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1.
Pediatr Nephrol ; 39(3): 955-979, 2024 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-37934274

RESUMO

BACKGROUND: The impact of disorders of fluid balance, including the pathologic state of fluid overload in sick children has become increasingly apparent. With this understanding, there has been a shift from application of absolute thresholds of fluid accumulation to an appreciation of the intricacies of fluid balance, including the impact of timing, trajectory, and disease pathophysiology. METHODS: The 26th Acute Disease Quality Initiative was the first to be exclusively dedicated to pediatric and neonatal acute kidney injury (pADQI). As part of the consensus panel, a multidisciplinary working group dedicated to fluid balance, fluid accumulation, and fluid overload was created. Through a search, review, and appraisal of the literature, summative consensus statements, along with identification of knowledge gaps and recommendations for clinical practice and research were developed. CONCLUSIONS: The 26th pADQI conference proposed harmonized terminology for fluid balance and for describing a pathologic state of fluid overload for clinical practice and research. Recommendations include that the terms daily fluid balance, cumulative fluid balance, and percent cumulative fluid balance be utilized to describe the fluid status of sick children. The term fluid overload is to be preserved for describing a pathologic state of positive fluid balance associated with adverse events. Several recommendations for research were proposed including focused validation of the definition of fluid balance, fluid overload, and proposed methodologic approaches and endpoints for clinical trials.


Assuntos
Injúria Renal Aguda , Insuficiência Cardíaca , Desequilíbrio Hidroeletrolítico , Recém-Nascido , Humanos , Criança , Doença Aguda , Desequilíbrio Hidroeletrolítico/diagnóstico , Desequilíbrio Hidroeletrolítico/etiologia , Desequilíbrio Hidroeletrolítico/terapia , Equilíbrio Hidroeletrolítico , Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/terapia , Estado Terminal
2.
Pediatr Nephrol ; 39(3): 1005-1014, 2024 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-37934273

RESUMO

BACKGROUND: Acute kidney injury (AKI) is independently associated with increased morbidity and mortality across the life course, yet care for AKI remains mostly supportive. Raising awareness of this life-threatening clinical syndrome through education and advocacy efforts is the key to improving patient outcomes. Here, we describe the unique roles education and advocacy play in the care of children with AKI, discuss the importance of customizing educational outreach efforts to individual groups and contexts, and highlight the opportunities created through innovations and partnerships to optimize lifelong health outcomes. METHODS: During the 26th Acute Disease Quality Initiative (ADQI) consensus conference, a multidisciplinary group of experts discussed the evidence and used a modified Delphi process to achieve consensus on recommendations on AKI research, education, practice, and advocacy in children. RESULTS: The consensus statements developed in response to three critical questions about the role of education and advocacy in pediatric AKI care are presented here along with a summary of available evidence and recommendations for both clinical care and research. CONCLUSIONS: These consensus statements emphasize that high-quality care for patients with AKI begins in the community with education and awareness campaigns to identify those at risk for AKI. Education is the key across all healthcare and non-healthcare settings to enhance early diagnosis and develop mitigation strategies, thereby improving outcomes for children with AKI. Strong advocacy efforts are essential for implementing these programs and building critical collaborations across all stakeholders and settings.


Assuntos
Injúria Renal Aguda , Humanos , Criança , Doença Aguda , Escolaridade , Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/terapia , Consenso
3.
Cardiol Young ; : 1-6, 2024 May 16.
Artigo em Inglês | MEDLINE | ID: mdl-38752303

