Dataset Information

Patient-centered outcomes in pediatric continuous kidney replacement therapy: new morbidity and worsened functional status in survivors.

ABSTRACT:

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 (≥3 increase in FSS); majority qualified as moderate to severe disability (FSS ≥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.

SUBMITTER: Smith M

PROVIDER: S-EPMC8263014 | biostudies-literature | 2021 Jul

REPOSITORIES: biostudies-literature

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Publications

Patient-centered outcomes in pediatric continuous kidney replacement therapy: new morbidity and worsened functional status in survivors.

Smith Mallory M Bell Cynthia C Vega Molly Wong MW Tufan Pekkucuksen Naile N Loftis Laura L McPherson Mona M Graf Jeanine J Akcan Arikan Ayse A

Pediatric nephrology (Berlin, Germany) 20210707 1

<h4>Background</h4>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 ai ...[more]

PMID: 34235579

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Project description:ImportanceContinuous kidney replacement therapy (CKRT) is increasingly used in youths with critical illness, but little is known about longer-term outcomes, such as persistent kidney dysfunction, continued need for dialysis, or death.ObjectiveTo characterize the incidence and risk factors, including liberation patterns, associated with major adverse kidney events 90 days after CKRT initiation (MAKE-90) in children, adolescents, and young adults.Design, setting, and participantsThis international, multicenter cohort study was conducted among patients aged 0 to 25 years from The Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK) registry treated with CKRT for acute kidney injury or fluid overload from 2015 to 2021. Exclusion criteria were dialysis dependence, concurrent extracorporeal membrane oxygenation use, or receipt of CKRT for a different indication. Data were analyzed from May 2 to December 14, 2023.ExposurePatient clinical characteristics and CKRT parameters were assessed. CKRT liberation was classified as successful, reinstituted, or not attempted. Successful liberation was defined as the first attempt at CKRT liberation resulting in 72 hours or more without return to dialysis within 28 days of CKRT initiation.Main outcomes and measuresMAKE-90, including death or persistent kidney dysfunction (dialysis dependence or ≥25% decline in estimated glomerular filtration rate from baseline), were assessed.ResultsAmong 969 patients treated with CKRT (529 males [54.6%]; median [IQR] age, 8.8 [1.7-15.0] years), 630 patients (65.0%) developed MAKE-90. On multivariable analysis, cardiac comorbidity (adjusted odds ratio [aOR], 1.60; 95% CI, 1.08-2.37), longer duration of intensive care unit admission before CKRT initiation (aOR for 6 days vs 1 day, 1.07; 95% CI, 1.02-1.13), and liberation pattern were associated with MAKE-90. In this analysis, patients who successfully liberated from CKRT within 28 days had lower odds of MAKE-90 compared with patients in whom liberation was attempted and failed (aOR, 0.32; 95% CI, 0.22-0.48) and patients without a liberation attempt (aOR, 0.02; 95% CI, 0.01-0.04).Conclusions and relevanceIn this study, MAKE-90 occurred in almost two-thirds of the population and patient-level risk factors associated with MAKE-90 included cardiac comorbidity, time to CKRT initiation, and liberation patterns. These findings highlight the high incidence of adverse outcomes in this population and suggest that future prospective studies are needed to better understand liberation patterns and practices.

Project description:ImportanceContinuous kidney replacement therapy (CKRT) is the preferred method of kidney support for children with critical illness in pediatric intensive care units (PICUs). However, there are no data on the current CKRT management practices in European PICUs.ObjectiveTo describe current CKRT practices across European PICUs.Design, setting, and participantsThis cross-sectional survey of PICUs in 20 European countries was conducted by the Critical Care Nephrology Section of the European Society of Pediatric and Neonatal Intensive Care from April 1, 2020, to May 31, 2022. Participants included intensivists and nurses working in European PICUs. The survey was developed in English and distributed using SurveyMonkey. One response from each PICU that provided CKRT was included in the analysis. Data were analyzed from June 1 to June 30, 2022.Main outcome and measuresDemographic characteristics of European PICUs along with organizational and delivery aspects of CKRT (including prescription, liberation from CKRT, and training and education) were assessed.ResultsOf 283 survey responses received, 161 were included in the analysis (response rate, 76%). The attending PICU consultant (70%) and the PICU team (77%) were mainly responsible for CKRT prescription, whereas the PICU nurses were responsible for circuit setup (49%) and bedside machine running (67%). Sixty-one percent of permanent nurses received training to use CKRT, with no need for certification or recertification in 36% of PICUs. Continuous venovenous hemodiafiltration was the preferred dialytic modality (51%). Circuit priming was performed with normal saline (67%) and blood priming in children weighing less than 10 kg (56%). Median (IQR) CKRT dose was 35 (30-50) mL/kg/h in neonates and 30 (30-40) mL/kg/h in children aged 1 month to 18 years. Forty-one percent of PICUs used regional unfractionated heparin infusion, whereas 35% used citrate-based regional anticoagulation. Filters were changed for filter clotting (53%) and increased transmembrane pressure (47%). For routine circuit changes, 72 hours was the cutoff in 62% of PICUs. Some PICUs (34%) monitored fluid removal goals every 4 hours, with variation from 12 hours (17%) to 24 hours (13%). Fluid removal goals ranged from 1 to 3 mL/kg/h. Liberation from CKRT was performed with a diuretic bolus followed by an infusion (32%) or a diuretic bolus alone (19%).Conclusions and relevanceThis survey study found a wide variation in current CKRT practice, including organizational aspects, education and training, prescription, and liberation from CKRT, in European PICUs. This finding calls for concerted efforts on the part of the pediatric critical care and nephrology communities to streamline CKRT education and training, research, and guidelines to reduce variation in practice.

