florida
| | - Nadir Yeyha
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Jerry J. Zimmerman
- Department of Pediatrics, Seattle Children’s Hospital, Seattle Children’s Research Institute, University of Washington School of Medicine, Seattle, WA
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Sakhuja A, Bataineh A, Dealmeida D, Bilderback A, Ambrosino R, Fuhrman DY, Kellum JA. Creating a High-Specificity Acute Kidney Injury Detection System for Clinical and Research Applications. Am J Kidney Dis 2021; 78:764-766. [PMID: 34052358 PMCID: PMC8545763 DOI: 10.1053/j.ajkd.2021.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 03/18/2021] [Indexed: 01/03/2023]
Affiliation(s)
- Ankit Sakhuja
- Center for Critical Care Nephrology, CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA; Division of Cardiovascular Critical Care, Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV
| | - Ayham Bataineh
- Center for Critical Care Nephrology, CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Dilhari Dealmeida
- Department of Health Information Management, University of Pittsburgh, Pittsburgh, PA
| | - Andrew Bilderback
- Wolff Center of University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Richard Ambrosino
- eRecord, University of Pittsburgh Medical Center, Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh PA
| | - Dana Y. Fuhrman
- Center for Critical Care Nephrology, CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA; Children’s Hospital of University of Pittsburgh Medical Center, Pittsburgh, PA
| | - John A. Kellum
- Center for Critical Care Nephrology, CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
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Fuhrman DY, Kellum JA. Acute Kidney Injury in the Intensive Care Unit: Advances in the Identification, Classification, and Treatment of a Multifactorial Syndrome. Crit Care Clin 2021; 37:xiii-xv. [PMID: 33752867 DOI: 10.1016/j.ccc.2021.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Dana Y Fuhrman
- Department of Critical Care Medicine and, Pediatrics, UPMC Children's Hospital of Pittsburgh The Center for Critical Care Nephrology, 4401 Penn Avenue, Children's Hospital Drive, Faculty Pavilion, Suite 2000, Pittsburgh, PA 15224, USA.
| | - John A Kellum
- Department of Critical Care Medicine, The Center for Critical Care Nephrology, 3347 Forbes Avenue, Suite 220, Pittsburgh, PA 15213, USA.
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Abstract
Renal functional reserve (RFR) is described as the difference between a glomerular filtration rate (GFR) measured at baseline and after protein stimulation. The percent change in GFR after a protein load varies based on differences in experimental conditions, with the use of an oral meat protein stimulus and a creatinine clearance method to quantify GFR showing the greatest RFR. A decline in RFR has been found in numerous patient groups. Recent investigations have suggested that a lower RFR may be associated with an increased risk of acute kidney injury and eventual chronic kidney disease.
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Affiliation(s)
- Dana Y Fuhrman
- Pediatrics, Critical Care Medicine, and Nephrology, Department of Critical Care Medicine, The Center for Critical Care Nephrology, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Children's Hospital Drive, Faculty Pavilion, Suite 2000, Pittsburgh, PA 15224, USA.
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21
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Abstract
OBJECTIVES Acute kidney injury is a major cause of morbidity and mortality in critically ill children. A growing body of evidence has shown that acute kidney injury affects immune function, yet little is known about the association between acute kidney injury and subsequent infection in pediatric patients. Our objective was to examine the association of non-septic acute kidney injury with the development of subsequent sepsis in critically ill children. DESIGN A single-center retrospective cohort study. SETTING The pediatric and cardiac ICUs at a tertiary pediatric care center. PATIENTS All patients 0-18 years old without a history of chronic kidney disease, who did not have sepsis prior to or within the initial 48 hours of ICU admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We analyzed data for 5,538 children (median age, 5.3 yr; 58.2% male), and identified 255 (4.6%) with stage 2 or 3 acute kidney injury. Suspected sepsis occurred in 46 children (18%) with stage 2 or 3 acute kidney injury compared to 286 children (5.4%) with stage 1 or no acute kidney injury. On adjusted analysis, children with stage 2 or 3 acute kidney injury had 2.05 times greater odds of developing sepsis compared to those with stage 1 or no acute kidney injury (95% CI, 1.39-3.03; p < 0.001). Looking at acute kidney injury severity, children with stage 2 and 3 acute kidney injury had a 1.79-fold (95% CI, 1.15-2.79; p = 0.01) and 3.24-fold (95% CI, 1.55-6.80; p = 0.002) increased odds of developing suspected sepsis, respectively. CONCLUSIONS Acute kidney injury is associated with an increased risk for subsequent infection in critically ill children. These results further support the concept of acute kidney injury as a clinically relevant immunocompromised state.