RESUMO

INTRODUCTION: Acute kidney injury is associated with worse outcomes after cardiac surgery. The haemodynamic goals to ameliorate kidney injury are not clear. Low post-operative renal perfusion pressure has been associated with acute kidney injury in adults. Inadequate oxygen delivery may also cause kidney injury. This study evaluates pressure and oximetric haemodynamics after paediatric cardiac surgery and their association with acute kidney injury. MATERIALS AND METHODS: Retrospective case-control study at a children's hospital. Patients were < 6 months of age who underwent a Society of Thoracic Surgery-European Association for Cardio-Thoracic Surgery Congenital Heart Surgery categories ≥ 3. Low renal perfusion pressure was time and depth below several tested thresholds. The primary outcome was serum creatine-defined acute kidney injury in the first 7 days. RESULTS: Sixty-six patients (median age 8 days) were included. Acute kidney injury occurred in 36%. The time and depth of renal perfusion pressure < 42 mmHg in the first 24 hours was greater in acute kidney injury patients (94 versus 35 mmHg*minutes of low renal perfusion pressure/hour, p = 0.008). In the multivariable model, renal perfusion pressure < 42 mmHg was associated with acute kidney injury (aOR: 2.07, 95%CI: 1.25-3.82, p = 0.009). Mean arterial pressure, central venous pressure, and measures of inadequate oxygen delivery were not associated with acute kidney injury. CONCLUSION: Periods of low renal perfusion pressure (<42 mmHg) in the first 24 post-operative hours are associated with acute kidney injury. Renal perfusion pressure is a potential modifiable target that may mitigate the impact of acute kidney injury after paediatric cardiac surgery.

4.
Pediatr Transplant ; 27(4): e14499, 2023 06.
Artigo em Inglês | MEDLINE | ID: mdl-36951112

RESUMO

BACKGROUND: Positive fluid balance (FB) is associated with poor outcomes in critically ill children but has not been studied in pediatric liver transplant (LT) recipients. Our goal is to investigate the relationship between postoperative FB and outcomes in pediatric LT recipients. METHODS: We performed a retrospective cohort study of first-time pediatric LT recipients at a quaternary care children's hospital. Patients were stratified into three groups based on their FB in the first 72 h postoperatively: <10%, 10-20%, and > 20%. Outcomes were pediatric intensive care unit (PICU) and hospital length of stay, ventilator-free days (VFD) at 28 days, day 3 severe acute kidney injury, and postoperative complications. Multivariate analyses were adjusted for age, preoperative admission status, and Pediatric Risk of Mortality (PRISM)-III score. RESULTS: We included 129 patients with median PRISM-III score of 9 (interquartile range, IQR 7-15) and calculated Pediatric End-stage Liver Disease score of 15 (IQR 2-23). A total of 37 patients (28.7%) had 10-20% FB, and 26 (20.2%) had >20% FB. Greater than 20% FB was associated with an increased likelihood of an additional PICU day (adjusted incident rate ratio [aIRR] 1.62, 95% CI: 1.18-2.24), an additional hospital day (aIRR 1.39, 95% CI: 1.10-1.77), and lower likelihood of a VFD at 28 days (aIRR 0.85, 95% CI: 0.74-0.97). There were no differences between groups in the likelihood of postoperative complications. CONCLUSIONS: In pediatric LT recipients, >20% FB at 72 h postoperatively is associated with increased morbidities, independent of age and severity of illness. Additional studies are needed to explore the impact of fluid management strategies on outcomes.


Assuntos
Doença Hepática Terminal , Transplante de Fígado , Criança , Humanos , Lactente , Estudos Retrospectivos , Doença Hepática Terminal/cirurgia , Doença Hepática Terminal/complicações , Tempo de Internação , Índice de Gravidade de Doença , Respiração Artificial , Equilíbrio Hidroeletrolítico , Unidades de Terapia Intensiva Pediátrica , Complicações Pós-Operatórias/etiologia , Estado Terminal
5.
Pediatr Nephrol ; 38(2): 565-572, 2023 02.
Artigo em Inglês | MEDLINE | ID: mdl-35552525

RESUMO

BACKGROUND: Continuous kidney replacement therapy (CKRT) is a mainstay of therapy for management of severe acute kidney injury (AKI) in critically ill pediatric patients. There is limited data on the risk of chronic kidney disease (CKD) after discharge in this population. METHODS: This is a single-center, retrospective cohort study of all pediatric patients ages 0-17 years who received CKRT from 2013 to 2017. The study excluded patients with pre-existing CKD, those who died prior to discharge, and those who had insufficient follow-up data. Patients were followed after hospital discharge and electronic health record data was collected and analyzed to assess for incidence of and risk factors for kidney sequelae. RESULTS: A total of 42 patients were followed at a median time of 27 months (IQR 17.2, 39.8). Of these, 26.2% had evidence of CKD and 19% were at risk for CKD. Lower eGFR at hospital discharge was associated with increased odds of kidney sequelae (aOR 0.985; 95% CI 0.972, 0.996). Ages 0- < 1 and 12-17 were not significantly different (aOR 0.235, 95% CI 0.024, 1.718) and had the highest incidence of kidney sequelae (50% and 77%, respectively). Ages 1-5 and 6-11 had a decreased odds of kidney sequelae compared to the 12-17 year age group (aOR 0.098; 95% CI 0.009, 0.703 and aOR 0.035; 95% CI 0.001, 0.39, respectively). Only 54.8% of patients (n = 23) were seen in the nephrology clinic after discharge. CONCLUSIONS: Patients who receive CKRT for AKI have a significant risk of CKD, while follow-up with a pediatric nephrologist in these high-risk patients is sub-optimal. A higher resolution version of the Graphical abstract is available as Supplementary information.


