Division of Pediatric Critical Care Medicine, Department of Pediatrics, Northwell, New Hyde Park, NY.
Feinstein Institutes for Medical Research, Northwell, New Hyde Park, NY.
Crit Care Explor. 2024 Aug 7;6(8):e1134. doi: 10.1097/CCE.0000000000001134. eCollection 2024 Aug 1.
Pediatric acute kidney injury (AKI) is a prevalent and morbid complication of shock. Its pathogenesis and early identification remain elusive.
We aim to determine whether renal blood flow (RBF) measurements by point-of-care ultrasound (POCUS) and renin-angiotensin-aldosterone system (RAAS) hormones in pediatric shock associate with vasoactive requirements and AKI.
DESIGN, SETTING, AND PARTICIPANTS: This is a single-center prospective, noninterventional observational cohort study in one tertiary PICU in North American from 2020 to 2022 that enrolled children younger than 18 years with shock without preexisting end-stage renal disease.
RBF was measured by POCUS on hospital days 1 and 3 and plasma RAAS hormone levels were measured on day 1. The primary outcome was the presence of AKI by Kidney Disease Improving Global Outcomes criteria at first ultrasound with key secondary outcomes of creatinine, blood urea nitrogen (BUN), Vasoactive-Inotrope Score (VIS), and norepinephrine equivalent dosing (NED) 48 hours after first ultrasound.
Fifty patients were recruited (20 with AKI, mean age 10.5 yr, 48% female). POCUS RBF showed lower qualitative blood flow (power Doppler ultrasound [PDU] score) and higher regional vascular resistance (renal resistive index [RRI]) in children with AKI (p = 0.017 and p = 0.0007). Renin and aldosterone levels were higher in the AKI cohort (p = 0.003 and p = 0.007). Admission RRI and PDU associated with higher day 3 VIS and NED after adjusting for age, day 1 VIS, and RAAS hormones. Admission renin associated with higher day 3 creatinine and BUN after adjusting for age, day 1 VIS, and the ultrasound parameters.
In pediatric shock, kidney blood flow was abnormal and renin and aldosterone were elevated in those with AKI. Kidney blood flow abnormalities are independently associated with future cardiovascular dysfunction; renin elevations are independently associated with future kidney dysfunction. Kidney blood flow by POCUS may identify children who will have persistent as opposed to resolving AKI. RAAS perturbations may drive AKI in pediatric shock.
儿科急性肾损伤（AKI）是休克的一种普遍且严重的并发症。其发病机制和早期识别仍然难以捉摸。
我们旨在确定儿科休克患者的床边超声（POCUS）测量的肾血流（RBF）和肾素-血管紧张素-醛固酮系统（RAAS）激素是否与血管活性需求和 AKI 相关。
设计、地点和参与者：这是一项 2020 年至 2022 年在北美一家三级儿科重症监护病房进行的单中心前瞻性非干预性观察队列研究，纳入了年龄小于 18 岁、无终末期肾病的休克患儿。
在入院第 1 天和第 3 天通过 POCUS 测量 RBF，在第 1 天测量血浆 RAAS 激素水平。主要结局是首次超声检查时根据肾脏病预后质量倡议（KDIGO）标准存在 AKI，次要结局是肌酐、血尿素氮（BUN）、血管活性-正性肌力药物评分（VIS）和首次超声检查后 48 小时的去甲肾上腺素等效剂量（NED）。
共招募了 50 名患者（AKI 组 20 名，平均年龄 10.5 岁，48%为女性）。AKI 患儿的 POCUS RBF 表现为较低的定性血流（功率多普勒超声[PDU]评分）和较高的区域性血管阻力（肾阻力指数[RRI]）（p = 0.017 和 p = 0.0007）。AKI 组的肾素和醛固酮水平较高（p = 0.003 和 p = 0.007）。调整年龄、第 1 天 VIS 和 RAAS 激素后，入院时的 RRI 和 PDU 与第 3 天的 VIS 和 NED 相关。调整年龄、第 1 天 VIS 后，入院时的肾素与第 3 天的肌酐和 BUN 相关。
在儿科休克中，肾脏血流异常，肾素和醛固酮在 AKI 患者中升高。肾脏血流异常与未来心血管功能障碍独立相关；肾素升高与未来肾功能障碍独立相关。POCUS 测量的肾脏血流可识别出那些将持续存在而非缓解 AKI 的患儿。RAAS 紊乱可能导致儿科休克中的 AKI。
