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Background Continuous kidney replacement therapy (CKRT) has become an integral part of the care of critically ill children. However, uncertainty exists regarding the current state of how CKRT is prescribed and delivered in children. The main objective of this study was to identify the current practices for pediatric CKRT. Methods We conducted a systematic review of the literature from 2012 to 2022 to identify data regarding CKRT timing of initiation, dosing, anticoagulation, fluid removal, and quality monitoring. Using this data, we then performed a two-round modified Delphi process using a multinational internet-assisted survey of prescribers of CKRT. Results The survey was constructed using 172 articles that met inclusion criteria (12% of studies were pediatric focused). A total of 147 and 126 practitioners completed the survey in rounds 1 and 2, respectively. Participants represented Europe (9.5-11.6%) and North America including pediatric intensivists, nephrologists, and advance practice providers. Consensus (defined as a [greater than or equal to] 75% participant response of 'sometimes' or 'always') was achieved for 26 statements. There was consensus in the practices of CKRT initiation, dosing, method of anticoagulation, and fluid removal. In contrast, there appears to be greater variability in the methods used for monitoring anticoagulation and the quality of the delivered treatment. Conclusions Our study results suggest that the current state of pediatric CKRT practice is reflective of the literature over the last 10 years, which is largely based on the care of adult patients. This data provides a framework to study best practices to further improve outcomes for children receiving CKRT. Graphical abstract, Author(s): Dana Y. Fuhrman [sup.1] [sup.2] [sup.3] , Katja M. Gist [sup.4] , Ayse Akcan-Arikan [sup.5] [sup.6] Author Affiliations: (1) grid.239553.b, 0000 0000 9753 0008, Department of Critical Care Medicine, [...]

Kidney support therapy (KST), previously referred to as Renal Replacement Therapy, is utilized to treat children and adults with severe acute kidney injury (AKI), fluid overload, inborn errors of metabolism, and kidney failure. Several forms of KST are available including peritoneal dialysis (PD), intermittent hemodialysis (iHD), and continuous kidney support therapy (CKST). Traditionally, extracorporeal KST (CKST and iHD) in neonates has had unique challenges related to small patient size, lack of neonatal-specific devices, and risk of hemodynamic instability due to large extracorporeal circuit volume relative to patient total blood volume. Thus, PD has been the most commonly used modality in infants, followed by CKST and iHD. In recent years, CKST machines designed for small children and novel filters with smaller extracorporeal circuit volumes have emerged and are being used in many centers to provide neonatal KST for toxin removal and to achieve fluid and electrolyte homeostasis, increasing the options available for this unique and vulnerable group. These new treatment options create a dramatic paradigm shift with recalibration of the benefit: risk equation. Renewed focus on the infrastructure required to deliver neonatal KST safely and effectively is essential, especially in programs/units that do not traditionally provide KST to neonates. Building and implementing a neonatal KST program requires an expert multidisciplinary team with strong institutional support. In this review, we first describe the available neonatal KST modalities including newer neonatal and infant-specific platforms. Then, we describe the steps needed to develop and sustain a neonatal KST team, including recommendations for provider and nursing staff training. Finally, we describe how quality improvement initiatives can be integrated into programs., Author(s): Tahagod H. Mohamed [sup.1] [sup.2] , Jolyn Morgan [sup.3] , Theresa A. Mottes [sup.4] , David Askenazi [sup.5] , Jennifer G. Jetton [sup.6] , Shina Menon [sup.7] Author Affiliations: [...]

Introduction Multisystem inflammatory syndrome (MIS-C) is a rare paediatric hyper-inflammatory disorder that occurs following SARS-CoV-2 infection. Acute kidney injury (AKI) occurs in approximately one-quarter to one-third of the patients with MIS-C and is associated with poor prognosis in critically ill children. This systematic review is aimed to evaluate the incidence of AKI, mortality, and the need for kidney replacement therapy (KRT) in patients with MIS-C. Methods We searched databases from Medline, EMBASE, Cochrane Register, and Google Scholar from December 2019 to December 2021 with our search strategy. Studies meeting the following criteria were included in this systematic review: (1) articles on AKI in MIS-C; (2) studies providing AKI in MIS-C and COVID-19 infection separately; (3) studies reporting outcomes such as mortality, KRT, serum creatinine; length of hospital/ICU stay. Quality assessment The quality of the included studies was independently assessed by using the National Heart Lung and Blood Institute (NHLBI) quality assessment tool for cohort studies and case series. Statistical analysis Outcomes and their 95% confidence intervals (CI) were reported if a meta-analysis of these outcomes was conducted. Heterogeneity was reported using I.sup.2 statistics, and heterogeneity [greater than or equal to] 50% was considered high. We used Baujat's plot for the contribution of each study toward overall heterogeneity. In sensitivity analysis, the summary estimates were assessed by repeating meta-analysis after omitting one study at a time. Forest plots were used for reporting outcomes in each study and with their 95% CI. All statistical tests were performed using R software version 4.0.3. Results A total of 24 studies were included in this systematic review and of these, 11 were included in the meta-analysis. The pooled proportion of patients with MIS-C developing AKI was 20% (95% CI: 14-28%, I.sup.2 = 80%). Pooled proportion of death in children with MIS-C was 4% (95% CI: 1-14%; I.sup.2 = 93%). The odds of death in patients with AKI were 4.68 times higher than in patients without AKI (95% CI: 1.06-20.7%; I.sup.2 = 17%). The overall pooled proportion of MIS-C-induced AKI patients requiring KRT was 15% (95% CI: 4-42%; I.sup.2 = 91%). Conclusion Approximately one-fifth of children with MIS-C develop AKI which is associated with higher odds of death. PROSPERO registration: CRD42022306170 Graphical abstract A higher resolution version of the Graphical abstract is available as Supplementary information, Author(s): Anchal Kumar Tripathi [sup.1] , Rakesh Kumar Pilania [sup.2] , Girish Chandra Bhatt [sup.1] , Mahendra Atlani [sup.3] , Amber Kumar [sup.1] , Shikha Malik [sup.1] Author Affiliations: (1) [...]

Background The aim of the study was to determine the prevalence of congenital anomalies of the kidney and urinary tract (CAKUT) in the neonatal intensive care unit (NICU) and to evaluate risk factors associated with worse outcomes. We hypothesized that infants with CAKUT with extra-renal manifestations have higher mortality. Methods This is a cohort study of all inborn infants who were diagnosed with any form of CAKUT discharged from NICUs managed by the Pediatrix Medical Group from 1997 to 2018. Logistic and linear regression models were used to analyze risk factors associated with in-hospital mortality. Results The prevalence of CAKUT was 1.5% among infants hospitalized in 419 NICUs. Among the 13,383 infants with CAKUT analyzed, median gestational age was 35 (interquartile range [IQR] 31-38) weeks and median birth weight was 2.34 (IQR 1.54-3.08) kg. Overall in-hospital mortality for infants with CAKUT was 6.8%. Oligohydramnios (adjusted odds ratio [aOR] 4.5, 95% confidence interval [CI] 2.2-9.1, p < 0.001), extra-renal anomalies (aOR 2.5, 95% CI 2.0-3.1, p < 0.001), peak SCr (aOR 1.02, 95% CI 1.01-1.03, p < 0.001) and exposure to nephrotoxic medications (aOR 1.4, 95% CI 1.1-1.7, p = 0.01) were associated with increased mortality, while a history of urological surgery or intervention was associated with lower mortality (aOR 0.6, 95% CI 0.4-0.7, p < 0.001). Conclusions Infants hospitalized in the NICU who have CAKUT and the independent risk factors for mortality (e.g., oligohydramnios and presence of extra-renal anomalies) require close monitoring, minimizing of exposure to nephrotoxic drugs, and timely urological surgery or intervention. Graphical abstract A higher resolution version of the Graphical abstract is available as Supplementary information, Author(s): Esther Huimin Leow [sup.1] , Jan Hau Lee [sup.2] [sup.3] , Christoph P. Hornik [sup.4] [sup.5] , Yong Hong Ng [sup.1] , Thomas Hays [sup.6] , Reese H. Clark [...]