Assuntos
Injúria Renal Aguda , Terapia de Substituição Renal Contínua , Insuficiência Renal Crônica , Humanos , Criança , Recém-Nascido , Lactente , Pré-Escolar , Adolescente , Estudos Retrospectivos , Rim , Insuficiência Renal Crônica/complicações , Terapia de Substituição Renal Contínua/efeitos adversos , Injúria Renal Aguda/etiologia , Fatores de Risco , Progressão da Doença
6.
Pediatr Res ; 91(1): 235-240, 2022 01.
Artigo em Inglês | MEDLINE | ID: mdl-33731814

RESUMO

BACKGROUND: Large volumes of non-resuscitation fluids are often administered to critically ill children. We hypothesize that excess maintenance fluid is a significant contributor to non-resuscitation fluid and that non-resuscitation fluid administered beyond hydration requirements is associated with worse clinical outcomes in critically ill children. METHODS: We evaluated all patients admitted to two large urban pediatric intensive care units (PICU) between January 2010-August 2016 and January 2010-August 2018, respectively, who survived and remained in the hospital for at least 3 days following PICU admission. The primary outcome was in-hospital mortality. Association of excess fluid with outcomes was adjusted for confounders (age, Pediatric Risk of Mortality III score, study site, day 3 acute kidney injury, PICU era, resuscitation volume, and volume output) using multivariable regression. RESULTS: We evaluated 14,483 patients; 52% received non-resuscitation fluid in excess of hydration requirements. Non-resuscitation fluid in excess of hydration requirements was associated with higher in-hospital mortality after adjustment for confounders (adjusted odds ratio 1.01 per 10 mL/kg in excess fluid, 95% confidence interval: 1.002-1.02). CONCLUSIONS: Non-resuscitation fluid in excess of hydration requirements is associated with increased mortality in critically ill children. Excess maintenance fluid is a modifiable contributor to this fluid volume. Strategies to reduce excess maintenance fluids warrant further study. IMPACT: Critically ill children frequently receive non-resuscitation fluid in excess of their estimated hydration requirements. Non-resuscitation fluid volume in excess of estimated hydration requirements is associated with higher morbidity and mortality in critically ill children. Critically ill children receive a large volume burden from maintenance fluid. Maintenance fluid represents a modifiable contributor of non-resuscitation fluid in excess of hydration requirements. Strategies focused on limitation of maintenance fluid warrant further study.


Assuntos
Estado Terminal , Hidratação , Ressuscitação , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Estudos Retrospectivos , Desequilíbrio Hidroeletrolítico
7.
Crit Care ; 25(1): 266, 2021 07 29.
Artigo em Inglês | MEDLINE | ID: mdl-34325729

