Dialysis disequilibrium syndrome (DDS) in pediatric patients on dialysis: systematic review and clinical practice recommendations.

BACKGROUND AND OBJECTIVES: Dialysis disequilibrium syndrome (DDS) is a rare neurological complication, most commonly affecting patients undergoing new initiation of hemodialysis (HD), but can also be seen in patients receiving chronic dialysis who miss regular treatments, patients having acute kidney injury (AKI), and in those treated with continuous kidney replacement therapy (CKRT) or peritoneal dialysis (PD). Although the pathogenesis is not well understood, DDS is likely a result of multiple physiological abnormalities. In this systematic review, we provide a synopsis of the data available on DDS that allow for a clear picture of its pathogenesis, preventive measures, and focus on effective management strategies. METHODS: We conducted a literature search on PubMed/Medline and Embase from January 1960 to January 2021. Studies were included if the patient developed DDS irrespective of age and gender. A summary table was used to summarize the data from individual studies and included study type, population group, age group, sample size, patient characteristics, blood and dialysate flow rate, and overall outcome. A descriptive analysis calculating the frequency of population size, symptoms, and various treatments was performed using R software version 3.1.0. RESULTS: A total of 49 studies (321 samples) were identified and analyzed. Out of the included 49 studies, a total of 48 studies reported the presence of DSS among patients (1 study reported based on number of dialysis and therefore was not considered for analysis). Among these 48 studies, 74.3% (226/304) patients were reported to have DSS. The most common symptoms were nausea (25.2%), headache (24.8%), vomiting (23.9%), muscle cramps (18.1%), affected level of consciousness (8.8%), confusion (4.4%), and seizure (4.9%) among the 226 DDS patients. Furthermore, 12 studies decided to switch from HD to alternative dialysis modalities including continuous venovenous hemofiltration/hemodiafiltration (CVVH/CVVHDF) or PD which reported no DDS symptoms. CONCLUSION: Early recognition and timely prevention are crucial for DDS patients. We have provided comprehensive clinical practice points for pediatric, adolescent, and young adult populations. However, it is essential to recognize that DDS was reported more frequently in the early dialysis era, as there was a lack of advanced dialysis technology and limited resources.

Re-evaluating Renal Angina Index: An Authentic, Evidence-Based Instrument for Acute Kidney Injury Assessment: Critical Appraisal.

Background/Introduction: Renal angina index (RAI) used to calculate and accurately predict risk for the development of acute kidney injury (AKI) has been heavily explored. AKI is traditionally diagnosed by an increase in serum creatinine (SCr) concentration or oliguria, both of which are neither specific nor sensitive, especially among children. An RAI score may be calculated by combining objective signs of kidney dysfunction (such as SCr) and patient context, such as AKI risk factors, thus potentially serving as a more accurate indicator for AKI. Objective: Due to the propitious and novel nature of RAI, this editorial commentary aims to analyze the current literature on RAI and determine how well RAI serves as a predictor of AKI outcomes. Method: A comprehensive literature search was conducted in PubMed/Medline and Google Scholar between January 2012 and July 2020. Literature included the prognostic aspect of early prediction of AKI in the pediatric and adult population via RAI. Results: The initial literature search included 149 studies, and a total of 10 studies reporting the outcomes of interest were included. The overall sample size across these studies was 11,026. The predictive ability of RAI had a pooled (95% CI) sensitivity of 79.21%, specificity of 73.22%, and negative predictive value of 94.83%. Conclusion: RAI shows benefit in the prediction of AKI among adult and pediatric populations. However, there is a lack of sufficient data, and further prospective studies are needed in pediatric populations to use RAI as a principal AKI indicator among clinicians.

Critical analysis of acute kidney injury in pediatric COVID-19 patients in the intensive care unit.

BACKGROUND AND OBJECTIVES: COVID-19 is responsible for the 2019 novel coronavirus disease pandemic. Despite the vast research about the adult population, there has been little data collected on acute kidney injury (AKI) epidemiology, associated risk factors, treatments, and mortality in pediatric COVID-19 patients admitted to the ICU. AKI is a severe complication of COVID-19 among children and adolescents. METHODS: A comprehensive literature search was conducted in PubMed/MEDLINE and Cochrane Center Trials to find all published literature related to AKI in COVID-19 patients, including incidence and outcomes. RESULTS: Twenty-four studies reporting the outcomes of interest were included. Across all studies, the overall sample size of COVID positive children was 1,247 and the median age of this population was 9.1 years old. Among COVID positive pediatric patients, there was an AKI incidence of 30.51%, with only 0.56% of these patients receiving KRT. The mortality was 2.55% among all COVID positive pediatric patients. The incidence of multisystem inflammatory syndrome in children (MIS-C) among COVID positive patients was 74.29%. CONCLUSION: AKI has shown to be a negative prognostic factor in adult patients with COVID-19 and now also in the pediatric cohort with high incidence and mortality rates. Additionally, our findings show a strong comparison in epidemiology between adult and pediatric COVID-19 patients; however, they need to be confirmed with additional data and studies.