Purpose This study aimed to investigate the association between preoperative dipstick albuminuria (DA) and acute kidney injury (AKI) in high-risk patients following non-cardiac surgery. Methods This was a single-center prospective cohort study. Adult patients with high risk of AKI undergoing non-cardiac surgery were enrolled. The primary outcome was AKI, defined according to KDIGO criteria within 7 days following non-cardiac surgery. DA status was determined by urinalysis performed within 24 h of hospital admission. Multivariate logistic regression model was used to analyze the association between preoperative DA and postoperative AKI. Results During the study period, 552 patients were enrolled and 8.5% of them developed postoperative AKI. The overall rate of preoperative positive DA was 26.4% with 30 and [greater than or equal to] 100 mg/dL DA accounting for 19.2% and 7.2%, respectively. Patients with more severe preoperative DA had much higher rate of postoperative AKI (5.2% in patients with negative or trace DA, 13.2% in patients with 30 mg/dL DA and 30.0% in patients with [greater than or equal to] 100 mg/dL DA, P < 0.001). After adjusting for several perioperative variables, preoperative 30 mg/dL DA (OR 2.575; 95% CI 1.049-6.322; P = 0.039) and [greater than or equal to] 100 mg/dL DA (OR 3.868; 95% CI 1.246-12.010; P = 0.019) showed an independent association with postoperative AKI. In addition, patients with higher DA status demonstrated significantly increased level of postoperative urine biomarkers and their ratio to urine creatinine. Conclusions Preoperative DA was independently associated with AKI in high-risk patients following non-cardiac surgery. Preoperative routine urinalysis for determination of DA status was suggested in early risk stratification., Author(s): Jiao-Nan Yang [sup.1], Zhuo Li [sup.2] [sup.3], Mei-Ling Wang [sup.4], Xue-Ying Li [sup.5], Shuang-Ling Li [sup.2] [sup.6], Nan Li [sup.2] [sup.6] Author Affiliations: (1) grid.412474.0, 0000 0001 0027 0586, [...]

Critical illness is often complicated by acute kidney injury (AKI). In patients with severe AKI, renal replacement therapy (RRT) is deployed to address metabolic dysfunction and volume excess until kidney function recovers. This review is intended to provide a comprehensive update on key aspects of RRT prescription and delivery to critically ill patients. Recently completed trials have enhanced the evidence base regarding several RRT practices, most notably the timing of RRT initiation and anticoagulation for continuous therapies. Better evidence is still needed to clarify several aspects of care including optimal targets for ultrafiltration and effective strategies for RRT weaning and discontinuation., Author(s): Ron Wald [sup.1] [sup.2] , William Beaubien-Souligny [sup.3] , Rahul Chanchlani [sup.4] , Edward G. Clark [sup.5] , Javier A. Neyra [sup.6] , Marlies Ostermann [sup.7] , Samuel A. [...]

Clinical and pathophysiological understanding of septic shock has progressed exponentially in the previous decades, translating into a steady decrease in septic shock-related morbidity and mortality. Even though large randomized, controlled trials have addressed fundamental aspects of septic shock resuscitation, many questions still exist. In this review, we will describe the current standards of septic shock resuscitation, but the emphasis will be placed on evolving concepts in different domains such as clinical resuscitation targets, adequate use of fluids and vasoactive drugs, refractory shock, and the use of extracorporeal therapies. Multiple research opportunities remain open, and collaborative endeavors should be performed to fill in these gaps., Author(s): Jan Bakker [sup.1] [sup.2] [sup.3] [sup.4], Eduardo Kattan [sup.4], Djillali Annane [sup.5] [sup.6], Ricardo Castro [sup.4], Maurizio Cecconi [sup.7] [sup.8], Daniel De Backer [sup.9], Arnaldo Dubin [sup.10] [sup.11], Laura [...]

Background Ongoing measures to improve pediatric continuous kidney replacement therapy (CKRT) have lowered mortality rates, shifting the focus to survivor functional status. While septic acute kidney injury generates new morbidity in pediatric critically ill patients, acquired morbidities and functional status of CKRT population are unknown. We predicted that CKRT survivors are at risk for new morbidity and would have worse functional status at PICU discharge compared to baseline, and aimed to describe associated factors. Methods Retrospective cohort study over 24 months of CKRT patients surviving to PICU discharge in a quaternary children's hospital. Functional outcome was determined by Functional Status Scale (FSS). Results FSS scores were higher at PICU and hospital discharge compared to baseline. Of 45 CKRT survivors, 31 (69%) had worse FSS score at PICU discharge and 51% had new morbidity ([greater than or equal to]3 increase in FSS); majority qualified as moderate to severe disability (FSS [greater than or equal to]10). Four patients (9%) had new tracheostomy, 3 (7%) were ventilator dependent, and 10 (22%) were dialysis dependent. Most (23/45, 51%) required outpatient rehabilitation. Cumulative days on sedation, controlled for illness severity, were independently associated with worse FSS at PICU discharge (aOR 25.18 (3.73, 169.92)). In adjusted analyses, duration of sedation was associated with new morbidity, while neurologic comorbidity, percent fluid overload at CKRT start, and nonrenal comorbidity were associated with moderate to severe disability at PICU discharge when controlled for baseline FSS. Conclusions CKRT survivors, with new morbidity and worse functional outcomes at PICU discharge, are a newly described vulnerable population requiring targeted follow-up. Deliberate decrease of sedation exposure in patients with decreased clearance due to organ dysfunction needs to be studied as a modifiable risk factor., Author(s): Mallory Smith [sup.1] [sup.2] , Cynthia Bell [sup.3] , Molly Wong Vega [sup.4] , Naile Tufan Pekkucuksen [sup.4] , Laura Loftis [sup.5] , Mona McPherson [sup.5] , Jeanine Graf [...]