RESUMO

BACKGROUND: Hyperchloremia and chloride load have been associated with worse clinical outcomes in critically ill patients. We sought to evaluate the electrolyte profile and clinical outcomes associated with a unit-wide transition from saline to balanced fluids for resuscitation and maintenance fluids in a pediatric intensive care unit (PICU). METHODS: A before and after analysis of all patients admitted to the PICU in a large, urban, academic hospital between August 2018 and March 2020. The transition from the use of saline to the use of balanced fluids for both resuscitation and maintenance fluid as standard care occurred in June 2019. The primary outcome was day 3 acute kidney injury (AKI). The secondary outcomes included mortality, ventilator-free days (VFDs), need for renal replacement therapy (RRT), hospital length of stay (LOS), and electrolyte abnormalities. RESULTS: Overall, 2863 patients (47% female) with a day 3 AKI rate of 12.9% (n = 130) and a mortality rate of 2.8% (n = 79) were included. After adjusting for confounders (age, PRISM III, mechanical ventilation, and immunocompromised state, septic shock), there were no significant differences in the odds of day 3 AKI (pre 13%, post 12.5%; adjusted odds ratio [aOR] 0.96, 95%CI 0.65-1.42). There were no differences in the secondary outcomes. The post-intervention period had fewer patients with hyperchloremia (pre 15.5% vs. post 10.4%, p = < 0.0001) and hyperkalemia (pre 3.2% vs. post 1.4%, p = 0.02) and more patients with hypochloremia (pre 9.5% vs. post 14.4%, p = < 0.0001) and hypokalemia (pre 38.2% vs. post 47.2%, p = < 0.0001). In reference to the normochloremic cohort, the hypochloremic cohort had an increase in day 3 AKI, need for RRT, hyperchloremia, and hyperkalemia, and a decrease in hypokalemia; and the hyperchloremic cohort had an increase in VFD and a decrease in hospital LOS. CONCLUSIONS: Following a unit-wide implementation of balanced fluids as standard care, there were no differences in rates of day 3 AKI or other clinical outcomes. However, there were lower rates of hyperkalemia and hyperchloremia and higher rates of hypokalemia and hypochloremia. Further evaluation of the effect of balanced fluids and the clinical significance of electrolyte abnormalities in critically ill children is needed.


Assuntos
Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Ressuscitação/normas , Desequilíbrio Hidroeletrolítico/complicações , Injúria Renal Aguda/etiologia , Distribuição de Qui-Quadrado , Criança , Pré-Escolar , Estudos de Coortes , Estudos Controlados Antes e Depois , Estado Terminal/terapia , Feminino , Humanos , Lactente , Unidades de Terapia Intensiva Pediátrica/organização & administração , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Avaliação de Resultados em Cuidados de Saúde/métodos , Pediatria/métodos , Ressuscitação/métodos , Ressuscitação/estatística & dados numéricos , Estudos Retrospectivos , Estatísticas não Paramétricas
8.
Pediatr Nephrol ; 35(7): 1331-1339, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32152726

RESUMO

BACKGROUND: Serum chloride derangements are associated with poor clinical outcomes, including acute kidney injury (AKI) and mortality. We sought to determine the association between persistent hyperchloremia and renal recovery in critically ill children with AKI. METHODS: We performed a retrospective cohort study of all patients with day 2 AKI admitted to a large academic pediatric intensive care unit from January 2014 to December 2015. After applying exclusion criteria, 348 patients were categorized as (1) hyperchloremia on both day 2 and day 7 (PersistentCl), (2) hyperchloremia on day 2 with normochloremia on day 7 (RecoveredCl), (3) normochloremia on day 2 with hyperchloremia on day 7 (DelayedCl), and (4) no hyperchloremia on day 2 nor day 7 (NormalCl). Hyperchloremia was defined as ≥ 110 mEq/L. The primary outcome was renal recovery on day 7, defined as the absence of AKI criteria. Secondary outcomes included discharge renal recovery, mortality, duration of mechanical ventilation, and hospital length of stay. RESULTS: Day 7 renal recovery rates for PersistentCl, RecoveredCl, DelayedCl, and NormalCl were 37%, 66%, 71%, and 52% respectively. PersistentCl had lower odds of day 7 renal recovery (aOR = 0.29; 95% CI, 0.14 to 0.60; p = 0.0009), lower odds of discharge renal recovery (aOR = 0.22; 95% CI, 0.11 to 0.48; p = 0.0001), and higher odds of mortality (aOR = 3.50; 95% CI, 1.11 to 11.10; p = 0.03) when compared with RecoveredCl after adjusting for confounders. CONCLUSIONS: Persistent hyperchloremia is independently associated with impaired renal recovery as well as higher mortality. Prospective studies are indicated to determine if serum chloride represents a modifiable risk factor for poor outcomes. Graphical abstract.