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Affiliation(s)
- Cassandra L. Formeck
- Division of Nephrology, Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine
- CRISMA Center (Clinical Research, Investigation, and Systems Modeling of Acute Illness), Department of Critical Care Medicine, University of Pittsburgh School of Medicine
| | - Emily L. Joyce
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine
- Division of Nephrology, Department of Pediatrics, University Hospitals Rainbow Babies & Children’s, Cleveland, Ohio, USA
| | - Dana Y. Fuhrman
- Division of Nephrology, Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine
- CRISMA Center (Clinical Research, Investigation, and Systems Modeling of Acute Illness), Department of Critical Care Medicine, University of Pittsburgh School of Medicine
- Department of Critical Care Medicine, UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15261, USA
| | - John A. Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine
- CRISMA Center (Clinical Research, Investigation, and Systems Modeling of Acute Illness), Department of Critical Care Medicine, University of Pittsburgh School of Medicine
- Department of Critical Care Medicine, UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15261, USA
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22
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Bataineh A, Dealmeida D, Bilderback A, Ambrosino R, Al-Jaghbeer MJ, Fuhrman DY, Kellum JA. Sustained effects of a clinical decision support system for acute kidney injury. Nephrol Dial Transplant 2020; 35:1819-1821. [PMID: 32572486 DOI: 10.1093/ndt/gfaa099] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 04/10/2020] [Indexed: 12/14/2022] Open
Affiliation(s)
- Ayham Bataineh
- Department of Critical Care Medicine, Center for Critical Care Nephrology, CRISMA Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Dilhari Dealmeida
- Department of Health Information Management, University of Pittsburgh, Pittsburgh, PA, USA
| | - Andrew Bilderback
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Richard Ambrosino
- eRecord, Department of Biomedical Informatics, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Dana Y Fuhrman
- Department of Critical Care Medicine, Center for Critical Care Nephrology, CRISMA Center, University of Pittsburgh, Pittsburgh, PA, USA.,Departments of Critical Care Medicine and Pediatrics, Children's Hospital of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - John A Kellum
- Department of Critical Care Medicine, Center for Critical Care Nephrology, CRISMA Center, University of Pittsburgh, Pittsburgh, PA, USA
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Fuhrman DY, Kellum JA, Joyce EL, Miyashita Y, Mazariegos GV, Ganoza A, Squires JE. The use of urinary biomarkers to predict acute kidney injury in children after liver transplant. Pediatr Transplant 2020; 24:e13608. [PMID: 31652022 PMCID: PMC7216780 DOI: 10.1111/petr.13608] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/19/2019] [Accepted: 09/20/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND AKI after pediatric liver transplantation is associated with increased morbidity and mortality. The role of urinary biomarkers for the prediction of AKI in pediatric patients after liver transplantation has not been previously reported. The primary objective of this prospective pilot study was to determine the predictive capabilities of urinary KIM-1, NGAL, TIMP-2, and IGFBP7 for diagnosing AKI. METHODS Sixteen children undergoing liver transplantation were enrolled in the study over a 19-month time period. The Kidney Disease Improving Outcomes criteria for urine output and serum creatinine were used to define AKI. Predictive ability was evaluated using the area under the curve obtained by ROC analysis. RESULTS AKI occurred in 6 (37.5%) of the patients between 2 and 4 days after transplant. There were no differences in any of the biomarkers prior to transplant. When obtained within 6 hours after transplant, the area under the ROC curve for predicting AKI was 0.758 (95% CI: 0.458-1.00) for KIM-1, 0.900 (95% CI: 0.724-1.00) for NGAL, and 0.933 (95% CI: 0.812-1.00) for the product of TIMP-2 and IGFBP7 ([TIMP-2]·[IGFBP7]). CONCLUSIONS Our results show that both NGAL and [TIMP-2]·[IGFBP7] provide significant discrimination for AKI risk following liver transplant in children. Larger studies are needed to determine the optimal time point for measuring these biomarkers and to validate our findings.
