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SPECIAL CONSIDERATIONS DURING THE PROVISION OF CRRT DURING THE COVID-19 SURGE
THE KIDNEY DURING VASODILATORY SHOCK
PROGRESSION OF ACUTE KIDNEY INJURY IN CRITICALLY ILL CHILDREN
Abstract
Background and Aims
Acute kidney injury (AKI) is common in critically ill children. We sought to describe the prevalence and progression of AKI in critically ill children.
Methods
This was a retrospective observational study conducted in a multi-disciplinary Paediatric Intensive Care Unit (PICU) from January 2015 to December 2018. All children from birth to ≤16 years old who were admitted to the PICU were included. We used the Kidney Disease: Improving Global Outcomes (KDIGO) criteria as AKI reference standard. The progression of patients with AKI were followed through the first 7 days of PICU admission. Patients were defined as Early AKI if AKI was present within 48 hours of admission. Recovery from AKI was defined as not fulfilling KDIGO criteria from 48 hours until seven days of admission while partially recovered from AKI were defined as a reduction from a higher stage to lower stage of AKI in the same period.
Results
The prevalence of AKI in our cohort (n=7505) was 9.2%. There were 554 (7.4%) children who had Early AKI. Recovery from Early AKI was seen in 70.4% of these children while 1.4% had partial recovery (Figure 1). Worsening of stage of AKI was observed in 6.5% (n=36) of these children. Out of these children who progressed to a worse stage, 36% (n=13) died.
Conclusions
Nearly one in ten children admitted to our PICU had AKI as defined by KDIGO. AKI persisted beyond seven days in one third of these children. Further studies are needed to follow-up patients with persistent AKI at hospital discharge.
FLUID OVERLOAD AND RENAL FUNCTION IN CHILDREN AFTER LIVING-DONOR RENAL TRANSPLANTATION – A SINGLE CENTER RETROSPECTIVE ANALYSIS
Abstract
Background and Aims
Background: We aimed to compare renal function after kidney transplantation in children who were treated with higher versus lower fluid volumes.
Methods
Methods: A retrospective analysis of 81 living-donor renal transplantation pediatric patients between the years 2007-2018. We analyzed associations of the decrease in serum creatinine (delta creatinine) with fluid balance, central venous pressure (CVP), pulmonary congestion, mean arterial pressure (MAP), and MAP-CVP percentiles in the first 3 post-operative days. After correcting creatinine for fluid overload, we also assessed associations of these variables with the above parameters. Finally, we evaluated the association between delta creatinine and estimated glomerular filtration rate (eGFR) at three months follow-up.
Results
Results: Both delta creatinine and delta corrected creatinine were found to be associated with pulmonary congestion on the second and third post-operative days (p<0.02). In addition, trends for positive correlations were found of delta creatinine with fluid balance/kg (p=0.07), and of delta corrected creatinine with fluid balance/kg and CVP (p=0.06-0.07) on the second post-operative day. An association was also demonstrated between the accumulated fluid balance of the first two days and eGFR at three months after transplantation (p=0.03).
Conclusions
Conclusion: An association was demonstrated between indices of fluid overload, above 80ml/kg, and greater improvement in renal function.
REPRODUCIBILITY AND USEFULNESS OF DOPPLER ULTRASOUND IN THE ASSESSMENT OF RENAL PERFUSION BEFORE AND AFTER CRRT IN THE PEDIATRIC INTENSIVE CARE UNIT
Abstract
Background and Aims
Aims: To assess observer variability and to describe RRI and PI in a pediatric experimental animal model in piglets with and without AKI and in critically ill pediatric patients before and after the onset of CRRT. A secondary objective was to correlate the findings in doppler ultrasound with the those obtained from the direct measurement of renal blood flow in the experimental animal model.
Methods
Doppler-based RRI and PI was assessed by two operators in a pediatric animal model of hemodynamically stable piglets with and without AKI and in critically ill children requiring CRRT.