Assuntos
Injúria Renal Aguda/mortalidade , Cloretos/sangue , Desequilíbrio Hidroeletrolítico/mortalidade , Injúria Renal Aguda/etiologia , Adolescente , Bicarbonatos/sangue , Criança , Pré-Escolar , Feminino , Humanos , Unidades de Terapia Intensiva Pediátrica , Masculino , Estudos Retrospectivos , Desequilíbrio Hidroeletrolítico/sangue
10.
Pediatr Nephrol ; 33(6): 1079-1085, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29404689

RESUMO

BACKGROUND: The optimal fluid management in critically ill children is currently under investigation with several studies suggesting that hyperchloremia, chloride load, and the use of chloride-rich fluids contribute to worse outcomes. METHODS: This is a single-center retrospective cohort study of Pediatric Intensive Care Unit patients from 2008 to 2016 requiring continuous renal replacement therapy (CRRT). Patients were excluded if they had end-stage renal disease, a disorder of chloride transport, or concurrent provision of extracorporeal membrane oxygenation therapy. RESULTS: Patients (n = 66) were dichotomized into two groups (peak chloride (Cl) ≥ 110 mmol/L vs. peak Cl < 110 mmol/L prior to CRRT initiation). Hyperchloremia was present in 39 (59%) children. Baseline characteristics were similar between groups. Fluid overload at CRRT initiation was more common in patients with hyperchloremia (11.5% IQR 3.8-22.4) compared to those without (5.5% IQR 0.9-13.9) (p = 0.04). Mortality was significantly higher in patients with hyperchloremia (n = 26, 67%) compared to those without (n = 8, 29%) (p = 0.006). Patients with hyperchloremia had 10.9 times greater odds of death compared to those without hyperchloremia, after adjusting for percent fluid overload, PRISM III score, time to initiation of CRRT, height, and weight (95% CI 2.4 to 49.5, p = 0.002). CONCLUSIONS: Hyperchloremia is common among critically ill children prior to CRRT initiation. In this population, hyperchloremia is independently associated with mortality. Further studies are needed to determine the impact of hyperchloremia on all critically ill children and the impact of chloride load on outcomes.


Assuntos
Cloretos/sangue , Estado Terminal/mortalidade , Terapia de Substituição Renal/mortalidade , Desequilíbrio Hidroeletrolítico/mortalidade , Adolescente , Criança , Pré-Escolar , Estudos de Coortes , Estado Terminal/terapia , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva Pediátrica , Tempo de Internação/estatística & dados numéricos , Masculino , Terapia de Substituição Renal/efeitos adversos , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Análise de Sobrevida
12.
Crit Care Explor ; 6(10): e1156, 2024 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-39318499

RESUMO

OBJECTIVES: Continuous renal replacement therapy (CRRT) and shock are both associated with high morbidity and mortality in the ICU. Adult data suggest renoprotective effects of vasopressin vs. catecholamines (norepinephrine and epinephrine). We aimed to determine whether vasopressin use during CRRT was associated with improved kidney outcomes in children and young adults. DESIGN: Secondary analysis of Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK), a multicenter, retrospective cohort study. SETTING: Neonatal, cardiac, PICUs at 34 centers internationally from January 1, 2015, to December 31, 2021. PATIENTS/SUBJECTS: Patients younger than 25 years receiving CRRT for acute kidney injury and/or fluid overload and requiring vasopressors. Patients receiving vasopressin were compared with patients receiving only norepinephrine/epinephrine. The impact of timing of vasopressin relative to CRRT start was assessed by categorizing patients as: early (on or before day 0), intermediate (days 1-2), and late (days 3-7). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 1016 patients, 665 (65%) required vasopressors in the first week of CRRT. Of 665, 248 (37%) received vasopressin, 473 (71%) experienced Major Adverse Kidney Events at 90 days (MAKE-90) (death, renal replacement therapy dependence, and/or > 125% increase in serum creatinine from baseline 90 days from CRRT initiation), and 195 (29%) liberated from CRRT on the first attempt within 28 days. Receipt of vasopressin was associated with higher odds of MAKE-90 (adjusted odds ratio [aOR], 1.80; 95% CI, 1.20-2.71; p = 0.005) but not liberation success. In the vasopressin group, intermediate/late initiation was associated with higher odds of MAKE-90 (aOR, 2.67; 95% CI, 1.17-6.11; p = 0.02) compared with early initiation. CONCLUSIONS: Nearly two-thirds of children and young adults receiving CRRT required vasopressors, including over one-third who received vasopressin. Receipt of vasopressin was associated with more MAKE-90, although earlier initiation in those who received it appears beneficial. Prospective studies are needed to understand the appropriate timing, dose, and subpopulation for use of vasopressin.


