Major Adverse Kidney Events in Pediatric Continuous Kidney Replacement Therapy
Authors: Fuhrman Dana Y. , Stenson Erin K. , Alhamoud Issa , Alobaidi Rashid , Bottari Gabriella , Fernandez Sarah , Guzzi Francesco , Haga Taiki , Kaddourah Ahmad , Marinari Eleonora , Mohamed Tahagod H. , Morgan Catherine J. , Mottes Theresa , Neumayr Tara M. , Ollberding Nicholas J. , Raggi Valeria , Ricci Zaccaria , See Emily , Stanski Natalja L. , Zang Huaiyu , Zangla Emily , Gist Katja M. ,   WE-ROCK Investigators, Ahern Emily , Akcan Arikan Ayse , Alobaidi Rashid , Anton-Martin Pilar , Balani Shanthi S , Barhight Matthew , Basalely Abby , Bigelow Amee , Cappoli Andrea , Ciccia Eileen A , Collins Michaela , Colosimo Denise , Cortina Gerard , Damian Mihaela A , DeAbreu Gabrielle , Deep Akash , Ding Kathy L , Dolan Kristin J , Gorga Stephen M , Harvey Elizabeth , Hasson Denise C , Hill-Horowitza Taylor , Inthavong Haleigh , Joseph Catherine , Kakajiwala Aadil , Kessel Aaron D , Korn Sarah , Krallman Kelli A , Kwiatkowski David M , Lee Jasmine , Lequier Laurance , Madani Kia Tina , Mah Kenneth , Martin Susan D , Menon Shina , Muff-Luett Melissa A , Namachivayam Siva , De la Mata Navazo Sara , Nhan Jennifer , O'Rourke Abigail , Pinto Matthew G , Qutob Dua , Reynaud Stephanie , Rumlow Zachary A , Santiago Lozano María J , Selewski David T , Serpe Carmela , Serratore Alyss , Shah Ananya , Shih Weiwen V , Shin H Stella , Slagle Cara L , Solomon Sonia , Soranno Danielle E , Srivastava Rachana , Starr Michelle C , Strong Amy E , Taylor Susan A , Thadani Sameer V , Uber Amanda M , Van Wyk Brynna , Webb Tennille N , Zappitelli Michael , Zangla Emily E 
Published: February 2024

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.