Kenneth Mah

All Publications

• The Association Between Vasopressin and Adverse Kidney Outcomes in Children and Young Adults Requiring Vasopressors on Continuous Renal Replacement Therapy. Critical care explorations Hasson, D. C., Gist, K. M., Seo, J., Stenson, E. K., Kessel, A., Haga, T., LaFever, S., Santiago, M. J., Barhight, M., Selewski, D., Ricci, Z., Ollberding, N. J., Stanski, N. L., Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK) Collaborative, Ahern, E., Akcan Arikan, A., Alhamoud, I., Alobaidi, R., Anton-Martin, P., Balani, S. S., Barhight, M., Basalely, A., Bigelow, A. M., Bottari, G., Cappoli, A., Ciccia, E. A., Collins, M., Colosimo, D., Cortina, G., Damian, M. A., De la Mata Navazo, S., DeAbreu, G., Deep, A., Ding, K. L., Dolan, K. J., Fernandez Lafever, S. N., Fuhrman, D. Y., Gelbart, B., Gist, K. M., Gorga, S. M., Guzzi, F., Guzzo, I., Haga, T., Harvey, E., Hasson, D. C., Hill-Horowitz, T., Inthavong, H., Joseph, C., Kaddourah, A., Kakajiwala, A., Kessel, A. D., Korn, S., Krallman, K. A., Kwiatkowski, D. M., Lee, J., Lequier, L., Madani Kia, T., Mah, K. E., Marinari, E., Martin, S. D., Menon, S., Mohamed, T. H., Morgan, C., Mottes, T. A., Muff-Luett, M. A., Namachivayam, S., Neumayr, T. M., Nhan Md, J., O'Rourke, A., Ollberding, N. J., Pinto, M. G., Qutob, D., Raggi, V., Reynaud, S., Ricci, Z., Rumlow, Z. A., Santiago Lozano, M. J., See, E., Selewski, D. T., Serpe, C., Serratore, A., Shah, A., Shih, W. V., Stella Shin, H., Slagle, C. L., Solomon, S., Soranno, D. E., Srivastava, R., Stanski, N. L., Starr, M. C., Stenson, E. K., Strong, A. E., Taylor, S. A., Thadani, S. V., Uber, A. M., Van Wyk, B., Webb, T. N., Zang, H., Zangla, E. E., Zappitelli, M., Christine, T., Alvarez, E., Bixler, E., Brown, E. B., Brown, C. L., Burrell, A., Dash, A., Ehrlich, J. L., Farma, S., Gahring, K., Gales, B., Hilgenkamp, M. R., Jain, S., Kanwar, K., Lusk, J., Meyer, C. J., Plomaritas, K., Porter, J., Potts, J., Serratore, A., Schneider, E., Sinha, V., Strack, P. J., Taylor, S., Twombley, K., Van Wyk, B., Wallace, S., Wang, J., Woods, M., Zinger, M., Zong, A. 2024; 6 (10): e1156

  Abstract

  OBJECTIVES: Continuous renal replacement therapy (CRRT) and shock are both associated with high morbidity and mortality in the ICU. Adult data suggest renoprotective effects of vasopressin vs. catecholamines (norepinephrine and epinephrine). We aimed to determine whether vasopressin use during CRRT was associated with improved kidney outcomes in children and young adults.DESIGN: Secondary analysis of Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK), a multicenter, retrospective cohort study.SETTING: Neonatal, cardiac, PICUs at 34 centers internationally from January 1, 2015, to December 31, 2021.PATIENTS/SUBJECTS: Patients younger than 25 years receiving CRRT for acute kidney injury and/or fluid overload and requiring vasopressors. Patients receiving vasopressin were compared with patients receiving only norepinephrine/epinephrine. The impact of timing of vasopressin relative to CRRT start was assessed by categorizing patients as: early (on or before day 0), intermediate (days 1-2), and late (days 3-7).INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: Of 1016 patients, 665 (65%) required vasopressors in the first week of CRRT. Of 665, 248 (37%) received vasopressin, 473 (71%) experienced Major Adverse Kidney Events at 90 days (MAKE-90) (death, renal replacement therapy dependence, and/or > 125% increase in serum creatinine from baseline 90 days from CRRT initiation), and 195 (29%) liberated from CRRT on the first attempt within 28 days. Receipt of vasopressin was associated with higher odds of MAKE-90 (adjusted odds ratio [aOR], 1.80; 95% CI, 1.20-2.71; p = 0.005) but not liberation success. In the vasopressin group, intermediate/late initiation was associated with higher odds of MAKE-90 (aOR, 2.67; 95% CI, 1.17-6.11; p = 0.02) compared with early initiation.CONCLUSIONS: Nearly two-thirds of children and young adults receiving CRRT required vasopressors, including over one-third who received vasopressin. Receipt of vasopressin was associated with more MAKE-90, although earlier initiation in those who received it appears beneficial. Prospective studies are needed to understand the appropriate timing, dose, and subpopulation for use of vasopressin.

  View details for DOI 10.1097/CCE.0000000000001156

  View details for PubMedID 39318499

• Characteristics and Outcomes of Children and Young Adults With Sepsis Requiring Continuous Renal Replacement Therapy: A Comparative Analysis From the Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK). Critical care medicine Stanski, N. L., Gist, K. M., Hasson, D., Stenson, E. K., Seo, J., Ollberding, N. J., Muff-Luett, M., Cortina, G., Alobaidi, R., See, E., Kaddourah, A., Fuhrman, D. Y. 2024

  Abstract

  Pediatric sepsis-associated acute kidney injury (AKI) often requires continuous renal replacement therapy (CRRT), but limited data exist regarding patient characteristics and outcomes. We aimed to describe these features, including the impact of possible dialytrauma (i.e., vasoactive requirement, negative fluid balance) on outcomes, and contrast them to nonseptic patients in an international cohort of children and young adults receiving CRRT.A secondary analysis of Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK), an international, multicenter, retrospective study.Neonatal, cardiac and PICUs at 34 centers in nine countries from January 1, 2015, to December 31, 2021.Patients 0-25 years old requiring CRRT for AKI and/or fluid overload.None.Among 1016 patients, 446 (44%) had sepsis at CRRT initiation and 650 (64%) experienced Major Adverse Kidney Events at 90 days (MAKE-90) (defined as a composite of death, renal replacement therapy [RRT] dependence, or > 25% decline in estimated glomerular filtration rate from baseline at 90 d from CRRT initiation). Septic patients were less likely to liberate from CRRT by 28 days (30% vs. 38%; p < 0.001) and had higher rates of MAKE-90 (70% vs. 61%; p = 0.002) and higher mortality (47% vs. 31%; p < 0.001) than nonseptic patients; however, septic survivors were less likely to be RRT dependent at 90 days (10% vs. 18%; p = 0.011). On multivariable regression, pre-CRRT vasoactive requirement, time to negative fluid balance, and median daily fluid balance over the first week of CRRT were not associated with MAKE-90; however, increasing duration of vasoactive requirement was independently associated with increased odds of MAKE-90 (adjusted OR [aOR], 1.16; 95% CI, 1.05-1.28) and mortality (aOR, 1.20; 95% CI, 1.1-1.32) for each additional day of support.Septic children requiring CRRT have different clinical characteristics and outcomes compared with those without sepsis, including higher rates of mortality and MAKE-90. Increasing duration of vasoactive support during the first week of CRRT, a surrogate of potential dialytrauma, appears to be associated with these outcomes.

  View details for DOI 10.1097/CCM.0000000000006405

  View details for PubMedID 39258974

• Characteristics and outcomes of children ≤ 10 kg receiving continuous kidney replacement therapy: a WE-ROCK study. Pediatric nephrology (Berlin, Germany) Menon, S., Starr, M. C., Zang, H., Collins, M., Damian, M. A., Fuhrman, D., Krallman, K., Soranno, D. E., Webb, T. N., Slagle, C., Joseph, C., Martin, S. D., Mohamed, T., Beebe, M. E., Ricci, Z., Ollberding, N., Selewski, D., Gist, K. M. 2024

  Abstract

  Continuous kidney replacement therapy (CKRT) is often used for acute kidney injury (AKI) or fluid overload (FO) in children ≤ 10 kg. Intensive care unit (ICU) mortality in children ≤ 10 kg reported by the prospective pediatric CRRT (ppCRRT, 2001-2003) registry was 57%. We aimed to evaluate characteristics associated with ICU mortality using a contemporary registry.The Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK) registry is a retrospective, multinational, observational study of children and young adults aged 0-25 years receiving CKRT (2015-2021) for AKI or FO. This analysis included patients ≤ 10 kg at hospital admission.ICU mortality and major adverse kidney events at 90 days (MAKE-90) defined as death, persistent kidney dysfunction, or dialysis within 90 days, respectively.A total of 210 patients were included (median age 0.53 years (IQR, 0.1, 0.9)). ICU mortality was 46.5%. MAKE-90 occurred in 150/207 (72%). CKRT was initiated at a median 3 days (IQR 1, 9) after ICU admission and lasted a median 6 days (IQR 3, 16). On multivariable analysis, pediatric logistic organ dysfunction score (PELOD-2) at CKRT initiation was associated with increased odds of ICU mortality (aOR 2.64, 95% CI 1.68-4.16), and increased odds of MAKE-90 (aOR 2.2, 95% CI 1.31-3.69). Absence of comorbidity was associated with lower MAKE-90 (aOR 0.29, 95%CI 0.13-0.65).We report on a contemporary cohort of children ≤ 10 kg treated with CKRT for acute kidney injury and/or fluid overload. ICU mortality is decreased compared to ppCRRT. The extended risk of death and morbidity at 90 days highlights the importance of close follow-up.

