Real-Time Acute Kidney Injury Risk Stratification–Biomarker Directed Fluid Management Improves Outcomes in Critically Ill Children and Young Adults

Goldstein, Stuart L.; Krallman, Kelli A.; Roy, Jean-Philippe; Collins, Michaela; Chima, Ranjit S.; Basu, Rajit K.; Chawla, Lakhmir; Fei, Lin

doi:10.1016/j.ekir.2023.09.019

Cited by 17 publications

(3 citation statements)

References 34 publications

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“…An AKI clinical decision support algorithm using a sequential risk stratification tool (renal angina index), urine neutrophil gelatinase–associated lipocalin, and the furosemide stress test to optimize AKI prediction for early CRRT initiation in children who were critically ill was reported to have improved outcomes in a single center. 51 The results will likely enhance our understanding of when to initiate CRRT and serve as a model to build similar tools for other populations. Indeed, the arbitrary nature of when to use CRRT extends to adults, as was highlighted by a recent review.…”

Section: Discussionmentioning

confidence: 95%

“…Time to CRRT Initiation and 90-Day Major Adverse Kidney Events in Youth children who were critically ill was reported to have improved outcomes in a single center. 51 The results will likely enhance our understanding of when to initiate CRRT and serve as a model to build similar tools for other populations. Indeed, the arbitrary nature of when to use CRRT extends to adults, as was highlighted by a recent review.…”

Section: Jama Network Open | Nephrologymentioning

confidence: 95%

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Time to Continuous Renal Replacement Therapy Initiation and 90-Day Major Adverse Kidney Events in Children and Young Adults

Gist,

Menon,

Anton-Martin

et al. 2024

JAMA Netw Open

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ImportanceIn clinical trials, the early or accelerated continuous renal replacement therapy (CRRT) initiation strategy among adults with acute kidney injury or volume overload has not demonstrated a survival benefit. Whether the timing of initiation of CRRT is associated with outcomes among children and young adults is unknown.ObjectiveTo determine whether timing of CRRT initiation, with and without consideration of volume overload (VO; &lt;10% vs ≥10%), is associated with major adverse kidney events at 90 days (MAKE-90).Design, Setting, and ParticipantsThis multinational retrospective cohort study was conducted using data from the Worldwide Exploration of Renal Replacement Outcome Collaborative in Kidney Disease (WE-ROCK) registry from 2015 to 2021. Participants included children and young adults (birth to 25 years) receiving CRRT for acute kidney injury or VO at 32 centers across 7 countries. Statistical analysis was performed from February to July 2023.ExposureThe primary exposure was time to CRRT initiation from intensive care unit admission.Main Outcomes and measuresThe primary outcome was MAKE-90 (death, dialysis dependence, or persistent kidney dysfunction [&gt;25% decline in estimated glomerular filtration rate from baseline]).ResultsData from 996 patients were entered into the registry. After exclusions (n = 27), 969 patients (440 [45.4%] female; 16 (1.9%) American Indian or Alaska Native, 40 (4.7%) Asian or Pacific Islander, 127 (14.9%) Black, 652 (76.4%) White, 18 (2.1%) more than 1 race; median [IQR] patient age, 8.8 [1.7-15.0] years) with data for the primary outcome (MAKE-90) were included. Median (IQR) time to CRRT initiation was 2 (1-6) days. MAKE-90 occurred in 630 patients (65.0%), of which 368 (58.4%) died. Among the 601 patients who survived, 262 (43.6%) had persistent kidney dysfunction. Of patients with persistent dysfunction, 91 (34.7%) were dependent on dialysis. Time to CRRT initiation was approximately 1 day longer among those with MAKE-90 (median [IQR], 3 [1-8] days vs 2 [1-4] days; P = .002). In the generalized propensity score–weighted regression, there were approximately 3% higher odds of MAKE-90 for each 1-day delay in CRRT initiation (odds ratio, 1.03 [95% CI, 1.02-1.04]).Conclusions and RelevanceIn this cohort study of children and young adults receiving CRRT, longer time to CRRT initiation was associated with greater risk of MAKE-90 outcomes, in particular, mortality. These findings suggest that prospective multicenter studies are needed to further delineate the appropriate time to initiate CRRT and the interaction between CRRT initiation timing and VO to continue to improve survival and reduce morbidity in this population.

