Acute kidney injury (AKI) after cardiopulmonary bypass surgery to correct congenital heart disease is common. We prevent fluid overload and further cardiac compromise in oliguric infants with continuous peritoneal dialysis (CPD). The effect of CPD on kidney recovery is unknown, thus indications to discontinue CPD are unclear. We aimed to determine if CPD affects kidney recovery, measured by urine output and novel urinary AKI biomarker concentrations.
Methods
Twenty infants <90 days old with congenital heart disease who underwent bypass surgery and were post-operatively treated with CPD were randomized at the time of clinical readiness for CPD discontinuation to 1) discontinue CPD (control) or 2) continue 24 h more CPD (experimental). Urine output (ml/kg per h), total output (ml/kg per h) and urinary neutrophil gelatinase-associated lipocalin, interleukin-18, liver-type fatty acid binding protein, and kidney injury molecule-1 were assessed post-surgery until CPD catheter removal.
Results
24 hours preceding randomization, there were no differences in mean urine output or total output; 24 hours post-randomization, the control group had higher mean urine output (4.2 ± 2.6 ml/kg per h vs. 2.8 ± 2.0 ml/kg per h, p = 0.02) but lower total output (6.3 ± 2.1 ml/kg per h vs. 4.7 ± 2.7 ml/kg per h, p = 0.01). Median biomarker concentrations did not differ significantly between groups at any time point.
Conclusions
Our results suggest renal replacement therapy does not change the time course of kidney function recovery.
KrawczeskiC.D., WooJ.G., Wangy, BennettM.R., MaQ., DevarajanP.Neutrophil gelatinase-associated lipocalin concentrations predict development of acute kidney injury in neonates and children after cardiopulmonary bypass. J Pediatr.2011; 158(6): 1009–1015, e1.
2.
MishraJ., DentC., TarabishiR.Neutrophil gelatinaseassociated lipocalin (NGAL) as a biomarker for acute renal injury after cardiac surgery. Lancet.2005; 365(9466): 1231–1238.
3.
ZappitelliM., BernierP.L., SaczkowskiR.S.A small post-operative rise in serum creatinine predicts acute kidney injury in children undergoing cardiac surgery. Kidney Int.2009; 76(8): 885–892.
4.
BlinderJ.J., GoldsteinS.L., LeeV.V.Congenital heart surgery in infants: effects of acute kidney injury on outcomes. J Thorac Cardiovasc Surg.2012; 143(2): 368–374.
5.
KrawczeskiC.D., GoldsteinS.L., WooJ.G.Temporal relationship and predictive value of urinary acute kidney injury biomarkers after pediatric cardiopulmonary bypass. J Am Coll Cardiol.2011; 58(22): 2301–2309.
6.
Hui-StickleS., BrewerE.D., GoldsteinS.L.Pediatric ARF epidemiology at a tertiary care center from 1999 to 2001. Am J Kidney Dis.2005; 45(1): 96–101.
7.
ZappitelliM., WashburnK.K., ArikanA.A.Urine neutrophil gelatinase-associated lipocalin is an early marker of acute kidney injury in critically ill children: a prospective cohort study. Crit Care.2007; 11(4): R84.
8.
GibneyN., HosteE., BurdmannE.A.Timing of initiation and discontinuation of renal replacement therapy in AKI: unanswered key questions. Clin J Am Soc Nephrol.2008; 3(3): 876–880.
9.
PedersenK.R., HjortdalV.E., ChristensenS.Clinical outcome in children with acute renal failure treated with peritoneal dialysis after surgery for congenital heart disease. Kidney Int Suppl.2008; (108): S81–S86.
10.
ChanK.L., IpP., ChiuC.S., CheungYf.Peritoneal dialysis after surgery for congenital heart disease in infants and young children. Ann Thorac Surg.2003; 76(5): 1443–1449.
11.
SorofJ.M., StrombergD., BrewerE.D., FeltesT F., FraserC.D.Jr.. Early initiation of peritoneal dialysis after surgical repair of congenital heart disease. Pediatr Nephrol.1999; 13(8): 641–645.
12.
DittrichS., DähnertI., VogelM.Peritoneal dialysis after infant open heart surgery: observations in 27 patients. Ann Thorac Surg.1999; 68(1): 160–163.
13.
StrombergD., FraserCDJr..SorofJ.M., DrescherK., FeltesT F.Peritoneal dialysis. An adjunct to pediatric postcardiotomy fluid management. Tex Heart Inst J.1997; 24(4): 269–277.
14.