Project description:Increasing numbers of patients are undergoing hematopoietic cell transplantation (HCT); however, further characterization of late kidney outcomes in HCT recipients is needed. This study investigated long-term kidney outcomes in HCT survivors and compared the risk of late kidney morbidity/mortality in these survivors with that in non-HCT cancer survivors and the general population. A cohort of long-term (≥2 years) allogeneic and autologous HCT survivors treated for cancer at our institution between 1992 and 2009 (n = 1792) was compared with a non-HCT cancer cohort selected from the state cancer registry (n = 5455) matched on diagnosis, sex, and age at year of cancer diagnosis/HCT (index date). Additional comparisons were made with a matched general population sample drawn from state driver's licensing files (DOL; n = 16,340). Statewide hospital discharge codes and death registry codes (International Classification of Diseases 9/10) were used to identify cases of acute kidney failure (AKF) and chronic kidney disease (CKD) occurring ≥2 years after the index date. Cumulative incidence rates and hazard ratios (HRs; according to multivariable proportional hazard models) estimated the absolute and relative risks of AKF and CKD. Among HCT survivors, we examined the influence of additional characteristics including estimated glomerular filtration rate (eGFR) at 1-year post-HCT. The cumulative incidence rates of late kidney complications were slightly greater in the HCT survivors versus the non-HCT cancer survivors at 10 years after the index date. Both groups were more likely to experience late AKF or CKD morbidity/mortality compared with the general population (AKF: HCT, 9.4%; non-HCT, 7.7%; DOL, 1.8%; CKD: HCT, 5.7%; non-HCT, 5.0%; DOL, 1.2%). Differences between HCT survivors and non-HCT survivors were seen primarily starting 5 years after the index date, with increased hazards for late AKF (HR, 1.4; 95% confidence interval [CI], 1.1 to 1.9) and CKD (HR, 1.9; 95% CI, 1.3 to 2.8). Among allogeneic HCT survivors, the presence of hypertension at <2 years post-HCT was significantly associated with subsequent AKF (HR, 2.9; 95% CI, 1.7 to 5.0) and CKD (HR, 5.2; 95% CI, 2.7 to 10.0) at 2 to 10 years post-HCT, with similar associations seen for autologous HCT survivors. Low eGFR (<60 mL/min/1.73 m2) at 1 year post-HCT was associated with late AKF morbidity/mortality for both allogeneic (HR, 5.3; 95% CI, 2.1 to 13.2) and autologous HCT (HR, 2.7; 95% CI, 1.2 to 6.3) compared with survivors with normal eGFR (>90 mL/min/1.73 m2). Overall, the risk for hospitalization or death from AKF or CKD continued to increase with time from HCT and exceeded that of non-HCT cancer survivors at >5 years after treatment. Appropriate screening and early intervention with medication adjustments or lifestyle modifications in those with hypertension or evidence of abnormal eGFR post-HCT could potentially mitigate this risk.

Project description:Pediatric sepsis remains a significant cause of childhood morbidity and mortality, disproportionately affecting resource-limited settings. As more patients survive, it is paramount that we improve our understanding of post-sepsis morbidity and its impact on functional outcomes. The functional status scale (FSS) is a pediatric validated outcome measure quantifying functional impairment, previously demonstrating decreased function following critical illnesses, including sepsis, in resource-rich settings. However, functional outcomes utilizing the FSS in pediatric sepsis survivors have never been studied in resource-limited settings or in non-critically ill septic children. In a Tanzanian cohort of pediatric sepsis patients, we aimed to evaluate morbidity associated with an acute septic episode using the FSS modified for resource-limited settings. This was a prospective cohort study at an urban referral hospital in Tanzania, including children with sepsis aged 28 days to 14 years old over a 12-month period. The FSS was adapted to the site's available resources. Functional status scale scores were obtained by interviewing guardians both at the time of presentation to determine the child's baseline and at 28-day follow-up. The primary outcome was "decline in functional status," as defined by a change in FSS score of at least 3. In this cohort, 4.3% of the 1,359 surviving children completing 28-day follow-up had a "decline in functional status." Conversely, 13.8% of guardians reported that their child was not yet back to their pre-illness state. Three-quarters of children reported as not fully recovered were not identified via the FSS as having a decline in functional status. In our cohort of pediatric sepsis patients, we identified a low rate of decline in functional status when using the FSS adapted for resource-limited settings. A higher proportion of children were subjectively identified as not being recovered to baseline. This suggests that the FSS has limitations in this population, despite being adapted for resource-limited settings. Next steps include developing and validating a further revised FSS to better capture patients identified as not recovered but missed by the current FSS.

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Dataset Information

Patient-centered outcomes in pediatric continuous kidney replacement therapy: new morbidity and worsened functional status in survivors.

Background

Methods

Results

Conclusions

Publications

Patient-centered outcomes in pediatric continuous kidney replacement therapy: new morbidity and worsened functional status in survivors.

Similar Datasets

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