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