  View details for DOI 10.1007/s00467-024-06438-x

  View details for PubMedID 39164502

  View details for PubMedCentralID 5933049

• An evaluation of the outcomes associated with peritoneal catheter use in neonates undergoing cardiac surgery: A multicenter study. JTCVS open Kwiatkowski, D. M., Alten, J. A., Mah, K. E., Selewski, D. T., Raymond, T. T., Afonso, N. S., Blinder, J. J., Coghill, M. T., Cooper, D. S., Koch, J. D., Krawczeski, C. D., Morales, D. L., Neumayr, T. M., Rahman, A. K., Reichle, G., Tabbutt, S., Webb, T. N., Borasino, S. 2024; 19: 275-295

  Abstract

  The study objective was to determine if intraoperative peritoneal catheter placement is associated with improved outcomes in neonates undergoing high-risk cardiac surgery with cardiopulmonary bypass.This propensity score-matched retrospective study used data from 22 academic pediatric cardiac intensive care units. Consecutive neonates undergoing Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery category 3 to 5 cardiac surgery with cardiopulmonary bypass at centers participating in the NEonatal and Pediatric Heart Renal Outcomes Network collaborative were studied to determine the association of the use of an intraoperative placed peritoneal catheter for dialysis or passive drainage with clinical outcomes, including the duration of mechanical ventilation.Among 1490 eligible neonates in the NEonatal and Pediatric Heart Renal Outcomes Network dataset, a propensity-matched analysis was used to compare 395 patients with peritoneal catheter placement with 628 patients without peritoneal catheter placement. Time to extubation and most clinical outcomes were similar. Postoperative length of stay was 5 days longer in the peritoneal catheter placement cohort (17 vs 22 days, P = .001). There was a 50% higher incidence of moderate to severe acute kidney injury in the no-peritoneal catheter cohort (12% vs 18%, P = .02). Subgroup analyses between specific treatments and in highest risk patients yielded similar associations.This study does not demonstrate improved outcomes among neonates with placement of a peritoneal catheter during cardiac surgery. Outcomes were similar apart from longer hospital stay in the peritoneal catheter cohort. The no-peritoneal catheter cohort had a 50% higher incidence of moderate to severe acute kidney injury (12% vs 18%). This analysis does not support indiscriminate peritoneal catheter use, although it may support the utility for postoperative fluid removal among neonates at risk for acute kidney injury. A multicenter controlled trial may better elucidate peritoneal catheter effects.

  View details for DOI 10.1016/j.xjon.2024.03.009

  View details for PubMedID 39015443

  View details for PubMedCentralID PMC11247230

• Cardiac Surgery-Associated Acute Kidney Injury in Neonates Undergoing the Norwood Operation: Retrospective Analysis of the Multicenter Neonatal and Pediatric Heart and Renal Outcomes Network Dataset, 2015-2018. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies Bertrandt, R. A., Gist, K., Hasson, D., Zang, H., Reichle, G., Krawczeski, C., Winlaw, D., Bailly, D., Goldstein, S., Selewski, D., Alten, J., Neonatal and Pediatric Heart and Renal Outcomes Network (NEPHRON) Investigators, Brandewie, K. L., Diddle, J. W., Ghbeis, M., Mah, K. E., Neumayr, T. M., Raymond, T. T., Prodhan, P., Garcia, X., Ramer, S., Albertson, M., Cooper, D., Rodriquez, Z., Lukacs, M., Gaies, M., Sammons, A., Sanchez de Toledo, J., Domnina, Y. A., Saenz, L., Baust, T., Kluck, J., Koch, J. D., Sasaki, J., Raees, A., Afonso, N. S., O'Neal, E. R., Lasa, J. J., Phillips, P. A., Hock, K., Borasino, S., Kwiatkowski, D. M., Blinder, J., Valentine, K. M., Tadphale, S. D., Buckley, J. R., Clarke, S. A., Zhang, W., Smith, A., Absi, M., Askenazi, D. J. 2024

  Abstract

  OBJECTIVES: Cardiac surgery-associated acute kidney injury (CS-AKI) is associated with adverse outcomes. Single-center studies suggest that the prevalence of CS-AKI is high after the Norwood procedure, or stage 1 palliation (S1P), but multicenter data are lacking.DESIGN: A secondary analysis of the Neonatal and Pediatric Heart and Renal Outcomes Network (NEPHRON) multicenter cohort who underwent S1P. Using neonatal modification of Kidney Disease Improving Global Outcomes (KDIGO) criteria, perioperative associations between CS-AKI with morbidity and mortality were examined. Sensitivity analysis, with the exclusion of prophylactic peritoneal dialysis (PD) patients, was performed.SETTING: Twenty-two hospitals participating in the Pediatric Cardiac Critical Care Consortium (PC4) and contributing to NEPHRON.PATIENTS: Three hundred forty-seven neonates (< 30 d old) with S1P managed between September 2015 and January 2018.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: Of 347 patients, CS-AKI occurred in 231 (67%). The maximum stages were as follows: stage 1, in 141 of 347 (41%); stage 2, in 51 of 347 (15%); and stage 3, in 39 of 347 (11%). Severe CS-AKI (stages 2 and 3) peaked on the first postoperative day. In multivariable analysis, preoperative feeding was associated with lower odds of CS-AKI (odds ratio [OR] 0.48; 95% CI, 0.27-0.86), whereas prophylactic PD was associated with greater odds of severe CS-AKI (OR 3.67 [95% CI, 1.88-7.19]). We failed to identify an association between prophylactic PD and increased creatinine (OR 1.85 [95% CI, 0.82-4.14]) but cannot exclude the possibility of a four-fold increase in odds. Hospital mortality was 5.5% (n = 19). After adjusting for risk covariates and center effect, severe CS-AKI was associated with greater odds of hospital mortality (OR 3.67 [95% CI, 1.11-12.16]). We failed to find associations between severe CS-AKI and respiratory support or length of stay. The sensitivity analysis using PD failed to show associations between severe CS-AKI and outcome.CONCLUSIONS: KDIGO-defined CS-AKI occurred frequently and early postoperatively in this 2015-2018 multicenter PC4/NEPHRON cohort of neonates after S1P. We failed to identify associations between resource utilization and CS-AKI, but there was an association between severe CS-AKI and greater odds of mortality in this high-risk cohort. Improving the precision for defining clinically relevant neonatal CS-AKI remains a priority.

  View details for DOI 10.1097/PCC.0000000000003498

  View details for PubMedID 38483198

• Factors associated with successful liberation from continuous renal replacement therapy in children and young adults: analysis of the worldwide exploration of renal replacement outcomes collaborative in Kidney Disease Registry. Intensive care medicine Stenson, E. K., Alhamoud, I., Alobaidi, R., Bottari, G., Fernandez, S., Fuhrman, D. Y., Guzzi, F., Haga, T., Kaddourah, A., Marinari, E., Mohamed, T., Morgan, C., Mottes, T., Neumayr, T., Ollberding, N. J., Raggi, V., Ricci, Z., See, E., Stanski, N. L., Zang, H., Zangla, E., Gist, K. M., WE-ROCK Investigators, Cappoli, A., Ciccia, E. A., Collins, M., Colosimo, D., Cortina, G., Damian, M. A., De la Mata Navazo, S., DeAbreu, G., Deep, A., Ding, K. L., Dolan, K. J., Fernandez, S. N., Fuhrman, D. Y., Gelbart, B., Gist, K. M., Gorga, S. M., Guzzi, F., Guzzo, I., Harvey, E., Hasson, D. C., Hill-Horowitz, T., Inthavong, H., Joseph, C., Kaddourah, A., Kakajiwala, A., Kessel, A. D., Korn, S., Krallman, K. A., Kwiatkowski, D. M., Lee, J., Lequier, L., Kia, T. M., Mah, K. E., Marinari, E., Martin, S. D., Menon, S., Mohamed, T. H., Morgan, C., Mottes, T. A., Muff-Luett, M. A., Namachivayam, S., Neumayr, T. M., Nhan, J., O'Rourke, A., Ollberding, N. J., Pinto, M. G., Qutob, D., Raggi, V., Reynaud, S., Ricci, Z., Rumlow, Z. A., Santiago, M. J., See, E., Selewski, D. T., Serpe, C., Serratore, A., Shah, A., Shih, W. V., Stella, H. S., Slagle, C. L., Solomon, S., Soranno, D. E., Srivastava, R., Stanski, N. L., Starr, M. C., Stenson, E. K., Strong, A. E., Taylor, S. A., Thadani, S. V., Uber, A. M., Wyk, B., Webb, T. N., Zang, H., Zangla, E. E., Zappitelli, M. 2024

