Risk factors for postoperative acute kidney injury in pediatric cardiac surgery patients receiving angiotensin-converting enzyme inhibitors

Department of Pharmacy, Texas Children's Hospital, Houston, TX, USA.
Pediatric Critical Care Medicine (Impact Factor: 2.34). 09/2011; 12(5):555-9. DOI: 10.1097/PCC.0b013e31820ac40a
Source: PubMed


Angiotensin-converting enzyme inhibitor therapy is often initiated in pediatric patients who have had cardiac surgery. Acute kidney injury can occur in patients secondary to angiotensin-converting enzyme inhibitor initiation. Risk factors for acute kidney injury after angiotensin-converting enzyme inhibitor initiation have yet to be defined in postoperative pediatric cardiac patients.
To identify the frequency of acute kidney injury in patients receiving angiotensin-converting enzyme inhibitor therapy in postoperative pediatric cardiac surgical patients and to identify risk factors for acute kidney injury in this patient population.
The pharmacy and surgery databases were used to identify all patients <18 yrs of age who received angiotensin-converting enzyme inhibitor therapy after cardiac surgery at our institution from January 2006 to December 2007. Patients who did not have a baseline serum creatinine and at least one serum creatinine obtained after angiotensin-converting enzyme inhibitor initiation were excluded. Data collection included demographic information and cardiac pathophysiology/surgery, diuretic and/or nephrotoxic medication use, and angiotensin-converting enzyme inhibitor characteristics and initiation date. Baseline, daily, and maximum serum creatinine values were collected. Acute kidney injury was defined as the maximum change in pediatric-modified RIFLE (Risk, Injury, Failure, Loss, End-stage) acute kidney injury criteria within 48 hrs of initiation or increase in dose of angiotensin-converting enzyme inhibitor. Descriptive statistics were used to characterize the patient population, and a multivariate logistic regression model was developed to identify independent predictors of angiotensin-converting enzyme inhibitor-associated acute kidney injury. The study included 415 patient admissions (386 patients), 57% (n = 239) being male and infants (31 days to 2 yrs) being the most common age group. A functional single ventricle was present in 46% of the patients. Enalapril was initiated in 60% (n = 250) and captopril in 40% (n = 165) of patient admissions. Acute kidney injury occurred in 21% (n = 88) of patients initiated on an angiotensin-converting enzyme inhibitor (pediatric-modified RIFLE categories: R = 15%, I = 3%, F = 4%). Logistic regression identified cyanosis, coadministration of furosemide, and baseline estimated creatinine clearance as independent risk factors for any degree of angiotensin-converting enzyme inhibitor-associated acute kidney injury (p < .05). The hospital lengths of stay of patients with angiotensin-converting enzyme inhibitor-associated acute kidney injury (median 12 days, range 4-298 days) were greater compared to those of patients without angiotensin-converting enzyme inhibitor-associated acute kidney injury (median 10 days, range 3-199 days, p < .05).
Initiation of angiotensin-converting enzyme inhibitor after cardiac surgery in pediatric patients may result in acute kidney injury. The presence of cyanosis and coadministration of furosemide are independent risk factors for acute kidney injury in patients receiving angiotensin-converting enzyme inhibitor.