Background Current guidelines for initiation of kidney replacement do not include specific recommendations for prescription parameters and monitoring. Case outline A 16-year-old girl presented with kidney failure with creatinine of 19.8 mg/dL and BUN of 211 mg/dL. She initiated continuous kidney replacement therapy (CKRT) with clearance of 1,300 mL/min/1.73 m.sup.2 which was increased to 1,950 mL/min/1.73 m.sup.2 at 17 h of stable therapy. Complications At 31 h of therapy, she developed generalized seizure activity. CT imaging was negative for acute intracranial process, and EEG demonstrated diffuse encephalopathy. CKRT was discontinued, and BUN was noted to be 47 mg/dL at that time (a 79% reduction from presenting BUN). Key management points * The potential for development of DDS is not isolated to intermittent hemodialysis and may occur later in presentation. * A decreased clearance rate should be considered in those with risk factors for development of dialysis disequilibrium syndrome (DDS). * Frequent monitoring of BUN/serum osmolality is important to allow for adjustment of the KRT prescription following initiation of therapy. * Additional research is needed to guide risk assessment for DDS and therapeutic timing and goals in the early stages of KRT initiation. * Inclusion of more specific guidelines surrounding DDS would assist in providing important support for nephrologists. List of relevant guidelines KDIGO clinical practice guideline for acute kidney injury [1] Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease [2] The Renal Association Clinical Practice Guideline Acute Kidney Injury (AKI) [3] The Japanese Clinical Practice Guideline for Acute Kidney Injury [4], Author(s): Jessica L. Stahl [sup.1] , Russell S. Whelan [sup.2] [sup.3] , Jordan M. Symons [sup.2] [sup.3] Author Affiliations: (1) grid.10698.36, 0000000122483208, Division of Nephrology and Hypertension, Department of Medicine, [...]

Author(s): David T. Selewski [sup.1] , David J. Askenazi [sup.2] , Kianoush Kashani [sup.3] , Rajit K. Basu [sup.4] , Katja M. Gist [sup.5] , Matthew W. Harer [sup.6] , [...]

Background Kidney replacement therapy (KRT) is frequently used in critically ill children. The objective of this study is to investigate if the requirement for hemodialysis (HD) is an independent risk factor for mortality in mechanically ventilated children Methods In this retrospective cohort study, we analyzed the 2012 and 2016 Kids Inpatient Database and used a weighted sample to obtain a national outcome estimate. For our analysis, we included children aged one month to 17 years who were mechanically ventilated; we then compared the demographics, comorbidities, and mortality rates of those patients who had undergone HD with those who did not. Statistical analysis was performed using the chi-squared test and regression models. The patients were matched 1:2 with a correlative propensity score using age, weekend admission, elective admission, gender, hospital region, income quartiles, race, presence of kidney failure, bone marrow transplantation (BMT), cardiac surgery, trauma, and All Patients Refined Diagnosis Related Groups (APR-DRG) severity score. The mortality rate was compared between the matched groups. Results Out of 100,289 mechanically ventilated children, 1393 (1.4%) underwent HD. The mortality rate was 32.5% in the HD group, compared with 8.8% in the control group (p < 0.05). Factors that were associated with higher mortality in HD patients included severe sepsis, BMT, cardiopulmonary resuscitation (CPR), and extracorporeal membrane oxygenation therapy (ECMO). After propensity score-matched analysis, HD was still significantly associated with a higher risk of mortality (31.9% vs. 22.0%, p < 0.05) Conclusions The requirement for HD in mechanically ventilated children is associated with higher mortality., Author(s): Madhuradhar Chegondi [sup.1] , Sushil Devarashetty [sup.2] , Niveditha Balakumar [sup.2] , Prithvi Sendi [sup.2] , Balagangadhar R. Totapally [sup.2] [sup.3] Author Affiliations: (1) Division of Critical Care Medicine, [...]

Neonatal acute kidney injury (AKI) is common. Critically ill neonates are at risk for AKI for many reasons including the severity of their underlying illnesses, prematurity, and nephrotoxic medications. In this educational review, we highlight four clinical scenarios in which both the illness itself and the medications indicated for their treatment are risk factors for AKI: sepsis, perinatal asphyxia, patent ductus arteriosus, and necrotizing enterocolitis. We review the available evidence regarding medications commonly used in the neonatal period with known nephrotoxic potential, including gentamicin, acyclovir, indomethacin, vancomycin, piperacillin-tazobactam, and amphotericin. We aim to illustrate the complexity of decision-making involved for both neonatologists and pediatric nephrologists when managing infants with these conditions and advocate for ongoing multidisciplinary collaboration in the development of better AKI surveillance protocols and AKI mitigation strategies to improve care for these vulnerable patients., Author(s): Heidi J. Murphy [sup.1] , Brady Thomas [sup.2] , Brynna Van Wyk [sup.3] , Sarah B. Tierney [sup.4] , David T. Selewski [sup.1] , Jennifer G. Jetton [sup.3] Author [...]

Objective The aim of this study was to characterize continuous renal replacement therapy (CRRT) utilization on extracorporeal membrane oxygenation (ECMO) and to determine the association of both fluid overload (FO) at CRRT initiation and fluid removal during CRRT with mortality in a large multicenter cohort. Methods Retrospective chart review of all children < 18 years of age concurrently treated with ECMO and CRRT from January 1, 2007, to December 31, 2011, at six tertiary care children's hospital. Children treated with hemodialysis or peritoneal dialysis were excluded from the FO analysis. Measurements and main results A total of 756 of the 1009 children supported with ECMO during the study period had complete FO data. Of these, 357 (47.2%) received either CRRT or were treated with an in-line filter and thus entered into the final analysis. Survival to ECMO decannulation was 66.4% and survival to hospital discharge was 44.3%. CRRT initiation occurred at median of 1 day (IQR 0, 2) after ECMO initiation. Median FO at CRRT initiation was 20.1% (IQR 5, 40) and was significantly lower in ECMO survivors vs. non-survivors (15.3% vs. 30.5% p = 0.005) and in hospital survivors vs. non-survivors (13.5% vs. 25.9%, p = 0.004). Median FO at CRRT discontinuation was significantly lower in ECMO survivors (23% vs. 37.6% p = 0.002) and hospital survivors vs. non-survivors (22.6% vs. 36.1%, p = 0.002). In ECMO survivors, after adjusting for pH at CRRT initiation, non-renal complications, ECMO mode, support type, center, patient age and AKI, FO at CRRT initiation (p = 0.01), and FO at CRRT discontinuation (p = 0.0002) were independently associated with duration of ECMO. In a similar multivariable analysis, FO at CRRT initiation (adjusted adds ratio [aOR] 1.09, 95% CI 1.00-1.18, p = 0.045) and at CRRT discontinuation (aOR 1.11, 95% CI 1.03-1.19, p = 0.01) were independently associated with hospital mortality. Conclusions In a multicenter pediatric ECMO cohort, this study demonstrates that severe FO was very common at CRRT initiation. We found an independent association between the degree of FO at CRRT initiation with adverse outcomes including mortality and increased duration of ECMO support. The results suggest that intervening prior to the development of significant FO may be a clinical therapeutic target and warrants further evaluation., Author(s): Stephen M. Gorga [sup.1] , Rashmi D. Sahay [sup.3] , David J. Askenazi [sup.2] , Brian C. Bridges [sup.4] , David S. Cooper [sup.5] , Matthew L. Paden [sup.6] [...]

Acute kidney injury (AKI) is an increasingly frequent complication among hospitalized children. It is associated with high morbidity and mortality, especially in neonates and children requiring dialysis. The different renal replacement therapy (RRT) options for AKI have expanded from peritoneal dialysis (PD) and intermittent hemodialysis (HD) to continuous RRT (CRRT) and hybrid modalities. Recent advances in the provision of RRT in children allow a higher standard of care for increasingly ill and young patients. In the absence of evidence indicating better survival with any dialysis method, the most appropriate dialysis choice for children with AKI is based on the patient's characteristics, on dialytic modality performance, and on the institutional resources and local practice. In this review, the available dialysis modalities for pediatric AKI will be discussed, focusing on indications, advantages, and limitations of each of them., Author(s): Lara de Galasso [sup.1] , Stefano Picca [sup.1] , Isabella Guzzo [sup.1] Author Affiliations: (1) grid.414125.7, 0000 0001 0727 6809, Division of Nephrology and Dialysis, Department of Pediatrics, Bambino [...]