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Affiliation(s)
- Dana Y. Fuhrman
- Department of Critical Care Medicine, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA,Department of Critical Care Medicine, The Center for Critical Care Nephrology, Pittsburgh, PA, USA,Division of Pediatric Nephrology, Department of Pediatrics, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - John A. Kellum
- Department of Critical Care Medicine, The Center for Critical Care Nephrology, Pittsburgh, PA, USA
| | - Emily L. Joyce
- Department of Critical Care Medicine, The Center for Critical Care Nephrology, Pittsburgh, PA, USA,Division of Pediatric Nephrology, Department of Pediatrics, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Yosuke Miyashita
- Division of Pediatric Nephrology, Department of Pediatrics, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - George V. Mazariegos
- Hillman Center for Pediatric Liver Transplantation, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Armando Ganoza
- Hillman Center for Pediatric Liver Transplantation, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - James E. Squires
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
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Joyce EL, DeAlmeida DR, Fuhrman DY, Priyanka P, Kellum JA. eResearch in acute kidney injury: a primer for electronic health record research. Nephrol Dial Transplant 2019; 34:401-407. [PMID: 29617846 DOI: 10.1093/ndt/gfy052] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 02/08/2018] [Indexed: 12/29/2022] Open
Abstract
Acute kidney injury (AKI) has a significant impact on patient morbidity and mortality as well as overall health care costs. eResearch, which integrates information technology and information management to optimize research strategies, provides a perfect platform for necessary ongoing AKI research. With the recent adoption of a widely accepted definition of AKI and near-universal use of electronic health records, eResearch is becoming an important tool in AKI research. Conducting eResearch in AKI should ideally be based on a relatively uniform methodology. This article is the first of its kind to describe a methodology for pursuing eResearch specific to AKI and includes an illustrative database example for critically ill patients. We discuss strategies for using serum creatinine and urine output in large databases to identify and stage AKI and ways to interpolate missing values and validate data. Issues specific to the pediatric population include variation in serum creatinine with growth, varied severity of illness scoring systems and medication dosage based on weight. Many of these same strategies used to optimize AKI eResearch can be applicable to real-time AKI alerts with potential integration of additional clinical variables.
