853 may help; another measure used by many centers is to run normal saline (which has an acidic pH) as a post filter replacement solution (being care ful to monitor electrolytes) CRRT Complications Be[.]
43 Diagnosis and Treatment of Acute Kidney Injury in Children and Adolescents may help; another measure used by many centers is to run normal saline (which has an acidic pH) as a post-filter replacement solution (being careful to monitor electrolytes) 853 utritional Management for AKI N and RST-AKI Critically ill children with AKI are at high risk for malnutrition due to many factors: increased CRRT Complications energy requirements due to hypercatabolism, Being aware of potential CRRT complications is increased protein-energy wasting due to AKI, crucial to being able to avoid and prevent them and inadequate nutrition supplementation due to and to act quickly when they occur Catheter- severe fluid restriction Malnourished children related complications are highest in neonates and with AKI are also known to have worse outare often related to insertion (hemorrhage, infec- comes As a result, delivery of adequate nutrition) Pneumothorax and hemothorax after neck tion is often an indication for starting RST [1] line insertions are rare but potential risks [97] Nutrition guidelines for critically ill children are Vascular access risk is reduced using ultrasound- summarized in Table 43.12 A goal for children guided insertion Hypothermia is very important with AKI should include adequate nutrition, to prevent and can occur very quickly in patients rather than restriction Choice of nutrition is simon CRRT. Measures to warm the blood in the ilar to other patients in the ICU and children with extracorporeal circuit should be routinely used CKD. Generally, children with oligoanuric AKI especially in the smallest patients Hypotension is require low salt, low potassium, and low phosa major risk with CRRT, occurring in up to 30% phate formulas Children with tubular dysfuncof patients shortly after initiation [97] Appropriate tion (particularly in the recovery phase of AKI) use of blood priming and avoiding excessive ultra- or children receiving CRRT may have increased filtration are vital Avoiding the use of AN69 mem- electrolyte losses, requiring supplementation branes is the best way to avoid bradykinin release In patients with AKI receiving RST, indirect syndrome-associated hypotension However, calorimetry remains the gold standard and recin centers using these membranes, measures ommended measurement tool for caloric requiredescribed above (see Hemofilters), being wary ments, but it is not used routinely in the ICU. The of the risks and being ready to administer and/or Caldwell-Kennedy equation is recommended by adjust inotropic medications when initiating CRRT KDIGO to approximate resting energy expenare important A preventable but important com- diture (bottom of Table 43.12) Some experts plication of CRRT is electrolyte imbalance, which suggest 20–30% increased requirements as a can be severe if not treated During CRRT, patient ballpark measure It is important to provide caloserum electrolytes will ultimately equilibrate with ries in the form of carbohydrates, proteins, and the dialysis/replacement solution selected If not lipids Consider including glucose and citrate monitored and addressed quickly, profound hypo- in carbohydrate intake for patients on PD and kalemia, hypophosphatemia, and hypomagnese- CRRT, respectively mia can occur Circuit clotting risk is higher in Adequate protein intake is essential for hyperchildren, likely related to lower access size, blood catabolic critically ill children Protein intake flow, and hemofilter size used Several measures/ >1.5 g/kg/day was associated with the greatest aspects of CRRT described above are aimed at reduction in mortality for critically ill children in reducing risk of circuit clotting Incorrect or inad- one large systematic review [99] More studies are equate dosing of drugs and nutrition due to lack of needed to identify the optimal intake for patients accounting for clearance is another complication with AKI. For children receiving PD