Author(s): Kianoush B. Kashani [sup.1] [sup.2], Antoine G. Schneider [sup.3], Zaccaria Ricci [sup.4] Author Affiliations: (1) grid.66875.3a, 0000 0004 0459 167X, Division of Nephrology and Hypertension, Department of Medicine, Mayo [...]

Wide ranges of age and weight in pediatric patients makes renal replacement therapy (RRT) in acute kidney injury (AKI) challenging, particularly in the pediatric intensive care unit (PICU), wherein children are often hemodynamically unstable. Standard hemodialysis (HD) is difficult in this group of children and continuous veno-venous hemofiltration/dialysis (CVVH/D) has been the accepted modality in the developed world. Unfortunately, due to cost constraints, CVVH/D is often not available and peritoneal dialysis (PD) remains the common mode of RRT in resource-poor facilities. Acute PD has its drawbacks, and intermittent HD (IHD) done slowly over a prolonged period has been explored as an alternative. Various modes of slow sustained IHD have been described in the literature with the recently introduced term prolonged intermittent RRT (PIRRT) serving as an umbrella terminology for all of these modes. PIRRT has been widely accepted in adults with studies showing it to be as effective as CVVH/D but with an added advantage of being more cost-effective. Pediatric data, though scanty, has been promising. In this current review, we elaborate on the practical aspects of undertaking PIRRT in children as well as summarize its current status., Author(s): Rajiv Sinha [sup.1] , Sidharth Kumar Sethi [sup.2] , Timothy Bunchman [sup.3] , Valentine Lobo [sup.4] , Rupesh Raina [sup.5] Author Affiliations: (1) 0000 0004 1801 0469, grid.414710.7, Institute [...]

End-stage kidney disease (ESKD) is one of the most prevalent diseases in the world with significant morbidity and mortality. Current modes of renal replacement therapy include dialysis and renal transplantation. Although dialysis is an acceptable mode of renal replacement therapy, it does have its shortcomings, which include poorer life expectancy compared with renal transplantation, risk of infections and vascular thrombosis, lack of vascular access and absence of biosynthetic functions of the kidney. Renal transplantation, in contrast, is the preferred option of renal replacement therapy, with improved morbidity and mortality rates and quality of life, compared with dialysis. Renal transplantation, however, may not be available to all patients with ESKD. Some of the key factors limiting the availability and efficiency of renal transplantation include shortage of donor organs and the constant risk of rejection with complications associated with over-immunosuppression respectively. This review focuses chiefly on the potential roles of bioengineering in overcoming limitations in renal transplantation via the development of cell-based bioartificial dialysis devices as bridging options before renal transplantation, and the development of new sources of organs utilizing cell and organ engineering., Author(s): Wee-Song Yeo [sup.1] , Yao-Chun Zhang [sup.2] Author Affiliations: (Aff1) 0000 0004 0451 6143, grid.410759.e, Division of Pediatric Nephrology, Dialysis and Renal Transplantation, Shaw-National Kidney Foundation, National University Hospital [...]

Our understanding of the epidemiology and the impact of acute kidney injury (AKI) and fluid overload on outcomes has improved significantly over the past several decades. Fluid overload occurs commonly in critically ill children with and without associated AKI. Researchers in pediatric AKI have been at the forefront of describing the impact of fluid overload on outcomes in a variety of populations. A full understanding of this topic is important as fluid overload represents a potentially modifiable risk factor and a target for intervention. In this state-of-the-art review, we comprehensively describe the definition of fluid overload, the impact of fluid overload on kidney function, the impact of fluid overload on the diagnosis of AKI, the association of fluid overload with outcomes, the targeted therapy of fluid overload, and the impact of the timing of renal replacement therapy on outcomes., Author(s): David T Selewski [sup.1] , Stuart L Goldstein [sup.2] Author Affiliations: (1) 0000000086837370, grid.214458.e, Division of Nephrology, Department of Pediatrics & Communicable Diseases, C.S. Mott Children's Hospital, University of [...]

Author(s): Miet Schetz [sup.1], John Prowle [sup.2] [sup.3] Author Affiliations: (1) 0000 0001 0668 7884, grid.5596.f, Division of Cellular and Molecular Medicine, Clinical Department and Laboratory of Intensive Care Medicine, [...]

Author(s): Lui G. Forni [sup.1] [sup.2], Michael Darmon [sup.3] [sup.4], Miet Schetz [sup.5] Author Affiliations: (1) grid.451052.7, 0000 0004 0581 2008, Department of Intensive Care Medicine, Royal Surrey County Hospital, [...]

Acute kidney injury (AKI) is a frequent complication of critical illness and carries a significant risk of short- and long-term mortality, chronic kidney disease (CKD) and cardiovascular events. The degree of renal recovery from AKI may substantially affect these long-term endpoints. Therefore maximising recovery of renal function should be the goal of any AKI prevention and treatment strategy. Defining renal recovery is far from straightforward due in part to the limitations of the tests available to assess renal function. Here, we discuss common pitfalls in the evaluation of renal recovery and provide suggestions for improved assessment in the future. We review the epidemiology of renal recovery and of the association between AKI and the development of CKD. Finally, we stress the importance of post-discharge follow-up of AKI patients and make suggestions for its incorporation into clinical practice. Summary key points are that risk factors for non-recovery of AKI are age, CKD, comorbidity, higher severity of AKI and acute disease scores. Second, AKI and CKD are mutually related and seem to have a common denominator. Third, despite its limitations full recovery of AKI may best be defined as the absence of AKI criteria, and partial recovery as a fall in AKI stage. Fourth, after an episode of AKI, serial follow-up measurements of serum creatinine and proteinuria are warranted to diagnose renal impairment and prevent further progression. Measures to promote recovery are similar to those preventing renal harm. Specific interventions promoting repair are still experimental., Author(s): L. G. Forni [sup.1] [sup.2], M. Darmon [sup.3], M. Ostermann [sup.4], H. M. Oudemans-van Straaten [sup.5], V. Pettilä [sup.6], J. R. Prowle [sup.7], M. Schetz [sup.8], M. Joannidis [sup.9] [...]

Background Continuous renal replacement therapy (CRRT) has emerged as the modality of choice for the management of high-risk neonates with acute kidney injury (AKI), inborn errors of metabolism and multi-organ dysfunction. The aim of this study was to evaluate fluid overload (FO) and investigate the factors associated with outcomes in neonates undergoing CRRT. Methods We retrospectively reviewed the medical records of 34 neonates with AKI who were admitted to the neonatal intensive care unit (NICU) of Samsung Medical Center, Seoul, Republic of Korea between January 2007 and December 2014 where they underwent at least 24 h of CRRT. Results The survival rates of patients with an FO of [greater than or equal to]30 % at the time of CRRT initiation were lower than those of patients with an FO of Conclusions Neonates with a higher percentage FO and higher levels of serum creatinine at CRRT initiation showed poor outcomes. Early initiation of CRRT before the development of severe FO or azotemia might improve the outcomes of neonates requiring CRRT., Author(s): Sang Taek Lee[sup.1] , Heeyeon Cho[sup.1] Author Affiliations: (1) Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, 135-710, Gangnam-gu, SeoulSouth Korea Introduction There has [...]