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Affiliation(s)
- Emily L Joyce
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
- Center for Critical Care Nephrology, UPMC and University of Pittsburgh, Pittsburgh, PA, USA
- Clinical Research, Investigation and Systems Modeling of Acute Illness (CRISMA) Laboratory, Pittsburgh, PA, USA
| | - Dilhari R DeAlmeida
- Department of Health Information Management, University of Pittsburgh, Pittsburgh, PA, USA
| | - Dana Y Fuhrman
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
- Center for Critical Care Nephrology, UPMC and University of Pittsburgh, Pittsburgh, PA, USA
- Clinical Research, Investigation and Systems Modeling of Acute Illness (CRISMA) Laboratory, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Priyanka Priyanka
- Center for Critical Care Nephrology, UPMC and University of Pittsburgh, Pittsburgh, PA, USA
- Clinical Research, Investigation and Systems Modeling of Acute Illness (CRISMA) Laboratory, Pittsburgh, PA, USA
| | - John A Kellum
- Center for Critical Care Nephrology, UPMC and University of Pittsburgh, Pittsburgh, PA, USA
- Clinical Research, Investigation and Systems Modeling of Acute Illness (CRISMA) Laboratory, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Affiliation(s)
- John A Kellum
- Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA, USA. .,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Dana Y Fuhrman
- Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
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Fuhrman DY, Nguyen L, Hindes M, Kellum JA. Baseline tubular biomarkers in young adults with congenital heart disease as compared to healthy young adults: Detecting subclinical kidney injury. CONGENIT HEART DIS 2019; 14:963-967. [PMID: 31793232 DOI: 10.1111/chd.12862] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/31/2019] [Accepted: 11/18/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND There are significant implications for kidney disease in young adults with congenital heart disease. Prior investigations have not focused on the use of urinary tubular biomarkers for the early identification of kidney disease in this growing patient group. OBJECTIVE Determine if young adults with congenital heart disease have differences in the baseline concentration of urinary tubular biomarkers when compared to healthy young adults. DESIGN/METHODS In a pilot case control study, 30 patients from 18 to 35 years of age with congenital heart disease and a normal serum creatinine were recruited during a routine follow-up visit. In the same age group, 30 control subjects without history of heart or kidney disease were recruited. Urine samples were obtained to measure beta 2-microglobin, alpha 1-microglobin, N-acetyl-B-D-glucosaminidase, liver fatty acid binding protein, kidney injury molecule-1, insulin-like growth factor binding protein 7, and tissue inhibitor of metalloproteinases-2. Comparisons were done using Wilcoxon rank-sum or Fisher's exact test. RESULTS No study participants had proteinuria on urine dipstick. Median concentrations of kidney injury molecule-1 were higher (P = .01) and concentrations of insulin-like growth factor binding protein 7 (P = .001) and tissue inhibitor of metalloproteinases-2 (P = .009) were lower in the subjects with congenital heart disease when compared to the control subjects. There were no significant differences between the groups with respect to the other biomarkers. CONCLUSION Our data suggest that young adults with congenital heart disease may have subclinical kidney dysfunction. Lower levels of insulin-like growth factor binding protein 7 and tissue inhibitor of metalloproteinases-2 may indicate an impaired ability to respond to injury, while higher levels of kidney injury molecule-1 may reflect early tubular injury.
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Affiliation(s)
- Dana Y Fuhrman
- Department of Critical Care Medicine, The Center for Critical Care Nephrology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Department of Critical Care Medicine, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lan Nguyen
- Department of Pediatrics, Division of Pediatric Cardiology, The Center for Critical Care Nephrology, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Morgan Hindes
- Department of Pediatrics, Division of Pediatric Cardiology, The Center for Critical Care Nephrology, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - John A Kellum
- Department of Critical Care Medicine, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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Joyce EL, Kane-Gill SL, Priyanka P, Fuhrman DY, Kellum JA. Piperacillin/Tazobactam and Antibiotic-Associated Acute Kidney Injury in Critically Ill Children. J Am Soc Nephrol 2019; 30:2243-2251. [PMID: 31501354 DOI: 10.1681/asn.2018121223] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 08/07/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND There continues to be uncertainty about whether piperacillin/tazobactam (TZP) increases the risk of AKI in critically ill pediatric patients. We sought to compare rates of AKI among critically ill children treated with TZP or cefepime, an alternative frequently used in intensive care units, with and without vancomycin. METHODS We conducted a retrospective cohort study assessing the risk of AKI in pediatric intensive care unit patients after exposure to vancomycin, TZP, and cefepime, alone or in combination, within 48 hours of admission. The primary outcome was development of stage 2 or 3 AKI or an increase in AKI stage from 2 to 3 within the 6 days after the 48-hour exposure window. Secondary outcomes included lengths of stay, need for RRT, and mortality. RESULTS Of 5686 patients included, 494 (8.7%) developed stage 2 or 3 AKI. The adjusted odds of developing AKI after medication exposure were 1.56 for TZP (95% confidence interval [95% CI], 1.23 to 1.99), 1.13 for cefepime (95% CI, 0.79 to 1.64), and 0.86 for vancomycin (95% CI, 0.69 to 1.07). The adjusted odds of developing AKI for vancomycin plus TZP versus vancomycin plus cefepime was 1.38 (95% CI, 0.85 to 2.24). CONCLUSIONS Observational data in critically ill children show that TZP use is associated with increased odds of AKI. A weaker, nonsignificant association between vancomycin plus TZP and AKI compared with vancomycin plus cefepime, creates some uncertainty about the nature of the association between TZP and AKI. However, cefepime is an alternative not associated with AKI.