  Abstract

  PURPOSE: Continuous renal replacement therapy (CRRT) is used for supportive management of acute kidney injury (AKI) and disorders of fluid balance (FB). Little is known about the predictors of successful liberation in children and young adults. We aimed to identify the factors associated with successful CRRT liberation.METHODS: The Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease study is an international multicenter retrospective study (32 centers, 7 nations) conducted from 2015 to 2021 in children and young adults (aged 0-25years) treated with CRRT for AKI or FB disorders. Patients with previous dialysis dependence, tandem extracorporeal membrane oxygenation use, died within the first 72h of CRRT initiation, and those who never had liberation attempted were excluded. Patients were categorized based on first liberation attempt: reinstituted (resumption of any dialysis within 72h) vs. success (no receipt of dialysis for≥72h). Multivariable logistic regression was used to identify factors associated with successful CRRT liberation.RESULTS: A total of 622 patients were included: 287 (46%) had CRRT reinstituted and 335 (54%) were successfully liberated. After adjusting for sepsis at admission and illness severity parameters, several factors were associated with successful liberation, including higher VIS (vasoactive-inotropic score) at CRRT initiation (odds ratio [OR] 1.35 [1.12-1.63]), higher PELOD-2 (pediatric logistic organ dysfunction-2) score at CRRT initiation (OR 1.71 [1.24-2.35]), higher urine output prior to CRRT initiation (OR 1.15 [1.001-1.32]), and shorter CRRT duration (OR 0.19 [0.12-0.28]).CONCLUSIONS: Inability to liberate from CRRT was common in this multinational retrospective study. Modifiable and non-modifiable factors were associated with successful liberation. These results may inform the design of future clinical trials to optimize likelihood of CRRT liberation success.

  View details for DOI 10.1007/s00134-024-07336-4

  View details for PubMedID 38436726

• Continuous Kidney Replacement Therapy and Survival in Children and Young Adults: Findings From the Multi-National WE-ROCK Collaborative. American journal of kidney diseases : the official journal of the National Kidney Foundation Starr, M. C., Gist, K. M., Zang, H., Ollberding, N. J., Balani, S., Cappoli, A., Ciccia, E., Joseph, C., Kakajiwala, A., Kessel, A., Muff-Luett, M., Santiago Lozano, M. J., Pinto, M., Reynaud, S., Solomon, S., Slagle, C., Srivastava, R., Shih, W. V., Webb, T., Menon, S. 2024

  Abstract

  There are limited studies describing the epidemiology and outcomes of children and young adults receiving continuous kidney replacement therapy (CKRT). We aimed to describe associations between patient characteristics, CKRT prescription, and survival.Retrospective multicenter cohort study.& Participants: 980 patients aged birth-25 years old who received CKRT between 2015 and 2021 at 1 of 32 centers in 7 countries participating in the Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Diseases (WE-ROCK).CKRT for acute kidney injury or volume overload.Death before ICU discharge.Descriptive statistics.Median age was 8.8 years (IQR 1.6, 15.0) with a median weight of 26.8 kg (IQR 11.6, 55.0). CKRT was initiated a median of 2 days (IQR 1, 6) after ICU admission and lasted a median of 6 days (IQR 3, 14). The most common CKRT modality was continuous veno-venous hemodiafiltration. Citrate anticoagulation was used in 62%, and the internal jugular vein was the most common catheter placement location (66%). 629 participants (64.1%) survived at least until ICU discharge. The CKRT dose, filter type, and anticoagulation were similar in those who did and did not survive to ICU discharge. There were apparent practice variations by institutional ICU size.Retrospective design; limited representation from centers outside United States.In this study of children and young adults receiving CKRT approximately two-thirds survived at least until ICU discharge. While variations in dialysis mode, dose, catheter size and location, and anticoagulation were observed, survival was not detected to be associated with these parameters.

  View details for DOI 10.1053/j.ajkd.2023.12.017

  View details for PubMedID 38364956

• Major Adverse Kidney Events in Pediatric Continuous Kidney Replacement Therapy. JAMA network open Fuhrman, D. Y., Stenson, E. K., Alhamoud, I., Alobaidi, R., Bottari, G., Fernandez, S., Guzzi, F., Haga, T., Kaddourah, A., Marinari, E., Mohamed, T. H., Morgan, C. J., Mottes, T., Neumayr, T. M., Ollberding, N. J., Raggi, V., Ricci, Z., See, E., Stanski, N. L., Zang, H., Zangla, E., Gist, K. M., WE-ROCK Investigators, Ahern, E., Akcan Arikan, A., Alobaidi, R., Anton-Martin, P., Balani, S. S., Barhight, M., Basalely, A., Bigelow, A., Cappoli, A., Ciccia, E. A., Collins, M., Colosimo, D., Cortina, G., Damian, M. A., DeAbreu, G., Deep, A., Ding, K. L., Dolan, K. J., Gorga, S. M., Harvey, E., Hasson, D. C., Hill-Horowitza, T., Inthavong, H., Joseph, C., Kakajiwala, A., Kessel, A. D., Korn, S., Krallman, K. A., Kwiatkowski, D. M., Lee, J., Lequier, L., Madani Kia, T., Mah, K., Martin, S. D., Menon, S., Muff-Luett, M. A., Namachivayam, S., De la Mata Navazo, S., Nhan, J., O'Rourke, A., Pinto, M. G., Qutob, D., Reynaud, S., Rumlow, Z. A., Santiago Lozano, M. J., Selewski, D. T., Serpe, C., Serratore, A., Shah, A., Shih, W. V., Shin, H. S., Slagle, C. L., Solomon, S., Soranno, D. E., Srivastava, R., Starr, M. C., Strong, A. E., Taylor, S. A., Thadani, S. V., Uber, A. M., Van Wyk, B., Webb, T. N., Zappitelli, M., Zangla, E. E. 2024; 7 (2): e240243

  Abstract

  Importance: Continuous kidney replacement therapy (CKRT) is increasingly used in youths with critical illness, but little is known about longer-term outcomes, such as persistent kidney dysfunction, continued need for dialysis, or death.Objective: To characterize the incidence and risk factors, including liberation patterns, associated with major adverse kidney events 90 days after CKRT initiation (MAKE-90) in children, adolescents, and young adults.Design, Setting, and Participants: This international, multicenter cohort study was conducted among patients aged 0 to 25 years from The Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK) registry treated with CKRT for acute kidney injury or fluid overload from 2015 to 2021. Exclusion criteria were dialysis dependence, concurrent extracorporeal membrane oxygenation use, or receipt of CKRT for a different indication. Data were analyzed from May 2 to December 14, 2023.Exposure: Patient clinical characteristics and CKRT parameters were assessed. CKRT liberation was classified as successful, reinstituted, or not attempted. Successful liberation was defined as the first attempt at CKRT liberation resulting in 72 hours or more without return to dialysis within 28 days of CKRT initiation.Main Outcomes and Measures: MAKE-90, including death or persistent kidney dysfunction (dialysis dependence or ≥25% decline in estimated glomerular filtration rate from baseline), were assessed.Results: Among 969 patients treated with CKRT (529 males [54.6%]; median [IQR] age, 8.8 [1.7-15.0] years), 630 patients (65.0%) developed MAKE-90. On multivariable analysis, cardiac comorbidity (adjusted odds ratio [aOR], 1.60; 95% CI, 1.08-2.37), longer duration of intensive care unit admission before CKRT initiation (aOR for 6 days vs 1 day, 1.07; 95% CI, 1.02-1.13), and liberation pattern were associated with MAKE-90. In this analysis, patients who successfully liberated from CKRT within 28 days had lower odds of MAKE-90 compared with patients in whom liberation was attempted and failed (aOR, 0.32; 95% CI, 0.22-0.48) and patients without a liberation attempt (aOR, 0.02; 95% CI, 0.01-0.04).Conclusions and Relevance: In this study, MAKE-90 occurred in almost two-thirds of the population and patient-level risk factors associated with MAKE-90 included cardiac comorbidity, time to CKRT initiation, and liberation patterns. These findings highlight the high incidence of adverse outcomes in this population and suggest that future prospective studies are needed to better understand liberation patterns and practices.