or CRRT, to be keenly aware of In children receiving pro- there is increased need for supplemental protein longed CRRT with immobilization, reduced bone intake due to increased protein losses across the mass and fractures may occur This complication peritoneal membrane or through the hemofilter, may be masked by the use of citrate (which may respectively For patients receiving CRRT, probind calcium released from bone resorption) [98] tein losses may be even greater with convective E H Ulrich et al 854 Table 43.12 Nutritional guidelinesa for critically ill childrenb 1A Malnutrition, including obesity, is associated with adverse clinical outcomes Nutritional assessment should be performed weekly (at a minimum) 1B On admission, weight, height/length, and (for patients 0.7 L/kg are less likely to be cleared by CRRT Higher protein binding reflects higher Vd Drugs with protein binding >80% are less likely to be cleared during CRRT Anionic proteins retained on the blood side of the filter reduce clearance of cationic molecules, called the Gibbs-Donnan effect Polysulfone dialyzers are apolar and adsorb proteins High-flux hemofilter allows free passage of non-protein-bound molecules Increased surface area for body weight will increase clearance; particularly important in neonatal CRRT Clearance will gradually decrease with older filter (increased clotting, protein adsorption) Higher blood flow rate for weight will increase clearance, although to a lesser extent than with IHD Increased dialysate and replacement fluid flow rate will increase diffusive and convective clearance, respectively, by CRRT Increased ultrafiltration will increase convective clearance (“solute drag”) CRRT continuous renal replacement therapy, D Daltons, IHD intermittent hemodialysis Drugs in AKI Drug dosing with RST for AKI will not be covered in any detail in this chapter However, awareness of this issue is important An essential function of the kidney is the excretion of drugs and their metabolites When glomerular filtration rate falls below 50%, dosing of many drugs must be adjusted to avoid toxic accumulation and complications On the other hand, for patients on CRRT, drug dosing may need to be increased to account for losses Dosing adjustment is vital for life-sustaining medications, such as antimicrobials When deciding whether or not a drug is cleared by RST, it is important to consider drug pharmacokinetics (Table 43.13) [100, 101] If drug dosing is not available in references, then drug characteristics can be searched to make reasonable inferences about clearance on dialysis Institutional phar- macists are thus invaluable team members of the AKI care team Conclusion Development of a standardized, graded definition of AKI reflects a deeper understanding of the pathophysiology and reduced health outcomes for children with AKI. Medical and surgical advancements allow neonates and children to survive previously fatal illnesses As a result, the incidence of AKI in critically ill children is very high However, significant technological innovations have allowed us to perform RST in children with AKI safely and effectively This progress in critical care reflects the growing importance of understanding AKI as it relates to short-term and long-term health outcomes, as well as the need for further advancement in the prediction, prevention, and treatment of AKI 856 References Mehta NM, Skillman HE, Irving SY, et al Guidelines for the provision and assessment of nutrition support therapy in the pediatric critically ill patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition Pediatr Crit Care Med 2017;18(7):675–715 Kaddourah A, Basu RK, Bagshaw SM, Goldstein SL, Investigators A. Epidemiology of acute kidney injury in critically ill children and young adults N Engl J Med 2017;376(1):11–20 Jetton JG, Boohaker LJ, Sethi SK, et al Incidence and outcomes of neonatal acute kidney injury (AWAKEN): a multicentre, multinational, observational cohort study Lancet Child Adolesc Health 2017;1(3):184–94 Li S, Krawczeski CD, Zappitelli M, et al Incidence, risk factors, and outcomes of acute kidney injury after pediatric cardiac surgery: a