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Affiliation(s)
- Emily L Joyce
- Division of Nephrology, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania; .,Department of Critical Care Medicine, Center for Critical Care Nephrology.,Department of Critical Care Medicine, CRISMA Center (Clinical Research, Investigation, and Systems Modeling of Acute Illness), and
| | - Sandra L Kane-Gill
- Department of Critical Care Medicine, Center for Critical Care Nephrology.,Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania; and.,Department of Pharmacy, UPMC, Pittsburgh, Pennsylvania.,Department of Critical Care Medicine, UPMC University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Priyanka Priyanka
- Department of Critical Care Medicine, Center for Critical Care Nephrology.,Department of Critical Care Medicine, CRISMA Center (Clinical Research, Investigation, and Systems Modeling of Acute Illness), and
| | - Dana Y Fuhrman
- Division of Nephrology, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Critical Care Medicine, Center for Critical Care Nephrology.,Department of Critical Care Medicine, CRISMA Center (Clinical Research, Investigation, and Systems Modeling of Acute Illness), and.,Department of Critical Care Medicine, UPMC University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - John A Kellum
- Department of Critical Care Medicine, Center for Critical Care Nephrology.,Department of Critical Care Medicine, CRISMA Center (Clinical Research, Investigation, and Systems Modeling of Acute Illness), and.,Department of Critical Care Medicine, UPMC University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Fuhrman DY, Kane-Gill S, Goldstein SL, Priyanka P, Kellum JA. Acute kidney injury epidemiology, risk factors, and outcomes in critically ill patients 16-25 years of age treated in an adult intensive care unit. Ann Intensive Care 2018; 8:26. [PMID: 29445884 PMCID: PMC5812957 DOI: 10.1186/s13613-018-0373-y] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Accepted: 02/09/2018] [Indexed: 01/17/2023] Open
Abstract
Background Most studies of acute kidney injury (AKI) have focused on older adults, and little is known about AKI in young adults (16–25 years) that are cared for in an adult intensive care unit (ICU). We analyzed data from a large single-center ICU database and defined AKI using the Kidney Disease Improving Global Outcomes criteria. We stratified patients 16–55 years of age into four age groups for comparison and used multivariable logistic regression to identify associations of potential susceptibilities and exposures with AKI and mortality. Results AKI developed in 52.6% (n = 8270) of the entire cohort and in 39.8% of the young adult age group (16–25 years). The AUCs for the age categories were similar at 0.754, 0.769, 0.772, and 0.770 for the 16–25-, 26–35-, 36–45-, and 45–55-year age groups, respectively. For the youngest age group, diabetes (OR 1.89; 95% CI 1.09–3.29), surgical reason for admission (OR 1.79; 95% CI 1.44–2.23), severity of illness (OR 1.02; 95% CI 1.02–1.03), hypotension (OR 1.13; 95% CI 1.04–1.24), and certain medications (vancomycin and calcineurin inhibitors) were all independently associated with AKI. AKI was a significant predictor for longer length of stay, ICU mortality, and mortality after discharge. Conclusions AKI is a common event for young adults admitted to an adult tertiary care center ICU with an associated increased length of stay and risk of mortality. Potentially modifiable risk factors for AKI including medications were identified for all stratified age groups.
