Chikako Terano1, Kenji Ishikura2,3, Masaru Miura4, Riku Hamada1, Ryoko Harada1, Tomoyuki Sakai5, Yuko Hamasaki6, Hiroshi Hataya1, Takashi Ando7, Masataka Honda1. 1. Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan. 2. Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan. kenzo@ii.e-mansion.com. 3. Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan. kenzo@ii.e-mansion.com. 4. Department of Cardiology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan. 5. Department of Pediatrics, Shiga University of Medical Science Hospital, Shiga, Japan. 6. Department of Pediatric Nephrology, Faculty of Medicine, Toho University, Tokyo, Japan. 7. Japan Clinical Research Support Unit, Tokyo, Japan.
Abstract
UNLABELLED: No large cohort study has yet determined the incidence of acute kidney injury (AKI) in children with heart failure treated with renin-angiotensin system (RAS) inhibitors. We thus retrospectively analyzed the incidence and risk factors for severe AKI (stages 2-3 according to the Kidney Disease Improving Global Outcomes (KDIGO) guidelines) at our institutions from 2008 to 2011. Among 312 children (162 boys; median age, 7.3 months), 59 cases of AKI occurred in 45 children. The incidence of AKI was 14.3 cases per 100 person-years overall (follow-up 413.6 person-years), or 27.3, 16.8, and 4.5 cases per 100 person-years in children aged <1, 1-3, and ≥4 years, respectively. Among them, 23 (39.0 %) children had metabolic acidosis and 14 (23.7 %) had hyperkalemia. Younger age, myocardial disease, cyanotic congenital heart disease, use of spironolactone, and cardiac surgery were independent risk factors for AKI. Furthermore, 37.3 % of children suffered dehydration during AKI. CONCLUSION: AKI incidence is relatively high in children, particularly younger children, with heart failure treated using RAS inhibitors. Careful monitoring of renal function and serum electrolytes is essential. Proper management of fluid balance after infection and cardiac surgery may reduce the risk of AKI. Temporary discontinuation in RAS inhibitors should be considered during dehydration or surgery. WHAT IS KNOWN: • Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are the two main classes of renin-angiotensin system (RAS) inhibitors used to treat hypertension, heart failure, and chronic kidney disease. Acute kidney injury (AKI) and hyperkalemia are potentially life-threatening complications associated with the use of ACEIs and ARBs. Some reports have suggested that dehydration and cardiac surgery are risk factors for AKI in children. However, no large-scale cohort studies have determined the incidence of AKI, its risk factors, and its outcomes in children with heart failure treated with ACEIs and/or ARBs. What is new: • In this retrospective cohort study, we determined the incidence, severity, and risk factors for severe AKI in children with heart failure treated with ACEIs and/or ARBs. The incidence of AKI in these children was relatively high (14.3 episodes per 100 person-years). In addition, younger age, myocardial disease, cyanotic congenital heart disease, concomitant use of spironolactone, and cardiac surgery were risk factors for AKI. Furthermore, 37.3 % of children had dehydration during AKI episodes. • Our results suggested that appropriate fluid balance after infection and cardiac surgery might reduce the risk of AKI and its complications. Temporary discontinuation or reductions in the levels of ACEIs and/or ARBs during dehydration or before surgery may also be warranted in these patients.
UNLABELLED: No large cohort study has yet determined the incidence of acute kidney injury (AKI) in children with heart failure treated with renin-angiotensin system (RAS) inhibitors. We thus retrospectively analyzed the incidence and risk factors for severe AKI (stages 2-3 according to the Kidney Disease Improving Global Outcomes (KDIGO) guidelines) at our institutions from 2008 to 2011. Among 312 children (162 boys; median age, 7.3 months), 59 cases of AKI occurred in 45 children. The incidence of AKI was 14.3 cases per 100 person-years overall (follow-up 413.6 person-years), or 27.3, 16.8, and 4.5 cases per 100 person-years in children aged <1, 1-3, and ≥4 years, respectively. Among them, 23 (39.0 %) children had metabolic acidosis and 14 (23.7 %) had hyperkalemia. Younger age, myocardial disease, cyanotic congenital heart disease, use of spironolactone, and cardiac surgery were independent risk factors for AKI. Furthermore, 37.3 % of children suffered dehydration during AKI. CONCLUSION: AKI incidence is relatively high in children, particularly younger children, with heart failure treated using RAS inhibitors. Careful monitoring of renal function and serum electrolytes is essential. Proper management of fluid balance after infection and cardiac surgery may reduce the risk of AKI. Temporary discontinuation in RAS inhibitors should be considered during dehydration or surgery. WHAT IS KNOWN: • Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are the two main classes of renin-angiotensin system (RAS) inhibitors used to treat hypertension, heart failure, and chronic kidney disease. Acute kidney injury (AKI) and hyperkalemia are potentially life-threatening complications associated with the use of ACEIs and ARBs. Some reports have suggested that dehydration and cardiac surgery are risk factors for AKI in children. However, no large-scale cohort studies have determined the incidence of AKI, its risk factors, and its outcomes in children with heart failure treated with ACEIs and/or ARBs. What is new: • In this retrospective cohort study, we determined the incidence, severity, and risk factors for severe AKI in children with heart failure treated with ACEIs and/or ARBs. The incidence of AKI in these children was relatively high (14.3 episodes per 100 person-years). In addition, younger age, myocardial disease, cyanotic congenital heart disease, concomitant use of spironolactone, and cardiac surgery were risk factors for AKI. Furthermore, 37.3 % of children had dehydration during AKI episodes. • Our results suggested that appropriate fluid balance after infection and cardiac surgery might reduce the risk of AKI and its complications. Temporary discontinuation or reductions in the levels of ACEIs and/or ARBs during dehydration or before surgery may also be warranted in these patients.
Authors: S Devi Chiravuri; Lori Q Riegger; Robert Christensen; Russell R Butler; Shobha Malviya; Alan R Tait; Terri Voepel-Lewis Journal: Paediatr Anaesth Date: 2011-02-10 Impact factor: 2.556
Authors: Demetrius Ellis; Abhay Vats; Michael L Moritz; Susanne Reitz; Mary Jo Grosso; Janine E Janosky Journal: J Pediatr Date: 2003-07 Impact factor: 4.406
Authors: R A P Weir; John J V McMurray; Margareta Puu; Scott D Solomon; Bertil Olofsson; Christopher B Granger; Salim Yusuf; Eric L Michelson; Karl Swedberg; Marc A Pfeffer Journal: Eur J Heart Fail Date: 2008-01-31 Impact factor: 15.534
Authors: Cristina Castro Díez; Feras Khalil; Holger Schwender; Michiel Dalinghaus; Ida Jovanovic; Nina Makowski; Christoph Male; Milica Bajcetic; Marijke van der Meulen; Saskia N de Wildt; László Ablonczy; András Szatmári; Ingrid Klingmann; Jennifer Walsh; Stephanie Läer Journal: BMJ Paediatr Open Date: 2019-01-31