prospective multicenter study Crit Care Med 2011;39(6):1493–9 KDIGO Acute Kidney Injury Work Group KDIGO clinical practice guideline for acute kidney injury Kidney Int Suppl 2012;2(1):1–138 Zappitelli M, Ambalavanan N, Askenazi DJ, et al Developing a neonatal acute kidney injury research definition: a report from the NIDDK neonatal AKI workshop Pediatr Res 2017;82(4):569–73 Schwartz GJ, Schneider MF, Maier PS, et al Improved equations estimating GFR in children with chronic kidney disease using an immunonephelometric determination of cystatin C. Kidney Int 2012;82(4):445–53 Malhotra R, Siew ED. Biomarkers for the early detection and prognosis of acute kidney injury Clin J Am Soc Nephrol 2017;12(1):149–73 Mehta RL, Cerda J, Burdmann EA, et al International Society of Nephrology’s 0by25 initiative for acute kidney injury (zero preventable deaths by 2025): a human rights case for nephrology Lancet 2015;385(9987):2616–43 10 Fleming GM, Sahay R, Zappitelli M, et al The incidence of acute kidney injury and its effect on neonatal and pediatric extracorporeal membrane oxygenation outcomes: a multicenter report from the kidney intervention during extracorporeal membrane oxygenation study group Pediatr Crit Care Med 2016;17(12):1157–69 11 Ueno K, Seki S, Shiokawa N, et al Validation of acute kidney injury according to the modified KDIGO criteria in infants after cardiac surgery for congenital heart disease Nephrology (Carlton) 2019;24(3):294–300 12 Greenberg JH, Zappitelli M, Devarajan P, et al Kidney outcomes years after pediatric cardiac surgery: the TRIBE-AKI Study JAMA Pediatr 2016;170(11):1071–8 13 Blinder JJ, Asaro LA, Wypij D, et al Acute kidney injury after pediatric cardiac surgery: a sec- E H Ulrich et al ondary analysis of the safe pediatric euglycemia after cardiac surgery trial Pediatr Crit Care Med 2017;18(7):638–46 14 McGregor TL, Jones DP, Wang L, et al Acute kidney injury incidence in noncritically ill hospitalized children, adolescents, and young adults: a retrospective observational study Am J Kidney Dis 2016;67(3):384–90 15 Goldstein SL, Kirkendall E, Nguyen H, et al Electronic health record identification of nephrotoxin exposure and associated acute kidney injury Pediatrics 2013;132(3):e756–67 16 Goldstein SL, Mottes T, Simpson K, et al A sustained quality improvement program reduces nephrotoxic medication-associated acute kidney injury Kidney Int 2016;90(1):212–21 17 Chawla LS, Eggers PW, Star RA, Kimmel PL. Acute kidney injury and chronic kidney disease as interconnected syndromes N Engl J Med 2014;371(1):58–66 18 Sigurjonsdottir VK, Chaturvedi S, Mammen C, Sutherland SM. Pediatric acute kidney injury and the subsequent risk for chronic kidney disease: is there cause for alarm? Pediatr Nephrol 2018;33(11):2047–55 19 Hessey E, Morissette G, Lacroix J, et al Long-term mortality after acute kidney injury in the pediatric ICU. Hosp Pediatr 2018;8(5):260–8 20 Hessey E, Morissette G, Lacroix J, et al Healthcare utilization after acute kidney injury in the pediatric intensive care unit Clin J Am Soc Nephrol 2018;13(5):685–92 21 Menon S, Kirkendall ES, Nguyen H, Goldstein SL. Acute kidney injury associated with high nephrotoxic medication exposure leads to chronic kidney disease after months J Pediatr 2014;165(3):522– 527.e522 22 Cooper DS, Claes D, Goldstein SL, et al Follow-up renal assessment of injury long-term after acute kidney injury (FRAIL-AKI) Clin J Am Soc Nephrol 2016;11(1):21–9 23 Madsen NL, Goldstein SL, Froslev T, Christiansen CF, Olsen M. Cardiac surgery in patients with congenital heart disease is associated with acute kidney injury and the risk of chronic kidney disease Kidney Int 2017;92(3):751–6 24 Hessey E, Ali R, Dorais M, et al Renal function follow-up and renal recovery after acute kidney injury in critically ill children Pediatr Crit Care Med 2017;18(8):733–40 25 Murray PT, Devarajan P, Levey AS, et al A framework and key research questions in AKI diagnosis and staging in different environments Clin J Am Soc Nephrol 2008;3(3):864–8 26 Basile DP, Anderson MD, Sutton TA. Pathophysiology of acute kidney injury Compr Physiol 2012;2(2):1303–53 27 Kumar S. Cellular