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Section: Discussionmentioning

confidence: 95%

Section: Jama Network Open | Nephrologymentioning

confidence: 95%

Time to Continuous Renal Replacement Therapy Initiation and 90-Day Major Adverse Kidney Events in Children and Young Adults

Gist,

Menon,

Anton-Martin

et al. 2024

JAMA Netw Open

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“…In the United States, the Bioporto NGAL Test (Bioporto Diagnostics, Denmark) was approved by the Food and Drug Administration (Silver Spring, Maryland) in December 2023 to aid in assessing the risk of AKI in patients aged 3 months to 21 yr. Approval was based on a study by Dr. Barasch’s colleagues at Cincinnati Children’s Hospital demonstrating that inclusion of urinary NGAL in a clinical risk index resulted in earlier diagnosis of AKI and application of continuous renal replacement therapy with decreased ICU length of stay and mortality. 36…”

mentioning

confidence: 99%

Perioperative Acute Renal Injury: Revisiting Pathophysiology

Sladen

2024

Anesthesiology

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Association between Increases in Urinary Neutrophil Gelatinase-associated Lipocalin and Acute Renal Dysfunction after Adult Cardiac Surgery. By Wagener G, Jan M, Kim M, Mori K, Barasch JM, Sladen RN, Lee HT: Anesthesiology 2006; 105:485–91 Background Acute renal dysfunction and subsequent acute renal failure after cardiac surgery are associated with high mortality and morbidity. Early therapeutic or preventive intervention is hampered by the lack of an early biomarker for acute renal injury. Recent studies showed that urinary neutrophil gelatinase–associated lipocalin (NGAL or lipocalin 2) is upregulated early (within 1 to 3 h) after murine renal injury and in pediatric acute renal dysfunction after cardiac surgery. The authors hypothesized that postoperative urinary NGAL concentrations are increased in adult patients developing acute renal dysfunction after cardiac surgery compared with patients without acute renal dysfunction. Methods After institutional review board approval, 81 cardiac surgical patients were prospectively studied. Urine samples were collected immediately before incision and at various time intervals after surgery for NGAL analysis by quantitative immunoblotting. Acute renal dysfunction was defined as peak postoperative serum creatinine increase by 50% or greater compared with preoperative serum creatinine. Results Sixteen of 81 patients (20%) developed postoperative acute renal dysfunction, and the mean urinary NGAL concentrations in patients who developed acute renal dysfunction were significantly higher early after surgery (after 1 h, mean ± SD, 4,195±6,520 vs. 1,068±2,129ng/ml; P < 0.01) compared with patients who did not develop acute renal dysfunction. Mean urinary NGAL concentrations continued to increase and remained significantly higher at 3 and 18 h after cardiac surgery in patients with acute renal dysfunction. In contrast, urinary NGAL in patients without acute renal dysfunction decreased rapidly after cardiac surgery. Conclusions Patients developing postoperative acute renal dysfunction had significantly higher urinary NGAL concentrations early after cardiac surgery. Urinary NGAL may therefore be a useful early biomarker of acute renal dysfunction after cardiac surgery. These findings may facilitate the early detection of acute renal injury and potentially prevent progression to acute renal failure.

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Recommendations for clinical trial design in acute kidney injury from the 31st acute disease quality initiative consensus conference. A consensus statement

Zarbock,

Forni,

Koyner

et al. 2024

Intensive Care Med

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Real-Time Acute Kidney Injury Risk Stratification–Biomarker Directed Fluid Management Improves Outcomes in Critically Ill Children and Young Adults

Cited by 17 publications

References 34 publications

Time to Continuous Renal Replacement Therapy Initiation and 90-Day Major Adverse Kidney Events in Children and Young Adults

Time to Continuous Renal Replacement Therapy Initiation and 90-Day Major Adverse Kidney Events in Children and Young Adults

Perioperative Acute Renal Injury: Revisiting Pathophysiology

Recommendations for clinical trial design in acute kidney injury from the 31st acute disease quality initiative consensus conference. A consensus statement

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