Pediatric acute kidney injury (AKI) represents a complex disease process for clinicians as it is multifactorial in cause and only limited treatment or preventatives are available. The renal microvasculature has recently been implicated in AKI as a strong therapeutic candidate involved in both injury and recovery. Significant progress has been made in the ability to study the renal microvasculature following ischemic AKI and its role in repair. Advances have also been made in elucidating cell-cell interactions and the molecular mechanisms involved in these interactions. The ability of the kidney to repair post AKI is closely linked to alterations in hypoxia, and these studies are elucidated in this review. Injury to the microvasculature following AKI plays an integral role in mediating the inflammatory response, thereby complicating potential therapeutics. However, recent work with experimental animal models suggests that the endothelium and its cellular and molecular interactions are attractive targets to prevent injury or hasten repair following AKI. Here, we review the cellular and molecular mechanisms of the renal endothelium in AKI, as well as repair and recovery, and potential therapeutics to prevent or ameliorate injury and hasten repair., Author(s): Katherine Maringer[sup.1] [sup.2] , Sunder Sims-Lucas[sup.1] [sup.2] [sup.3] Author Affiliations: (1) Rangos Research Center, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA (2) Division of Nephrology, Department of [...]

Background Mortality among critically ill children requiring continuous renal replacement therapy (CRRT) is high. Several factors have been identified as outcome predictors. Many studies have specifically reported a positive association between the fluid overload at CRRT initiation and the mortality of critically ill pediatric patients. Methods This study is a retrospective single-center analysis including all patients admitted to the pediatric intensive care unit (PICU) of our hospital who received CRRT between 2000 and 2012. One hundred thirty-one patients were identified and subsequently classified according to primary disease. Survival rates, severity of illness and fluid balance differed among subgroups. The primary outcome was patient survival to PICU discharge. Results Overall survival to PICU discharge was 45.8 %. Based on multiple regression analysis, mortality was independently associated with onco-hematological disease [odds ratio (OR) 11.7, 95 % confidence interval (CI) 1.3-104.7; p = 0.028], severe multiple organ dysfunction syndrome (MODS) (OR 5.1, 95 % CI 1.7-15; p = 0.003) and hypotension (OR 11.6, 95 % CI 1.4-93.2; p = 0.021). In the subgroup analysis, a fluid overload (FO) of more than 10 % (FO>10 %) at the beginning of CRRT seems to be a negative predictor of mortality (OR 10.9, 95 % CI 0.78-152.62; p = 0.07) only in children with milder disease (renal patients). Due to lack of statistical power, the independent effect of fluid overload on mortality could not be analyzed in all subgroups of patients. Conclusions In children treated with CRRT the underlying diagnosis and severity of illness are independent risk factors for mortality. The degree of FO is a negative predictor only in patients with milder disease., Author(s): Lara de Galasso[sup.1] , Francesco Emma[sup.2] , Stefano Picca[sup.2] , Matteo Di Nardo[sup.3] , Emanuele Rossetti[sup.3] , Isabella Guzzo[sup.2] Author Affiliations: (1) Nephrology and Dialysis A Unit, 'Sapienza' University [...]

Purpose To summarize evidence on long-term health-related quality-of-life (HRQL) among survivors of acute kidney injury (AKI) in the intensive care unit (ICU). Methods We performed a comprehensive search of the literature for studies reporting original data describing HRQL utilizing validated instruments. Search, study selection and data abstraction were performed in duplicate. Study quality was appraised. Due to study heterogeneity, data are primarily summarized qualitatively. Results Our search yielded 2193 articles of which 18 were selected for detailed analysis. The quality of these 18 studies was generally good. Numerous HRQL instruments were utilized, and assessment occurred at variable follow-up duration (range 2 months to 14.5 years). HRQL among AKI survivors was reduced when compared to age/sex-matched populations. HRQL among survivors with and without AKI was generally described as similar beyond 6 months. Physical component domains were consistently more impaired than mental component domains. Survivors had considerable limitations in activities of daily living, implying newly acquired disability, with few returning to work. Despite diminished HRQL, patients' HRQL was generally perceived as satisfactory, and the majority would receive similar treatment again, including renal replacement therapy in the ICU, if necessary. Conclusions Among survivors of critical illness complicated by AKI, HRQL was impaired when referenced to population norms, but it was not significantly different from that of survivors without AKI. Physical limitations and disabilities were more commonly exhibited by AKI patients. Importantly, the impaired HRQL was generally perceived as acceptable to patients, most of whom expressed willingness to undergo similar treatment in the future., Author(s): Pierre-Marc Villeneuve [sup.1] , Edward G. Clark [sup.2] [sup.3] , Lindsey Sikora [sup.4] , Manish M. Sood [sup.2] [sup.3] , Sean M. Bagshaw [sup.1] Author Affiliations: (1) grid.17089.37, Division [...]

Because of its multi-organ involvement, the syndrome of sepsis provides clinical challenges to a wide variety of health care providers. While multi-organ dysfunction triggered by sepsis requires general supportive critical care provided by intensivists, the impact of sepsis on renal function and the ability of renal replacement therapies to modulate its biologic consequences provide a significant opportunity for pediatric nephrologists and related care providers to impact outcomes. In this review, we aim to highlight newer areas of understanding of the pathobiology of sepsis with special emphasis on those aspects of particular interest to pediatric nephrology. As such, we aim to: (1) review the definition of sepsis and discuss advances in our mechanistic understanding of sepsis; (2) review current hypotheses regarding sepsis-induced acute kidney injury (AKI) and describe its epidemiology based on evolving definitions of AKI; (3) review the impact of renal failure on the immune system, highlighting the sepsis risk in this cohort and strategies that might minimize this risk; (4) review how renal replacement therapeutic strategies may impact sepsis-induced AKI outcomes. By focusing the review on these specific areas, we have omitted other important areas of the biology of sepsis and additional interactions with renal function from this discussion; however, we have aimed to provide a comprehensive list of references that provide contemporary reviews of these additional areas. Keywords Sepsis Multi-organ dysfunction * Intensive care * Acute kidney injury * Host immune response * Systemic inflammatory response syndrome, Defining 'sepsis' While the response of the human host to an invasive pathogen has been recognized for centuries, it was only in the early 1990s that any attempt at developing [...]

Author(s): Jason A. Roberts [sup.1] [sup.2] [sup.3] [sup.4], Jean-Yves Lefrant [sup.5] [sup.6], Jeffrey Lipman [sup.1] [sup.2] Author Affiliations: (1) 0000 0001 0688 4634, grid.416100.2, Department of Intensive Care Medicine, Royal [...]

Author(s): Rinaldo Bellomo [sup.1], Suvi T. Vaara [sup.2] [sup.3], John A. Kellum [sup.4] Author Affiliations: (1) 0000 0001 0162 7225, grid.414094.c, Department of Intensive Care and Department of Medicine, Austin [...]

