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Anton-Martin P, Modem V, Bridges B, Coronado Munoz A, Paden M, Ray M, Sandhu HS. Timing of Kidney Replacement Therapy Initiation and Survival during Pediatric Extracorporeal Membrane Oxygenation: An Extracorporeal Life Support Organization Registry Study. ASAIO J 2024:00002480-990000000-00403. [PMID: 38295389 DOI: 10.1097/mat.0000000000002151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024] Open
Abstract
To characterize kidney replacement therapy (KRT) and pediatric extracorporeal membrane oxygenation (ECMO) outcomes and to identify the optimal timing of KRT initiation during ECMO associated with increased survival. Observational retrospective cohort study using the Extracorporeal Life Support Organization Registry database in children (0-18 yo) on ECMO from January 1, 2016, to December 31, 2020. Of the 14,318 ECMO runs analyzed, 26% of patients received KRT during ECMO. Patients requiring KRT before ECMO had increased mortality to ECMO decannulation (29% vs. 17%, OR 1.97, P < 0.001) and to hospital discharge (58% vs. 39%, OR 2.16, P < 0.001). Patients requiring KRT during ECMO had an increased mortality to ECMO decannulation (25% vs. 15%, OR 1.85, P < 0.001) and to hospital discharge (56% vs. 34%, OR 2.47, P < 0.001). Multivariable logistic regression demonstrated that the need for KRT during ECMO was an independent predictor for mortality to ECMO decannulation (OR 1.49, P < 0.001) and to hospital discharge (OR 2.02, P < 0.001). Patients initiated on KRT between 24 and 72 hours after cannulation were more likely to survive to ECMO decannulation and showed a trend towards survival to hospital discharge as compared to those initiated before 24 hours and after 72 hours.
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Affiliation(s)
- Pilar Anton-Martin
- Department of Pediatrics, Division of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Vinai Modem
- Department of Pediatrics, Pediatric Intensive Care Unit, Cooks Children's Medical Center, Fort Worth, Texas
| | - Brian Bridges
- Department of Pediatrics, Division of Critical Care, Vanderbilt University School of Medicine/Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Alvaro Coronado Munoz
- Department of Pediatrics, Division of Critical Care, The Children's Hospital at Montefiore, Bronx, New York
| | - Matthew Paden
- Department of Pediatrics, Division of Critical Care, Emory University School of Medicine/Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Meredith Ray
- Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, Memphis, Tennessee; and
| | - Hitesh S Sandhu
- Department of Pediatrics, Division of Critical Care, University of Tennessee Health Science Center, Memphis, Tennessee
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Tadphale SD, Luckett PM, Quigley RP, Dhar AV, Gollhofer DK, Modem V. Fluid Removal in Children on Continuous Renal Replacement Therapy Improves Organ Dysfunction Score. J Pediatr Intensive Care 2023. [DOI: 10.1055/s-0043-1764499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023] Open
Abstract
AbstractThe objective is to assess impact of fluid removal on improvement in organ function in children who received continuous renal replacement therapy (CRRT) for management of acute kidney injury and/or fluid overload (FO). A retrospective review of eligible patients admitted to a tertiary level intensive care unit over a 3-year period was performed. Improvement in nonrenal organ function, the primary outcome, was defined as decrease in nonrenal component of Pediatric Logistic Organ Dysfunction (PELOD) score on day 3 of CRRT. The cohort was categorized into Group 1 (improvement) and Group 2 (no improvement or worsening) in nonrenal PELOD score. Multivariable logistic regression analysis was performed to identify independent predictors. A higher PELOD score at CRRT initiation (odds ratio [OR]: 1.11, 95% confidence interval [CI]: 1.05, 1.18, p < 0.001), belonging to infant-age group (OR: 4.53, 95% CI: 4.40, 5.13, p = 0.02) and greater fluid removal during initial 3 days of CRRT (OR: 1.05, 95% CI: 1.01, 1.10, p = 0.01) were associated with an improvement in nonrenal PELOD score at day 3 of CRRT. FO at CRRT initiation (OR: 0.66, 95% CI: 0.46, 0.93, p = 0.02) and having an underlying oncologic diagnosis (OR: 0.28, 95% CI: 0.09, 0.85, p = 0.03) were associated with worsening of nonrenal PELOD score at day 3 of CRRT. Careful consideration of certain modifiable patient and/or fluid removal kinetic factors may have an impact on outcomes.
