Predicting pediatric cardiac surgery-associated acute kidney injury using machine learning.

BACKGROUND: Prediction of cardiac surgery-associated acute kidney injury (CS-AKI) in pediatric patients is crucial to improve outcomes and guide clinical decision-making. This study aimed to develop a supervised machine learning (ML) model for predicting moderate to severe CS-AKI at postoperative day 2 (POD2). METHODS: This retrospective cohort study analyzed data from 402 pediatric patients who underwent cardiac surgery at a university-affiliated children's hospital, who were separated into an 80%-20% train-test split. The ML model utilized demographic, preoperative, intraoperative, and POD0 clinical and laboratory data to predict moderate to severe AKI categorized by Kidney Disease: Improving Global Outcomes (KDIGO) stage 2 or 3 at POD2. Input feature importance was assessed by SHapley Additive exPlanations (SHAP) values. Model performance was evaluated using accuracy, area under the receiver operating curve (AUROC), precision, recall, area under the precision-recall curve (AUPRC), F1-score, and Brier score. RESULTS: Overall, 13.7% of children in the test set experienced moderate to severe AKI. The ML model achieved promising performance, with accuracy of 0.91 (95% CI: 0.82-1.00), AUROC of 0.88 (95% CI: 0.72-1.00), precision of 0.92 (95% CI: 0.70-1.00), recall of 0.63 (95% CI: 0.32-0.96), AUPRC of 0.81 (95% CI: 0.61-1.00), F1-score of 0.73 (95% CI: 0.46-0.99), and Brier score loss of 0.09 (95% CI: 0.00-0.17). The top ten most important features assessed by SHAP analyses in this model were preoperative serum creatinine, surgery duration, POD0 serum pH, POD0 lactate, cardiopulmonary bypass duration, POD0 vasoactive inotropic score, sex, POD0 hematocrit, preoperative weight, and POD0 serum creatinine. CONCLUSIONS: A supervised ML model utilizing demographic, preoperative, intraoperative, and immediate postoperative clinical and laboratory data showed promising performance in predicting moderate to severe CS-AKI at POD2 in pediatric patients.

Acceptance of Acute Kidney Injury Alert by Providers in Cardiac Surgery Intensive Care Unit.

BACKGROUND: Acute kidney injury (AKI) is a common complication after cardiac surgery and is associated with worse outcomes. Its management relies on early diagnosis, and therefore, electronic alerts have been used to alert clinicians for development of AKI. Electronic alerts are, however, associated with high rates of alert fatigue. OBJECTIVES: We designed this study to assess the acceptance of user-centered electronic AKI alert by clinicians. METHODS: We developed a user-centered electronic AKI alert that alerted clinicians of development of AKI in a persistent yet noninterruptive fashion. As the goal of the alert was to alert toward new or worsening AKI, it disappeared 48 hours after being activated. We assessed the acceptance of the alert using surveys at 6 and 12 months after the alert went live. RESULTS: At 6 months after their implementation, 38.9% providers reported that they would not have recognized AKI as early as they did without this alert. This number increased to 66.7% by 12 months of survey. Most providers also shared that they re-dosed or discontinued medications earlier, provided earlier management of volume status, avoided intravenous contrast use, and evaluated patients by using point-of-care ultrasounds more due to the alert. Overall, 83.3% respondents reported satisfaction with the electronic AKI alerts at 6 months and 94.4% at 12 months. CONCLUSION: This study showed high rates of acceptance of a user-centered electronic AKI alert over time by clinicians taking care of patients with AKI.

Cardiometabolic risk factors in siblings from a statewide screening program.

BACKGROUND: The Coronary Artery Risk Detection in Appalachian Communities (CARDIAC) Project is a state-wide risk factor screening program that operated in West Virginia for 19 years and screened more than 100,000 5th graders for obesity, hypertension, and dyslipidemia. OBJECTIVES: We investigated siblings in the CARDIAC Project to assess whether cardiometabolic risk factors (CMRFs) correlate in siblings. METHODS: We identified 12,053 children from 5752 families with lipid panel, blood pressure, and anthropometric data. A linkage application (LinkPlus from the U.S. Centers for Disease Control and Prevention) matched siblings based on parent names, addresses, telephone numbers, and school to generate a linkage probability curve. Graphical and statistical analyses demonstrate the relationships between CMRFs in siblings. RESULTS: Siblings showed moderate intraclass correlation coefficient of 0.375 for low-density lipoprotein cholesterol (LDL-C), 0.34 for high-density lipoprotein cholesterol (HDL-C), and 0.22 for triglyceride levels. The body mass index (BMI) intraclass correlation coefficient (0.383) is slightly better (2%) than LDL-C or HDL-C, but the standardized beta values from linear regression suggest a 3-fold impact of sibling LDL-C over the child's own BMI. The odds ratio of a second sibling having LDL-C < 110 mg/dL with a first sibling at that level is 3.444:1 (Confidence Limit 3.031-3.915, P < .05). The odds ratio of a sibling showing an LDL-C ≥ 160 mg/dL, given a first sibling with that degree of elevated LDL-C is 29.6:1 (95% Confidence Limit: 15.54-56.36). The individual LDL-C level correlated more strongly with sibling LDL-C than with the individual's own BMI. Seventy-eight children with LDL-C > 160 mg/dL and negative family history would have been missed, which represents more than half of those with LDL-C > 160 mg/dL (78 vs 67 or 54%). CONCLUSIONS: Sibling HDL-C levels, LDL-C levels, and BMIs correlate within a family. Triglyceride and blood pressure levels are less well correlated. The identified CMRF relationships strengthen the main findings of the overall CARDIAC Project: an elevated BMI is not predictive of elevated LDL-C and family history of coronary artery disease poorly predicts cholesterol abnormality at screening. Family history does not adequately identify children who should be screened for cholesterol abnormality. Elevated LDL-C (>160 mg/dL) in a child strongly suggests that additional siblings and parents be screened if universal screening is not practiced.

