Advertisement

Filtering Down to Risks and Solutions: Risk Factors and Stratification After Pediatric Cardiac Surgery

  • Kevin Pettit.
    Affiliations
    Department of Pediatrics, The Heart Institute, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO
    Search for articles by this author
  • Katja M. Gist.
    Correspondence
    Address reprint requests to Katja Gist, DO, MSc, Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2003, Cincinnati OH 45229.
    Affiliations
    Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
    Search for articles by this author
      Summary
      Acute kidney injury after cardiac surgery (CS-AKI) is common in neonatal and pediatric populations and is a risk factor for poor outcomes, such as mortality and increased hospital resource utilization. This review presents a summary of CS-AKI risk factors, integration of biomarkers, and the need to improve risk stratification for targeting future clinical trials. To date, studies examining CS-AKI risk factors cannot be generalized easily owing to variability in patient age, surgical complexity or population, AKI definition, and center-specific practices. However, certain risk associations, such as younger age at surgery, history of prematurity, cardiopulmonary bypass time, and surgical complexity, have been identified across multiple, but not all, studies. CS-AKI appears to have different severity and duration phenotypes, and serum creatinine is limited in its ability to identify CS-AKI early and predict CS-AKI course. Treatment strategies are largely supportive, and efforts are ongoing to use biomarkers and clinical features to risk-stratify patients, which in turn may facilitate differential CS-AKI phenotyping and management with supportive care bundles, clinical decision support techniques, and modulation of modifiable risk factors.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Seminars in Nephrology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      REFERENCES

        • 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: 184-194
        • Kaddourah A
        • Basu RK
        • Bagshaw SM
        • Goldstein SL.
        Epidemiology of acute kidney injury in critically ill children and young adults.
        N Engl J Med. 2017; 376: 11-20
        • Zappitelli M
        • Bernier PL
        • Saczkowski RS
        • et al.
        A small post-operative rise in serum creatinine predicts acute kidney injury in children undergoing cardiac surgery.
        Kidney Int. 2009; 76: 885-892
        • Aydin SI
        • Seiden HS
        • Blaufox AD
        • et al.
        Acute kidney injury after surgery for congenital heart disease.
        Ann Thorac Surg. 2012; 94: 1589-1595
        • Taylor ML
        • Carmona F
        • Thiagarajan RR
        • et al.
        Mild postoperative acute kidney injury and outcomes after surgery for congenital heart disease.
        J Thorac Cardiovasc Surg. 2013; 146: 146-152
        • 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: 1493-1499
        • Blinder JJ
        • Goldstein SL
        • Lee VV
        • et al.
        Congenital heart surgery in infants: effects of acute kidney injury on outcomes.
        J Thorac Cardiovasc Surg. 2012; 143: 368-374
        • Morgan CJ
        • Zappitelli M
        • Robertson CM
        • et al.
        Risk factors for and outcomes of acute kidney injury in neonates undergoing complex cardiac surgery.
        J Pediatr. 2013; 162 (120-127 e1)
        • Blinder JJ
        • Asaro LA
        • Wypij D
        • et al.
        Acute kidney injury after pediatric cardiac surgery: a secondary analysis of the safe pediatric euglycemia after cardiac surgery trial.
        Pediatr Crit Care Med. 2017; 18: 638-646
        • Alten JA
        • Cooper DS
        • Blinder JJ
        • et al.
        Epidemiology of acute kidney injury after neonatal cardiac surgery: a report from the multicenter neonatal and pediatric heart and renal outcomes network.
        Crit Care Med. 2021; 49: e941-e951
        • Sasaki J
        • Rodriguez Z
        • Alten JA
        • et al.
        Epidemiology of neonatal acute kidney injury after cardiac surgery without cardiopulmonary bypass.
        Ann Thorac Surg. 2022; 114: 1786-1792
        • Kellum JA
        • Lameire N.
        Diagnosis, evaluation, and management of acute kidney injury: a KDIGO summary (part 1).
        Crit Care. 2013; 17: 204
        • Chiravuri SD
        • Riegger LQ
        • Christensen R
        • et al.
        Factors associated with acute kidney injury or failure in children undergoing cardiopulmonary bypass: a case-controlled study.
        Paediatr Anaesth. 2011; 21: 880-886
        • Rodriguez MM
        • Gomez AH
        • Abitbol CL
        • Chandar JJ
        • Duara S
        • Zilleruelo GE.
        Histomorphometric analysis of postnatal glomerulogenesis in extremely preterm infants.
        Pediatr Dev Pathol. 2004; 7: 17-25
        • Faa G
        • Gerosa C
        • Fanni D
        • et al.
        Marked interindividual variability in renal maturation of preterm infants: lessons from autopsy.
        J Matern Fetal Neonatal Med. 2010; 23: 129-133
        • Sutherland MR
        • Gubhaju L
        • Moore L
        • et al.
        Accelerated maturation and abnormal morphology in the preterm neonatal kidney.
        J Am Soc Nephrol. 2011; 22: 1365-1374
        • Piggott KD
        • Soni M
        • Decampli WM
        • et al.