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Affiliation(s)
- Sachin D. Tadphale
- Division of Pediatric Cardiology & Critical Care Medicine, UTHSC, Memphis, Tennessee, United States
| | - Peter M. Luckett
- Division of Pediatric Critical Care Medicine, UTSW, Dallas, Texas, United States
| | | | - Archana V. Dhar
- Division of Pediatric Critical Care Medicine, UTSW, Dallas, Texas, United States
| | - Diane K. Gollhofer
- Division of Critical Care Services, Children's Health-Dallas, Dallas, Texas, United States
| | - Vinai Modem
- Pediatric Intensive Care Unit, Cook Children's Medical Center, Fort Worth, Texas, United States
- Department of Pediatrics, TCU and UNTHSC School of Medicine, Fort Worth, Texas, United States
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Khin EE, Elmaghrabi AY, Alvarado LA, Modem V, Quigley R. Fluid balance assessment in pediatric hemodialysis patients by using whole-body bioimpedance spectroscopy (WB-BIS). Pediatr Nephrol 2022; 37:2449-2456. [PMID: 35166921 DOI: 10.1007/s00467-022-05469-6] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 01/14/2022] [Accepted: 01/14/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Fluid overload is a major factor in morbidity and mortality in dialysis patients. Whole-body bioimpedance spectroscopy (WB-BIS) is a noninvasive method for assessing fluid status. We hypothesized that fluid status measurement of changes in total body water (TBW), extracellular fluid (ECF), and intracellular fluid (ICF) by WB-BIS would correlate with the weight (Wt) changes before and after hemodialysis (HD) and the amount of ultrafiltration (UF) in pediatric HD patients. We also examined the relationship between the ECF percent of total body water (ECF%) and ECF/ICF ratio with the pre-HD systolic blood pressure percentile (SBP%ile). METHODS WB-BIS measurements were made both before and after HD on three separate occasions in each patient. Pre- and post-HD Wt, BP, and UF volumes were collected on the day of BIS measurement. RESULTS At total of 96 measurements were obtained from 16 HD patients. There were 6 females (mean age: 13.2 ± 4.5 yrs). UF correlated with changes in weight, TBW and ECF (p < 0.001) but not with ICF changes (p = 0.345). Pre-HD SBP%ile correlated with ECF%. CONCLUSIONS Our findings suggest that WB-BIS can be used to monitor the fluid status in pediatric HD patients. The fluid that is removed from the patient during the HD treatment primarily comes from the ECF and not the ICF. Mobilization of fluid from the ICF appears to be delayed. Patients with significantly higher pre-HD ECF% and ECF/ICF ratio had higher pre-HD systolic BP. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Ei E Khin
- Children's Medical Center, Dallas, TX, USA
- UT-Southwestern Medical Center, Dallas, TX, 75390, USA
- Texas Tech University Health Science Center El Paso, El Paso, TX, USA
| | - Ayah Y Elmaghrabi
- Children's Medical Center, Dallas, TX, USA
- UT-Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Luis A Alvarado
- Texas Tech University Health Science Center El Paso, El Paso, TX, USA
| | - Vinai Modem
- Cook's Children's Hospital, Fort Worth, TX, USA
| | - Raymond Quigley
- Children's Medical Center, Dallas, TX, USA.
- UT-Southwestern Medical Center, Dallas, TX, 75390, USA.