Results
There was a moderate correlation for both RRI (ICC 0.65, IQR0.51-0.76) and PI (ICC 0.63, IQR0.47-0.75). RRI and PI showed no correlation with RBF or with urine output . Baseline RRI and PI were normal in control [RRI 0.68 (SD 0.02), PI 1.25 (SD 0.09)] and in piglets with AKI [RRI 0.68 (SD 0.03), PI 1.20 (SD 0.13)]. Baseline RRI and PI were elevated in critically ill children before the onset of CRRT (RRI 0.85 (SD), PI 2.0 (SD)). RRI and PI did not change with CRRT in any of the study groups.
Conclusions
Observer variability between inexperienced pediatric intensivists was comparable with that between senior and junior operators. Doppler-based calculations did not correlate to invasive measurements of RBF. RRI and PI were normal in hemodynamically stable piglets with and without AKI. RRI and PI were high in hemodynamically unstable patients. RRI and PI didn´t change after the onset of CRRT or during the first 6 hours of therapy.
PERITONEAL DIALYSIS IN A PAEDIATRIC INTENSIVE CARE UNIT (PICU) FOLLOWING CARDIAC SURGERY: A SERVICE EVALUATION
Abstract
Background and Aims
Acute kidney injury (AKI) is a common morbidity after congenital cardiac surgery which affects around 1 in 4 children. Peritoneal dialysis (PD) catheters are often inserted following complex cardiac surgeries, but it is unclear which patients require this. The aim of this study is to explore the use of PD in a single large PICU and identify patient characteristics and risk factors for PD.
Methods
A retrospective cohort study between June 2019 and December 2019. All children who underwent cardiac surgery in single UK centre and required a PD catheter were included. We excluded extracorporeal support and confirmed bacteraemia as unmeasurable factors for AKI. Demographic and clinical data from electronic medical records was collected.
Results
39 patients were included, 11 (28%) required PD. 32 (82%) patients were less than 6 months old. Mean age 214 days (SD 528) in non-dialysis group versus mean age 129 days (SD 174) in dialysis group. 35 (90%) patients were less than 10kgs. Mean weight 4.9kgs (SD 3.8) in non- dialysis group versus mean weight 5.1kgs (SD 2.9) in dialysis group. Only cardiopulmonary bypass (CPB) time was higher for the dialysis group (p< 0.05). X- clamp time (p <0.20) and RACHS- 1 score (p <0.10) was not significant for PD. A syndrome or co-morbidity was not significant for PD (p<0.20).
Conclusions
These findings confirm CPB time as the most significant factor for requiring PD, however our small sample size prevents further conclusions. A larger sample may provide a basis to develop a risk stratification tool for this cohort.
ACUTE KIDNEY DISEASE AND RENAL RECOVERY IN CRITICALLY ILL PEDIATRIC PATIENTS REQUIRING CONTINUOUS RENAL REPLACEMENT THERAPY
Abstract
Background and Aims
Acute kidney disease (AKD) and renal recovery in pediatric continuous renal replacement therapy (CRRT) patients remain incompletely explored. We described patient centered renal outcomes in a large quaternary pediatric center.
Methods
Single center, retrospective study of pediatric patients (<18 years), who require CRRT between 2/2014 and 2/2020. Primary outcome was Major Adverse Kidney Events (death, dialysis dependency, or persistent renal dysfunction) at 30 days (MAKE30).
Results
300 patients (median age 59 months (IQR 12-158); 53% were male) were included. Of these patient 43 (14%) patients had CKD at admission. 253 (84%) were started on CRRT for acute kidney injury. The median CRRT duration was 11 days (IQR 3-25); the median PELOD-2 score at ICU admission and CRRT start were 6 (IQR 3-8) and 8 (IQR 6-10), respectively. Median fluid overload at CRRT start was 8.6% (IQR 0.7% – 24%). 48 (16%) patients required ECMO. When CKD patients were excluded,193/256 (75%) met MAKE 30, of which 83 (43%) patients died and 80 (42%) were dialysis dependent. PELOD-2 score at CRRT start was associated with MAKE 30 (1.24 (95% CI 1.11 to 1.38)); while age, diagnostic category, PELOD-2 at ICU admission or fluid overload were not associated with MAKE 30.
Conclusions
AKD and prolonged kidney dysfunction are very common in the pediatric CRRT population and associated with severity of organ dysfunction at CRRT start. Both renal and global outcomes of pediatric CRRT survivors require close monitoring. Predictors for failure of renal recovery should be further studied to identify modifiable risk factors.