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Kidney Replacement Therapies and Outcomes in Children With Crush Syndrome-Associated Kidney Injury
Demet Demirkol1, Tolga Besci1, Merve Havan2
1Department of Pediatric Intensive Care, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.
Insights
Late transfer to intensive care and high trauma scores in children with earthquake-related crush syndrome increase dialysis dependency. Early intervention is crucial for acute kidney injury (AKI) management in pediatric patients following entrapment.
Area of Science:
- Pediatric Nephrology
- Trauma Surgery
- Disaster Medicine
Background:
- Earthquake-related crush injuries can lead to crush syndrome and acute kidney injury (AKI) in children.
- Kidney replacement therapy (KRT) modalities vary in effectiveness for pediatric crush syndrome.
- Understanding factors influencing long-term dialysis dependency and intensive care unit (PICU) length of stay (LOS) is critical for optimizing outcomes.
Purpose of the Study:
- To investigate the characteristics and outcomes of pediatric crush syndrome patients following the 2023 Kahramanmaraş earthquake.
- To analyze the association between different KRT modalities and long-term dialysis dependency.
- To determine factors affecting PICU LOS in pediatric crush syndrome patients.
Main Methods:
- A multicenter, prospective, and retrospective cohort study involving 20 PICUs in Turkey.
- Inclusion of pediatric patients diagnosed with crush syndrome after the 2023 Kahramanmaraş earthquake requiring KRT.
- Analysis of data on patient demographics, injury severity, KRT modalities, and clinical outcomes.
Main Results:
- Of 183 pediatric patients, 90 required KRT. Continuous venovenous hemodiafiltration was used in 36.7% and intermittent hemodialysis (IHD) in 25.6%.
- IHD was associated with shorter PICU LOS (OR, 6.87).
- Late transfer to PICU (β=0.003) and high Pediatric Trauma Score (β=0.022) were independently associated with higher dialysis dependency at discharge.
Conclusions:
- Late intensive care transfer and high trauma scores are risk factors for long-term dialysis dependency in pediatric crush syndrome.
- Kidney Disease-Improving Global Outcomes (KDIGO) stage at admission correlates with serum creatinine phosphokinase levels.
- Emphasizes the need for prompt management and tailored KRT strategies in pediatric AKI secondary to crush injuries.
Importance:
This study addresses the characteristics, kidney replacement therapy (KRT) modalities, and outcomes in children diagnosed with crush syndrome following an earthquake in Turkey.
Objective:
To analyze the associations of different KRT modalities with long-term dialysis dependency and length of stay (LOS) in the pediatric intensive care unit (PICU).
Design, Setting, And Participants:
This multicenter, prospective, and retrospective cohort study was conducted across 20 PICUs in Turkey. Participants included children diagnosed with crush syndrome after the 2023 Kahramanmaraş earthquake, and eligibility criteria included age, diagnosis, and need for KRT. Data were analyzed from August to October 2024.
Exposure:
Children diagnosed with crush syndrome who underwent KRT.
Main Outcomes And Measures:
The primary outcome was dialysis dependency at discharge. Secondary outcomes included LOS in the PICU.
Results:
The study included 183 pediatric patients (median [IQR] age, 158 (108-192) months; 49 [54.4%] males) with earthquake-related injury, of whom 90 required KRT. The median (IQR) time under the rubble was 25.7 (1-137) hours. At admission, 51 patients (56.6%) had stage 3 acute kidney injury, and the median (IQR) serum creatinine phosphokinase level was 15 555 (9386-59 274) IU/L. There was a significant association between the Kidney Disease-Improving Global Outcomes (KDIGO) stage at admission and serum creatinine phosphokinase level (area under the curve, 0.750; 95% CI, 0.621-0.879; P < .001). Among patients undergoing KRT, 33 (36.7%) received continuous venovenous hemodiafiltration, and 23 (25.6%) underwent intermittent hemodialysis (IHD). IHD treatment was the only independent factor associated with shorter PICU LOS (odds ratio [OR], 6.87; 95% CI, 1.54-30.67; P = .01). The dialysis dependency at discharge was higher in children who were transferred late to the PICU (β = 0.003; 95% CI, 0.001-0.005; P < .001) and those with a high Pediatric Trauma Score (β = 0.022; 95% CI, 0.003-0.041; P = 02). IHD was not statistically significantly associated with remaining dialysis-dependent at discharge (OR, 2.18; 95% CI, 0.53-8.98; P = .28). The overall mortality rate in the cohort was 6 patients (6.6%).
Conclusions And Relevance:
This cohort study found that children who were transferred late to intensive care and those with a high trauma score after earthquake-related crush injury were more likely to remain dialysis-dependent at discharge. Furthermore, KDIGO stage at admission was associated with elevated serum creatinine phosphokinase levels. These findings highlight the critical importance of early intervention and appropriate treatment in children with AKI following prolonged entrapment.
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