        Acute kidney injury and fluid overload in neonates following surgery for congenital heart disease.
        World J Pediatr Congenit Heart Surg. 2015; 6: 401-406
        • Rabb H
        • Pluznick J
        • Noel S.
        The microbiome and acute kidney injury.
        Nephron. 2018; 140: 120-123
        • Treiber M
        • Pecovnik Balon B
        • Gorenjak M
        A new serum cystatin C formula for estimating glomerular filtration rate in newborns.
        Pediatr Nephrol. 2015; 30: 1297-1305
        • Kuntz RA
        • Holt DW
        • Turner S
        • Stichka L
        • Thacker B.
        Effects of conventional ultrafiltration on renal performance during adult cardiopulmonary bypass procedures.
        J Extra Corpor Technol. 2006; 38: 144-153
        • Gist KM
        • Henry BM
        • Borasino S
        • et al.
        Prophylactic peritoneal dialysis after the arterial switch operation: a retrospective cohort study.
        Ann Thorac Surg. 2021; 111: 655-661
        • Gist KM
        • Borasino S
        • SooHoo M
        • et al.
        Transient and persistent acute kidney injury phenotypes following the norwood operation: a retrospective study.
        Cardiol Young. 2022; 32: 564-571
        • Moffett BS
        • Goldstein SL.
        Acute kidney injury and increasing nephrotoxic-medication exposure in noncritically-ill children.
        Clin J Am Soc Nephrol. 2011; 6: 856-863
        • Goldstein SL
        • Kirkendall E
        • Nguyen H
        • Schaffzin JK
        • Bucuvalas J
        • Bracke T
        • et al.
        Electronic health record identification of nephrotoxin exposure and associated acute kidney injury.
        Pediatrics. 2013; 132: e756-e767
        • Goldstein SL
        • Mottes T
        • Simpson K
        • et al.
        A sustained quality improvement program reduces nephrotoxic medication-associated acute kidney injury.
        Kidney Int. 2016; 90: 212-221
        • Uber AM
        • Montez-Rath ME
        • Kwiatkowski DM
        • Krawczeski CD
        • Sutherland SM.
        Nephrotoxin exposure and acute kidney injury in critically ill children undergoing congenital cardiac surgery.
        Pediatr Nephrol. 2018; 33: 2193-2199
        • Wong JH
        • Selewski DT
        • Yu S
        • et al.
        Severe acute kidney injury following stage 1 Norwood palliation: effect on outcomes and risk of severe acute kidney injury at subsequent surgical stages.
        Pediatr Crit Care Med. 2016; 17: 615-623
        • Watkins SC
        • Williamson K
        • Davidson M
        • Donahue BS
        Long-term mortality associated with acute kidney injury in children following congenital cardiac surgery.
        Paediatr Anaesth. 2014; 24: 919-926
        • Hasson DC
        • Brinton JT
        • Cowherd E
        • Soranno DE
        • Gist KM.
        Risk factors for recurrent acute kidney injury in children who undergo multiple cardiac surgeries: a retrospective analysis.
        Pediatr Crit Care Med. 2019; 20: 614-620
        • 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: 751-756
        • Van den Eynde J
        • Salaets T
        • Louw JJ
        • et al.
        Persistent markers of kidney injury in children who developed acute kidney injury after pediatric cardiac surgery: a prospective cohort study.
        J Am Heart Assoc. 2022; 11e024266
        • Ostermann M
        • Zarbock A
        • Goldstein S
        • et al.
        Recommendations on acute kidney injury biomarkers from the acute disease quality initiative consensus conference: a consensus statement.
        JAMA Netw Open. 2020; 3e2019209
        • Mishra J
        • Dent C
        • Tarabishi R
        • Mitsnefes MM
        • Ma Q
        • Kelly C
        • et al.
        Neutrophil gelatinase-associated lipocalin (NGAL) as a biomarker for acute renal injury after cardiac surgery.
        Lancet. 2005; 365: 1231-1238
        • Dent CL
        • Ma Q
        • Dastrala S
        • et al.
        Plasma neutrophil gelatinase-associated lipocalin predicts acute kidney injury, morbidity and mortality after pediatric cardiac surgery: a prospective uncontrolled cohort study.
        Crit Care. 2007; 11: R127
        • Krawczeski CD
        • Woo JG
        • Wang Y
        • Bennett MR
        • Ma Q
        • Devarajan P.
        Neutrophil gelatinase-associated lipocalin concentrations predict development of acute kidney injury in neonates and children after cardiopulmonary bypass.
        J Pediatr. 2011; 158 (1009-1015 e1)
        • Krawczeski CD
        • Goldstein SL
        • Woo JG
        • et al.
        Temporal relationship and predictive value of urinary acute kidney injury biomarkers after pediatric cardiopulmonary bypass.
        J Am Coll Cardiol. 2011; 58: 2301-2309
        • Basu RK
        • Wong HR
        • Krawczeski CD
        • et al.
        Combining functional and tubular damage biomarkers improves diagnostic precision for acute kidney injury after cardiac surgery.