  View details for DOI 10.1001/jamanetworkopen.2024.0243

  View details for PubMedID 38393726

• Time to Continuous Renal Replacement Therapy Initiation and 90-Day Major Adverse Kidney Events in Children and Young Adults. JAMA network open Gist, K. M., Menon, S., Anton-Martin, P., Bigelow, A. M., Cortina, G., Deep, A., De la Mata-Navazo, S., Gelbart, B., Gorga, S., Guzzo, I., Mah, K. E., Ollberding, N. J., Shin, H. S., Thadani, S., Uber, A., Zang, H., Zappitelli, M., Selewski, D. T. 2024; 7 (1): e2349871

  Abstract

  In clinical trials, the early or accelerated continuous renal replacement therapy (CRRT) initiation strategy among adults with acute kidney injury or volume overload has not demonstrated a survival benefit. Whether the timing of initiation of CRRT is associated with outcomes among children and young adults is unknown.To determine whether timing of CRRT initiation, with and without consideration of volume overload (VO; <10% vs ≥10%), is associated with major adverse kidney events at 90 days (MAKE-90).This multinational retrospective cohort study was conducted using data from the Worldwide Exploration of Renal Replacement Outcome Collaborative in Kidney Disease (WE-ROCK) registry from 2015 to 2021. Participants included children and young adults (birth to 25 years) receiving CRRT for acute kidney injury or VO at 32 centers across 7 countries. Statistical analysis was performed from February to July 2023.The primary exposure was time to CRRT initiation from intensive care unit admission.The primary outcome was MAKE-90 (death, dialysis dependence, or persistent kidney dysfunction [>25% decline in estimated glomerular filtration rate from baseline]).Data from 996 patients were entered into the registry. After exclusions (n = 27), 969 patients (440 [45.4%] female; 16 (1.9%) American Indian or Alaska Native, 40 (4.7%) Asian or Pacific Islander, 127 (14.9%) Black, 652 (76.4%) White, 18 (2.1%) more than 1 race; median [IQR] patient age, 8.8 [1.7-15.0] years) with data for the primary outcome (MAKE-90) were included. Median (IQR) time to CRRT initiation was 2 (1-6) days. MAKE-90 occurred in 630 patients (65.0%), of which 368 (58.4%) died. Among the 601 patients who survived, 262 (43.6%) had persistent kidney dysfunction. Of patients with persistent dysfunction, 91 (34.7%) were dependent on dialysis. Time to CRRT initiation was approximately 1 day longer among those with MAKE-90 (median [IQR], 3 [1-8] days vs 2 [1-4] days; P = .002). In the generalized propensity score-weighted regression, there were approximately 3% higher odds of MAKE-90 for each 1-day delay in CRRT initiation (odds ratio, 1.03 [95% CI, 1.02-1.04]).In this cohort study of children and young adults receiving CRRT, longer time to CRRT initiation was associated with greater risk of MAKE-90 outcomes, in particular, mortality. These findings suggest that prospective multicenter studies are needed to further delineate the appropriate time to initiate CRRT and the interaction between CRRT initiation timing and VO to continue to improve survival and reduce morbidity in this population.

  View details for DOI 10.1001/jamanetworkopen.2023.49871

  View details for PubMedID 38165673

  View details for PubMedCentralID PMC10762580

• Neonatal Chylothorax and Early Fluid Overload After Cardiac Surgery: Retrospective Analysis of the Neonatal and Pediatric Heart and Renal Outcomes Network Registry (2015-2018). Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies Brandewie, K., Alten, J., Winder, M., Mah, K., Holmes, K., Reichle, G., Smith, A., Zang, H., Bailly, D. 2023

  Abstract

  To evaluate the association between postoperative cumulative fluid balance (FB) and development of chylothorax in neonates after cardiac surgery.Multicenter, retrospective cohort identified within the Neonatal and Pediatric Heart and Renal Outcomes Network (NEPHRON) Registry.Twenty-two hospitals were involved with NEPHRON, from September 2015 to January 2018.Neonates (< 30 d old) undergoing index cardiac operation with or without cardiopulmonary bypass (CPB) entered into the NEPHRON Registry. Postoperative chylothorax was defined in the Pediatric Cardiac Critical Care Consortium as lymphatic fluid in the pleural space secondary to a leak from the thoracic duct or its branches.None.Of the 2240 NEPHRON patients, 4% (n = 89) were treated for chylothorax during postoperative day (POD) 2-21. Median (interquartile range [IQR]) time to diagnosis was 8 (IQR 6, 12) days. Of patients treated for chylothorax, 81 of 89 (91%) had CPB and 68 of 89 (76%) had Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery Congenital Heart Surgery 4-5 operations. On bivariate analysis, chylothorax patients had higher POD 1 FB (3.2 vs. 1.1%, p = 0.014), higher cumulative POD 2 FB (1.5 vs. -1.5%, p < 0.001), achieved negative daily FB by POD 1 less often (69% vs. 79%, p = 0.039), and had lower POD 1 urine output (1.9 vs. 3. 2 mL/kg/day, p ≤ 0.001) than those without chylothorax. We failed to identify an association between presence or absence of chylothorax and peak FB (5.2 vs. 4.9%, p = 0.9). Multivariable analysis shows that higher cumulative FB on POD 2 was associated with greater odds (odds ratio [OR], 95% CI) of chylothorax development (OR 1.5 [95% CI, 1.1-2.2]). Further multivariable analysis shows that chylothorax was independently associated with greater odds of longer durations of mechanical ventilation (OR 5.5 [95% CI, 3.7-8.0]), respiratory support (OR 4.3 [95% CI, 2.9-6.2]), use of inotropic support (OR 2.9 [95% CI, 2.0-4.3]), and longer hospital length of stay (OR 3.7 [95% CI, 2.5-5.4]).Chylothorax after neonatal cardiac surgery for congenital heart disease (CHD) is independently associated with greater odds of longer duration of cardiorespiratory support and hospitalization. Higher early (POD 2) cumulative FB is associated with greater odds of chylothorax. Contemporary, prospective studies are needed to assess whether early fluid mitigation strategies decrease postoperative chylothorax development.

  View details for DOI 10.1097/PCC.0000000000003415

  View details for PubMedID 38088768

• Persistent acute kidney injury and fluid accumulation with outcomes after the Norwood procedure: report from NEPHRON. Pediatric nephrology (Berlin, Germany) Hasson, D. C., Alten, J. A., Bertrandt, R. A., Zang, H., Selewski, D. T., Reichle, G., Bailly, D. K., Krawczeski, C. D., Winlaw, D. S., Goldstein, S. L., Gist, K. M., Neonatal, P. H., Smith, A., Brandewie, K. L., Bhat, P. N., Diddle, J. W., Ghbeis, M., Mah, K. E., Neumayr, T. M., Raymond, T. T., Prodhan, P., Garcia, X., Ramer, S., Albertson, M., Cooper, D. S., Rodriguez, Z., Lukacs, M., Gaies, M., Sammons, A., de Toledo, J. S., Domnina, Y. A., Saenz, L., Baust, T., Kluck, J., Koch, J. D., Sasaki, J., Raees, A., Afonso, N. S., O'Neill, E. R., Lasa, J. J., Phillips, P. A., Hock, K. M., Borasino, S., Kwiatkowski, D., Blinder, J., Valentine, K., Tadphale, S., Buckley, J. R., Clarke, S., Zhang, W., Absi, M., Askenazi, D. J. 2023

  Abstract

  BACKGROUND: Cardiac surgery-associated acute kidney injury (CS-AKI) is common, but its impact on clinical outcomes is variable. Parsing AKI into sub-phenotype(s) and integrating pathologic positive cumulative fluid balance (CFB) may better inform prognosis. We sought to determine whether durational sub-phenotyping of CS-AKI with CFB strengthens association with outcomes among neonates undergoing the Norwood procedure.METHODS: Multicenter, retrospective cohort study from the Neonatal and Pediatric Heart and Renal Outcomes Network. Transient CS-AKI: present only on post-operative day (POD) 1 and/or 2; persistent CS-AKI: continued after POD 2. CFB was evaluated per day and peak CFB during the first 7 postoperative days. Primary and secondary outcomes were mortality, respiratory support-free and hospital-free days (at 28, 60days, respectively). The primary predictor was persistent CS-AKI, defined by modified neonatal Kidney Disease: Improving Global Outcomes criteria.RESULTS: CS-AKI occurred in 59% (205/347) neonates: 36.6% (127/347) transient and 22.5% (78/347) persistent; CFB>10% occurred in 18.7% (65/347). Patients with either persistent CS-AKI or peak CFB>10% had higher mortality. Combined persistent CS-AKI with peak CFB>10% (n=21) associated with increased mortality (aOR: 7.8, 95% CI: 1.4, 45.5; p=0.02), decreased respiratory support-free (predicted mean 12 vs. 19; p<0.001) and hospital-free days (17 vs. 29; p=0.048) compared to those with neither.CONCLUSIONS: The combination of persistent CS-AKI and peak CFB>10% after the Norwood procedure is associated with mortality and hospital resource utilization. Prospective studies targeting intra- and postoperative CS-AKI risk factors and reducing CFB have the potential to improve outcomes. A higher resolution version of the Graphical abstract is available as Supplementary information.

