Clinical phenotypes of acute kidney injury are associated with unique outcomes in critically ill septic children.
Journal
Pediatric research
ISSN: 1530-0447
Titre abrégé: Pediatr Res
Pays: United States
ID NLM: 0100714
Informations de publication
Date de publication:
11 2021
11 2021
Historique:
received:
22
07
2020
accepted:
25
12
2020
revised:
04
11
2020
pubmed:
4
2
2021
medline:
29
3
2022
entrez:
3
2
2021
Statut:
ppublish
Résumé
Assessment of acute kidney injury (AKI) in septic patients remains imprecise. In adults, the classification of septic patients by clinical AKI phenotypes (severity and timing) demonstrates unique associations with patient outcome vs. broadly defined AKI. In a multinational prospective observational study, AKI diagnosis in critically ill septic children was stratified by duration (transient vs. persistent) and severity (mild vs. severe by creatinine change and urine output). The outcomes of interest were mortality and intensive care unit resource complexity at 28 days. Seven hundred and fifty-seven septic children were studied (male 52.7%, age 4.6 years (1.5-11.9)). Mortality (overall 12.1%) was different between severe AKI and mild AKI (18.3 vs. 4.4%, p < 0.001) as well as intensive care unit (ICU) complexity (overall 34.5%, 45 vs. 21.7%, p < 0.001). Patients with Persistent AKI had fewer ICU-free days (17 (7, 21) vs. 24 (17, 26), p < 0.001) and higher ICU complexity (52.8 vs. 22.9%, p = 0.002) than transient AKI, even after exclusion of patients with early mortality. AKI phenotypes incorporating temporal and severity data correlate with unique survival (range 4.4-21.6%) and ICU-free days (range of 15-25 days) CONCLUSIONS: The outcome of septic children with AKI changes by clinical phenotype. Our findings underscore the importance of prognostic enrichment in sepsis and AKI for the purpose of trial design and patient management. Although AKI occurs commonly in patients with sepsis (S-AKI), outcomes for children with S-AKI varies based on the severity and timing of the AKI. Existing S-AKI pediatric data utilize a broad singular definition of kidney injury. Increasing the precision of AKI classification results in a new understanding of how S-AKI associates with patient outcome. A refined classification of S-AKI identifies subgroups of children, making possible a targeted and a personalized medicine approach to S-AKI study and management.
Sections du résumé
BACKGROUND
Assessment of acute kidney injury (AKI) in septic patients remains imprecise. In adults, the classification of septic patients by clinical AKI phenotypes (severity and timing) demonstrates unique associations with patient outcome vs. broadly defined AKI.
METHODS
In a multinational prospective observational study, AKI diagnosis in critically ill septic children was stratified by duration (transient vs. persistent) and severity (mild vs. severe by creatinine change and urine output). The outcomes of interest were mortality and intensive care unit resource complexity at 28 days.
RESULTS
Seven hundred and fifty-seven septic children were studied (male 52.7%, age 4.6 years (1.5-11.9)). Mortality (overall 12.1%) was different between severe AKI and mild AKI (18.3 vs. 4.4%, p < 0.001) as well as intensive care unit (ICU) complexity (overall 34.5%, 45 vs. 21.7%, p < 0.001). Patients with Persistent AKI had fewer ICU-free days (17 (7, 21) vs. 24 (17, 26), p < 0.001) and higher ICU complexity (52.8 vs. 22.9%, p = 0.002) than transient AKI, even after exclusion of patients with early mortality. AKI phenotypes incorporating temporal and severity data correlate with unique survival (range 4.4-21.6%) and ICU-free days (range of 15-25 days) CONCLUSIONS: The outcome of septic children with AKI changes by clinical phenotype. Our findings underscore the importance of prognostic enrichment in sepsis and AKI for the purpose of trial design and patient management.
IMPACT
Although AKI occurs commonly in patients with sepsis (S-AKI), outcomes for children with S-AKI varies based on the severity and timing of the AKI. Existing S-AKI pediatric data utilize a broad singular definition of kidney injury. Increasing the precision of AKI classification results in a new understanding of how S-AKI associates with patient outcome. A refined classification of S-AKI identifies subgroups of children, making possible a targeted and a personalized medicine approach to S-AKI study and management.
