Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Multicenter Study
. 2024 Feb 5;7(2):e240243.
doi: 10.1001/jamanetworkopen.2024.0243.

Major Adverse Kidney Events in Pediatric Continuous Kidney Replacement Therapy

Dana Y Fuhrman  1 , Erin K Stenson  2 , Issa Alhamoud  3 , Rashid Alobaidi  4 , Gabriella Bottari  5 , Sarah Fernandez  6 , Francesco Guzzi  7 , Taiki Haga  8 , Ahmad Kaddourah  9   10 , Eleonora Marinari  5 , Tahagod H Mohamed  11 , Catherine J Morgan  12 , Theresa Mottes  13 , Tara M Neumayr  14 , Nicholas J Ollberding  15 , Valeria Raggi  5 , Zaccaria Ricci  16 , Emily See  17 , Natalja L Stanski  15 , Huaiyu Zang  15 , Emily Zangla  18 , Katja M Gist  15 ; WE-ROCK Investigators
Collaborators, Affiliations
Multicenter Study

Major Adverse Kidney Events in Pediatric Continuous Kidney Replacement Therapy

Dana Y Fuhrman et al. JAMA Netw Open. .

Abstract

Importance: Continuous kidney replacement therapy (CKRT) is increasingly used in youths with critical illness, but little is known about longer-term outcomes, such as persistent kidney dysfunction, continued need for dialysis, or death.

Objective: To characterize the incidence and risk factors, including liberation patterns, associated with major adverse kidney events 90 days after CKRT initiation (MAKE-90) in children, adolescents, and young adults.

Design, setting, and participants: This international, multicenter cohort study was conducted among patients aged 0 to 25 years from The Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK) registry treated with CKRT for acute kidney injury or fluid overload from 2015 to 2021. Exclusion criteria were dialysis dependence, concurrent extracorporeal membrane oxygenation use, or receipt of CKRT for a different indication. Data were analyzed from May 2 to December 14, 2023.

Exposure: Patient clinical characteristics and CKRT parameters were assessed. CKRT liberation was classified as successful, reinstituted, or not attempted. Successful liberation was defined as the first attempt at CKRT liberation resulting in 72 hours or more without return to dialysis within 28 days of CKRT initiation.

Main outcomes and measures: MAKE-90, including death or persistent kidney dysfunction (dialysis dependence or ≥25% decline in estimated glomerular filtration rate from baseline), were assessed.

Results: Among 969 patients treated with CKRT (529 males [54.6%]; median [IQR] age, 8.8 [1.7-15.0] years), 630 patients (65.0%) developed MAKE-90. On multivariable analysis, cardiac comorbidity (adjusted odds ratio [aOR], 1.60; 95% CI, 1.08-2.37), longer duration of intensive care unit admission before CKRT initiation (aOR for 6 days vs 1 day, 1.07; 95% CI, 1.02-1.13), and liberation pattern were associated with MAKE-90. In this analysis, patients who successfully liberated from CKRT within 28 days had lower odds of MAKE-90 compared with patients in whom liberation was attempted and failed (aOR, 0.32; 95% CI, 0.22-0.48) and patients without a liberation attempt (aOR, 0.02; 95% CI, 0.01-0.04).

Conclusions and relevance: In this study, MAKE-90 occurred in almost two-thirds of the population and patient-level risk factors associated with MAKE-90 included cardiac comorbidity, time to CKRT initiation, and liberation patterns. These findings highlight the high incidence of adverse outcomes in this population and suggest that future prospective studies are needed to better understand liberation patterns and practices.

PubMed Disclaimer

Conflict of interest statement

Conflict of Interest Disclosures: Dr Mottes reported serving on the Baxter Speaker Board and Seastar Medical Scientific Advisory Board outside the submitted work. Dr Stanski reported receiving grants from the National Institute of General Medical Sciences during the conduct of the study and reimbursement for study section participation from the National Institutes of Health SAT Study Section outside the submitted work and having a patent for methods related to prediction of sepsis-associated acute kidney injury pending. Dr Gist reported receiving consulting fees from Bioporto Diagnostics and Potrero Medical Consulting and grants from Gerber Foundation outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Study Flowchart
CKRT indicates continuous kidney replacement therapy; CKD, chronic kidney disease; MAKE-90, major adverse kidney events (including death, dialysis, or persistent kidney dysfunction) at 90 days.
Figure 2.
Figure 2.. Kaplan-Meier Curves for Mortality
A, The Kaplan-Meier mortality curve within 90 days for the 3 groups is shown. Time 0 is the day of continuous kidney replacement therapy (CKRT) initiation. At 90 days after CKRT initiation, there was a statistically significant mortality difference among patients in the liberated (26 of 335 patients [7.8%]), reinstituted (42 of 288 patients [14.6%]), and not attempted (278 of 357 patients [77.9%]) groups (log-rank P < .001). B, This difference persisted when comparing the liberated group with the reinstituted group (log-rank P = .006).
See this image and copyright information in PMC

References

    1. Kaddourah A, Basu RK, Bagshaw SM, Goldstein SL; AWARE Investigators . Epidemiology of acute kidney injury in critically ill children and young adults. N Engl J Med. 2017;376(1):11-20. doi:10.1056/NEJMoa1611391 - DOI - PMC - PubMed
    1. Billings FT IV, Shaw AD. Clinical trial endpoints in acute kidney injury. Nephron Clin Pract. 2014;127(1-4):89-93. doi:10.1159/000363725 - DOI - PMC - PubMed
    1. Palevsky PM, Baldwin I, Davenport A, Goldstein S, Paganini E. Renal replacement therapy and the kidney: minimizing the impact of renal replacement therapy on recovery of acute renal failure. Curr Opin Crit Care. 2005;11(6):548-554. doi:10.1097/01.ccx.0000179936.21895.a3 - DOI - PubMed
    1. Liu C, Peng Z, Dong Y, et al. . Continuous renal replacement therapy liberation and outcomes of critically ill patients with acute kidney injury. Mayo Clin Proc. 2021;96(11):2757-2767. doi:10.1016/j.mayocp.2021.05.031 - DOI - PubMed
    1. Wald R, Bagshaw SM; START-AKI Investigators . Timing of initiation of renal-replacement therapy in acute kidney injury: reply. N Engl J Med. 2020;383(18):1797-1798. - PubMed

Publication types