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Acute kidney injury and fluid overload in infants and children after cardiac surgery

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Abstract

Acute kidney injury is a common and serious complication after congenital heart surgery, particularly among infants. This comorbidity has been independently associated with adverse outcomes including an increase in mortality. Postoperative acute kidney injury has a complex pathophysiology with many risk factors, and therefore no single medication or therapy has been demonstrated to be effective for treatment or prevention. However, it has been established that the associated fluid overload is one of the major determinants of morbidity, particularly in infants after cardiac surgery. Therefore, in the absence of an intervention to prevent acute kidney injury, much of the effort to improve outcomes has focused on treating and preventing fluid overload. Early renal replacement therapy, often in the form of peritoneal dialysis, has been shown to be safe and beneficial in infants with oliguria after heart surgery. As understanding of the pathophysiology of acute kidney injury and the ability to confidently diagnose it earlier continues to evolve, it is likely that novel preventative and therapeutic interventions will be available in the future.

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Author information

Authors and Affiliations

  1. Division of Pediatric Cardiology, Stanford University School of Medicine, 750 Welch Road, Suite 321, Palo Alto, CA, 94062, USA

    David M. Kwiatkowski & Catherine D. Krawczeski

Authors
  1. David M. Kwiatkowski
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  2. Catherine D. Krawczeski
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Corresponding author

Correspondence to David M. Kwiatkowski.

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Conflicts of interest

The authors declare that they have no conflicts of interest.

Additional information

Key summary points

1. AKI is common in infants and children after cardiac surgery with CPB.

2. In this cohort, AKI is associated with worse outcomes, including mortality.

3. Diagnosis of AKI is impaired by the reliance on serum creatinine.

4. Fluid overload is one of the major determinants of morbidity and mortality in children with postoperative AKI.

5. Early peritoneal dialysis is a safe and effective method of fluid removal in patients after congenital heart surgery.

Answers

1. d; 2. a; 3. d; 4. e; 5. b

Questions (answers are provided following the reference list)

Questions (answers are provided following the reference list)

  1. 1.

    Using KDIGO AKI criteria, what minimum creatinine change defines AKI?

    1. a)

      Creatinine increase of 0.3 mg/dl

    2. b)

      Creatinine increase of 0.5 mg/dl

    3. c)

      Creatinine increase of 2 times baseline

    4. d)

      Creatinine increase of 0.3 mg/dl or 1.5 times baseline

    5. e)

      Creatinine increase of 0.5 mg/dl or 2 times baseline

  2. 2.

    What is the most common timeframe for AKI after CPB in infants and children?

    1. a)

      First 24–48 h, lasting for 1–2 days

    2. b)

      First 24–48 h, lasting for 4 days

    3. c)

      First 72–96 h, lasting for 1–2 days

    4. d)

      First 72–96 h, lasting for 4 days

    5. e)

      Greater than 7 days, lasting for 1 day

  3. 3.

    Which of the following is a biomarker of renal tubule structural injury?

    1. a)

      Cystatin-C

    2. b)

      Creatinine

    3. c)

      Urine output

    4. d)

      NephroCheck

  4. 4.

    Which of the following is not associated with fluid overload?

    1. a)

      Decreased nutritional absorption

    2. b)

      Increased rate of infection

    3. c)

      Decreased myocardial contraction

    4. d)

      Increased mortality

    5. e)

      Increased lung compliance

  5. 5.

    In an infant with oliguria after cardiac surgery, which of the following therapies is shown to be associated with less fluid overload and a lower rate of prolonged mechanical ventilation?

    1. a)

      Dobutamine

    2. b)

      Peritoneal dialysis

    3. c)

      Nesiritide

    4. d)

      Furosemide

    5. e)

      Aminophylline

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Kwiatkowski, D.M., Krawczeski, C.D. Acute kidney injury and fluid overload in infants and children after cardiac surgery. Pediatr Nephrol 32, 1509–1517 (2017). https://doi.org/10.1007/s00467-017-3643-2

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  • DOI: https://doi.org/10.1007/s00467-017-3643-2

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