and molecular pathways of renal repair after acute kidney injury Kidney Int 2018;93(1):27–40 43 Diagnosis and Treatment of Acute Kidney Injury in Children and Adolescents 28 Gorga SM, Murphy HJ, Selewski DT. An update on neonatal and pediatric acute kidney injury Curr Pediatr Rep 2018;6:278–90 29 Venkatachalam MA, Weinberg JM, Kriz W, Bidani AK. Failed tubule recovery, AKI-CKD transition, and kidney disease progression J Am Soc Nephrol 2015;26(8):1765–76 30 Goldstein SL, Currier H, Graf C, Cosio CC, Brewer ED, Sachdeva R. Outcome in children receiving continuous venovenous hemofiltration Pediatrics 2001;107(6):1309–12 31 Selewski DT, Cornell TT, Lombel RM, et al Weight- based determination of fluid overload status and mortality in pediatric intensive care unit patients requiring continuous renal replacement therapy Intensive Care Med 2011;37(7):1166–73 32 Askenazi DJ, Koralkar R, Hundley HE, Montesanti A, Patil N, Ambalavanan N. Fluid overload and mortality are associated with acute kidney injury in sick near-term/term neonate Pediatr Nephrol 2013;28(4):661–6 33 Macedo E, Bouchard J, Soroko SH, et al Fluid accumulation, recognition and staging of acute kidney injury in critically-ill patients Crit Care 2010;14(3):R82 34 Liu KD, Thompson BT, Ancukiewicz M, et al Acute kidney injury in patients with acute lung injury: impact of fluid accumulation on classification of acute kidney injury and associated outcomes Crit Care Med 2011;39(12):2665–71 35 Basu RK, Andrews A, Krawczeski C, Manning P, Wheeler DS, Goldstein SL. Acute kidney injury based on corrected serum creatinine is associated with increased morbidity in children following the arterial switch operation Pediatr Crit Care Med 2013;14(5):e218–24 36 Bouchard J, Soroko SB, Chertow GM, et al Fluid accumulation, survival and recovery of kidney function in critically ill patients with acute kidney injury Kidney Int 2009;76(4):422–7 37 Payen D, de Pont AC, Sakr Y, et al A positive fluid balance is associated with a worse outcome in patients with acute renal failure Crit Care 2008;12(3):R74 38 Hassinger AB, Wald EL, Goodman DM. Early postoperative fluid overload precedes acute kidney injury and is associated with higher morbidity in pediatric cardiac surgery patients Pediatr Crit Care Med 2014;15(2):131–8 39 Basu RK, Chawla LS, Wheeler DS, Goldstein SL. Renal angina: an emerging paradigm to identify children at risk for acute kidney injury Pediatr Nephrol 2012;27(7):1067–78 40 Basu RK, Zappitelli M, Brunner L, et al Derivation and validation of the renal angina index to improve the prediction of acute kidney injury in critically ill children Kidney Int 2014;85(3):659–67 41 Basu RK, Kaddourah A, Goldstein SL. Assessment of a renal angina index for prediction of severe acute kidney injury in critically ill children: a multicen- 857 tre, multinational, prospective observational study Lancet Child Adolesc Health 2018;2(2):112–20 42 Menon S, Goldstein SL, Mottes T, et al Urinary biomarker incorporation into the renal angina index early in intensive care unit admission optimizes acute kidney injury prediction in critically ill children: a prospective cohort study Nephrol Dial Transplant 2016;31(4):586–94 43 Chawla LS, Davison DL, Brasha-Mitchell E, et al Development and standardization of a furosemide stress test to predict the severity of acute kidney injury Crit Care 2013;17(5):R207 44 Koyner JL, Davison DL, Brasha-Mitchell E, et al Furosemide stress test and biomarkers for the prediction of AKI severity J Am Soc Nephrol 2015;26(8):2023–31 45 Borasino S, Wall KM, Crawford JH, et al Furosemide response predicts acute kidney injury after cardiac surgery in infants and neonates Pediatr Crit Care Med 2018;19(4):310–7 46 Kakajiwala A, Kim JY, Hughes JZ, et al Lack of furosemide responsiveness predicts acute kidney injury in infants after cardiac surgery Ann Thorac Surg 2017;104(4):1388–94 47 Basu RK, Wheeler DS. Approaches to the management of acute kidney injury in children Recent Pat Biomark 2011;1(1):49–59 48 Raina A, Pandita A, Harish R, Yachha M, Jamwal A. Treating perinatal asphyxia with theophylline at birth helps to reduce the severity of