Fluid Overload Confounds Creatinine-Based Definitions of Acute Kidney Injury in Pediatric ARDS
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Renal, Pulmonary, Pediatrics, 2022
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INTRODUCTION/HYPOTHESIS: Fluid overload (FO) is a risk factor for higher mortality and fewer ventilator free days (VFDs) in pediatric acute respiratory distress syndrome (ARDS). The interplay between acute kidney injury (AKI), fluid balance, and outcomes remains understudied. We utilized a large pediatric ARDS cohort to assess the association between AKI and outcomes. We hypothesized that timing of AKI onset is associated with differences in mortality and VFDs in pediatric ARDS, and explored whether AKI diagnosis is affected by concurrent FO. METHODS: We performed a secondary analysis of a prospective ARDS cohort of intubated children meeting Berlin criteria, excluding subjects with chronic kidney disease. Daily fluid intake, urine output, fluid balance, measured creatinine, FO-adjusted creatinine (creatinine x [1+ fluid balance/total body water]), and use of continuous renal replacement therapy on days 1-7 from ARDS onset were retrospectively abstracted. Baseline creatinine was determined using an age-dependent formula. Subjects were classified by timing of AKI onset (KDIGO 2/3) into 4 groups: no AKI (never met criteria), early AKI (onset days 1-3), late AKI (onset days 4-7), and persistent AKI (onset early, continued past day 4). Primary outcomes (mortality and VFDs) and daily FO and FO-adjusted creatinine were compared between AKI groups using Fisher exact or Kruskal-Wallis tests. RESULTS: The cohort comprised 720 children, of whom 26% had AKI (early 10%; late 3%; persistent 13%). AKI groups had higher mortality (36-38%) than the no AKI group (12%; all p < 0.001), and fewer VFDs (all p < 0.001). Thirty-three (6%) subjects were reclassified from no AKI to AKI when FO-adjusted creatinine replaced measured creatinine; this subset had higher mortality (24%) than the rest of the no AKI group (11%; p = 0.043) and fewer VFDs (p < 0.001). In the late AKI group, FO and FO-adjusted creatinine increased one day prior to meeting AKI criteria. CONCLUSIONS: AKI is associated with higher mortality and fewer VFDs in pediatric ARDS regardless of time of onset. FO-adjusted creatinine identifies patients who do not otherwise meet AKI criteria yet have worse outcomes, suggesting cryptic but potentially significant AKI. FO and FO-adjusted creatinine may predict development of AKI before creatinine and urine output.
Meta Tag
Content Type Presentation
Knowledge Area Renal
Knowledge Area Pulmonary
Knowledge Area Pediatrics
Knowledge Level Advanced
Membership Level Select
Tag Renal
Tag Acute Respiratory Distress Syndrome ARDS
Tag Pediatrics
Year 2022
fluid overload
acute kidney injury
pediatric acute respiratory distress syndrome


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