Peritoneal dialysis (PD) is generally considered the preferred extracorporeal therapy for neonates with acute kidney injury (AKI). However, there are situations when PD is not suitable, such as in patients with previous abdominal surgery, hyperammonemia and significant ascites or anasarca. Additionally, with a need to start PD soon after catheter placement, there is increased risk of PD catheter leak and infection. Extracorporeal continuous renal replacement therapy (CRRT) is challenging in severely ill neonates as it requires obtaining adequately sized central venous access to accommodate adequate blood flow rates and also adaptation of a CRRT machine meant for older children and adults. In addition, ultrafiltration often cannot be set in sufficiently small increments to be suitable for neonates. Although CRRT practices can be modified to fit the needs of infants and neonates, there is a need for a device designed specifically for this population. Until that becomes available, providing the highest level of care for neonates with AKI is dependent on the shared experiences of members of the pediatric nephrology community., Author(s): Leyat Tal[sup.1] , Joseph R. Angelo[sup.1] , Ayse Akcan-Arikan[sup.1] [sup.2] Author Affiliations: (1) Renal Section, Department of Pediatrics, Baylor College of Medicine, Houston, TXUSA (2) Section of Pediatric Critical [...]

Background The sequential organ failure assessment (SOFA) score is easy to calculate and has been well validated as an outcome predictor in critically ill adult patients. However, its use in children has been limited, mainly because of differences in basal reference levels of serum creatinine. Methods Data include 87 patients requiring continuous renal replacement therapy (CRRT) between January 2005 and July 2011. We modified the SOFA score by excluding the renal component to an extrarenal SOFA score, based on the assumption that CRRT may mitigate the renal effect on outcome and investigated the utility in predicting outcome with comparison with pediatric risk of mortality (PRISM) III, pediatric logistic organ dysfunction (PELOD), and SOFA scores. Results Results showed that 95.4 % (n = 83) had multiple organ dysfunction syndrome with an overall mortality of 50.6 %. The extrarenal SOFA score at CRRT initiation and [greater than or equal to]20 % fluid overload were significantly associated with mortality. In comparison with the predictive power of various scoring systems, the extrarenal SOFA score showed the largest area under the receiver operating characteristic curve (extrarenal SOFA 0.774, SOFA 0.770, PRISM III 0.660, and PELOD 0.650). Conclusions The extrarenal SOFA score may be a useful prognostic marker in critically ill children treated with CRRT., Author(s): Won Kyoung Jhang [sup.1] , Young A. Kim [sup.1] , Eun Ju Ha [sup.1] , Yoon Jung Lee [sup.1] , Ju Hoon Lee [sup.1] , Young Seo Park [sup.1] [...]

Background The sequential organ failure assessment (SOFA) score is easy to calculate and has been well validated as an outcome predictor in critically ill adult patients. However, its use in children has been limited, mainly because of differences in basal reference levels of serum creatinine. Methods Data include 87 patients requiring continuous renal replacement therapy (CRRT) between January 2005 and July 2011. We modified the SOFA score by excluding the renal component to an extrarenal SOFA score, based on the assumption that CRRT may mitigate the renal effect on outcome and investigated the utility in predicting outcome with comparison with pediatric risk of mortality (PRISM) III, pediatric logistic organ dysfunction (PELOD), and SOFA scores. Results Results showed that 95.4% (n = 83) had multiple organ dysfunction syndrome with an overall mortality of 50.6%. The extrarenal SOFA score at CRRT initiation and > 20% fluid overload were significantly associated with mortality. In comparison with the predictive power of various scoring systems, the extrarenal SOFA score showed the largest area under the receiver operating characteristic curve (extrarenal SOFA 0.774, SOFA 0.770, PRISM III 0.660, and PELOD 0.650). Conclusions The extrarenal SOFA score may be a useful prognostic marker in critically ill children treated with CRRT. Keywords Multiple organ dysfunction syndrome * Continuous renal replacement therapy * Sequential organ failure assessment * Pediatric risk of mortality * Pediatric logistic organ dysfunction * Critically ill children, Introduction Pediatric patients with multiple organ dysfunction syndrome (MODS) often require several types of medications, blood product transfusions and nutritional support, which makes controlling and maintaining an adequate volume status [...]

Background Regional citrate anticoagulation (RCA) is one of the methods used to prevent clotting in continuous renal replacement therapy (CRRT). The aim of this study was to describe the outcomes and complications of RCA-CRRT in comparison to heparin anticoagulation (HA)-CRRT in critically ill children. Methods This study was a retrospective review of 30 critically ill children (16 on RCA- and 14 on HA-CRRT) who underwent at least 24 h of CRRT. The mean body weight of the children was 8.69 ± 5.63 kg. RCA-CRRT was performed with a commercially available pre-dilution citrate solution (Prismocitrate 18/0). Results The mean time on RCA-CRRT and HA-CRRT was 148.73 ± 131.58 and 110.24 ± 105.38 h, respectively. Circuit lifetime was significantly higher in RCA-CRRT than in HACRRT (58.04 ± 51.18 h vs. 37.64 ± 32.51 h, respectively; p = 0.030). Circuit clotting was observed in 11.63 % of children receiving RCA-CRRT and 34.15 % of those receiving HACRRT. Episodic electrolyte and metabolic disturbances were more common in children receiving RCA-CRRT. The survival at discharge from the hospital was 37.5 and 14.3 % among children receiving RCA-CRRT and HA-CRRT, respectively. Conclusions In critically ill children with a low body weight, RCA appeared to be safe and easy to used. Among our patient cohort, RCA was more effective in preventing circuit clotting and provided a better circuit lifetime than HA. Keywords Anticoagulation * Citrate * Children * Renal replacement therapy, Introduction Continuous forms of renal replacement therapy (CRRT) have become established as the treatment of choice for supporting critically ill patients with acute kidney injury [1, 2]. These patients present [...]

The rapid understanding of the cellular and molecular bases of organ function and disease processes will be translated in the next decade into new therapeutic approaches to a wide range of clinical disorders, including acute and chronic renal failure. Central to these new therapies are the developing technologies of cell therapy and tissue engineering, which are based on the ability to expand stem or progenitor cells in tissue culture to perform differentiated tasks and to introduce these cells into the patient either via extracorporeal circuits or as implantable constructs. Cell therapy devices are currently being developed to replace the filtrative, metabolic, and endocrinologic functions of the kidney lost in both acute and chronic renal failure. This review summarizes the current state of development of a wearable or implantable bioartificial kidney. These devices have the promise to be combined to produce a wearable or implantable bioartificial kidney for full renal replacement therapy that may significantly diminish morbidity and mortality in patients with acute or chronic kidney disease. Keywords Extracorporeal cell therapy Tissue engineering * Progenitorcells * Acute renalfailure * End-stage renal disease, Introduction The kidney was the first solid organ whose function was approximated by a machine and a synthetic device. In fact, renal substitution therapy with hemodialysis (HD) or peritoneal dialysis [...]

The changing epidemiology of acute kidney injury (AKI) in adults and children has resulted in more patients being treated for kidney injury occurring in the context of multi-organ failure requiring treatment in the intensive care unit (ICU). AKI complicating critical illness has complex, multi-factorial etiology, and supportive care, including organ support, remains the mainstay of therapy. In the day-to-day management of AKI in the ICU two of the major challenges are the inadequacy of current diagnostics for the early identification of AKI and the relationship between hemodynamic resuscitation strategies and the development of AKI. This review focuses on these areas from the intensivist's perspective. Given that the diagnosis of AKI is often delayed, the prevention of complications and limitation of secondary renal injury are of particular importance. Fluid overload is increasingly being associated with adverse patient outcomes in critical illness and may contribute to persistent renal dysfunction. Thus, hemodynamic management strategies in AKI should be tailored to limit fluid overload as much as possible. Keywords Acute kidney injury * Diagnosis * Critical care * Fluid overload * Adults * Children, Introduction AKI epidemiology Acute kidney injury (AKI) remains a significant clinical challenge in both adult and pediatric critical care. Increased awareness and the adoption of consensus definitions for the diagnosis [...]