Identifiants
pubmed: 33531676
doi: 10.1038/s41390-021-01363-3
pii: 10.1038/s41390-021-01363-3
pmc: PMC7852056
doi:
Types de publication
Journal Article
Observational Study
Langues
eng
Sous-ensembles de citation
IM
Pagination
1031-1038Informations de copyright
© 2021. The Author(s), under exclusive licence to the International Pediatric Research Foundation, Inc.
Références
J Nephrol. 2018 Aug;31(4):523-535
pubmed: 29188454
Am J Nephrol. 2019;50(1):19-28
pubmed: 31203271
Contrib Nephrol. 2013;182:30-44
pubmed: 23689654
Curr Opin Crit Care. 2014 Dec;20(6):581-7
pubmed: 25314242
Contrib Nephrol. 2013;182:5-12
pubmed: 23689652
Semin Nephrol. 2015 Jan;35(1):2-11
pubmed: 25795495
J Am Soc Nephrol. 2019 Mar;30(3):505-515
pubmed: 31058607
Kidney Int. 2019 Nov;96(5):1083-1099
pubmed: 31443997
Clin J Am Soc Nephrol. 2013 Sep;8(9):1482-93
pubmed: 23744003
Crit Care Med. 2018 Jun;46(6):843-849
pubmed: 29432349
Kidney Int Rep. 2020 Mar 12;5(6):839-850
pubmed: 32518866
Sci Transl Med. 2019 Nov 13;11(518):
pubmed: 31723040
Crit Care. 2011;15(6):R273
pubmed: 22098946
J Pharmacol Exp Ther. 2016 May;357(2):228-39
pubmed: 26857961
BMJ. 2019 Jan 9;364:k4891
pubmed: 30626586
Am J Respir Crit Care Med. 2015 Jun 1;191(11):1226-31
pubmed: 26029837
Curr Opin Crit Care. 2013 Dec;19(6):544-53
pubmed: 24240820
Clin J Am Soc Nephrol. 2014 Apr;9(4):654-62
pubmed: 24677554
Front Immunol. 2018 Jun 28;9:1502
pubmed: 30002660
N Engl J Med. 2017 Jan 5;376(1):11-20
pubmed: 27959707
Can J Kidney Health Dis. 2019 Oct 14;6:2054358119880188
pubmed: 31662875
Curr Opin Crit Care. 2014 Dec;20(6):588-95
pubmed: 25320909
Pediatr Ann. 2018 Jul 1;47(7):e286-e291
pubmed: 30001443
Nat Rev Nephrol. 2018 Oct;14(10):607-625
pubmed: 30135570
Kidney Int. 2015 Jan;87(1):62-73
pubmed: 25317932
J Clin Trials. 2015;5(3):
pubmed: 26719818
Am J Respir Crit Care Med. 2020 Apr 1;201(7):848-855
pubmed: 31916857
J Am Soc Nephrol. 2016 Jan;27(1):49-58
pubmed: 26510884
Nat Rev Nephrol. 2018 Apr;14(4):217-230
pubmed: 29355173
Crit Care Clin. 2020 Jan;36(1):155-165
pubmed: 31733677
Intensive Care Med. 2020 May;46(5):1050-1051
pubmed: 32047942
Crit Care. 2014 Sep 02;18(5):501
pubmed: 25575158
Nephrol Dial Transplant. 2020 Aug 1;35(8):1295-1305
pubmed: 31725154
Crit Care. 2020 Apr 15;24(1):150
pubmed: 32295614
Nephron. 2015;131(4):247-51
pubmed: 26673455
Curr Opin Crit Care. 2019 Oct;25(5):489-497
pubmed: 31335383
Crit Care Med. 2015 Aug;43(8):1646-53
pubmed: 25962083
Crit Care Med. 2016 Dec;44(12):2241-2250
pubmed: 27513354
Kidney Int. 2014 Mar;85(3):513-21
pubmed: 24107851
Nat Rev Nephrol. 2017 Apr;13(4):241-257
pubmed: 28239173
Crit Care. 2014 Jan 24;18(1):103
pubmed: 24460790
Rev Assoc Med Bras (1992). 2019 Sep 12;65(8):1094-1101
pubmed: 31531608