Our review article published in "Pediatric Nephrology" journal !

Today we publish a much awaited review on "Nutritional Management of a Critically Ill child with Acute Kidney Injury" in the journal "Pediatric Nephrology". Thanks to Drs Rupesh Raina, Timothy Bunchman, Vijay Kher, Norma Maxvold and Pranaw Jha for all the help and support.

Link to the article here

Importance of NINJA in Pediatric Nephrology

Current issue of Kidney International shows an excellent study from Dr Goldstein's group, Cincinatti. It talks on development and validation of a systematic screening program called Nephrotoxic Injury Negated by Just-in-time Action (NINJA), whereby children admitted to a noncritical care unit in our hospital deemed to be at high-risk of NTMx-AKI were recommended to have a daily serum creatinine (SCr) ordered to assess for AKI development.

By intensive monitoring, the exposure rate decreased by 38% (11.63–7.24 exposures/1000 patient days), and the AKI rate decreased by 64% (2.96–1.06 episodes/1000 patient days).

This figure shows improvement in exposure rates following NINJA. 

What should be the dose of CRRT in patients with sepsis?

Continuous renal replacement therapy (CRRT) has been suggested to play a part in immunomodulation by cytokine removal. However, the effect of continuous venovenous hemodiafiltration (CVVHDF) dose on inflammatory cytokine removal and its influence on patient outcomes are not yet clear.

Randomised Controlled Trial published in American Journal of Kidney Diseases 2016

Intervention: Conventional (40 mL/kg/h) and high (80 mL/kg/h) doses of CVVHDF for the duration of CRRT
Results: High-dose CVVHDF, but not the conventional dose, significantly reduced interleukin 6 (IL-6), IL-8, IL-1b, and IL-10 levels.
Conclusions
High CVVHDF dose did not improve patient outcomes despite its significant influence on inflammatory cytokine removal. CRRT-induced immunomodulation may not be sufficient to influence clinical end points.
Personal view: These patients are so sick, that these studies usually fail to find a change in the hard clinical end points. 

Eculizumab for aHUS: The first use in India

We used Eculizumab in an American boy with aHUS, and kept him in remission, till his genetic results came back normal. This was the first time in the country, that someone used this drug, since it is very costly and not available in the country.
We publish our experience today in Indian Journal of Nephrology to raise the awareness about the treatment, and the difficulties faced in doing the right thing in the right way!

Think together; kidney-liver-lung-spleen-heart-gut interactions

Recent data from basic and clinical research have begun to elucidate complex organ interactions in AKI between kidney and distant organs, including heart, lung, spleen, brain, liver, and gut. This review serves to update the topic of organ cross talk in AKI and focuses on potential therapeutic targets to improve patient outcomes during AKI-associated multiple organ failure.
Link to the Kidney International Article

Fluid overload as an adverse marker for neonatal mortality

Another study from Seoul, shows that neonates with a higher percentage fluid overload and higher levels of serum creatinine at CRRT initiation showed poor outcomes. Early initiation of CRRT before the development of severe FO or azotemia might improve the outcomes of neonates requiring CRRT.

The survival rates of patients with an FO of ≥30 % at the time of CRRT initiation were lower than those of patients with an FO of <30 % at the same time-point.

Early RRT may help in these sick children! 

Ultilising FE-urea for differentiating types of AKI

The fractional excretion of urea nitrogen (FEUN) is less influenced by furosemide, which inhibits sodium and chloride reabsorption at the thick ascending loop of Henle. In adults, FEUN has been shown to be a useful biomarker in the differential diagnosis of prerenal AKI and ATN, especially in patients receiving diuretic therapy.
Current issue of Pediatric Nephrology has an excellent paper on FE-urea vs FENa in children with AKI, and finding the etiology.

Free Online articles on Pediatric Nephrology

This month ERA-EDTA provides free online articles for all for childhood renal disorders.

Following are my favourites:

• Editorial on "World Kidney Day"
• Excellent prospective study on biomarkers and renal angina index in critically ill children by Dr Goldstein's group
• A chapter on Pediatric AKI by Dr Rees
• A chapter on Pediatric transplantation by Dr Minnie Sarwal
• Plasmapheresis experience from CMC Vellore, India
• A chapter on Pediatric Hypertension