renal dysfunction in term neonates Acta Paediatr 2016;105(10):e448–51 49 Harer MW, Askenazi DJ, Boohaker LJ, et al Association between early caffeine citrate administration and risk of acute kidney injury in preterm neonates: results from the AWAKEN study JAMA Pediatr 2018;172(6):e180322 50 Axelrod DM, Sutherland SM, Anglemyer A, Grimm PC, Roth SJ. A double-blinded, randomized, placebo- controlled clinical trial of aminophylline to prevent acute kidney injury in children following congenital heart surgery with cardiopulmonary bypass Pediatr Crit Care Med 2016;17(2):135–43 51 Acosta AA, Hogg RJ. Rasburicase for hyperuricemia in hemolytic uremic syndrome Pediatr Nephrol 2012;27(2):325–9 52 Hobbs DJ, Steinke JM, Chung JY, Barletta GM, Bunchman TE. Rasburicase improves hyperuricemia in infants with acute kidney injury Pediatr Nephrol 2010;25(2):305–9 53 Zarbock A, Kellum JA, Schmidt C, et al Effect of early vs delayed initiation of renal replacement therapy on mortality in critically ill patients with acute kidney injury: the ELAIN randomized clinical trial JAMA 2016;315(20):2190–9 54 Gaudry S, Hajage D, Schortgen F, et al Initiation strategies for renal-replacement therapy in the intensive care unit N Engl J Med 2016;375(2):122–33 55 Barbar SD, Clere-Jehl R, Bourredjem A, et al Timing of renal-replacement therapy in patients 858 with acute kidney injury and sepsis N Engl J Med 2018;379(15):1431–42 56 Sutherland SM, Zappitelli M, Alexander SR, et al Fluid overload and mortality in children receiving continuous renal replacement therapy: the prospective pediatric continuous renal replacement therapy registry Am J Kidney Dis 2010;55(2):316–25 57 Vasudevan A, Phadke K, Yap HK. Peritoneal dialysis for the management of pediatric patients with acute kidney injury Pediatr Nephrol 2017;32(7):1145–56 58 Warady BA, Bunchman T. Dialysis therapy for children with acute renal failure: survey results Pediatr Nephrol 2000;15(1–2):11–3 59 Madenci AL, Thiagarajan RR, Stoffan AP, Emani SM, Rajagopal SK, Weldon CB. Characterizing peritoneal dialysis catheter use in pediatric patients after cardiac surgery J Thorac Cardiovasc Surg 2013;146(2):334–8 60 Kwiatkowski DM, Menon S, Krawczeski CD, et al Improved outcomes with peritoneal dialysis catheter placement after cardiopulmonary bypass in infants J Thorac Cardiovasc Surg 2015;149(1):230–6 61 Kwiatkowski DM, Goldstein SL, Cooper DS, Nelson DP, Morales DL, Krawczeski CD. Peritoneal dialysis vs furosemide for prevention of fluid overload in infants after cardiac surgery: a randomized clinical trial JAMA Pediatr 2017;171(4):357–64 62 Ryerson LM, Mackie AS, Atallah J, et al Prophylactic peritoneal dialysis catheter does not decrease time to achieve a negative fluid balance after the Norwood procedure: a randomized controlled trial J Thorac Cardiovasc Surg 2015;149(1):222–8 63 Bojan M, Gioanni S, Vouhe PR, Journois D, Pouard P. Early initiation of peritoneal dialysis in neonates and infants with acute kidney injury following cardiac surgery is associated with a significant decrease in mortality Kidney Int 2012;82(4):474–81 64 Liang KV, Sileanu FE, Clermont G, et al Modality of RRT and recovery of kidney function after AKI in patients surviving to hospital discharge Clin J Am Soc Nephrol 2016;11(1):30–8 65 Rabindranath K, Adams J, Macleod AM, Muirhead N. Intermittent versus continuous renal replacement therapy for acute renal failure in adults Cochrane Database Syst Rev 2007;3:CD003773 66 Truche AS, Darmon M, Bailly S, et al Continuous renal replacement therapy versus intermittent hemodialysis in intensive care patients: impact on mortality and renal recovery Intensive Care Med 2016;42(9):1408–17 67 Symons JM, Chua AN, Somers MJ, et al Demographic characteristics of pediatric continuous renal replacement therapy: a report of the prospective pediatric continuous renal replacement therapy registry Clin J Am Soc Nephrol 2007;2(4):732–8 68 Askenazi D, Ingram D, White S, et al Smaller circuits for smaller patients: improving renal support therapy with Aquadex Pediatr Nephrol 2016;31(5):853–60 69 Coulthard MG, Crosier J, Griffiths C, et al Haemodialysing babies weighing