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Acute and Chronic Renal Consequences of Cardiac Disease in Children
Introduction
The complex interplay between the cardiovascular and renal systems has received significant clinical, translational, and basic research attention over the past 2 decades. In both the acute and chronic care settings, dysfunction of either the heart or the kidneys can lead to dysfunction of the other organ. While this interaction has been obvious and well known in severe cases (e.g., advanced kidney failure leading to hyperkalemia and resultant cardiac dysrhythmias), recent understanding of less severe or even subclinical interactions with profound bidirectional effects have been realized.
This chapter reviews these interactions under the construct of the cardiorenal syndromes, with a focus on acute and chronic renal consequences of cardiac disease, and on potential novel diagnostic and therapeutic maneuvers to improve patient outcomes.
Classification of the Cardiorenal Syndromes
The Acute Dialysis Quality Initiative convened a consensus conference in 2008 to codify heart-kidney interactions into five distinct cardiorenal syndrome categories ( Table 78.1 ). The cardiorenal syndromes are categorized as either acute or chronic, and whether the heart or kidney is the primary organ that is injured, or whether both are injured secondary to a systemic process.
Table 78.1
Classification of Cardiorenal Syndrome Types and Associated Clinical Syndromes
| Type | Time Course | Primary Dysfunction | Secondary Dysfunction | Clinical Syndromes |
|---|---|---|---|---|
| 1 | Acute | Cardiac | AKI | Acute decompensated heart failure Cardiogenic shock Acute coronary syndrome |
| 2 | Chronic | Cardiac | AKI or CKD | LV dysfunction Diastolic dysfunction Cardiomyopathy |
| 3 | Acute | Renal | Acute heart dysfunction or injury | Cardiopulmonary bypass Primary acute kidney disease leading to volume overload/electrolyte disturbance Contrast nephropathy |
| 4 | Chronic | Renal | Chronic cardiac dysfunction | Chronic hypertension Cardiac calcifications Left ventricular hypertrophy |
| 5 | Acute/Chronic | Systemic | Both | Systemic collagen vascular disease Oncologic disease Sepsis |
AKI , Acute kidney injury; CKD , chronic kidney disease; LV , left ventricular.
Acute Cardiorenal Syndromes: Type 1 and Type 3
The acute cardiorenal syndromes present significant challenges in patient management because recognition of acute disease can be delayed, and interventions can be invasive and sometimes exacerbate the clinical problem. Development of standardized acute kidney injury (AKI) definitions and staging criteria have led to an appreciation of the association between AKI and poor outcomes in children with heart disease. The evolution of these definitions and criteria have culminated in a harmonized construct from the Kidney Disease Improving Global Outcomes (KDIGO) AKI Work Group ( Table 78.2 ). As noted above, the critical clinical and epidemiologic advance from a standardized AKI definition and staging criteria has been the realization that even the doubling of serum creatinine or 12 hours of oliguria are associated with morbidity and mortality in children.
Table 78.2
Kidney Disease Improving Global Outcomes Acute Kidney Injury Work Group Criteria
From Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl. 2012;2:1–138.
| Serum Creatinine Criteria | Urine Output Criteria | |
|---|---|---|
| Definition | Increase by ≥0.3 mg/dL within 48 h or Increase to 1.5 times baseline, which is known or presumed to have occurred within the prior 7 days |
Urine volume <0.5 mL/kg/h for 6 h |
| Stage 1 Stage 2 Stage 3 |
1.5–1.9 times baseline or ≥0.3 mg/dL increase 2.0–2.9 times baseline 3.0 times baseline or Increase in plasma creatinine to ≥4.0 mg/dL or Initiation of renal replacement therapy a or In patients age <18 y, a decrease in eGFR b to <35 mL/min/1.73 m 2 |
<0.5 mL/kg/h for 6–12 h <0.5 mL/kg/h for ≥12 h <0.3 mL/kg/h for ≥24 h or Anuria for ≥12 h |
eGFR , Estimated glomerular filtration rate.
a Renal replacement therapy utilization was assessed as an outcome for the current study and is omitted from stage 3.
b eGFR was calculated from the original Schwartz formula, where eGFR = k × patient height (cm)/plasma creatinine (mg/dL) and k is a constant defined as 0.45 (infant <1 year), 0.55 (child or adolescent female) or 0.70 (adolescent male).
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