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Published on: August 9, 2014
Patterns of Multiple Organ Dysfunction and Renal Recovery in Critically Ill Children and Young Adults Receiving
Sameer Thadani1,2, Dana Fuhrman3,4,5, Claire Hanson4
1Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX.
Insights
Critically ill children with acute kidney injury requiring dialysis often develop multiple organ dysfunction syndrome. Extrarenal organ dysfunction and worsening MODS are linked to poor kidney recovery in these patients.
Area of Science:
- Pediatric critical care medicine
- Nephrology
- Intensive care
Background:
- Acute kidney injury requiring dialysis (AKI-D) is common in critically ill children with multiple organ dysfunction syndrome (MODS).
- Continuous renal replacement therapy (CRRT) is the standard treatment for AKI-D in this population.
- Mid-term renal outcomes for pediatric patients with AKI-D treated with CRRT are not well understood.
Purpose of the Study:
- To investigate the mid-term renal outcomes of critically ill children and young adults with AKI-D.
- To identify patterns of organ dysfunction and their impact on renal recovery.
- To analyze factors associated with major adverse kidney events at 30 days (MAKE30).
Main Methods:
- Retrospective cohort study conducted at two quaternary care pediatric hospitals.
- Included patients aged 26 years or younger who received CRRT between 2014 and 2020, excluding those with pre-existing chronic kidney disease.
- Organ dysfunction assessed using the Pediatric Logistic Organ Dysfunction-2 (PELOD-2) score; MODS defined as ≥2 organ dysfunctions.
Main Results:
- 373 patients analyzed; 97% developed MODS by CRRT initiation.
- 71% of patients experienced MAKE30.
- Independent predictors of MAKE30 included AKI-D, neurologic dysfunction, hematologic/oncologic dysfunction at CRRT start, and progressive MODS.
Conclusions:
- The majority of critically ill children with AKI-D develop MODS by the time CRRT is initiated.
- Poor renal recovery is associated with specific extrarenal organ dysfunctions and worsening MODS.
- Future clinical trials for renal recovery should consider incorporating extrarenal organ support strategies and modifiable risk factors.
Objectives:
Acute kidney injury requiring dialysis (AKI-D) commonly occurs in the setting of multiple organ dysfunction syndrome (MODS). Continuous renal replacement therapy (CRRT) is the modality of choice for AKI-D. Mid-term outcomes of pediatric AKI-D supported with CRRT are unknown. We aimed to describe the pattern and impact of organ dysfunction on renal outcomes in critically ill children and young adults with AKI-D.
Design:
Retrospective cohort.
Setting:
Two large quarternary care pediatric hospitals.
Patients:
Patients 26 y old or younger who received CRRT from 2014 to 2020, excluding patients with chronic kidney disease.
Interventions:
None.
Measurements And Main Results:
Organ dysfunction was assessed using the Pediatric Logistic Organ Dysfunction-2 (PELOD-2) score. MODS was defined as greater than or equal to two organ dysfunctions. The primary outcome was major adverse kidney events at 30 days (MAKE30) (decrease in estimated glomerular filtration rate greater than or equal to 25% from baseline, need for renal replacement therapy, and death). Three hundred seventy-three patients, 50% female, with a median age of 84 mo (interquartile range [IQR] 16-172) were analyzed. PELOD-2 increased from 6 (IQR 3-9) to 9 (IQR 7-12) between ICU admission and CRRT initiation. Ninety-seven percent of patients developed MODS at CRRT start and 266 patients (71%) had MAKE30. Acute kidney injury (adjusted odds ratio [aOR] 3.55 [IQR 2.13-5.90]), neurologic (aOR 2.07 [IQR 1.15-3.74]), hematologic/oncologic dysfunction (aOR 2.27 [IQR 1.32-3.91]) at CRRT start, and progressive MODS (aOR 1.11 [IQR 1.03-1.19]) were independently associated with MAKE30.
Conclusions:
Ninety percent of critically ill children and young adults with AKI-D develop MODS by the start of CRRT. Lack of renal recovery is associated with specific extrarenal organ dysfunction and progressive multiple organ dysfunction. Currently available extrarenal organ support strategies, such as therapeutic plasma exchange lung-protective ventilation, and other modifiable risk factors, should be incorporated into clinical trial design when investigating renal recovery.
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