  View details for DOI 10.1007/s00467-023-06235-y

  View details for PubMedID 38057432

• Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK). Kidney international reports Menon, S., Krallman, K. A., Arikan, A. A., Fuhrman, D. Y., Gorga, S. M., Mottes, T., Ollberding, N., Ricci, Z., Stanski, N. L., Selewski, D. T., Soranno, D. E., Zappitelli, M., Zang, H., Gist, K. M., WE-ROCK Investigators, Ahern, E., Akcan Arikan, A., Alhamoud, I., Alobaidi, R., Anton-Martin, P., Balani, S. S., Barhight, M., Basalely, A., Bigelow, A. M., Bottari, G., Cappoli, A., Ciccia, E. A., Collins, M., Colosimo, D., Cortina, G., Damian, M. A., De la Mata Navazo, S., DeAbreu, G., Deep, A., Ding, K. L., Dolan, K. J., Fernandez Lafever, S. N., Fuhrman, D. Y., Gelbart, B., Gist, K. M., Gorga, S. M., Guzzi, F., Guzzo, I., Haga, T., Harvey, E., Hasson, D. C., Hill-Horowitz, T., Inthavong, H., Joseph, C., Kaddourah, A., Kakajiwala, A., Kessel, A. D., Korn, S., Krallman, K. A., Kwiatkowski, D. M., Lee, J., Lequier, L., Kia, T. M., Mah, K. E., Marinari, E., Martin, S. D., Menon, S., Mohamed, T. H., Morgan, C., Mottes, T. A., Muff-Luett, M. A., Namachivayam, S., Neumayr, T. M., Md, J. N., O'Rourke, A., Ollberding, N. J., Pinto, M. G., Qutob, D., Raggi, V., Reynaud, S., Ricci, Z., Rumlow, Z. A., Santiago Lozano, M. J., See, E., Selewski, D. T., Serpe, C., Serratore, A., Shah, A., Shih, W. V., Shin, H. S., Slagle, C. L., Solomon, S., Soranno, D. E., Srivastava, R., Stanski, N. L., Starr, M. C., Stenson, E. K., Strong, A. E., Taylor, S. A., Thadani, S. V., Uber, A. M., Van Wyk, B., Webb, T. N., Zang, H., Zangla, E. E., Zappitelli, M. 2023; 8 (8): 1542-1552

  Abstract

  Introduction: Continuous renal replacement therapy (CRRT) is used for the symptomatic management of acute kidney injury (AKI) and fluid overload (FO). Contemporary reports on pediatric CRRT are small and single center in design. Large international studies evaluating CRRT practice and outcomes are lacking. Herein, we describe the design of a multinational collaborative.Methods: The Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK) is an international collaborative of pediatric specialists whose mission is to improve short- and long-term outcomes of children treated with CRRT. The aims of this multicenter retrospective study are to describe the epidemiology, liberation patterns, association of fluid balance and timing of CRRT initiation, and CRRT prescription with outcomes.Results: We included children (n= 996, 0-25 years) admitted to an intensive care unit (ICU) and treated with CRRT for AKI or FO at 32 centers (in 7 countries) from 2018 to 2021. Demographics and clinical characteristics before CRRT initiation, during the first 7 days of both CRRT, and liberation were collected. Outcomes include the following: (i) major adverse kidney events at 90 days (mortality, dialysis dependence, and persistent kidney dysfunction), and (ii) functional outcomes (functional stats scale).Conclusion: The retrospective WE-ROCK study represents the largest international registry of children receiving CRRT for AKI or FO. It will serve as a broad and invaluable resource for the field of pediatric critical care nephrology that will improve our understanding of practice heterogeneity and the association of CRRT with clinical and patient-centered outcomes. This will generate preliminary data for future interventional trials in this area.

  View details for DOI 10.1016/j.ekir.2023.05.026

  View details for PubMedID 37547524

• Peritoneal catheters in neonates undergoing complex cardiac surgery: a multi-centre descriptive study. Cardiology in the young Kwiatkowski, D. M., Alten, J. A., Raymond, T. T., Selewski, D. T., Blinder, J. J., Afonso, N. S., Coghill, M. T., Cooper, D. S., Koch, J. D., Krawczeski, C. D., Mah, K. E., Neumayr, T. M., Rahman, A. K., Reichle, G., Tabbutt, S., Webb, T. N., Borasino, S. 2023: 1-10

  Abstract

  The use of peritoneal catheters for prophylactic dialysis or drainage to prevent fluid overload after neonatal cardiac surgery is common in some centres; however, the multi-centre variability and details of peritoneal catheter use are not well described.Twenty-two-centre NEonatal and Pediatric Heart Renal Outcomes Network (NEPHRON) study to describe multi-centre peritoneal catheter use after STAT category 3-5 neonatal cardiac surgery using cardiopulmonary bypass. Patient characteristics and acute kidney injury/fluid outcomes for six post-operative days are described among three cohorts: peritoneal catheter with dialysis, peritoneal catheter with passive drainage, and no peritoneal catheter.Of 1490 neonates, 471 (32%) had an intraoperative peritoneal catheter placed; 177 (12%) received prophylactic dialysis and 294 (20%) received passive drainage. Sixteen (73%) centres used peritoneal catheter at some frequency, including six centres in >50% of neonates. Four centres utilised prophylactic peritoneal dialysis. Time to post-operative dialysis initiation was 3 hours [1, 5] with the duration of 56 hours [37, 90]; passive drainage cohort drained for 92 hours [64, 163]. Peritoneal catheter were more common among patients receiving pre-operative mechanical ventilation, single ventricle physiology, and higher complexity surgery. There was no association with adverse events. Serum creatinine and daily fluid balance were not clinically different on any post-operative day. Mortality was similar.In neonates undergoing complex cardiac surgery, peritoneal catheter use is not rare, with substantial variability among centres. Peritoneal catheters are used more commonly with higher surgical complexity. Adverse event rates, including mortality, are not different with peritoneal catheter use. Fluid overload and creatinine-based acute kidney injury rates are not different in peritoneal catheter cohorts.

  View details for DOI 10.1017/S104795112300135X

  View details for PubMedID 37337694

• Early postoperative weight-based fluid overload is associated with worse outcomes after neonatal cardiac surgery. Pediatric nephrology (Berlin, Germany) Brandewie, K. L., Selewski, D. T., Bailly, D. K., Bhat, P. N., Diddle, J. W., Ghbeis, M., Krawczeski, C. D., Mah, K. E., Neumayr, T. M., Raymond, T. T., Reichle, G., Zang, H., Alten, J. A. 2023

  Abstract

  Evaluate the association of postoperative day (POD) 2 weight-based fluid balance (FB-W) > 10% with outcomes after neonatal cardiac surgery.Retrospective cohort study of 22 hospitals in the NEonatal and Pediatric Heart and Renal Outcomes Network (NEPHRON) registry from September 2015 to January 2018. Of 2240 eligible patients, 997 neonates (cardiopulmonary bypass (CPB) n = 658, non-CPB n = 339) were weighed on POD2 and included.Forty-five percent (n = 444) of patients had FB-W > 10%. Patients with POD2 FB-W > 10% had higher acuity of illness and worse outcomes. Hospital mortality was 2.8% (n = 28) and not independently associated with POD2 FB-W > 10% (OR 1.04; 95% CI 0.29-3.68). POD2 FB-W > 10% was associated with all utilization outcomes, including duration of mechanical ventilation (multiplicative rate of 1.19; 95% CI 1.04-1.36), respiratory support (1.28; 95% CI 1.07-1.54), inotropic support (1.38; 95% CI 1.10-1.73), and postoperative hospital length of stay (LOS 1.15; 95% CI 1.03-1.27). In secondary analyses, POD2 FB-W as a continuous variable demonstrated association with prolonged durations of mechanical ventilation (OR 1.04; 95% CI 1.02-1.06], respiratory support (1.03; 95% CI 1.01-1.05), inotropic support (1.03; 95% CI 1.00-1.05), and postoperative hospital LOS (1.02; 95% CI 1.00-1.04). POD2 intake-output based fluid balance (FB-IO) was not associated with any outcome.POD2 weight-based fluid balance > 10% occurs frequently after neonatal cardiac surgery and is associated with longer cardiorespiratory support and postoperative hospital LOS. However, POD2 FB-IO was not associated with clinical outcomes. Mitigating early postoperative fluid accumulation may improve outcomes but requires safely weighing neonates in the early postoperative period. A higher resolution version of the Graphical abstract is available as Supplementary information.