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Affiliation(s)
- Dana Y Fuhrman
- Children's Hospital of Pittsburgh, 4401 Penn Avenue, Children's Hospital Drive, Faculty Pavilion Suite 2000, Pittsburgh, PA, 15224, USA.
| | - Sandra Kane-Gill
- School of Pharmacy, University of Pittsburgh, 638 Salk Hall, 3501 Terrace Street, Pittsburgh, PA, 15261, USA
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Priyanka Priyanka
- The Center for Critical Care Nephrology, 3347 Forbes Avenue, Ste 220, Pittsburgh, PA, 15213, USA
| | - John A Kellum
- The Center for Critical Care Nephrology, 3347 Forbes Avenue, Ste 220, Pittsburgh, PA, 15213, USA
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Fuhrman DY, Schneider MF, Dell KM, Blydt-Hansen TD, Mak R, Saland JM, Furth SL, Warady BA, Moxey-Mims MM, Schwartz GJ. Albuminuria, Proteinuria, and Renal Disease Progression in Children with CKD. Clin J Am Soc Nephrol 2017; 12:912-920. [PMID: 28546440 PMCID: PMC5460717 DOI: 10.2215/cjn.11971116] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 02/21/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES The role of albuminuria as an indicator of progression has not been investigated in children with CKD in the absence of diabetes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Children were enrolled from 49 centers of the CKD in Children study between January of 2005 and March of 2014. Cross-sectional multivariable linear regression (n=647) was used to examine the relationship between urine protein-to-creatinine (UP/C [milligrams per milligram]) and albumin-to-creatinine (ACR [milligrams per gram]) with eGFR (milliliters per minute per 1.73 m2). Parametric time-to-event analysis (n=751) was used to assess the association of UP/C, ACR, and urine nonalbumin-to-creatinine (Unon-alb/cr [milligrams per gram]) on the time to the composite endpoint of initiation of RRT or 50% decline in eGFR. RESULTS The median follow-up time was 3.4 years and 202 individuals experienced the event. Participants with a UP/C≥0.2 mg/mg and ACR≥30 mg/g had a mean eGFR that was 16 ml/min per 1.73 m2 lower than those with a UP/C<0.2 mg/mg and ACR<30 mg/g. Individuals with ACR<30 mg/g, but a UP/C≥0.2 mg/mg, had a mean eGFR that was 9.3 ml/min per 1.73 m2 lower than those with a UP/C<0.2 mg/mg and ACR<30 mg/g. When categories of ACR and Unon-alb/cr were created on the basis of clinically meaningful cutoff values of UP/C with the same sample sizes for comparison, the relative times (RTs) to the composite end-point were almost identical when comparing the middle (RT=0.31 for UP/C [0.2-2.0 mg/mg], RT=0.38 for ACR [56-1333 mg/g], RT=0.31 for Unon-alb/cr [118-715 mg/g]) and the highest (RT=0.08 for UP/C [>2.0 mg/mg], RT=0.09 for ACR [>1333 mg/g], RT=0.07 for Unon-alb/cr [>715 mg/g]) levels to the lowest levels. A similar trend was seen when categories were created on the basis of clinically meaningful cutoff values of ACR (<30, 30-300, >300 mg/g). CONCLUSIONS In children with CKD without diabetes, the utility of an initial UP/C, ACR, and Unon-alb/cr for characterizing progression is similar.
