medwireNews: Major adverse kidney events at 90 days (MAKE-90) occur in nearly two thirds of children, adolescents, and young adults after initiation of continuous kidney replacement therapy (CKRT), suggest findings from an international registry.
Cardiac comorbidity, duration of intensive care before CKRT initiation, and liberation patterns significantly predicted the likelihood of patients experiencing MAKE-90, say the investigators.
The researchers collated information from The Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK) for 969 patients (54.6% men) who were given CKRT for acute kidney injury or fluid overload at 32 centers in seven countries between 2015 and 2021. The participants were aged 0–25 years, with the average age being 8.8 years.
MAKE-90, encompassing persistent kidney dysfunction (estimated glomerular filtration rate reduction ≥25% from baseline), continued requirement for any type of CKRT, and mortality due to any cause, was observed in 65.0% of the patient population. Among these patients, rates of mortality, dialysis, and persistent kidney dysfunction were 58.4%, 14.4%, and 41.6%, respectively, and the corresponding rates in the overall study population were 38.0%, 9.4%, and 27.0%.
Dana Fuhrman (University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pennsylvania, USA) and colleagues report that individuals without pre-existing comorbidities comprised the smallest portion of the MAKE-90 cohort, accounting for only 13.5%. By contrast, those with cardiovascular, oncologic, or immunologic comorbidities comprised the majority of the MAKE-90 population, at 23.0%, 25.6%, and 19.5%, respectively.
Patients were significantly less likely to experience MAKE-90 if they did not require CKRT or another dialysis modality for at least 72 hours after discontinuing CKRT than if they returned to CKRT or dialysis within 72 hours, or if liberation was not attempted within 28 days of beginning CKRT, at 17.5% versus 28.4% and 54.1%, respectively.
Mortality rates among these three groups were also statistically different, at a corresponding 7.8%, 14.6%, and 77.9%.
Multivariable analysis demonstrated that the absence of any comorbidity was protective against MAKE-90, with a significant adjusted odds ratio (aOR) of 0.48 after considering age, sex, race, creatinine level, sepsis, and a raft of other characteristics.
In particular, patients with cardiovascular comorbidities were 1.60 times more likely to experience MAKE-90 than those without such comorbidities, whereas no significant risk increase was detected for those with comorbid oncologic or immunologic illnesses.
And the probability of MAKE-90 was significantly lower in patients who were successfully liberated from CKRT than in those who returned to CKRT within 72 hours or were unable to attempt liberation (aOR=0.32 and 0.02, respectively).
The duration between intensive care unit admission and CKRT initiation was also independently associated with a significantly increased odds of MAKE-90, with the aOR 1.07 for durations of 6 days versus 1 day.
“Our study results support the need for future prospective studies exploring a causative relationship between CKRT parameters and clinically relevant outcomes in children, adolescents, and young adults,” conclude Fuhrman et al.
Acknowledging the lack of consensus guidelines on the optimal timing of CKRT discontinuation, the researchers add that their “study highlights the need for a shift in the paradigm of how we study CKRT in youths, from focusing on CKRT initiation to a more wholistic approach systematically evaluating liberation.”
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