  View details for DOI 10.1007/s00467-023-05929-7

  View details for PubMedID 36973562

  View details for PubMedCentralID 5716912

• Improvement in Multidisciplinary Provider Rounding (Surgical Rounds) in the Pediatric Cardiac ICU: An Application of Lean Methodology. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies Brown, T. N., Justice, L., Malik, F., Lehenbauer, D., O'Donnell, A., Brown, J. M., Powers, T., Neogi, S., Cooper, D. S., Mah, K. E. 2023

  Abstract

  Provider-only, combined surgical, and medical multidisciplinary rounds ("surgical rounds") are essential to achieve optimal outcomes in large pediatric cardiac ICUs. Lean methodology was applied with the aims of identifying areas of waste and nonvalue-added work within the surgical rounds process. Thereby, the goals were to improve rounding efficiency and reduce rounding duration while not sacrificing critical patient care discussion nor delaying bedside rounds or surgical start times.Single-center improvement science study with observational and interventional phases from February 2, 2021, to July 31, 2021.Tertiary pediatric cardiac ICU.Cardiothoracic surgery and cardiac intensive care team members participating in daily "surgical" rounds.Implementation of technology automation, creation of work instructions, standardization of patient presentation content and order, provider training, and novel role assignment.Sixty-one multidisciplinary rounds were observed (30 pre, 31 postintervention). During the preintervention period, identified inefficiencies included prolonged preparation time, redundant work, presentation variability and extraneous information, and frequent provider transitions. Application of targeted interventions resulted in a 26% decrease in indexed rounds duration (2.42 vs 1.8 min; p = 0.0003), 50% decrease in indexed rounds preparation time (0.53 vs 0.27 min; p < 0.0001), and 66% decrease in transition time between patients (0.09 vs 0.03 min; p < 0.0001). The number of presenting provider changes also decreased (9 vs 4; p < 0.0001). Indexed discussion duration did not change (1 vs 0.98 min; p = 0.08) nor did balancing measures (bedside rounds and surgical start times) change (8.5 vs 9 min; p = 0.89 and 38 vs 22 min; p = 0.09).Lean methodology can be effectively applied to multidisciplinary rounds in a joint cardiothoracic surgery/cardiac intensive care setting to decrease waste and inefficiency. Interventions resulted in decreased preparation time, transition time, presenting provider changes, total rounds duration indexed to patient census, and anecdotal improvements in provider satisfaction.

  View details for DOI 10.1097/PCC.0000000000003218

  View details for PubMedID 36804342

• Acute Cardiac Care for Neonatal Heart Disease. Pediatrics Cooper, D. S., Hill, K. D., Krishnamurthy, G., Sen, S., Costello, J. M., Lehenbauer, D., Twite, M., James, L., Mah, K. E., Taylor, C., McBride, M. E. 2022; 150 (Suppl 2)

  Abstract

  This manuscript is one component of a larger series of articles produced by the Neonatal Cardiac Care Collaborative that are published in this supplement of Pediatrics. In this review article, we summarize the contemporary physiologic principles, evaluation, and management of acute care issues for neonates with complex congenital heart disease. A multidisciplinary team of authors was created by the Collaborative's Executive Committee. The authors developed a detailed outline of the manuscript, and small teams of authors were assigned to draft specific sections. The authors reviewed the literature, with a focus on original manuscripts published in the last decade, and drafted preliminary content and recommendations. All authors subsequently reviewed and edited the entire manuscript until a consensus was achieved. Topics addressed include cardiopulmonary interactions, the pathophysiology of and strategies to minimize the development of ventilator-induced low cardiac output syndrome, common postoperative physiologies, perioperative bleeding and coagulation, and common postoperative complications.

  View details for DOI 10.1542/peds.2022-056415J

  View details for PubMedID 36317971

• Assessment of fluid balance after neonatal cardiac surgery: a description of intake/output vs. weight-based methods. Pediatric nephrology (Berlin, Germany) Neumayr, T. M., Alten, J. A., Bailly, D. K., Bhat, P. N., Brandewie, K. L., Diddle, J. W., Ghbeis, M., Krawczeski, C. D., Mah, K. E., Raymond, T. T., Reichle, G., Zang, H., Selewski, D. T., NEPHRON Investigators, Prodhan, P., Garcia, X., Ramer, S., Albertson, M., Gaies, M., Cooper, D. S., Rodriquez, Z., Lukacs, M., Zanaboni, D., de Toledo, J. S., Domnina, Y. A., Saenz, L., Baust, T., Kluck, J., Duncan, L., Koch, J. D., Freytag, J., Sammons, A., Abraha, H., Butcher, J., Sasaki, J., Bertrandt, R. A., Buckley, J. R., Schroeder, L., Raees, A., Sosa, L. J., Afonso, N. S., O'Neal, E. R., Lasa, J. J., Phillips, P. A., Ardisana, A., Gonzalez, K., Doman, T., Viers, S., Zhang, W., Hock, K. M., Borasino, S., Blinder, J. J. 2022

  Abstract

  BACKGROUND: Fluid overload associates with poor outcomes after neonatal cardiac surgery, but consensus does not exist for the most clinically relevant method of measuring fluid balance (FB). While weight change-based FB (FB-W) is standard in neonatal intensive care units, weighing infants after cardiac surgery may be challenging. We aimed to identify characteristics associated with obtaining weights and to understand how intake/output-based FB (FB-IO) and FB-W compare in the early postoperative period in this population.METHODS: Observational retrospective study of 2235 neonates undergoing cardiac surgery from 22 hospitals comprising the NEonatal and Pediatric Heart and Renal Outcomes Network (NEPHRON) database.RESULTS: Forty-five percent (n=998) of patients were weighed on postoperative day (POD) 2, varying from 2 to 98% among centers. Odds of being weighed were lower for STAT categories 4 and 5 (OR 0.72; 95% CI 0.53-0.98), cardiopulmonary bypass (0.59; 0.42-0.83), delayed sternal closure (0.27; 0.19-0.38), prophylactic peritoneal dialysis use (0.58; 0.34-0.99), and mechanical ventilation on POD 2 (0.23; 0.16-0.33). Correlation between FB-IO and FB-W was weak for every POD 1-6 and within the entire cohort (correlation coefficient 0.15; 95% CI 0.12-0.17). FB-W measured higher than paired FB-IO (mean bias 12.5%; 95% CI 11.6-13.4%) with wide 95% limits of agreement (-15.4-40.4%).CONCLUSIONS: Weighing neonates early after cardiac surgery is uncommon, with significant practice variation among centers. Patients with increased severity of illness are less likely to be weighed. FB-W and FB-IO have weak correlation, and further study is needed to determine which cumulative FB metric most associates with adverse outcomes. A higher resolution version of the Graphical abstract is available as Supplementary information.

  View details for DOI 10.1007/s00467-022-05697-w

  View details for PubMedID 36066771

• Preventing Cardiac Arrest in the Pediatric Cardiac Intensive Care Unit Through Multicenter Collaboration. JAMA pediatrics Alten, J., Cooper, D. S., Klugman, D., Raymond, T. T., Wooton, S., Garza, J., Clarke-Myers, K., Anderson, J., Pasquali, S. K., Absi, M., Affolter, J. T., Bailly, D. K., Bertrandt, R. A., Borasino, S., Dewan, M., Domnina, Y., Lane, J., McCammond, A. N., Mueller, D. M., Olive, M. K., Ortmann, L., Prodhan, P., Sasaki, J., Scahill, C., Schroeder, L. W., Werho, D. K., Zaccagni, H., Zhang, W., Banerjee, M., Gaies, M., PC4 CAP Collaborators, Florez, A. R., Mah, K., Murphy, L. D., Louden, E., Moellinger, A., Scalici McAtee, M., Kane, J., Roper, S., Bradley, B., Dick, A., Bhakta, R. T., Das, A., Shah, T., Burton, G., Manzuri, S., Briceno-Medina, M., Grandberry, M. H., Diddle, J. W., Riley, C. M., Fortkiewicz, J. M., Hom, L. A., Parikh, K., Almasarweh, S., Kayoum, A. A., Koch, J., Richardson, A., Wellnitz, C., Delgado-Corcoran, C., Hardin-Reynolds, T., Do, T. B., Wilhelmi, A. J., McMorrow Sciuto, S., Daley, S., Wolovits, J. S., Yu, P., Gerstmann, J., Mannan, T., Buckley, J. R., Tabbutt, S., Chan, T., Davis, A., Hammel, J., Burgert, A., Norton, B., Molitor-Kirsch, E., Miller-Smith, L., Tieves, K. S., Walz, K., Rosenberg, C., Owens, G. E., Mikesell, K., Wald, E., Clark, J., Laubhan, C., DiMaria, K., Wilkes, R., Steadman, P., Davis, A. L., Smith, A., Lasa, J. J., Zahn-Schafer, R., Maynord, P., Smith, A. H., Mastropietro, C. W., Broo, M., Vinson, E., Duncan, L., Kluck, J., Ruiz, M., Gretchen, C., Moga, M. 2022

