Fluid Overload and Renal Angina Index at Admission Are Associated With Worse Outcomes in Critically Ill Children

Abstract

Objectives: We investigated the association of fluid overload and oxygenation in critically sick children, and their correlation with various outcomes (duration of ventilation, ICU stay, and mortality). We also assessed whether renal angina index (RAI) at admission can predict mortality or acute kidney injury (AKI) on day 3 after admission.Design and setting: Prospective study, pediatric intensive care in a tertiary hospital.Duration: June 2013-June 2014.Patients: Patients were included if they needed invasive mechanical ventilation for >24 h and had an indwelling arterial catheter. Patients with congenital heart disease or those who received renal replacement therapy (RRT) were excluded.Methods: Oxygenation index, fluid overload percent (daily, cumulative), RAI at admission and pediatric logistic organ dysfunction (PELOD) score were obtained in all critically ill children. KDIGO classification was used to define AKI, using both creatinine and urine output criteria. Admission data for determination of RAI included the use of vasopressors, invasive mechanical ventilation, percent fluid overload, and change in kidney function (estimated creatinine clearance). Univariable and multivariable approaches were used to assess the relations between fluid overload, oxygenation index and clinical outcomes. An RAI cutoff >8 was used to predict AKI on day 3 of admission and mortality.Results: One hundred and two patients were recruited. Fluid overload predicted oxygenation index in all patients, independent of age, gender and PELOD score (p < 0.05). Fluid overload was associated with longer duration of ventilation (p < 0.05), controlled for age, gender, and PELOD score. Day-3 AKI rates were higher in patients with a RAI of 8 or more, and higher areas under the RAI curve had better prediction rates for Day-3 AKI. An RAI <8 had high negative predictive values (80–95%) for Day-3 AKI. RAI was better than traditional markers of pediatric severity of illness (PELOD) score for prediction of AKI on day 3.Conclusions: This study emphasizes that positive fluid balance adversely affects intensive care in critically ill children. Further, the RAI prediction model may help optimize treatment and improve clinical prediction of AKI.

Risk Stratification for Acute Kidney Injury in Critically-ill Children

“…There have been multiple studies on the validation of RAI in critical children. In an earlier study from India, we demonstrated that RAI was better than traditional markers of AKI and illness severity scores with high AUC in RAI ≥8, and higher negative predictive values for RAI <8 [8]. The study [9], published in the current issue of Indian Pediatrics, adds on to the evidence that day 0 RAI has a good sensitivity, specificity, and negative predictive value for AKI on day 3 of admission.…”

Delayed Umbilical Cord Clamping is Not Associated with Acute Kidney Injury in Very Low Birth Weight Neonates

“…The current study data provide evidence of safety for DCC from a kidney perspective in VLBW infants who typically have an AKI rate of 29% during their NICU hospitalization. 10 With recent evidence from pediatric studies that fluid overload increases the risk of AKI 15 and with DCC providing nearly an equivalent of a blood transfusion, this is an important addition to the safety profile of DCC that has not been analyzed in prior studies.…”

Recommendations for hemodynamic Monitoring for Critically Ill Children – Expert Consensus Statement issued by the Cardiovascular Dynamics Section of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC)

“…Volume resuscitation in hemodynamically unstable patients is one of the most commonly used therapeutic options. Nevertheless, excessive uid administration may impair tissue perfusion even further by promoting edema and third-space uid accumulation [6,7,60]. A rise in cardiac output (or stroke volume) as a result of volume resuscitation is called uid responsiveness.…”

“…However, the optimal way to resuscitate children with circulatory failure is controversial. The exact order and quantity of uids or vasoactive drug administration in the critically-ill child with shock is supported by little evidence, although there are several consensus statements [4,5] Overzealous uid resuscitation is detrimental to some children [6,7]. There is some consensus regarding the rst-line treatment in patients with shock or signi cant hemodynamic instability, but debate remains concerning how much uid should be administered, which type of vasoactive drug should be used, how to assess the hemodynamic changes and ultimately what hemodynamic clinical goal should be targeted to guide optimal treatment.…”