Follow-up after neonatal heart disease repair: watch out for chronic kidney disease and hypertension!

Abstract

Background With advances in care, neonates undergoing cardiac repairs are surviving more frequently. Our objectives were to 1) estimate the prevalence of chronic kidney disease (CKD) and hypertension 6 years after neonatal congenital heart surgery and 2) determine if cardiac surgery-associated acute kidney injury (CS-AKI) is associated with these outcomes. Methods Two-center prospective, longitudinal single-visit cohort study including children with congenital heart disease surgery as neonates between January 2005 and December 2012. CKD (estimated glomerular filtration rate < 90 mL/min/1.73m2 or albumin/creatinine ≥3 mg/mmol) and hypertension (systolic or diastolic blood pressure ≥ 95th percentile for age, sex, and height) prevalence 6 years after surgery was estimated. The association of CS-AKI (Kidney Disease: Improving Global Outcomes definition) with CKD and hypertension was determined using multiple regression. Results Fifty-eight children with median follow-up of 6 years were evaluated. CS-AKI occurred in 58%. CKD and hypertension prevalence were 17% and 30%, respectively; an additional 15% were classified as having elevated blood pressure. CS-AKI was not associated with CKD or hypertension. Classification as cyanotic postoperatively was the only independent predictor of CKD. Postoperative days in hospital predicted hypertension at follow-up. Conclusions The prevalence of CKD and hypertension is high in children having neonatal congenital heart surgery. This is important; early identification of CKD and hypertension can improve outcomes. These children should be systematically followed for the evolution of these negative outcomes. CS-AKI defined by current standards may not be a useful clinical tool to decide who needs follow-up and who does not.

Long-Term Renal Outcomes in Children With Acute Kidney Injury Post Cardiac Surgery

“…Similar results were demonstrated by Huynh in neonatal population, that cardiac surgery associated AKI was not associated with chronic kidney disease (GFR <90ml/min/1.73m2) or hypertension. They found however a chronic kidney disease and hypertension prevalence as 17% and 30% respectively in the whole group on follow up of 6 years [10]. Similar results were found in TRIBE-AKI and Zappitelli et al respectively with no correlation of post-operative AKI and chronic kidney disease on follow up [19][20][21][22].…”

“…Complexity of cardiac surgery was categorized using the risk adjustment for congenital heart surgery-1 (RACHS-1), the consensus-based scoring system commonly used to classify the complexity of cardiac surgeries; with higher scores indicating more complex surgeries [25]. We also recorded the STAT score (The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery), a more objective score for evaluation of our cohort [10,25]. A detailed clinical history, including history of medications taken, duration of hospital stay and need of dialysis was recorded.…”

“…Post-operative AKI in children is known to have adverse outcomes including increased ventilation days, length of stay in pediatric intensive care [PICU] and mortality [1][2][3][4][5][6][7][8]. It is now well known, that younger the child undergoing the surgery, higher is the risk of AKI, with the risk being higher in neonates as high as 50-60% depending on the complexities of the surgical operation [3,4,9,10].…”

Acute Kidney Injury in Critically Ill Children Is Not all Acute: Lessons Over the Last 5 Years

“…Six studies reported long-term kidney outcomes following PICU-AKI exclusively in subjects who underwent cardiac surgery ( 2 , 4 , 24 , 25 , 29 , 31 ). Unlike the general PICU population, there is conflicting evidence on whether AKI after cardiac surgery is associated with negative long-term kidney outcomes.…”

“…In a cardiac sub-group of 88 heart transplant recipients, advanced CKD (GFR <60 mL/min/1.73 m 2 ) developed in 5% of the population after 1-year follow-up and was more common in those who did not fully recover kidney function and in those with more severe AKI (stage 2 or 3 by KDIGO) ( 2 ). Lastly, in an exclusively neonatal cohort of 58 subjects who underwent cardiac surgery, with a median follow-up of 6 years, AKI was not associated with CKD or hypertension despite a high prevalence overall (17 and 30%, respectively) ( 29 ). Post-operative cyanosis was the only independent predictor of CKD.…”