Assuntos
Injúria Renal Aguda , Terapia de Substituição Renal Contínua , Vasoconstritores , Vasopressinas , Humanos , Vasoconstritores/uso terapêutico , Estudos Retrospectivos , Feminino , Masculino , Criança , Vasopressinas/uso terapêutico , Pré-Escolar , Adolescente , Injúria Renal Aguda/terapia , Injúria Renal Aguda/mortalidade , Lactente , Adulto Jovem , Recém-Nascido , Estudos de Coortes , Terapia de Substituição Renal
13.
Crit Care Explor ; 4(11): e0792, 2022 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-36349289

RESUMO

We propose a novel metric evaluating the impact an exposure to a large positive fluid balance over time has on clinical outcomes in children with respiratory failure, termed "fluid overload mechanically ventilated" (FOMV) days. We performed a retrospective cohort study of mechanically ventilated children. Using multivariable regression analyses, each FOMV day was associated with a 5% decreased likelihood of having a ventilator-free day (adjusted incidence rate ratio [aIRR], 0.95; 95% CI, 0.95-0.96), a 5% increased likelihood of having an additional day of stay (aIRR, 1.05; 95% CI 1.05-1.06), and a 6% increased relative risk of death (aRR, 1.06; 95% CI, 1.01-1.11). FOMV is a novel exposure measure in children with acute respiratory failure associated with poor outcomes paralleling published data demonstrating dose-dependent exposure to a positive fluid balance is associated with worse outcomes. FOMV is a targetable exposure metric for future use in quality improvement initiatives and research studies that may help to determine the efficacy of interventions.

14.
JAMA Netw Open ; 5(9): e2229442, 2022 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-36178697

RESUMO

Importance: Increasing evidence indicates that acute kidney injury (AKI) occurs frequently in children and young adults and is associated with poor short-term and long-term outcomes. Guidance is required to focus efforts related to expansion of pediatric AKI knowledge. Objective: To develop expert-driven pediatric specific recommendations on needed AKI research, education, practice, and advocacy. Evidence Review: At the 26th Acute Disease Quality Initiative meeting conducted in November 2021 by 47 multiprofessional international experts in general pediatrics, nephrology, and critical care, the panel focused on 6 areas: (1) epidemiology; (2) diagnostics; (3) fluid overload; (4) kidney support therapies; (5) biology, pharmacology, and nutrition; and (6) education and advocacy. An objective scientific review and distillation of literature through September 2021 was performed of (1) epidemiology, (2) risk assessment and diagnosis, (3) fluid assessment, (4) kidney support and extracorporeal therapies, (5) pathobiology, nutrition, and pharmacology, and (6) education and advocacy. Using an established modified Delphi process based on existing data, workgroups derived consensus statements with recommendations. Findings: The meeting developed 12 consensus statements and 29 research recommendations. Principal suggestions were to address gaps of knowledge by including data from varying socioeconomic groups, broadening definition of AKI phenotypes, adjudicating fluid balance by disease severity, integrating biopathology of child growth and development, and partnering with families and communities in AKI advocacy. Conclusions and Relevance: Existing evidence across observational study supports further efforts to increase knowledge related to AKI in childhood. Significant gaps of knowledge may be addressed by focused efforts.


Assuntos
Injúria Renal Aguda , Nefrologia , Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/epidemiologia , Injúria Renal Aguda/terapia , Criança , Consenso , Cuidados Críticos , Técnica Delphi , Humanos
15.
Kidney360 ; 2(5): 869-872, 2021 05 27.
Artigo em Inglês | MEDLINE | ID: mdl-35373066

RESUMO

Kinetic eGFR can be part of a multidimensional approach for AKI prediction combined with biomarkers, fluid corrected creatinine, and renal angina.Kinetic eGFR on day 1 is not independently associated with severe day-3 AKI in children and young adults who are critically ill.