Comparison of Intraoperative Aminophylline Versus Furosemide in Treatment of Oliguria During Pediatric Cardiac Surgery.

OBJECTIVES: To determine if intraoperative aminophylline was superior to furosemide to prevent or attenuate postoperative cardiac surgery-associated acute kidney injury. DESIGN: Single-center, historical control, retrospective cohort study. SETTING: PICU, university-affiliated children's hospital. PATIENTS: Children with congenital heart disease in PICU who received furosemide or aminophylline to treat intraoperative oliguria. INTERVENTIONS: Intraoperative oliguria was treated either with furosemide (September 2007 to February 2012) or with aminophylline (February 2012 to June 2013). The postoperative 48 hours renal outcomes of the aminophylline group were compared with the furosemide group. The primary outcomes were acute kidney injury and renal replacement therapy use at 48 hours postoperatively. Surgical complexity was accounted for by the use of Risk Adjustment for Congenital Heart Surgery-1 score. MEASUREMENTS AND MAIN RESULTS: The study involves 69 months of observation. There were 200 cases younger than 21 years old reviewed for this study. Eighty-five cases (42.5%) developed acute kidney injury. The aminophylline group patients produced significantly more urine (mL/kg/hr) during the first 8 hours postoperatively than furosemide patients (5.1 vs 3.4 mL/kg/hr; p = 0.01). The urine output at 48 hours postoperatively was similar between the two groups. There was no difference in acute kidney injury incidence at 48 hours between the aminophylline and furosemide groups (38% vs 47%, respectively; p = 0.29). Fewer aminophylline group subjects required renal replacement therapy compared to the furosemide group subjects (n = 1 vs 7, respectively; p = 0.03). In the multi-variant predictive model, intraoperative aminophylline infusion was noted as a negative predictive factor for renal replacement therapy, but not for cardiac surgery-associated acute kidney injury. CONCLUSION: The intraoperative use of aminophylline was more effective than furosemide in reversal of oliguria in the early postoperative period. There were less renal replacement therapy-requiring acute kidney injury in children in the aminophylline group. Future prospective studies of intraoperative aminophylline to prevent cardiac surgery-associated acute kidney injury may be warranted.

Ketogenic diet: rapid onset of selenium deficiency-induced cardiac decompensation.

Selenium-deficiency cardiomyopathy is a known secondary complication from long-term treatment with a ketogenic diet for medical refractory epilepsy. Our patient, a 5-year-old boy on a ketogenic diet for intractable seizures, had a normal selenium level before starting the diet, but he shortly thereafter developed acute reversible cardiomyopathy and ventricular tachycardia, which was unmasked during a hospitalization for an elective operative procedure. His cardiomyopathy was suspected to be secondary to a selenium-deficient state and was confirmed by way of a markedly low serum selenium level and supported by rapid improvement with the initiation of selenium supplementation and cessation of the ketogenic diet. For patients being initiated on a ketogenic diet, current screening guidelines call for baseline and follow-up selenium levels every 3 months during the first year along with RDA selenium supplementation, which is 30 mcg/day. Most of the new ketogenic diet formulas meet this requirement. Our patient underwent elective surgery before his planned 3-month selenium level check and had potentially preventable complications. Secondary to this experience, we suggest that all patients initiated on a ketogenic diet should have a preoperative electrocardiogram (EKG), an echocardiogram, and selenium level determined before any elective surgery. These steps would prevent unnecessary perioperative morbidity and mortality.

Octreotide efficacy in the treatment of chylothoraces following cardiac surgery in infants and children.

OBJECTIVE: To examine the efficacy of octreotide in resolving chylothoraces in infants and children following cardiac surgery. DESIGN: Retrospective chart review. SETTING: Pediatric intensive care unit of a tertiary care center. PATIENTS: All children who received octreotide for the treatment of chylothoraces following surgery for congenital heart disease over a 30-month period between 2001-2004. INTERVENTIONS: Octreotide infusion. MEASUREMENTS AND MAIN RESULTS: Eight courses of octreotide treatment were identified in seven patients who met our inclusion criteria. The median duration of therapy was 5 days, and dosing ranged from 1 to 4 microg/kg/hr. Treatment did not result in an overall decrease in average chest tube output after 3 days of therapy. However, in two patients (29%) the chylothoraces ultimately resolved during the octreotide infusion. Treatment was well tolerated, and no serious side effects were noted. CONCLUSION: In contrast to previously published reports, we find octreotide therapy for postoperative chylothoraces to be successful in only a minority of cases.

Left-sided CHILD syndrome caused by a nonsense mutation in the NSDHL gene.

Congenital hemidysplasia with ichthyosiform nevus and limb defects (CHILD) syndrome is a rare X-linked dominant malformation syndrome characterized by unilaterally distributed ichthyosiform nevi, often sharply delimited at the midline, and ipsilateral limb defects. At least two-thirds of cases demonstrate involvement of the right side. Mutations in an essential enzyme of cholesterol biosynthesis, NAD(P)H steroid dehydrogenase-like [NSDHL], have been reported in five unrelated patients with right-sided CHILD syndrome and in a sixth patient with bilaterally, symmetric nevi and mild skeletal anomalies, but not with CHILD syndrome as originally defined. Although all of the molecularly diagnosed cases with the CHILD phenotype to date have had right-sided disease, we report here a novel nonsense mutation (E151X) of NSDHL in an infant with left-sided CHILD syndrome. This result demonstrates that both right- and left-sided CHILD syndrome can be caused by mutations in the same gene.