Acute Kidney Injury in Pediatric Severe Sepsis: An Independent Risk Factor for Death and New Disability. (Stulce)

Fitzgerald JC, et al. Acute Kidney Injury in Pediatric Severe Sepsis: An Independent Risk Factor for Death and New Disability. Crit Care Med. 2016 Dec;44(12):2241-2250.

OBJECTIVES: The prevalence of septic acute kidney injury and impact on functional status of PICU survivors are unknown. We used data from an international prospective severe sepsis study to elucidate functional outcomes of children suffering septic acute kidney injury.

DESIGN: Secondary analysis of patients in the Sepsis PRevalence, OUtcomes, and Therapies point prevalence study: acute kidney injury was defined on the study day using Kidney Disease Improving Global Outcomes definitions. Patients with no acute kidney injury or stage 1 acute kidney injury (“no/mild acute kidney injury”) were compared with those with stage 2 or 3 acute kidney injury (“severe acute kidney injury”). The primary outcome was a composite of death or new moderate disability at discharge defined as a Pediatric Overall Performance Category score of 3 or higher and increased by 1 from baseline.

SETTING: One hundred twenty-eight PICUs in 26 countries.

PATIENTS: Children with severe sepsis in the Sepsis PRevalence, OUtcomes, and Therapies study.


MEASUREMENTS AND MAIN RESULTS: One hundred two (21%) of 493 patients had severe acute kidney injury. More than twice as many patients with severe acute kidney injury died or developed new moderate disability compared with those with no/mild acute kidney injury (64% vs 30%; p < 0.001). Severe acute kidney injury was independently associated with death or new moderate disability (adjusted odds ratio, 2.5; 95% CI, 1.5-4.2; p = 0.001) after adjustment for age, region, baseline disability, malignancy, invasive mechanical ventilation, albumin administration, and the pediatric logistic organ dysfunction score.

CONCLUSIONS: In a multinational cohort of critically ill children with severe sepsis and high mortality rates, septic acute kidney injury is independently associated with further increased death or new disability.

Factors Associated With Mortality in Neonates Requiring Extracorporeal Membrane Oxygenation for Cardiac Indications: Analysis of the Extracorporeal Life Support Organization Registry Data. (Duke)

Ford MA, et al. Factors Associated With Mortality in Neonates Requiring Extracorporeal Membrane Oxygenation for Cardiac Indications: Analysis of the Extracorporeal Life Support Organization Registry Data. Pediatr Crit Care Med. 2016 Sep;17(9):860-70.

OBJECTIVES: Survival among neonates supported with extracorporeal membrane oxygenation for cardiac indications is 39%. Previous single-center studies have identified factors associated with mortality, but a comprehensive multivariate analysis is not available for this population. Understanding factors associated with mortality may help design treatment strategies, determine optimal timing for cannulation, and inform patient selection. This study identifies factors associated with mortality in neonates supported with extracorporeal membrane oxygenation for cardiac indications.

DESIGN: Retrospective cohort study.

SETTING: Two hundred and thirty U.S. and international centers reporting extracorporeal membrane oxygenation data to the Extracorporeal Life Support Organization.

SUBJECTS: Four thousand and four seventy one neonates with congenital and acquired cardiac disease supported with extracorporeal membrane oxygenation for cardiac indications during 2001-2011.


MEASUREMENTS AND RESULTS: The primary outcome measure was mortality prior to hospital discharge. Overall hospital mortality was 59%. Demographic and preextracorporeal membrane oxygenation factors associated with mortality were evaluated in a multivariable model. Factors associated with death prior to hospital discharge included lower body weight, earlier era, single ventricle physiology, lower preextracorporeal membrane oxygenation arterial pH, and longer time from intubation to extracorporeal membrane oxygenation cannulation. Lower pH was associated with increased mortality regardless of cardiac diagnosis and surgical complexity. The majority of survivors separated from extracorporeal membrane oxygenation less than 8 days after extracorporeal membrane oxygenation deployment.