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Affiliation(s)
- Dana Y Fuhrman
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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Rodenbach KE, Fuhrman DY, Maier PS, Schwartz GJ. Renal Response to a Protein Load in Healthy Young Adults as Determined by Iohexol Infusion Clearance, Cimetidine-Inhibited Creatinine Clearance, and Cystatin C Estimated Glomerular Filtration Rate. J Ren Nutr 2017; 27:275-281. [PMID: 28389059 DOI: 10.1053/j.jrn.2017.01.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 01/07/2017] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE Renal reserve (RR) measures the increase in glomerular filtration rate (GFR) in response to a protein load; lack of RR could indicate subclinical kidney disease but such a test is not routinely used in clinical practice. The purpose of this study was to compare a meat versus liquid protein load in a cystatin C-based (Cys-C) RR test using cimetidine-inhibited creatinine clearance (Cr Cl) and iohexol infusion clearance (Io Cl) for validation. The design was cross-sectional analysis and the setting was a Clinical Research Center. SUBJECTS Participants (N = 16), mean (standard deviation [SD]) age 22 (2) years, had normal health and blood pressure without proteinuria. INTERVENTION Participants 1 to 8 received a beef burger (1 g/kg protein) and participants 9 to 16 received a ProCel shake (1-1.5 g/kg protein). MAIN OUTCOME MEASURE RR defined as the difference in stimulated versus baseline GFR. RESULTS Baseline GFR (SD) in mL/minute/1.73 m2 averaged 103.0 (15.6) for Cr Cl, 94.8 (7.9) for Io Cl, and 117.0 (6.0) for Cys-C estimated GFR (eGFR). Mean RR (SD) for the burger group (N = 8, mL/minute/1.73 m2) was 16.6 (12.3) for Cr Cl (P = .006); 7.2 (3.7) for Io Cl (P < .001), and 4.9 (2.6) for Cys-C eGFR (P = .001). Mean RR for the shake group (N = 8) was 15.8 (5.8) for Cr Cl (P < .001), 10.1 (7.8) for Io Cl (P = .008), and 2.4 (2.9) for Cys-C eGFR (P = .05). CONCLUSION Protein loading stimulates Io Cl and Cr Cl after a beef or milk-based protein load. The change in Cys-C eGFR is significant but smaller for the shake and burger group, which may be due to the dilutional effect of water loading or the length of Cys-C half-life in the blood.
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Affiliation(s)
- Kyle E Rodenbach
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Dana Y Fuhrman
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Paula S Maier
- University of Rochester Medical Center, Rochester, New York
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Fuhrman DY, Kellum JA. Biomarkers for Diagnosis, Prognosis and Intervention in Acute Kidney Injury. Contrib Nephrol 2016; 187:47-54. [PMID: 26881914 DOI: 10.1159/000442364] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Biomarkers for acute kidney injury (AKI) can be used for diagnosis and prognosis and to guide therapy. With no pharmacologic therapy clinically available for the treatment of AKI, prevention and early detection are of paramount importance. Despite the initial enthusiasm for biomarker use when it was first introduced in the literature, published studies' results have shown variability in biomarker performance. The following chapter will discuss what our expectations of AKI biomarkers should be and how they can be currently used for a variety of clinical purposes.
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Abstract
BACKGROUND The kidney can increase glomerular filtration rate (GFR) in response to a protein load (renal reserve). In a pilot study of healthy young adults we examined renal reserve using changes in serum cystatin C (cysC). METHODS Glomerular filtration rate was obtained using iohexol single slope plasma disappearance. To stimulate GFR, subjects ingested a beefburger containing 60 grams of protein. CysC was measured by immunonephelometry before and 125-141 minutes after protein loading. RESULTS All subjects were found to have a normal iohexol plasma disappearance GFR with a mean of 104.6 ± 9.9 mL/min per 1.73 m(2). CysC decreased in each subject after the meat meal. Baseline cysC-based estimated GFR was 98.1 ± 9.1 mL/min per 1.73 m(2) with a mean increase of 12.0 ± 5.2 (p = 0.0003). CONCLUSIONS Our study showed a consistent decrease in serum cysC and increase in cysC-based estimated GFR following a protein load in young adults. Further studies are needed using renal clearance methods to confirm that cysC accurately determines renal reserve in patients with and without chronic kidney disease.
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Affiliation(s)
- Dana Y Fuhrman
- a Pediatric Nephrology, University of Rochester Medical Center , Rochester, NY USA
| | - Paula S Maier
- a Pediatric Nephrology, University of Rochester Medical Center , Rochester, NY USA
| | - George J Schwartz
- a Pediatric Nephrology, University of Rochester Medical Center , Rochester, NY USA
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