Successful antibiotic therapy in the critically ill requires sufficient drug concentrations at the site of infection that kill or suppress bacterial growth. The relationship between antibiotic exposure and achieving the above effects is referred to as pharmacokinetics/pharmacodynamics (PK/PD). The associated indices therefore provide logical targets for optimal antibiotic therapy. While dosing regimens to achieve such targets have largely been established from studies in animals and non-critically ill patients, they are often poorly validated in the ICU. Endothelial dysfunction, capillary leak, altered major organ blood flow, deranged plasma protein concentrations, extremes of body habitus, the application of extracorporeal support modalities, and a higher prevalence of intermediate susceptibility, independently, and in combination, significantly confound successful antibiotic treatment in this setting. As such, the prescription of standard doses are likely to result in sub-therapeutic concentrations, which in turn may promote treatment failure or the selection of resistant pathogens. This review article considers these issues in detail, summarizing the key changes in antibiotic PK/PD in the critically ill, and suggesting alternative dosing strategies that may improve antibiotic therapy in these challenging patients., Author(s): Andrew A. Udy [sup.1] [sup.2], Jason A. Roberts [sup.1] [sup.2] [sup.3], Jeffrey Lipman [sup.1] [sup.2] Author Affiliations: (1) grid.1003.2, 0000000093207537, Burns, Trauma, and Critical Care Research Centre, Royal Brisbane [...]

There is a growing appreciation for the role that acute kidney injury (AKI) plays in the propagation of critical illness. In children, AKI is not only an independent predictor of morbidity and mortality, but is also associated with especially negative outcomes when concurrent with acute lung injury (ALI). Experimental data provide evidence that kidney-lung crosstalk occurs and can be bidirectionally deleterious, although details of the precise molecular mechanisms involved in the AKI-ALI interaction remain incomplete. Clinically, ALI, and the subsequent clinical interventions used to stabilize gas exchange, carry consequences for the homeostasis of kidney function. Meanwhile, AKI negatively affects lung physiology significantly by altering the homeostasis of fluid balance, acid-base balance, and vascular tone. Experimental AKI research supports an 'endocrine' role for the kidney, triggering a cascade of extra-renal inflammatory responses affecting lung homeostasis. In this review, we will discuss the pathophysiologyof kidney-lung crosstalk, the multiple pathways by which AKI affects kidney-lung homeostasis, and discuss how these phenomena may be unique in critically ill children. Understanding how AKI may affect a 'balance of communication' that exists between the kidneys and the lungs is requisite when managing critically ill children, in whom imbalance is the norm. Keywords kidney-lung crosstalk * AKI * ALI * Fluid overload * Renal angina, Introduction Organ cross-talk is of particular importance to practitioners in the intensive care unit (ICU); many disease processes that affect ICU patients carry the potential to affect a number of [...]

Byline: Helmut. Schiffl Critically ill patients with severe acute kidney injury (AKI-D) require renal replacement therapy (RRT) increasingly. However, the optimal timing of initiation of RRT for non-life-threatening indications of [...]

Purpose Choice of renal replacement therapy (RRT) modality may affect renal recovery after acute kidney injury (AKI). We sought to compare the rate of dialysis dependence among severe AKI survivors according to the choice of initial renal replacement therapy (RRT) modality applied [continuous (CRRT) or intermittent (IRRT)]. Methods Systematic searches of peer-reviewed publications in MEDLINE and EMBASE were performed (last update July 2012). All studies published after 2000 reporting dialysis dependence among survivors from severe AKI requiring RRT were included. Data on follow-up duration, sex, age, chronic kidney disease, illness severity score, vasopressors, and mechanical ventilation were extracted when available. Results were pooled using a random-effects model. Results We identified 23 studies: seven randomized controlled trials (RCTs) and 16 observational studies involving 472 and 3,499 survivors, respectively. Pooled analyses of RCTs showed no difference in the rate of dialysis dependence among survivors (relative risk, RR 1.15 [95 % confidence interval (CI) 0.78-1.68], I.sup.2 = 0 %). However, pooled analyses of observational studies suggested a higher rate of dialysis dependence among survivors who initially received IRRT as compared with CRRT (RR 1.99 [95 % CI 1.53-2.59], I.sup.2 = 42 %). These findings were consistent with adjusted analyses (performed in 7/16 studies), which found a higher rate of dialysis dependence in IRRT-treated patients [odds ratio (OR) 2.2-25 (5 studies)] or no difference (2 studies). Conclusions Among AKI survivors, initial treatment with IRRT might be associated with higher rates of dialysis dependence than CRRT. However, this finding largely relies on data from observational trials, potentially subject to allocation bias, hence further high-quality studies are necessary., Author(s): Antoine G. Schneider [sup.1] [sup.2], Rinaldo Bellomo [sup.1] [sup.2], Sean M. Bagshaw [sup.3], Neil J. Glassford [sup.1] [sup.2], Serigne Lo [sup.4], Min Jun [sup.4], Alan Cass [sup.4], Martin Gallagher [...]

Background Acute kidney injury (AKI) is common and portends mortality in several neonatal cohorts. Fluid overload is independently associated with poor outcomes in children and adults but has not been extensively studied in neonates. Methods Between February 2010 and May 2011, we followed 58 neonates who met the following criteria: birth weight >2,000 g, gestational age ≥34 weeks, 5-min Apgar [less than or equal to]7, and parental consent. Serum creatinine (SCr) was measured daily for first 4 days of life. AKI was defined as a rise in SCr of > 0.3 mg/dl or persistent SCr above 1.5 mg/dl. Results AKI was present in 9/58 (15.6 %) neonates and was associated with higher birth weight, being male, lower 5-min Apgar scores, lower cord pH, delivery room intubation, and absence of maternal pre-eclampsia. Percent weight accumulation at day 3 of life was higher in those with AKI [median= 8.2, interquartile range (IQR)=4.4-21.6)] than without AKI (median=-4 (IQR=-6.5 to 0.0) (p Conclusions AKI incidence in this neonatal population is similar to other neonatal cohorts. Near-term/term infants with AKI have a higher mortality rate and a net positive fluid balance over the first few days of life. Keywords Epidemiology * Acute renal failure * Fluid overload * Mortality * Infant, Introduction Acute kidney injury (AKI) is common in the neonatal intensive care unit (NICU). Based on single-center prospective and retrospective data, the incidence of AKI is 19 % in premature [...]