CONCLUSIONS: Mortality for neonates supported with extracorporeal membrane oxygenation for cardiac indications is high. Severity of preextracorporeal membrane oxygenation acidosis was independently associated with increased risk of mortality. Earlier initiation of extracorporeal membrane oxygenation may reduce the degree and duration of acidosis and may improve survival. Further studies are needed to determine optimal timing of cannulation in this population.

A Simple and Robust Bedside Model for Mortality Risk in Pediatric Patients With Acute Respiratory Distress Syndrome. (Sirignano)

Spicer AC, et al. A Simple and Robust Bedside Model for Mortality Risk in Pediatric Patients With Acute Respiratory Distress Syndrome. Pediatr Crit Care Med. 2016 Aug 3. [Epub ahead of print]

OBJECTIVES: Despite declining mortality, acute respiratory distress syndrome is still involved in up to one third of pediatric intensive care deaths. The recently convened Pediatric Acute Lung Injury Consensus Conference has outlined research priorities for the field, which include the need for accurate bedside risk stratification of patients. We aimed to develop a simple yet robust model of mortality risk among pediatric patients with acute respiratory distress syndrome to facilitate the targeted application of high-risk investigational therapies and stratification for enrollment in clinical trials.

DESIGN: Prospective, multicenter cohort.

SETTING: Five academic PICUs.

PATIENTS: Three hundred eight children greater than 1 month and less than or equal to 18 years old, admitted to the ICU, with bilateral infiltrates on chest radiograph and PaO2/FIO2 ratio less than 300 in the clinical absence of left atrial hypertension.


MEASUREMENTS AND MAIN RESULTS: Twenty clinical variables were recorded in the following six categories: demographics, medical history, oxygenation, ventilation, radiographic imaging, and multiple organ dysfunction. Data were measured 0-24 and 48-72 hours after acute respiratory distress syndrome onset (day 1 and 3) and examined for associations with hospital mortality. Among 308 enrolled patients, mortality was 17%. Children with a history of cancer and/or hematopoietic stem cell transplant had higher mortality (47% vs 11%; p < 0.001). Oxygenation index, the PaO2/FIO2 ratio, extrapulmonary organ dysfunction, Pediatric Risk of Mortality-3, and positive cumulative fluid balance were each associated with mortality. Using two statistical approaches, we found that a parsimonious model of mortality risk using only oxygenation index and cancer/hematopoietic stem cell transplant history performed as well as other more complex models that required additional variables.

CONCLUSIONS: In the PICU, oxygenation index and cancer/hematopoietic stem cell transplant history can be used on acute respiratory distress syndrome day 1 or day 3 to predict hospital mortality without the need for more complex models. These findings may simplify risk assessment for clinical trials, counseling families, and high-risk interventions such as extracorporeal life support.

Obesity, Acute Kidney Injury, and Mortality in Critical Illness. (Emrath)

Danziger J, et al. Obesity, Acute Kidney Injury, and Mortality in Critical Illness. Crit Care Med. 2016 Feb;44(2):328-34.

OBJECTIVES: Although obesity is associated with risk for chronic kidney disease and improved survival, less is known about the associations of obesity with risk of acute kidney injury and post acute kidney injury mortality.

DESIGN: In a single-center inception cohort of almost 15,000 critically ill patients, we evaluated the association of obesity with acute kidney injury and acute kidney injury severity, as well as in-hospital and 1-year survival. Acute kidney injury was defined using the Kidney Disease Outcome Quality Initiative criteria.

MEASUREMENTS AND MAIN RESULTS: The acute kidney injury prevalence rates for normal, overweight, class I, II, and III obesity were 18.6%, 20.6%, 22.5%, 24.3%, and 24.0%, respectively, and the adjusted odds ratios of acute kidney injury were 1.18 (95% CI, 1.06-1.31), 1.35 (1.19-1.53), 1.47 (1.25-1.73), and 1.59 (1.31-1.87) when compared with normal weight, respectively. Each 5-kg/m increase in body mass index was associated with a 10% risk (95% CI, 1.06-1.24; p < 0.001) of more severe acute kidney injury. Within-hospital and 1-year survival rates associated with the acute kidney injury episodes were similar across body mass index categories.

CONCLUSION: Obesity is a risk factor for acute kidney injury, which is associated with increased short- and long-term mortality.