  Abstract

  Importance: Preventing in-hospital cardiac arrest (IHCA) likely represents an effective strategy to improve outcomes for critically ill patients, but feasibility of IHCA prevention remains unclear.Objective: To determine whether a low-technology cardiac arrest prevention (CAP) practice bundle decreases IHCA rate.Design, Setting, and Participants: Pediatric cardiac intensive care unit (CICU) teams from the Pediatric Cardiac Critical Care Consortium (PC4) formed a collaborative learning network to implement the CAP bundle consistent with the Institute for Healthcare Improvement framework; 15 hospitals implemented the bundle voluntarily. Risk-adjusted IHCA incidence rates were analyzed across 2 time periods, 12 months (baseline) and 18 months after CAP implementation (intervention) using difference-in-differences (DID) regression to compare 15 CAP and 16 control PC4 hospitals that chose not to participate in CAP but had IHCA rates tracked in the PC4 registry. Patients deemed at high risk for IHCA, based on a priori evidence-based criteria and empirical hospital-specific criteria, were selected to receive the CAP bundle. Data were collected from July 2018 to December 2019, and data were analyzed from March to August 2020.Interventions: CAP bundle included 5 elements developed to promote increased situational awareness and communication among bedside clinicians to recognize and mitigate deterioration in high-risk patients.Main Outcomes and Measures: Risk-adjusted IHCA incidence rate across all CICU admissions (IHCA events divided by all admissions).Results: The bundle was activated in 2664 of 10 510 CAP hospital admissions (25.3%); admission characteristics were similar across study periods. There was a 30% relative reduction in risk-adjusted IHCA incidence rate at CAP hospitals (intervention period: 2.6%; 95% CI, 2.2-2.9; baseline: 3.7%; 95% CI, 3.1-4.0), but no change at control hospitals (intervention period: 2.7%; 95% CI, 2.3-2.9; baseline: 2.7%; 95% CI, 2.2-3.0). DID analysis confirmed significantly reduced odds of IHCA among all admissions at CAP hospitals compared with control hospitals during the intervention period vs baseline (odds ratio, 0.72; 95% CI, 0.56-0.91; P=.01). DID odds ratios were 0.72 (95% CI, 0.53-0.98) for the surgical subgroup, 0.74 (95% CI, 0.48-1.14) for the medical subgroup, and 0.72 (95% CI, 0.50-1.03) for the high-risk admission subgroup at CAP hospitals after intervention. All-cause risk-adjusted mortality rate did not change after intervention.Conclusions and Relevance: Implementation of this CAP bundle led to significant IHCA reduction across multiple pediatric CICUs. Future studies may determine if this bundle can be effective in other critically ill populations.

  View details for DOI 10.1001/jamapediatrics.2022.2238

  View details for PubMedID 35788631

• Fluid Accumulation After Neonatal Congenital Cardiac Surgery; Clinical Implications and Outcomes. The Annals of thoracic surgery Bailly, D. K., Alten, J. A., Gist, K. M., Mah, K. E., Kwiatkowski, D. M., Valentine, K. M., Diddle, J. W., Tadphale, S., Clarke, S., Selewski, D. T., Banerjee, M., Reichle, G., Lin, P., Gaies, M., Blinder, J. J. 2022

  Abstract

  To determine the association between fluid balance metrics and mortality and other postoperative outcomes after neonatal cardiac surgery in a contemporary multi-center cohort.Observational cohort study across 22 hospitals in neonates (≤30 days) undergoing cardiac surgery. We explored overall % fluid overload, postoperative day 1 % fluid overload, peak % fluid overload, and time to first negative daily fluid balance. The primary outcome was in-hospital mortality. Secondary outcomes included postoperative duration of mechanical ventilation, and intensive care unit (ICU) and hospital length of stay. Multivariable logistic or negative binomial regression was used to determine independent associations between fluid overload variables and each outcome.The cohort included 2223 patients. In-hospital mortality was 3.9% (n=87). Overall median peak % fluid overload was 4.9%, (interquartile range 0.4-10.5%). Peak % fluid overload and postoperative day 1 % fluid overload were not associated with primary or secondary outcomes. Hospital resource utilization increased on each successive day of not achieving a first negative daily fluid balance and was characterized by longer duration of mechanical ventilation (incidence rate ratio 1.11, 95% confidence interval 1.08-1.14, ICU length of stay (incidence rate ratio 1.08, 95% confidence interval 1.03-1.12), and hospital length of stay (incidence rate ratio 1.09, 95% confidence interval 1.05-1.13).Time to first negative daily fluid balance, but not % fluid overload is associated with improved postoperative outcomes in neonates after cardiac surgery. Specific treatments to achieve an early negative fluid balance may decrease postoperative care durations.

  View details for DOI 10.1016/j.athoracsur.2021.12.078

  View details for PubMedID 35245511

• Extracorporeal Membrane Oxygenation in Patients with Univentricular Physiology. Extracorporeal Membrane Oxygenation - An Interdisciplinary Practice-based Learning Approach. Murphy, L. D., Cooper, D. S., Mah, K. E. Oxford University Press. 2022; 1: 293-300
• Reply to: Acute kidney injury after in-hospital pediatric cardiac arrest RESUSCITATION Mah, K. E., Alten, J. A. 2021; 163: 209-210

  View details for DOI 10.1016/j.resuscitation.2021.04.022

  View details for Web of Science ID 000653444500038

  View details for PubMedID 33930502

• Meningitis and high-grade, second-degree atrioventricular block in an adolescent: causal effect or coincidence? Cardiology in the young Murphy, L. D., Florez, A. R., Czosek, R. J., Cooper, D. S., Mah, K. E. 2021: 1-3

  Abstract

  We describe an adolescent with Streptococcus pneumoniae meningitis and symptomatic high-grade, second-degree atrioventricular block requiring permanent pacemaker placement. It is difficult to ascertain if these two diagnoses were independent or had a causal relationship though ongoing symptoms were not present prior to the infection. Because of this uncertainty, awareness that rhythm disturbances can be cardiac in origin but also secondary to other aetiologies, such as infection, is warranted.

  View details for DOI 10.1017/S1047951121001785

  View details for PubMedID 33966681

• A Scoping Review of Health Information Technology in Clinician Burnout APPLIED CLINICAL INFORMATICS Wu, D. Y., Xu, C., Kim, A., Bindhu, S., Mah, K. E., Eckman, M. H. 2021; 12 (03): 597-620

  Abstract

  Clinician burnout is a prevalent issue in healthcare, with detrimental implications in healthcare quality and medical costs due to errors. The inefficient use of health information technologies (HIT) is attributed to having a role in burnout.This paper seeks to review the literature with the following two goals: (1) characterize and extract HIT trends in burnout studies over time, and (2) examine the evidence and synthesize themes of HIT's roles in burnout studies.A scoping literature review was performed by following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines with two rounds of searches in PubMed, IEEE Xplore, ACM, and Google Scholar. The retrieved papers and their references were screened for eligibility by using developed inclusion and exclusion criteria. Data were extracted from included papers and summarized either statistically or qualitatively to demonstrate patterns.After narrowing down the initial 945 papers, 36 papers were included. All papers were published between 2013 and 2020; nearly half of them focused on primary care (n = 16; 44.4%). The most commonly studied variable was electronic health record (EHR) practices (e.g., number of clicks). The most common study population was physicians. HIT played multiple roles in burnout studies: it can contribute to burnout; it can be used to measure burnout; or it can intervene and mitigate burnout levels.This scoping review presents trends in HIT-centered burnout studies and synthesizes three roles for HIT in contributing to, measuring, and mitigating burnout. Four recommendations were generated accordingly for future burnout studies: (1) validate and standardize HIT burnout measures; (2) focus on EHR-based solutions to mitigate clinician burnout; (3) expand burnout studies to other specialties and types of healthcare providers, and (4) utilize mobile and tracking technology to study time efficiency.