We conducted a prospective study in pediatric patients presenting to an emergency center (EC) to (1) test the ability of urinary acute kidney injury (AKI) biomarkers to predict AKI presence and severity and (2) determine if these biomarkers offer similar precision in patients with versus without a known baseline SCr. The accuracy of five putative urinary biomarkers to detect AKI presence and severity was evaluated in 252 children presenting to our EC. AKI was defined by the modified pediatric RIFLE (pRIFLE) system. Eighteen children had AKI by pRIFLE, yet 33-50% of these AKI cases may have been missed since the EC SCr was 0.70 to 0.80) to predict patients with pRIFLE-Injury (>50% decrease in eCCl) versus patients with pRIFLE-Risk (25-50% decrease in eCCl) or without AKI. Our data suggest urinary biomarkers may serve well to detect AKI accurately in the pediatric EC setting, even in cases where SCr levels are normal. Further study is required to determine if these biomarkers obtained in the EC can predict AKI development or progression in hospitalized patients. Keywords Acute kidney injury * Biomarkers * Children * Emergency center, Introduction Substantial research over the past decade has been focused on discovery and validation of urinary biomarkers to detect acute kidney injury (AKI) development prior to a rise in serum [...]

The incidence of pediatric acute kidney injury (AKI) is increasing. AKI has been found to be independently associated with increased mortality, and current management options are limited in that they are mainly supportive. The use of various definitions of AKI can still be found in the literature, making it difficult to discern the epidemiology behind pediatric AKI. The use of a more uniform definition is a necessary first step to clarify AKI epidemiology and direct our research efforts, and it will ultimately improve prognosis. There is evidence that neonates and infants may be at higher risk for AKI than adults. However, the least amount of research is found for this youngest age group, and more focused efforts on this population are necessary. This paper reviews existing data on and definitions for pediatric AKI, general preventive and treatment strategies, as well as ongoing research efforts on AKI. We are hopeful that the prognosis of AKI will improve with collaboration on a multicenter, multinational scale in the form of prospective, long-term studies on pediatric AKI. Keywords Acute kidney injury * Children * Pediatric * Prognosis, Introduction Acute kidney injury (AKI) is independently associated with increased mortality and morbidity in both children and adults. Even small increments in serum creatinine (SCr) levels of as little as [...]

Purpose Anticoagulation during renal replacement therapy remains an important challenge for burn patients due to their high risk of bleeding. In this study we compared the efficacy and safety of citrate anticoagulation to heparin anticoagulation for hemodiafiltration (HDF) in severe burn patients, focusing on metabolic tolerance and handling of citrate. Methods Retrospective observational study (January 2000-December 2007) at a university teaching hospital. Among 548 patients admitted with burns, 70 severe burn septic shock patients (median age 57.5 years, interquartile range 42-76 years; median burned surface area 40%, interquartile range 30-60%) who underwent HDF for more than 24 h were included. Results Of the 70 HDF patients, 31 at high risk of bleeding were treated with citrate and 39 with heparin, with a mortality rate of 70.9 and 71.8%, respectively. In continuous venovenous hemodiafiltration (CVVHDF), the filter survival was higher with citrate, and hemorrhagic complications were lower (0.035 vs. 0.145 episodes/day, respectively). During citrate CVVHDF [median delivered dialysis dose: 578.9 ml kg.sup.-1 day.sup.-1 (461.5-769.2 ml kg.sup.-1 day.sup.-1)] in catecholamine-supported patients (norepinephrine 0.53 [mu]g kg.sup.-1 min.sup.-1), no metabolic derangements in pH, bicarbonates, Na+, K+, Ca++, and ionized calcium were observed. Systemic citratemia was within the normal range ( Conclusions In septic shock burn patients, citrate for CVVHDF was efficient and safe, and superior to heparin for hemorrhagic complications and filter survival. Observed metabolic stability was most likely due to a marked loss of citrate in effluent volume and subsequent low total citrate load for the patient., Author(s): Filippo Mariano [sup.1], Luisa Tedeschi [sup.2], Maurizio Morselli [sup.3], Maurizio Stella [sup.4], Giorgio Triolo [sup.1] Author Affiliations: (1) grid.413186.9, Nephrology and Dialysis Unit, Department of Medicine Area, CTO Hospital, [...]

Objective To study the clinical course in children requiring continuous renal replacement therapy (CRRT) and to analyse factors associated with mortality. Design Prospective observational study. Setting Paediatric intensive care department of a tertiary university hospital. Patients Critically ill children with CRRT were included in the study. Intervention Continuous renal replacement therapy. Measurements and results Univariate and multivariate analyses were performed to analyse the influence of each factor on mortality. The ability of the PRISM, PIM II and PELOD severity of illness scores to predict mortality was tested using receiver-operating characteristic curve statistics. A total of 174 children aged between 1 month and 22 years were treated with CRRT. Mortality was 35.6%, and multiorgan failure and haemodynamic disturbances were the principal causes of death. Mortality was higher in children less than 12 months of age (44.7%; P = 0.037) and in patients with a diagnosis of sepsis (44.1%; P = 0.001). Haemodynamic disturbances at the time of starting CRRT (hypotension or need for adrenaline >0.6 [micro]g/kg/min) and the presence of multiorgan failure were the factors associated with an increased risk of mortality. The PRISM scale was the severity score with the best predictive capacity, although all three scales underestimated the actual mortality. Conclusions Mortality in children who require CRRT is high. Haemodynamic disturbances and the presence of multiorgan failure at the time of starting the technique are the factors associated with a higher mortality. The clinical severity scores underestimate mortality in children requiring CRRT., Author(s): Maria J. Santiago [sup.1] [sup.3], Jesús López-Herce [sup.1] [sup.3], Javier Urbano [sup.1] [sup.3], Maria José Solana [sup.1] [sup.3], Jimena del Castillo [sup.1] [sup.3], Yolanda Ballestero [sup.1] [sup.3], Marta Botrán [...]

A prospective observational study was performed to analyze the clinical course of critically ill children who require continuous renal replacement therapy (CRRT). Variables associated with prolonged CRRT were analyzed. Of the 174 children treated with CRRT, 32 (18.3%) required CRRT for >14 days and 20 (11.5%) for >21 days. Prolonged CRRT was more common in patients with heart disease and those requiring mechanical ventilation, hemodiafiltration, and higher doses of heparin. The same factors were found when patients with CRRT for >14 days and 21 days were studied. Overall mortality rate was 35.6%; it was slightly higher in patients on prolonged CRRT (43.7% with CRRT>14 days and 45% with CRRT>21 days), though the differences were not statistically significant. We conclude that there were no differences in the preCRRT clinical characteristics, severity of illness, and renal function in critically ill children requiring prolonged CRRT. Prolonged CRRT was more frequently required by patients with heart disease and those on mechanical ventilation. Patients with prolonged CRRT required more frequent hemodiafiltration and higher doses of heparin. Mortality was slightly higher in children with longer CRRT, though this difference did not reach statistical significance. Keywords Acute renal failure * Continuous renal replacement therapy * Critically ill children * Prognostic factors * Dialysis, Introduction Acute kidney injury is a relatively common complication among critically ill children [1-3]. Though renal replacement therapy (RRT) is only required by a small percentage of these patients, the [...]

Byline: Yuen. Jeffrey, Shum. Hoi-Ping, Anne. Kit Hung, Lam. Chung-Ling, Yan. Wing-Wa, Lai. King-Yiu Context: Regional citrate anticoagulation for continuous renal replacement therapy is associated with a longer filter-life, less [...]

Byline: Arghya. Majumdar Acute kidney injury (AKI) is a common sequel of sepsis in the intensive care unit. It is being suggested that sepsis-induced AKI may have a distinct pathophysiology [...]