        J Am Coll Cardiol. 2014; 64: 2753-2762
        • Stanski N
        • Menon S
        • Goldstein SL
        • Basu RK.
        Integration of urinary neutrophil gelatinase-associated lipocalin with serum creatinine delineates acute kidney injury phenotypes in critically ill children.
        J Crit Care. 2019; 53: 1-7
        • Van den Eynde J
        • Schuermans A
        • Verbakel JY
        • et al.
        Biomarkers of acute kidney injury after pediatric cardiac surgery: a meta-analysis of diagnostic test accuracy.
        Eur J Pediatr. 2022; 181: 1909-1921
        • Meersch M
        • Schmidt C
        • Van Aken H
        • et al.
        Validation of cell-cycle arrest biomarkers for acute kidney injury after pediatric cardiac surgery.
        PLoS One. 2014; 9e110865
        • Gist KM
        • Goldstein SL
        • Wrona J
        • et al.
        Kinetics of the cell cycle arrest biomarkers (timp-2*igfbp-7) for prediction of acute kidney injury in infants after cardiac surgery.
        Pediatr Nephrol. 2017; 32: 1611-1619
        • Ramirez M
        • Chakravarti S
        • Busovsky-McNeal M
        • et al.
        Elevated levels of urinary biomarkers TIMP-2 and IGFBP-7 predict acute kidney injury in neonates after congenital heart surgery.
        J Pediatr Intensive Care. 2022; 11: 153-158
        • Tao Y
        • Heskia F
        • Zhang M
        • et al.
        Evaluation of acute kidney injury by urinary tissue inhibitor metalloproteinases-2 and insulin-like growth factor-binding protein 7 after pediatric cardiac surgery.
        Pediatr Nephrol. 2022; 37: 2743-2753
        • Bojan M
        • Pieroni L
        • Semeraro M
        • Froissart M.
        Cell-cycle arrest biomarkers: usefulness for cardiac surgery-related acute kidney injury in neonates and infants.
        Pediatr Crit Care Med. 2020; 21: 563-570
        • 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: 357-364
        • 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: 230-236
        • Sasser WC
        • Dabal RJ
        • Askenazi DJ
        • et al.
        Prophylactic peritoneal dialysis following cardiopulmonary bypass in children is associated with decreased inflammation and improved clinical outcomes.
        Congenit Heart Dis. 2014; 9: 106-115
        • Van den Eynde J
        • Cloet N
        • Van Lerberghe R
        • et al.
        Strategies to prevent acute kidney injury after pediatric cardiac surgery: a network meta-analysis.
        Clin J Am Soc Nephrol. 2021; 16: 1480-1490
        • Chawla LS
        • Bellomo R
        • Bihorac A
        • et al.
        Acute kidney disease and renal recovery: consensus report of the acute disease quality initiative (ADQI) 16 workgroup.
        Nat Rev Nephrol. 2017; 13: 241-257
        • LoBasso M
        • Schneider J
        • Sanchez-Pinto LN
        • et al.
        Acute kidney injury and kidney recovery after cardiopulmonary bypass in children.
        Pediatr Nephrol. 2022; 37: 659-665
        • Meersch M
        • Schmidt C
        • Hoffmeier A
        • et al.
        Prevention of cardiac surgery-associated AKI by implementing the KDIGO guidelines in high risk patients identified by biomarkers: the Prevaki randomized controlled trial.
        Intensive Care Med. 2017; 43: 1551-1561
        • Schaubroeck HAI
        • Vargas D
        • Vandenberghe W
        • Hoste EAJ.
        Impact of AKI care bundles on kidney and patient outcomes in hospitalized patients: a systematic review and meta-analysis.
        BMC Nephrol. 2021; 22: 335
        • Wilson FP
        • Martin M
        • Yamamoto Y
        • et al.
        Electronic health record alerts for acute kidney injury: multicenter, randomized clinical trial.
        BMJ. 2021; 372: m4786
        • 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: 659-667
        • Goldstein SL
        • Krallman KA
        • Kirby C
        • et al.
        Integration of the renal angina index and urine neutrophil gelatinase-associated lipocalin improves severe acute kidney injury prediction in critically ill children and young adults.
        Kidney Int Rep. 2022; 7: 1842-1849
        • Gist KM
        • SooHoo M
        • Mack E
        • et al.
        Modifying the renal angina index for predicting AKI and related adverse outcomes in pediatric heart surgery.
        World J Pediatr Congenit Heart Surg. 2022; 13: 196-202
        • Pande CK
        • Smith MB
        • Soranno DE
        • et al.
        The neglected price of pediatric acute kidney injury: non-renal implications.
        Front Pediatr. 2022; 10893993
        • Selewski DT
        • Askenazi DJ
        • Kashani K
        • Basu RK
        • Gist KM
        • Harer MW.
        Quality improvement goals for pediatric acute kidney injury: pediatric applications of the 22nd Acute Disease Quality Initiative (ADQI) conference.
        Pediatr Nephrol. 2020; 36: 733-746