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Anton-Martin P, Quigley R, Dhar A, Bhaskar P, Modem V. Early Fluid Accumulation and Intensive Care Unit Mortality in Children Receiving Extracorporeal Membrane Oxygenation. ASAIO J 2021; 67:84-90. [PMID: 32433305 DOI: 10.1097/mat.0000000000001167] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Purpose of this study was to evaluate the impact of early fluid accumulation and renal dysfunction on mortality in children receiving extracorporeal membrane oxygenation (ECMO). Retrospective cohort study of neonatal and pediatric patients who received ECMO between January 2010 and December 2012 in a tertiary level multidisciplinary pediatric intensive care unit (ICU). Ninety-six patients were included, and forty-six (48%) of them received continuous renal replacement therapy (CRRT) during ECMO. Overall mortality was 38.5%. Proportion of patients with acute kidney injury (AKI) at ICU admission was 33% and increased to 47% at ECMO initiation. High-risk diagnoses, extracorporeal cardiopulmonary resuscitation (ECPR), and venoarterial (VA)-ECMO were more common among nonsurvivors. Nonsurvivors had significantly higher proportion of AKI at ICU admission (OR: 2.59, p = 0.04) and fluid accumulation on ECMO day 1 (9% vs. 1%, p = 0.05) compared with survivors. Multivariable logistic regression analysis (adjusted for a propensity score based on nonrenal factors associated with increased mortality) demonstrated that fluid accumulation on ECMO day 1 is significantly associated with increased ICU mortality (OR: 1.07, p = 0.04). Fluid accumulation within the first 24 hours after ECMO cannulation is significantly associated with increased ICU mortality in neonatal and pediatric patients. Prospective studies evaluating the impact of conservative fluid management and CRRT during the initial phase of ECMO may help further define this relationship.
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Affiliation(s)
- Pilar Anton-Martin
- From the Department of Pediatrics, Division of Cardiology - Cardiac Critical Care, University of Tennessee Medical Science Center / Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Raymond Quigley
- Department of Pediatrics, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Archana Dhar
- Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; and
| | - Priya Bhaskar
- Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; and
| | - Vinai Modem
- Department of Pediatrics, Divisions of Critical Care and Nephrology, University of Texas Health Science Center Houston, Houston, Texas
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Anton-Martin P, Modem V, Taylor D, Potter D, Darnell-Bowens C. A retrospective study of sedation and analgesic requirements of pediatric patients on extracorporeal membrane oxygenation (ECMO) from a single-center experience. Perfusion 2016; 32:183-191. [PMID: 27729502 DOI: 10.1177/0267659116670483] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION The purpose of this study is to describe the sedative and analgesic requirements identifying factors associated with medication escalation in neonates and children supported on ECMO. METHOD Observational retrospective cohort study in a tertiary pediatric intensive care unit from June 2009 to June 2013. RESULTS One hundred and sixty patients were included in the study. Fentanyl and midazolam were the first line agents used while on ECMO. Higher opiate requirements were associated with younger age (p=0.01), thoracic cannulation (p=0.002), the use of dexmedetomidine (p=0.007) and prolonged use of muscle relaxants (p=0.03). Higher benzodiazepine requirements were associated with younger age (p=0.01), respiratory failure (p=0.02) and the use of second line agents (p=0.002). One third of the patients required second line agents as adjuvants for comfort without a decrease in opiate and/or benzodiazepine requirements. CONCLUSIONS Providing comfort to subpopulations of pediatric ECMO patients seems to be more challenging. The use of second line agents did not improve comfort in our cohort. Prospective studies are required to optimize analgesia and sedation management in children on ECMO.
