Association of Urinary Albumin:Creatinine Ratio with Outcome of Children with Sepsis

Abstract

Objective The aim of the study was to investigate the association of urinary albumin:creatinine ratio (ACR) with regard to the outcome of sepsis patients and to study the trends of ACR with severity of disease, organ dysfunction, microcirculation status, the use of inotrope, and mechanical ventilation use, and length of pediatric intensive care unit (PICU) stay. Materials and methods In the prospective observational study, the patients with varying categories of sepsis admitted in the PICU with stay >24 hours were enrolled consecutively. Urine samples were collected at the time of admission (ACR1), 12 hours (ACR2), and 24 hours (ACR3). Results One hundred and thirty-eight patients including 56 cases of sepsis, 31 of severe sepsis, 22 of septic shock, and 29 of multiorgan dysfunction syndrome (MODS) cases were analyzed. There were 29 (21%) deaths. ACR (median, IQR) was significantly higher in nonsurvivors [ACR1 198.9 (111.2–329.4) vs 124.5 (59.37–294.5), p 0.03], [ACR2 213.8 (112.5–350) vs 117.8 (62.6–211.9) p 0.008], [ACR3 231.8 (99.9–441.2 vs 114.4 (44.1–240.3), p 0.005]. The ACR is increased progressively with the increasing severity of sepsis ( p < 0.001). The performance of ACR operative characteristics was compared with that of PRISM and PELOD scores. In deceased, ACR was significantly correlated with blood pH, lactate, and base deficit. A cutoff value of ACR 102.7 mg/g had sensitivity 86.2%, specificity 40.4%, positive predictive value 27.8%, and negative predictive value 91.7%. The use of inotropes, mechanical ventilation (>48 hours), and mortality was significantly higher in patients with ACR >102 mg/g. The probability of death varied from 17.6 to 19% in the first 24 hours of admission. ACR was significantly cheaper as compared to PRISM score and PELOD score estimations. Conclusion Urinary ACR, a cost-effective tool, correlates with the severity of sepsis and associated morbidity and mortality in children. How to cite this article Sachdev A, Raheja K, Gupta N, Chugh P. Association of Urinary Albumin:Creatinine Ratio with Outcome of Children with Sepsis. Indian J Crit Care Med 2020;24(6):465–472.

Criteria for Pediatric Sepsis—A Systematic Review and Meta-Analysis by the Pediatric Sepsis Definition Taskforce*

“…Our meta-analysis provides strong support for greater organ dysfunction in nonsurvivors compared with survivors as shown by the pooled estimates for renal dysfunction ( 50 , 64 , 67 , 70 ), multi-organ dysfunction (MODS) ( 23 , 33 , 41 , 50 , 69 , 70 , 93 , 94 ), number of organ dysfunctions ( 28 , 40 , 64 , 83 ), PEdiatric Logistic Organ Dysfunction (PELOD) score ( 23 , 28 , 40 , 44 , 50 , 53 , 55 , 60 , 65 , 72 , 85 ), and PELOD-2 ( 85 , 86 , 95 ). Our meta-analysis also provides strong support for greater illness severity in nonsurvivors compared with survivors as shown by the pooled estimates pediatric Sequential (Sepsis-related) Organ Failure Assessment (pSOFA) ( 50 , 58 , 70 , 95 ) and Sequential (Sepsis-related) Organ Failure Assessment (SOFA) ( 85 , 86 , 95 ), PRISM ( 32 , 43 , 51 , 53 , 55 , 60 – 62 , 64 , 68 , 70 – 72 , 75 , 77 , 81 , 84 , 85 , 88 ), Pediatric Index of Mortality (PIM)-2 ( 79 , 85 ), and PIM-3 ( 23 , 61 , 65 , 85 ) (Supplementary Fig. 7,…”

“…Pooled estimates provide strong support for a difference in the following laboratory measures between nonsurvivors and survivors: lower serum pH (53,58,72,75)…”

“…6, http:// links.lww.com/CCM/G825). Pooled estimates did not support a difference between nonsurvivors and survivors in mean glucose (50,68,71,72,76), total bilirubin (53,58,76,81,85,86), WBC (26, 43, 50, 53, 58, 62, 71, 75-77, 81, 83, 85, 87, 89), hemoglobin (26,43,50,71,83,85), international normalized ratio (62, 81), prothrombin time (53,71,76,81,92), activated partial thromboplastin time (62,71,81,92), and brain natriuretic peptide (51,66,76).…”

The Glomerular Endothelium Restricts Albumin Filtration

“…Trauma, cardiovascular surgery, septic shock ( 303 ) and more recently in critical illness due to COVID-19 ( 7 , 295 ), all are associated with generalized EC activation and EC glycocalyx disruption. While proteinuria is common in critically ill patients ( 6 , 8 ), pulmonary and brain EC barrier disruption tend to have greater relevance for outcomes and therapy in these patients. Endothelial cell activation by inflammatory mediators, among them TNF-α and Il1-β, results in shedding of EC glycocalyx components exposing cell-surface adhesion molecules that enable the initial capture and rolling of leukocytes on the endothelium and integrin-dependent leukocyte transmigration ( 304 ).…”

“…In some cases, endothelial cell (EC) injury predominates, for instance the hemolytic uremic syndrome (HUS) ( 1 ), thrombotic thrombocytopenic purpura (TTP) ( 2 ), pre-eclampsia ( 3 , 4 ), and nephrotoxicity due to VEGF inhibitors ( 5 ). Transient proteinuria also accompanies generalized EC activation, in the presence of sepsis ( 6 ) or viral infections ( 7 , 8 ). Microalbuminuria is a feature of widespread EC dysfunction in diabetes ( 9 , 10 ) and in cardiovascular disease, where it is a predictor of cardiovascular risk ( 11 – 19 ).…”