Andersons pediatric cardiology 2097

syndromeatDCMdiagnosisconferredanincreasedriskof5-yearmortality
(hazardratio,2.4;95%confidenceinterval,0.8to7.4),andtheestimated
glomerularfiltrationratewaspositivelycorrelatedwithmeasuresofventricular
function.Thusthesepreliminarystudiessuggestcarefulattentionshouldbepaid
tokidneyfunctioninchildrenwithacutecardiacdysfunction.
ThemanagementofAKIinheartfailurehasalsobeenthesubjectofintense
clinicalstudyoverthepastdecadeinadults,withafocusondiuretic
administrationversusmechanicalfluidremovalviaultrafiltration.64,65Whilethis
focushasgeneratedrandomizedclinicaltrialscomparingdiureticsto
ultrafiltrationwithvaryingresults,apotentiallymorethoughtfulapproachisto
considerdiureticsasafirstlineoftreatmentandthenescalationtoultrafiltration
inpatientswhoareresistanttodiuretics.Patientswithheartfailuremayhave
AKIfromafunctional,prerenalcause,fromstructuralintrinsicrenaldamage,or
both.66PatientswithfunctionalAKImayrespondwelltodiureticsifrenal
perfusionandoncoticpressurearesufficient,whereaspatientswithstructural
AKImaynotrespondwell.
TheadditionalinformationprovidedbystructuralAKIbiomarkersintheacute
heartfailuresettinghasbeenrecentlyaddressed.First,onemeta-analysisof
pediatricandadultstudiesdemonstratedthat41%ofpatientswithelevated
NGALlevelswouldhavehadtheAKIdiagnosismissedbyserumcreatinine
alone,andpatientswithNGAL+/Cr−AKIhassimilarmorbidityandmortalityas
patientswithNGAL−/SCr+AKI.67Second,aprospectiveadultstudyrevealed
thatintegrationofaheartfailuremarker(B-typenatriureticpeptide)anda
kidneydamagemarker(plasmaNGAL)improvedthepredictionof30-day
mortalityandhospitalreadmissionrates.68Finally,inthechronic
cardiomyopathysetting,theurinarybiomarkersinterleukin-18,kidneyinjury
molecule-1,andNGALwereobservedinhigherconcentrationsthaninhealthy
matchedcontrols.69Inaddition,acombinedmodelusingcut-offvaluesof
kidneyinjurymolecule-1of235orgreater,interleukin-18of17.5orgreater,and
B-typenatriureticpeptideof15pg/mLresultedindifferentiationofpatientswith
mildlydepressedLV(55%>LVejectionfraction≥45%)andthosewithaleft

ventricularejectionfractionlessthan45%.


Summary
Thecomplexinterplaybetweenclinicallyapparentheartandkidneydysfunction,
aswellassubclinicalinjurydetectedbynovelbiomarkers,andtheassociation
withincreasedmorbidityandmortalityrepresentanareaincardiologythat
demandsmoreintenseresearchfocus.Theexistenceoftheseassociationsin
children,includingthechronicrenalconsequencesofheartdisease,validatesthe
conceptintheabsenceofmultiplechroniccomorbiditiesthatareubiquitousin
adults.Enhancedriskstratification,earliertargetedinterventions,andsystematic
follow-upofpatientsforthedevelopmentofkidneydiseasehavethepotentialto
improvetheimmediateandlong-termpatientoutcomes.


AnnotatedReferences
KidneyDisease:ImprovingGlobalOutcomes
(KDIGO).Acutekidneyinjuryworkgroup:
KDIGOclinicalpracticeguidelineforacute
kidneyinjury.KidneyInt.2012;suppl(2):1–138.
TheKDIGOcriteriarepresentthecurrentstandard
fordiagnosisofAKIdevelopmentandseverity.
AKIbythesecriteriahaverepeatedly
demonstratedindependentassociationsbetween
stage2or3AKIandmorbidityandmortalityin
pediatricpopulations,includingchildrenwho
developAKIaftercardiacsurgery..
BlinderJJ,GoldsteinSL,LeeVV,etal.Congenital
heartsurgeryininfants:effectsofacutekidney
injuryonoutcomes.JThoracCardiovascSurg.

2012;143(2):368–374.
Thisretrospectivestudyofmorethan400infants
aftercardiacsurgeryassessedforassociations
betweenAKIdevelopmentandseverityand
outcomes.Stage2or3AKIwasindependently
associatedwithpatientmortality,prolonged
mechanicalventilation,theneedforinotropic
supportandventriculardysfunction(30days
postoperatively).Inmultivariableanalysis,stage
2or3AKIconferredagreaterriskofmortality