Multisystem Inflammatory Syndrome in Children and Acute Kidney Injury: Retrospective Study of Five Italian PICUs

Abstract

Multisystem inflammatory syndrome in children (MIS-C) manifests with heart dysfunction and respiratory failure some weeks after a severe acute respiratory syndrome coronavirus disease 2 infection. The aim of our study was to explore the prevalence, severity, timing, and duration of acute kidney injury (AKI) in MIS-C patients. Furthermore, we evaluated which clinical variables and outcomes are associated with AKI.DESIGN: Multicenter retrospective study. SETTING:Five tertiary hospital PICUs in Italy. Data were collected in the first 7 days of PICU admission and renal function was followed throughout the hospital stay.PATIENTS: Patients less than 18 years old admitted to the PICU for greater than 24 hours with MIS-C. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS:We collected the following data, including: demographic information, inflammatory biomarkers, lactate levels, Pao 2 /Fio 2 , ejection fraction, N-terminal pro-B-type natriuretic peptide (NT-proBNP), renal function (serum creatinine, urinary output, fluid balance, and percentage fluid accumulation), Vasoactive-Inotropic Score (VIS), pediatric Sequential Organ Failure Assessment (pSOFA), and Pediatric Index of Mortality 3. AKI was diagnosed in eight of 38 patients (21%) and severe AKI was present in four of eight patients. In all cases, AKI was present at PICU admission and its median (interquartile range) duration was 3.5 days (1.5-5.7 d). We did not identify differences between AKI and no-AKI patients when not making correction for multiple comparisons, for example, in weight, ejection fraction, pSOFA, Pao 2 /Fio 2 , and lactates. We failed to identify any difference in these groups in urine output and fluid balance. Exploratory analyses of serial data between no-AKI and AKI patients showed significant differences on lymphocyte count, NT-proBNP value, ejection fraction, pSOFA, Pao 2 / Fio 2 , and VIS. CONCLUSIONS:In this multicenter Italian PICU experience, MIS-C is associated with AKI in one-in-five cases. In general, AKI is characterized by an associated reduction in glomerular filtration rate with a self-limiting time course. KEY WORDS: acute kidney injury; multisystem inflammatory syndrome in children; pediatric Sequential Organ Failure Assessment; severe acute respiratory syndrome coronavirus disease 2 M ultisystem inflammatory syndrome in children (MIS-C) is a clinical condition following infection with severe acute respiratory syndrome coronavirus disease 2 (SARS-CoV-2) (1). Patients may develop fever, gastrointestinal symptoms, cutaneous rash, conjunctivitis, and cardiac dysfunction (1, 2). The aim of treatment is to mitigate the systemic inflammatory reaction and to support cardiorespiratory function (3).

Renal Involvement in Multisystem Inflammatory Syndrome in Children: Not Only Acute Kidney Injury

“…In our study, AKI presented a self-limiting course with no patients needing renal replacement therapy and only one presenting with hypertension at 6-month followup. Our results are different from other reports, in which renal replacement therapy has been reported in up to 15% of patients with MIS-C and kidney involvement [20][21][22]26,27]. Since in our cohort AKI subgroup presented with a more severe disease course, requiring more frequently intensive care support and second line immunomodulatory therapy, we may suppose that a prompt diagnosis and support with a more aggressive therapeutical approach may have favored a complete recovery in our patients.…”

“…According to a recent systematic review and meta-analysis, up to one fifth of children with MIS-C develops AKI with the need of kidney replacement therapy in 5-37% of cases [20]. Moreover, AKI seems to be a negative prognostic factor since it is associated with higher probability of death and pediatric intensive care unit (PICU) admission [20,21].…”

Kidney complications associated with COVID-19 infection and vaccination in children and adolescents: a brief review

“…This appears consistent with reports that MIS-C develops a mean 2–6 weeks after infection with COVID-19. In addition, children with AKI have significantly lower serum albumin levels and higher white blood cell counts than those without AKI at admission [ 6 , 14 , 18 ].…”

“…11) Moreover, several observational studies of various sizes conducted from the beginning of the pandemic reported AKI incidence rates as high as approximately 11%-46% in children and adolescents with COVID-19 who are critically ill or developed MIS-C, similar to those observed in adults. 8,[12][13][14][15][16][17][18][19][20] In contrast, only a few studies reported the incidence of AKI in those with mild to moderate COVID-19. A multicenter cross-sectional study conducted in Turkey reported incidence rates of 16.9% for AKI and 31% for subclinical AKI.…”

Automated Calculator for the Pediatric Sequential Organ Failure Assessment Score: Development and External Validation in a Single-Center 7-Year Cohort, 2015–2021

“…T here has been increasing interest in the development of quantitative methods for evaluating the clinical status of critically ill children, partly due to advances in technology, improved data collection and analysis, and access to a wealth of electronic health record (EHR) data (1)(2)(3)(4)(5). The pediatric Sequential Organ Failure Assessment (pSOFA) score is one of these methods developed for the quantitative evaluation of the severity of illness of PICU patients (6)(7)(8). The score is an adaptation of the adult SOFA score that assesses the severity of organ dysfunction across six organ systems (9).…”