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Affiliation(s)
- Pilar Anton-Martin
- 1 Department of Pediatrics, Critical Care Division, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Vinai Modem
- 2 Department of Pediatrics, Critical Care Division, University of Texas Health Science Center at Houston, Texas, USA
| | - Donna Taylor
- 3 Department of Respiratory Therapy, Children's Health Dallas, Dallas, Texas, USA
| | - Donald Potter
- 3 Department of Respiratory Therapy, Children's Health Dallas, Dallas, Texas, USA
| | - Cindy Darnell-Bowens
- 1 Department of Pediatrics, Critical Care Division, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Herbert C, Patel M, Nugent A, Dimas VV, Guleserian KJ, Quigley R, Modem V. Serum Cystatin C as an Early Marker of Neutrophil Gelatinase-associated Lipocalin-positive Acute Kidney Injury Resulting from Cardiopulmonary Bypass in Infants with Congenital Heart Disease. CONGENIT HEART DIS 2015; 10:E180-8. [PMID: 25727405 DOI: 10.1111/chd.12253] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [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] [Accepted: 01/18/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Acute kidney injury (AKI) is a common complication resulting from cardiopulmonary bypass in infants. Urinary neutrophil gelatinase-associated lipocalin (NGAL) is a sensitive and specific marker of such injury. In this study, we compared the performance of serum cystatin C (Cys C) and serum creatinine (Cr) as early markers of renal dysfunction in infants undergoing cardiac surgery under bypass. STUDY DESIGN, SETTING, AND PATIENTS The study was designed as a prospective observational study. The study was conducted in the cardiac intensive care unit (ICU) of a tertiary, academic children's hospital in the United States. Infants (age <1 year) undergoing cardiac surgery under cardiopulmonary bypass were included in the study. OUTCOME MEASURE Acute kidney injury was defined based on postoperative urinary NGAL. RESULTS A total of 17 infants were included in the study, and five of them developed AKI. Serum Cys C and Cr levels were measured postoperatively on days 1, 2, and 3, and compared with baseline levels. On postoperative day 2, infants with AKI showed significant change from baseline in serum Cys C levels compared with non-AKI infants (28% vs. -9%, P = .03). The two groups did not show significant differences with respect to rise in serum Cr on any of the 3 postoperative days. Serum Cr on days 1 and 2 showed nonspecific increases in both AKI and non-AKI groups. The area under the receiver operating characteristic curve for day 2 Cys C was 0.87 (95% CI 0.67-1.00) in recognizing NGAL-positive AKI. CONCLUSIONS Postoperative serum Cys C appears to be a more specific and sensitive biomarker for NGAL-positive AKI resulting from cardiopulmonary bypass surgery in infants undergoing cardiac surgery.
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Affiliation(s)
- Carrie Herbert
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, Tex, USA
| | - Mehul Patel
- Department of Pediatrics, University of Michigan Health System, Ann Arbor, Mich, USA
| | - Alan Nugent
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, Tex, USA
| | - V Vivian Dimas
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, Tex, USA
| | - Kristine J Guleserian
- Department of Cardiothoracic Surgery, Children's Medical Center Dallas, Dallas, Tex, USA
| | - Raymond Quigley
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, Tex, USA
| | - Vinai Modem
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, Tex, USA
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Huggins N, Nugent A, Modem V, Rodriguez JS, Forbess J, Scott W, Dimas VV. Incidence of acute kidney injury following cardiac catheterization prior to cardiopulmonary bypass in children. Catheter Cardiovasc Interv 2014; 84:615-9. [PMID: 24459114 DOI: 10.1002/ccd.25405] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [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: 08/27/2013] [Revised: 12/31/2013] [Accepted: 01/20/2014] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To determine whether contrast administration was a risk factor for development of acute kidney injury (AKI) in cyanotic congenital heart disease (CHD) patients undergoing cardiopulmonary bypass (CPB). BACKGROUND AKI following CPB or contrast administration is well described. In previous studies, administration of contrast prior to CPB has been shown to increase the risk of AKI. Chronic cyanosis leads to glomerular damage and dysfunction, thus potentially placing this population at increased risk of developing AKI following contrast administration prior to CPB. METHODS One hundred twenty-two patients with cyanotic CHD undergoing preoperative cardiac catheterization (PCC) and subsequent CPB at Children's Medical Center of Dallas from January 1, 2007 until November 30, 2010 were identified, looking specifically at bi-directional Glenn (BDG) anastomoses and Fontan procedures. One hundred thirteen patients undergoing PCC ≤ 48 hr prior to and > 5 days prior to CPB were included. Occurrence of AKI following CPB was the primary outcome variable. RESULTS Logistic regression analysis revealed pre-catheterization serum creatinine was a risk factor for post-CPB AKI (P < 0.001) in both Fontan and BDG patients. All other variables were not significantly associated with the development of AKI in either BDG or Fontan patients. Length of stay (hospital or ICU) was not different among the groups regardless of the occurrence of AKI. CONCLUSIONS In this study of cyanotic CHD patients, contrast administration within 48 hr prior to CPB was not an additional risk factor for the development of AKI.
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Affiliation(s)
- Nicholas Huggins
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
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Stavinoha A, Modem V, Quigley R. Using noninvasive hemoglobin measurements to estimate measured hemoglobin in a pediatric hemodialysis unit. Hemodial Int 2013; 17 Suppl 1:S7-10. [DOI: 10.1111/hdi.12082] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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