Assuntos
Injúria Renal Aguda , Estado Terminal , Injúria Renal Aguda/diagnóstico , Criança , Creatinina , Taxa de Filtração Glomerular , Humanos , Rim , Adulto Jovem
16.
World J Pediatr Congenit Heart Surg ; 9(6): 696-704, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30322362

RESUMO

Children who undergo cardiac surgery with cardiopulmonary bypass are a unique population at high risk for postoperative acute kidney injury (AKI) and fluid overload. Fluid management is important in the postoperative care of these children as fluid overload is associated with increased morbidity and mortality. Peritoneal dialysis catheters are an important tool in the armamentarium of a cardiac intensivist and are used for passive drainage for fluid removal or dialysis for electrolyte and uremia control in AKI. Prophylactic placement of a peritoneal catheter is a safe method of fluid removal that is associated with few major complications. Early initiation of peritoneal dialysis has been associated with improved clinical markers and outcomes such as early achievement of a negative fluid balance, lower vasoactive medication needs, shorter duration of mechanical ventilation, and decreased mortality. In this review, we discuss the safety and potential benefits of peritoneal catheters for dialysis or passive drainage in children following cardiopulmonary bypass.


Assuntos
Injúria Renal Aguda , Procedimentos Cirúrgicos Cardíacos , Diálise Peritoneal/métodos , Cuidados Pós-Operatórios/métodos , Injúria Renal Aguda/etiologia , Injúria Renal Aguda/metabolismo , Injúria Renal Aguda/terapia , Criança , Humanos , Equilíbrio Hidroeletrolítico
17.
Intensive Care Med ; 44(12): 2183-2191, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30382307

RESUMO

PURPOSE: To determine if there is an association between mortality and admission chloride levels and/or increases in the chloride level in critically ill children. METHODS: We performed a retrospective cohort study of all patients admitted to the paediatric intensive care unit (PICU) from January 2014 to December 2015. Patients were excluded for the following reasons: (1) age < 90 days or > 18 years, (2) admission to the cardiac intensive care unit, (3) no laboratory values upon admission to the PICU, (4) history of end-stage renal disease, (5) a disorder of chloride transport, and (6) admission for diabetic ketoacidosis. The patients were stratified on the basis of admission chloride levels (hypochloraemia, < 96 mEq/L; normochloraemia, 96-109 mEq/L; and hyperchloraemia, ≥ 110 mEq/L) and dichotomised on the basis of an increase in chloride in the first day (< 5 mEq/L, ≥ 5 mEq/L). Our primary outcome was in-hospital mortality. RESULTS: A total of 1935 patients [55% female, median age 6.3 years IQR (1.9-13.4)] were included. The overall mortality was 4% (n = 71) and day 2 AKI occurred in 17% (n = 333. Hypochloraemia, hyperchloraemia, and an increase in serum chloride ≥ 5 mEq/L occurred in 2%, 21%, and 12%, respectively. After adjusting for confounders, increase in chloride ≥ 5 mEq/L was associated with a 2.3 (95% CI 1.03-5.21) greater odds of mortality. CONCLUSIONS: An increase in serum chloride level in the first day of admission is common and an independent risk factor for mortality in critically ill children. Further studies are warranted to identify how chloride disturbances contribute to mortality risk in critically ill children.


Assuntos
Cloretos/sangue , Estado Terminal/mortalidade , Injúria Renal Aguda/sangue , Injúria Renal Aguda/epidemiologia , Adolescente , Fatores Etários , Criança , Pré-Escolar , Feminino , Mortalidade Hospitalar , Hospitalização , Humanos , Lactente , Unidades de Terapia Intensiva Pediátrica , Masculino , Estudos Retrospectivos , Fatores de Risco
18.
J Neurosci ; 26(24): 6450-7, 2006 Jun 14.
Artigo em Inglês | MEDLINE | ID: mdl-16775132

RESUMO

Morphine dependence is characterized by somatic and motivational signs of withdrawal that likely contribute to the maintenance of addictive behavior. The nucleus accumbens (NAc) receives extensive dopaminergic input and is an important substrate for mediating these aversive states. In the NAc, the function of the transcription factor cAMP response element binding protein (CREB) and AMPA glutamate receptor subunit, type 1 (GluR1) can be regulated by dopamine (DA) D1 receptor-mediated phosphorylation (P-CREB, P-GluR1). However, the roles of D1 receptors, CREB, and GluR1 in morphine dependence are not well understood. Here, we show that somatic signs of naloxone-precipitated withdrawal were associated with increased P-CREB, but not P-GluR1, in the NAc of morphine-dependent rats. The D1 receptor agonist chloro-APB hydrobromide (SKF 82958) was rewarding in morphine-dependent rats and blocked naloxone-induced place aversions and somatic signs of withdrawal. Surprisingly, SKF 82958 increased P-GluR1, but not P-CREB, in the NAc, and naloxone reduced SKF 82958-mediated P-GluR1 induction specifically in morphine-dependent rats. Together, these results confirm that aversive treatments can increase CREB function in the NAc. Furthermore, they suggest a dependence-associated shift in the molecular mechanisms that regulate the consequences of D1 receptor stimulation, favoring activation of GluR1 rather than CREB. These data raise the possibility that the rewarding effects of SKF 82958 in morphine-dependent rats involve increased P-GluR1 in the NAc, although the involvement of other brain regions cannot be ruled out. Regardless, these findings suggest for the first time that D1 agonists might be useful for the treatment of withdrawal symptoms that contribute to the maintenance of opiate addiction in humans.


