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NON-DIALYTIC MANAGEMENT OF AKI
INFLUENCE ON RENAL FUNCTION OF HYPOTONIC VS ISOTONIC SALINE SERUM AS MAINTENANCE THERAPY IN THE IMMEDIATE POSTOPERATIVE PERIOD IN GENERAL SURGERY
Abstract
Background and Aims
To compare the risk of developing renal failure with hypotonic saline (HT) vs isotonic saline (IT) as maintenance serum therapy during postoperative general surgery.
Methods
Phase IV clinical trial. We included patients from 6 months to 14 years, weight over 6 kg, creatinine at admission normal, with cut-off point of 0.5 mg/dL in children under 8 years old and 0.7 mg/dL Variables: age, weight, sex, serum creatinine, urea and sodium, urinary sodium, diuresis (cc/kg/hour), in both groups at admission, 8, 24 and 48 hours. We performed descriptive statistics and comparison of groups, Significant level p<0.05.
Results
We analyzed 123 patients, 59 HT, 64 IT. Age 64±50 months, weight 20±14 kg, 54% female, 47% male (p>0.05). See Table 1.
Conclusions
Isotonic saline produces a significant increase in urinary sodium excretion compared to hypotonic saline as maintenance serum therapy after general surgery, but in patients with normal renal function on admission the use of hypotonic or isotonic serum no produces renal failure.
REGIONAL CITRATE VERSUS SYSTEMIC HEPARIN ANTICOAGULATION IN PAEDIATRIC CONTINUOUS RENAL REPLACEMENT THERAPY: THE BRISTOL EXPERIENCE
Abstract
Background and Aims
Regional citrate anticoagulation (RCA) for continuous renal replacement therapy (CRRT) is well-established in adult intensive care. The benefits in adults when compared to heparin include prolonged circuit life and reduced bleeding. There is limited evidence to show similar benefits in children. A new RCA protocol was introduced in November 2018. Here, we aim to look at its safety and whether it prolongs circuit life and reduces bleeding in our centre.
Methods
We carried out a retrospective review of patients on CRRT in Bristol PICU from 2017-2020. We collected demographic data, and electrolytes and blood product transfusions while on CRRT. Data was analysed using GraphPadPrism and SPSS.
Results
We identified 49 episodes of CRRT(heparin=30,citrate=19). Overall, anticoagulation type had no significant effect on circuit failure. Subgroup analysis of small patients(weight<12kg) showed citrate significantly reduced the risk of circuit failure(p=0.01, HR 0.444, Figure 1). Anticoagulation type had no significant effects on those with weight≥12kg. In this subgroup, non-haematological/oncological diagnoses reduced the risk of circuit failure compared to haematological/oncological diagnoses(p=0.009). Anticoagulation type had no significant effects on blood product requirement and electrolytes. One child developed signs consistent with citrate toxicity.
Conclusions
CRRT using citrate in our centre has been safe with minimal electrolyte abnormalities. No differences in circuit failure rate were seen overall, but there is a significantly reduced risk of circuit failure for those on citrate with a weight<12kg. Although the numbers are small, we demonstrate here the safety of RCA and add to the limited body of evidence that RCA might be beneficial for small children.
DIAGNOSIS OF AKI USING IOHEXOL IN CRITICALLY ILL CHILDREN AND NEONATES: PRELIMINARY RESULTS OF THE HERO STUDY.
Abstract
Background and Aims
Up to 35% of all PICU and NICU patients will develop acute kidney injury (AKI), which is associated with a poor outcome and thus emphasizes the importance of an early diagnosis. However, this prevalence is based on estimation of GFR (eGFR) using serum creatinine, which is known to be inaccurate and may reflect an overestimation of GFR in this population. We aimed to test our hypothesis that AKI prevalence will be higher in critically ill children when using measured GFR (mGFR) based on iohexol clearance, than using eGFR and to investigate agreement between methods.
Methods
Term-born neonates and children admitted to the ICU with at least one failing organ were included. mGFR was calculated using a plasma disappearance curve after injection of iohexol. In parallel, eGFR was estimated using the bedside Schwartz equation (40*height(cm)/serum creatinine(µmol/L). Patients were diagnosed with AKI when serum creatinine, eGFR or mGFR values exceeded mean age specific reference values +1SD or were below 150% of the median, respectively. Agreement between methods was determined using Bland-Altman-Plots.
Results
Nineteen neonates (median age 2(range 1-21)days) and 21 children (8(0-17)years) were included. mGFR based diagnosis did not lead to a higher prevalence of AKI. Yet, prevalences varied greatly among PICU and NICU patients and between used methods (range 5.3-47.7%). Bland-Altman plots show moderate agreement between mGFr and eGFR(figure1).
Conclusions
When using iohexol based mGFR, the prevalence of AKI was not higher compared to eGFR based prevalence in our population. However, AKI appears very prevalent in PICU but less in term NICU patients.
ACCURACY OF CREATININE-BASED AND CYSTATIN C-BASED EGFR FORMULAS COMPARED TO PLASMA IOHEXOL CLEARANCE IN CHILDREN AFTER CARDIO-PULMONARY BYPASS
Abstract
Background and Aims
Identification of patients with altered renal function after cardio-pulmonary bypass is often delayed due to lack of accurate methods for evaluation of glomerular filtration rate. We aimed to evaluate performance of eGFR formulas based on serum creatinine (Scr) and cystatin C (CysC) in comparison with iohexol clearance (CLiohex) after cardiac surgery.
Methods
Children who underwent cardiopulmonary bypass were included. After iohexol bolus injection, CLiohex was calculated from the plasma disappearance curve over a 360-minutes interval. Volumetric Absorptive Microsampling was used for iohexolsampling. CLiohex was compared with eGFR by 10 Scr- based and 11 CysC-based formulas. Accuracy of eGFR formulas was described as the percentage of GFR estimates within ±30% of CLiohex. AKI was defined as a decrease of GFR measured by CLiohex of ≥ 25 % of age-specific GFR reference values.
Results
19 patients, median age 2 months (range:0,13-135), were included after closure of ASD (n=1), VSD (n=3), AVSD (n=3), arterial switch procedure (n= 8), ROSS procedure (n=1), Norwood procedure (n=1), coronary surgery (n= 1) and truncus arteriosus repair (n= 1). Median CLiohex was 62 ml/min/1.73m2 (range 29-231). 21% of patients showed some degree of AKI according to CLiohex. eGFR formulas had a relatively good correlation with CLiohex, however, accuracy was poor; none of the eGFR formulas showed P30>75%. Widely used Schwartz formula performed unsatisfactory with P30=53%.
Conclusions
eGFR formulas based on Scr or CysC seem inaccurate to assess GFR in children after cardiac surgery. CLiohex could offer a feasible and safe alternative to reliably evaluate renal function in these vulnerable patients.