  View details for DOI 10.1055/s-0041-1731399

  View details for Web of Science ID 000670383100003

  View details for PubMedID 34233369

  View details for PubMedCentralID PMC8263130

• Commentary: The Vulcan mind MELD-XI. The Journal of thoracic and cardiovascular surgery Mah, K. E., Morales, D. L. 2021

  View details for DOI 10.1016/j.jtcvs.2021.03.052

  View details for PubMedID 33875260

• Acute kidney injury after in-hospital cardiac arrest. Resuscitation Mah, K. E., Alten, J. A., Cornell, T. T., Selewski, D. T., Askenazi, D. n., Fitzgerald, J. C., Topjian, A. n., Page, K. n., Holubkov, R. n., Slomine, B. S., Christensen, J. R., Dean, J. M., Moler, F. W. 2021

  Abstract

  Determine 1) frequency and risk factors for acute kidney injury (AKI) after in-hospital cardiac arrest (IHCA) in the Therapeutic Hypothermia after Pediatric Cardiac Arrest In-Hospital (THAPCA-IH) trial and associated outcomes; 2) impact of temperature management on post-IHCA AKI.Secondary analysis of THAPCA-IH; a randomized controlled multi-national trial at 37 children's hospitals.Serum creatinine (Cr) within 24 h of randomization.Prevalence of severe AKI defined by Stage 2 or 3 Kidney Disease Improving Global Outcomes Cr criteria. 12-month survival with favorable neurobehavioral outcome. Analyses stratified by entire cohort and cardiac subgroup. Risk factors and outcomes compared among cohorts with and without severe AKI.Subject randomization: 159 to hypothermia, 154 to normothermia. Overall, 80% (249) developed AKI (any stage), and 66% (207) developed severe AKI. Cardiac patients (204, 65%) were more likely to develop severe AKI (72% vs 56%,p = 0.006). Preexisting cardiac or renal conditions, baseline lactate, vasoactive support, and systolic blood pressure were associated with severe AKI. Comparing hypothermia versus normothermia, there were no differences in severe AKI rate (63% vs 70%,p = 0.23), peak Cr, time to peak Cr, or freedom from mortality or severe AKI (p = 0.14). Severe AKI was associated with decreased hospital survival (48% vs 65%,p = 0.006) and decreased 12-month survival with favorable neurobehavioral outcome (30% vs 53%,p < 0.001).Severe post-IHCA AKI occurred frequently especially in those with preexisting cardiac or renal conditions and peri-arrest hemodynamic instability. Severe AKI was associated with decreased survival with favorable neurobehavioral outcome. Hypothermia did not decrease incidence of severe AKI post-IHCA.

  View details for DOI 10.1016/j.resuscitation.2020.12.023

  View details for PubMedID 33450335

• Real-Time, Secure, and Confidential Data Sharing in the Fight Against COVID-19 and Beyond Mah, K. Cincinnati Children's Hospital Medical Center Research Horizons. 2021
• IMPROVING NURSE EMPOWERMENT DURING CARDIAC ARREST PREVENTION HUDDLES IS RELATED TO DECREASED ARREST Murphy, L., Florez, A., Mah, K., Munoz, J., Donnellan, A., Rose, S., LaMantia, S., Brown, J., Reedy, B., Schubert, A., Sanchez, M., Baumer, C., Baumer, A., Alten, J. LIPPINCOTT WILLIAMS & WILKINS. 2020

  View details for Web of Science ID 000530000201644

• Commentary: I am not throwing away my shot . . . to predict when your patient will decompensate JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Murphy, L. D., Cooper, D. S., Mah, K. E. 2019; 158 (1): 246-247

  View details for DOI 10.1016/j.jtcvs.2019.03.111

  View details for Web of Science ID 000472627000071

  View details for PubMedID 31248511

• Commentary: Fontan survivor-outwit, outlast, outplay but do not overstay (your welcome) JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Mah, K. E., Cooper, D. S. 2019; 157 (5): 2014-2015

  View details for DOI 10.1016/j.jtcvs.2018.11.118

  View details for Web of Science ID 000464437100101

  View details for PubMedID 30685179

• Stress Cardiomyopathy Due to Status Epilepticus After Fontan Procedure Global Journal of Pediatrics & Neonatal Care Ramachandran, P., Tseng, S. Y., Mah, K. E., Byrnes, J. W. 2019; 1 (2)

  View details for DOI 10.33552/GJPNC.2019.01.000509

• Fluid overload independent of acute kidney injury predicts poor outcomes in neonates following congenital heart surgery. Pediatric nephrology (Berlin, Germany) Mah, K. E., Hao, S. n., Sutherland, S. M., Kwiatkowski, D. M., Axelrod, D. M., Almond, C. S., Krawczeski, C. D., Shin, A. Y. 2017

  Abstract

  Fluid overload (FO) is common after neonatal congenital heart surgery and may contribute to mortality and morbidity. It is unclear if the effects of FO are independent of acute kidney injury (AKI).This was a retrospective cohort study which examined neonates (age < 30 days) who underwent cardiopulmonary bypass in a university-affiliated children's hospital between 20 October 2010 and 31 December 2012. Demographic information, risk adjustment for congenital heart surgery score, surgery type, cardiopulmonary bypass time, cross-clamp time, and vasoactive inotrope score were recorded. FO [(fluid in-out)/pre-operative weight] and AKI defined by Kidney Disease Improving Global Outcomes serum creatinine criteria were calculated. Outcomes were all-cause, in-hospital mortality and median postoperative hospital and intensive care unit lengths of stay.Overall, 167 neonates underwent cardiac surgery using cardiopulmonary bypass in the study period, of whom 117 met the inclusion criteria. Of the 117 neonates included in the study, 76 (65%) patients developed significant FO (>10%), and 25 (21%) developed AKI ≥ Stage 2. When analyzed as FO cohorts (< 10%,10-20%, > 20% FO), patients with greater FO were more likely to have AKI (9.8 vs. 18.2 vs. 52.4%, respectively, with AKI ≥ stage 2; p = 0.013) and a higher vasoactive-inotrope score, and be premature. In the multivariable regression analyses of patients without AKI, FO was independently associated with hospital and intensive care unit lengths of stay [0.322 extra days (p = 0.029) and 0.468 extra days (p < 0.001), respectively, per 1% FO increase). In all patients, FO was also associated with mortality [odds ratio 1.058 (5.8% greater odds of mortality per 1% FO increase); 95% confidence interval 1.008,1.125;p = 0.032].Fluid overload is an important independent contributor to outcomes in neonates following congenital heart surgery. Careful fluid management after cardiac surgery in neonates with and without AKI is warranted.

  View details for PubMedID 29128923

• The Effects of Sleep Extension on the Athletic Performance of Collegiate Basketball Players SLEEP Mah, C. D., Mah, K. E., Kezirian, E. J., Dement, W. C. 2011; 34 (7): 943-950

  Abstract

  To investigate the effects of sleep extension over multiple weeks on specific measures of athletic performance as well as reaction time, mood, and daytime sleepiness.Stanford Sleep Disorders Clinic and Research Laboratory and Maples Pavilion, Stanford University, Stanford, CA.Eleven healthy students on the Stanford University men's varsity basketball team (mean age 19.4 ± 1.4 years).Subjects maintained their habitual sleep-wake schedule for a 2-4 week baseline followed by a 5-7 week sleep extension period. Subjects obtained as much nocturnal sleep as possible during sleep extension with a minimum goal of 10 h in bed each night. Measures of athletic performance specific to basketball were recorded after every practice including a timed sprint and shooting accuracy. Reaction time, levels of daytime sleepiness, and mood were monitored via the Psychomotor Vigilance Task (PVT), Epworth Sleepiness Scale (ESS), and Profile of Mood States (POMS), respectively.Total objective nightly sleep time increased during sleep extension compared to baseline by 110.9 ± 79.7 min (P < 0.001). Subjects demonstrated a faster timed sprint following sleep extension (16.2 ± 0.61 sec at baseline vs. 15.5 ± 0.54 sec at end of sleep extension, P < 0.001). Shooting accuracy improved, with free throw percentage increasing by 9% and 3-point field goal percentage increasing by 9.2% (P < 0.001). Mean PVT reaction time and Epworth Sleepiness Scale scores decreased following sleep extension (P < 0.01). POMS scores improved with increased vigor and decreased fatigue subscales (P < 0.001). Subjects also reported improved overall ratings of physical and mental well-being during practices and games.Improvements in specific measures of basketball performance after sleep extension indicate that optimal sleep is likely beneficial in reaching peak athletic performance.

  View details for DOI 10.5665/SLEEP.1132

  View details for Web of Science ID 000292926500022

  View details for PubMedID 21731144

  View details for PubMedCentralID PMC3119836