Assuntos
Dependência de Morfina/metabolismo , Morfina/efeitos adversos , Naloxona/farmacologia , Antagonistas de Entorpecentes/farmacologia , Entorpecentes/efeitos adversos , Receptores de Dopamina D1/fisiologia , Síndrome de Abstinência a Substâncias/metabolismo , Animais , Comportamento Animal/efeitos dos fármacos , Benzazepinas/farmacologia , Western Blotting/métodos , Corpo Estriado/efeitos dos fármacos , Proteína de Ligação ao Elemento de Resposta ao AMP Cíclico/metabolismo , Agonistas de Dopamina/farmacologia , Relação Dose-Resposta a Droga , Interações Medicamentosas , Masculino , Dependência de Morfina/psicologia , Núcleo Accumbens/efeitos dos fármacos , Fosforilação/efeitos dos fármacos , Ratos , Ratos Sprague-Dawley , Receptores de AMPA/metabolismo , Síndrome de Abstinência a Substâncias/psicologia
20.
Psychopharmacology (Berl) ; 204(2): 227-39, 2009 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-19148621

RESUMO

RATIONALE: Chronic opiate administration induces neuroadaptations within the nucleus accumbens (NAc) and ventral tegmental area (VTA) that can contribute to dependence. We have shown that morphine dependence shifts the behavioral consequences of D1 dopamine (DA) receptor signaling: systemic administration of a D1 receptor agonist is rewarding and blocks naloxone-precipitated withdrawal signs in morphine-dependent rats, but has minimal effects in nondependent rats. These data suggest that D1 receptors acquire the ability to regulate reward and withdrawal in morphine-dependent rats. The brain regions involved in these effects are not known. OBJECTIVE: Studies were designed to test the hypothesis that the nucleus accumbens shell (NASh) and the ventral tegmental area (VTA) are important sites for mediating the behavioral effects of D1 receptor activation in morphine-dependent rats. MATERIALS AND METHODS: The effects of microinjecting the D1 receptor agonist SKF 82958 into the NASh or the VTA on place conditioning and somatic withdrawal signs were studied in morphine-dependent and nondependent rats. RESULTS: Intra-NASh microinjection of SKF 82958 (1 microg/side) established conditioned place preferences in morphine-dependent but not nondependent rats, but had no effect on naloxone-induced place aversions or somatic withdrawal signs. Intra-VTA microinjection of SKF 82958 (2 microg) did not establish place preferences under any conditions, but blocked naloxone-induced place aversions without effects on somatic withdrawal signs. CONCLUSIONS: There is an anatomical dissociation between D1 receptor-mediated reward and relief of withdrawal in morphine-dependent rats. When combined, the individual effects of D1 receptor activation in the NASh and VTA on the affective signs of precipitated morphine withdrawal resemble those seen with systemic administration.


Assuntos
Benzazepinas/farmacologia , Encéfalo/anatomia & histologia , Agonistas de Dopamina/farmacologia , Dependência de Morfina/psicologia , Receptores de Dopamina D1/agonistas , Recompensa , Síndrome de Abstinência a Substâncias/psicologia , Animais , Encéfalo/efeitos dos fármacos , Condicionamento Operante/efeitos dos fármacos , Masculino , Microinjeções , Naloxona/farmacologia , Antagonistas de Entorpecentes/farmacologia , Núcleo Accumbens , Ratos , Ratos Sprague-Dawley , Síndrome de Abstinência a Substâncias/tratamento farmacológico , Área Tegmentar Ventral/fisiologia
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