WernerH.A., WensleyD F., LirenmanD.S., LeBlancJ.G.Peritoneal dialysis in children after cardiopulmonary bypass. J Thorac Cardiovasc Surg.1997; 113(1): 64–68, discussion 68-70.
15.
BokeschP.M., KapuralM.B., MossadE.B.Do peritoneal catheters remove pro-inflammatory cytokines after cardiopulmonary bypass in neonates?Ann Thorac Surg.2000; 70(2): 639–643.
16.
KellumJ.A., MehtaR.L., AngusD.C., PalevskyP., RoncoC; ADQI Workgroup. The first international consensus conference on continuous renal replacement therapy. Kidney Int.2002; 62(5): 1853–1863.
17.
PalevskyP.M., O'ConnorT.Z., ChertowG.M., CrowleyS.T., ZhangJ.H., KellumJ.A.; US Department of Veterans Affairs/National Institutes of Health Acute Renal Failure Trial Network. Intensity of renal replacement therapy in acute kidney injury: perspective from within the Acute Renal Failure Trial Network Study. Crit Care.2009; 13(4): 310.
18.
DittrichS., AktuerkD., SeitzS.Effects of ultrafiltration and peritoneal dialysis on proinflammatory cytokines during cardiopulmonary bypass surgery in newborns and infants. Eur J Cardiothorac Surg.2004; 25(6): 935–940.
19.
HanW.K., WaikarS.S., JohnsonA.Urinary biomark-ers in the early diagnosis of acute kidney injury. Kidney Int.2008; 73(7): 863–869.
20.
ParikhC.R., MishraJ., Thiessen-PhilbrookH.Urinary IL-18 is an early predictive biomarker of acute kidney injury after cardiac surgery. Kidney Int.2006; 70(1): 199–203.
21.
PortillaD., DentC., SugayaT.Liver fatty acid-binding protein as a biomarker of acute kidney injury after cardiac surgery. Kidney Int.2008; 73(4): 465–472.
22.
DentC.L., MaQ., DastralaS.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(6): R127.
23.
BennettM., DentC.L., MaQ.Urine NGAL predicts severity of acute kidney injury after cardiac surgery: a prospective study. Clin J Am Soc Nephrol.2008; 3(3): 665–673.
24.
SrisawatN., MuruganR., LeeM.; Genetic and Inflammatory Markers of Sepsis (GenIMS) Study Investigators. Plasma neutrophil gelatinase-associated lipocalin predicts recovery from acute kidney injury following community-acquired pneumonia. Kidney Int.2011; 80(5): 545–552.
25.
JenkinsK.J., GauvreauK., NewburgerJ.W., SprayT.L., MollerJ.H., IezzoniL.I.Consensus-based method for risk adjustment for surgery for congenital heart disease. J Thorac Cardiovasc Surg.2002; 123(1): 110–118.
26.
ChaturvediS., FarmerT., KapkeG F.Assay validation for KIM-1: human urinary renal dysfunction biomarker. Int J Biol Sci.2009; 5(2): 128–134.
27.
ChowS.C., ChangM.Adaptive design methods in clinical trials - a review. Orphanet J Rare Dis.2008; 3: 11.
28.
BaiardiP., GiaquintoC., GirottoS., ManfrediC., CeciA; TEDDY Network of Excellence. Innovative study design for paediatric clinical trials. Eur J Clin Pharmacol.2011; 67(Suppl 1): 109–115.
29.
UchinoS., BellomoR., MorimatsuH.Discontinuation of continuous renal replacement therapy: a post hoc analysis of a prospective multicenter observational study. Crit Care Med.2009; 37(9): 2576–2582.
30.
CruzD.N., RicciZ., BagshawS.M., PiccinniP., GibneyN., RoncoC.Renal replacement therapy in adult critically ill patients: when to begin and when to stop. Contrib Nephrol.2010; 165: 263–273.
31.
BlackwoodJ., JoffeA.R., RobertsonC.M.Western Canadian Complex Pediatric Therapies Follow-up Group. Association of hemoglobin and transfusion with outcome after operations for hypoplastic left heart. Ann Thorac Surg.2010; 89(5): 1378–1384, e1-e2.
32.
de GeusH.R., BetjesM.G., BakkerJ.Neutrophil gelatinase-associated lipocalin clearance during veno-venous continuous renal replacement therapy in critically ill patients. Intensive Care Med.2010; 36(12): 2156–2157.
33.
AskenaziD.J., AmbalavananN., GoldsteinS.L.Acute kidney injury in critically ill newborns: what do we know? What do we need to learn?Pediatr Nephrol.2009; 24(2): 265–274.