30 Reads
  • [Show abstract] [Hide abstract]
    ABSTRACT: Hypothermic cardiopulmonary bypass (CPB), although associated with a reduction in oxygen requirement, has a number of disadvantages including detrimental effects on enzymatic function, energy generation, and cellular integrity. Normothermic perfusion is potentially a more physiologic method to maintain the functional integrity of major organ systems. One of the aims of this trial was to compare the effect of normothermic and hypothermic CPB on renal injury in pediatric patients undergoing cardiac surgery. Fifty-nine children (median age, 78 months; interquartile range, 39-130) undergoing corrective cardiac surgery were randomized to either hypothermic (28°C) or normothermic (35°C-37°C) CPB. Urinary albumin, retinal binding protein (RBP) and N-acetyl-β-glucosaminidase (NAG) were measured preoperatively, end of CPB, 4, and 24 hours postoperatively and were expressed as a ratio of urinary creatinine. Serum creatinine was measured preoperatively, end of CPB, and 24 and 48 hours postoperatively. Results are expressed as a difference in means (normotheric - hypothermic) or as a ratio of geometric means (normothermic/hypothermic). Baseline characteristics were similar in both groups. For these biochemical markers no significant interactions between treatment and postintervention time were found. Serum creatinine (-2.10; 95% confidence interval [CI], -6.51-2.31), RBP (ratio, 0.96; 95% CI, 0.65-1.41), and NAG (ratio, 0.86; 95% CI, 0.56-1.36) were similar in the 2 groups (P ≥ .34), but the urinary albumin was significantly lower in the normothermic group (ratio, 0.63; 95% CI, 0.42-0.95, P = .03). Normothermic CPB is associated with similar renal impairment to hypothermic CPB in children undergoing heart surgery.
    The Journal of thoracic and cardiovascular surgery 08/2011; 142(5):1114-21, 1121.e1-2. DOI:10.1016/j.jtcvs.2011.08.008 · 4.17 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The RIFLE (risk, injury, failure, loss, and end-stage renal disease) classification system was developed to standardize the definition of acute kidney injury (AKI) in adults. We hypothesized that AKI was associated with increased mortality and morbidity. Acute kidney injury was defined as a decrease in the amount of estimated creatinine clearance based on pediatric-modified RIFLE (pRIFLE) criteria. Using propensity score analysis, 325 patients who had AKI were matched to 325 patients who did not have AKI from a database of 1,510 consecutive pediatric patients who underwent cardiac surgery between January 2004 and December 2008 at a single center. The association between AKI and outcome was analyzed after propensity score matching of perioperative variables. Four hundred eighty-one patients (31.9%) had AKI according to the RIFLE categories. Of those 1,510, 173 (11.5%) reached pRIFLE criteria for risk; 26 (1.7%) reached the criteria for injury; and 282 (18.7%) reached the criteria for failure. Fifty-five patients (3.6%) died. The 2 matched groups were well balanced in terms of measured perioperative variables. Mortality rate was 5.2% in the AKI and 2.5% in the matched control group (p=0.09). Occurrence of low cardiac output syndrome (p=0.002), need for dialysis (p<0.001), and infection (p=0.03) were significantly higher, and duration of mechanical ventilation (p<0.001) and length of intensive care unit stay (p<0.001) were significantly longer compared with the matched control group. Acute kidney injury was independently associated with an increased occurrence of postoperative complications but not with mortality after pediatric cardiac surgery.
    The Annals of thoracic surgery 01/2012; 93(6):1984-90. DOI:10.1016/j.athoracsur.2011.10.046 · 3.85 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Empiric dosing of gentamicin has not been evaluated in critically ill neonates with unrepaired congenital heart disease (CHD). Many factors may alter gentamicin pharmacokinetics in this patient population and there are few data describing gentamicin dosing regimens in this patient population. To determine whether an empiric gentamicin dosing regimen for neonates achieves acceptable serum trough concentrations in neonatal patients with unrepaired CHD receiving alprostadil. Term neonates with unrepaired CHD who received gentamicin for empiric treatment of sepsis were identified over a 3-year period. Patients were included if they received gentamicin 4 mg/kg/dose every 24 hours, were receiving alprostadil for maintenance of a patent ductus arteriosus, and had at least one gentamicin serum trough concentration determined. Patients were evaluated to determine whether they achieved a serum trough concentration of <1 mg/L, and differences in patient characteristics were noted for those who achieved an appropriate trough concentration and those who did not. Twenty-eight patients met study criteria, and 22% of patients had a trough gentamicin concentration of <1 mg/L at a mean (SD) time of 23.6 (0.3) hours after a dose. Few statistically significant differences in patient characteristics were noted for those who achieved an appropriate serum trough concentration and those who did not, and included Apgar scores at 1 minute and later day of life at admission. Current empiric gentamicin dosing regimens may not be appropriate for critically ill neonates with unrepaired CHD. Routine serum concentration monitoring may be warranted in this population.
    Annals of Pharmacotherapy 08/2012; 46(9):1193-7. DOI:10.1345/aph.1Q792 · 2.06 Impact Factor
Show more