Akcan-Arikan Ayse, Gebhard Daniel J, Arnold Megan A, Loftis Laura L, Kennedy Curtis E
1Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX. 2Renal Section, Department of Pediatrics, Baylor College of Medicine, Houston, TX. 3Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Texas Health Science Center, San Antonio, TX.
Pediatr Crit Care Med. 2017 Jun;18(6):524-530. doi: 10.1097/PCC.0000000000001123.
Interruptive acute kidney injury alerts are reported to decrease acute kidney injury-related mortality in adults. Critically ill children have multiple acute kidney injury risk factors; although recognition has improved due to standardized definitions, subtle changes in serum creatinine make acute kidney injury recognition challenging. Age and body habitus variability prevent a uniform maximum threshold of creatinine. Exposure of nephrotoxic medications is common but not accounted for in kidney injury scores. Current severity of illness measures do not include fluid overload, a well-described mortality risk factor. We hypothesized that a multidimensional measure of renal status would better characterize renal severity of illness while maintaining or improving on correlation measures with adverse outcomes, when compared with traditional acute kidney injury staging.
A novel, real-time, multidimensional, renal status measure, combining acute kidney injury, fluid overload greater than or equal to 15%, and nephrotoxin exposure, was developed (Fluid Overload Kidney Injury Score) and prospectively applied to all patient encounters. Peak Fluid Overload Kidney Injury Score values prior to discharge or death were used to measure correlation with outcomes.
Quarternary PICU of a freestanding children's hospital.
All patients admitted over 18 months.
None.
Peak Fluid Overload Kidney Injury Score ranged between 0 and 14 in 2,830 PICU patients (median age, 5.5 yr; interquartile range, 1.3-12.9; 55% male), 66% of patients had Fluid Overload Kidney Injury Score greater than or equal to 1. Fluid Overload Kidney Injury Score was independently associated with PICU mortality and PICU and hospital length of stay when controlled for age, Pediatric Risk of Mortality-3, ventilator, pressor, and renal replacement therapy use (p = 0.047). Mortality increased from 1.5% in Fluid Overload Kidney Injury Score 0 to 40% in Fluid Overload Kidney Injury Score 8+. When urine output points were excluded, Fluid Overload Kidney Injury Score was more strongly correlated with mortality than fluid overload or acute kidney injury definitions alone.
A multidimensional score of renal disease burden was significantly associated with adverse PICU outcomes. Further studies will evaluate Fluid Overload Kidney Injury Score as a warning and decision support tool to impact patient-centered outcomes.
据报道，中断性急性肾损伤警报可降低成人急性肾损伤相关死亡率。危重症儿童有多种急性肾损伤风险因素；尽管由于标准化定义，急性肾损伤的识别有所改善，但血清肌酐的细微变化使急性肾损伤的识别具有挑战性。年龄和体型的差异使得无法设定统一的肌酐最高阈值。肾毒性药物的暴露很常见，但在肾损伤评分中未予以考虑。目前的疾病严重程度衡量指标不包括液体超负荷，而液体超负荷是一个已被充分描述的死亡风险因素。我们假设，与传统的急性肾损伤分期相比，一种多维的肾脏状态衡量指标能更好地描述疾病的肾脏严重程度，同时维持或改善与不良结局的相关性指标。
开发了一种新的实时多维肾脏状态衡量指标（液体超负荷肾损伤评分），该指标结合了急性肾损伤、液体超负荷大于或等于15%以及肾毒素暴露情况，并前瞻性地应用于所有患者。出院或死亡前的液体超负荷肾损伤评分峰值用于衡量与结局的相关性。
一家独立儿童医院的四级儿科重症监护病房。
所有18个月以上入院的患者。
无。
2830例儿科重症监护病房患者的液体超负荷肾损伤评分峰值在0至14之间（中位年龄5.5岁；四分位间距1.3 - 12.9；55%为男性），66%的患者液体超负荷肾损伤评分大于或等于1。在控制年龄、儿科死亡风险-3、呼吸机、血管活性药物和肾脏替代治疗的使用情况后，液体超负荷肾损伤评分与儿科重症监护病房死亡率以及儿科重症监护病房和住院时间独立相关（p = 0.047）。死亡率从液体超负荷肾损伤评分为0时的1.5%增加到液体超负荷肾损伤评分8分及以上时的40%。当排除尿量指标后，液体超负荷肾损伤评分与死亡率的相关性比单独的液体超负荷或急性肾损伤定义更强。
肾脏疾病负担的多维评分与儿科重症监护病房的不良结局显著相关。进一步的研究将评估液体超负荷肾损伤评分作为一种警示和决策支持工具，以影响以患者为中心的结局。
