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Original Investigation |

Kidney Outcomes 5 Years After Pediatric Cardiac Surgery The TRIBE-AKI Study ONLINE FIRST

Jason H. Greenberg, MD, MHS1,2; Michael Zappitelli, MD, MSc3; Prasad Devarajan, MD4; Heather R. Thiessen-Philbrook, MMath2; Catherine Krawczeski, MD5; Simon Li, MD, MPH6; Amit X. Garg, MD7; Steve Coca, DO, MS2,8; Chirag R. Parikh, MD, PhD2,9,10 ; for the TRIBE-AKI Consortium
[+] Author Affiliations
1Section of Nephrology, Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
2Program of Applied Translational Research, Yale University School of Medicine, New Haven, Connecticut
3Division of Pediatric Nephrology, Department of Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada
4Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
5Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
6Division of Critical Care, Department of Pediatrics, Maria Fareri Children’s Hospital, Valhalla, New York
7Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada
8Section of Nephrology, Department of Internal Medicine, Mount Sinai School of Medicine, New York, New York
9Section of Nephrology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
10VA Medical Center, West Haven, Connecticut
JAMA Pediatr. Published online September 12, 2016. doi:10.1001/jamapediatrics.2016.1532
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Importance  Acute kidney injury (AKI) after pediatric cardiac surgery is associated with high short-term morbidity and mortality; however, the long-term kidney outcomes are unclear.

Objective  To assess long-term kidney outcomes after pediatric cardiac surgery and to determine if perioperative AKI is associated with worse long-term kidney outcomes.

Design, Setting, and Participants  This prospective multicenter cohort study recruited children between ages 1 month to 18 years who underwent cardiopulmonary bypass for cardiac surgery and survived hospitalization from 3 North American pediatric centers between July 2007 and December 2009. Children were followed up with telephone calls and an in-person visit at 5 years after their surgery.

Exposures  Acute kidney injury defined as a postoperative serum creatinine rise from preoperative baseline by 50% or 0.3 mg/dL or more during hospitalization for cardiac surgery.

Main Outcomes and Measures  Hypertension (blood pressure ≥95th percentile for height, age, sex, or self-reported hypertension), microalbuminuria (urine albumin to creatinine ratio >30 mg/g), and chronic kidney disease (serum creatinine estimated glomerular filtration rate [eGFR] <90 mL/min/1.73 m2 or microalbuminuria).

Results  Overall, 131 children (median [interquartile range] age, 7.7 [5.9-9.9] years) participated in the 5-year in-person follow-up visit; 68 children (52%) were male. Fifty-seven of 131 children (44%) had postoperative AKI. At follow-up, 22 children (17%) had hypertension (10 times higher than the published general pediatric population prevalence), while 9 (8%), 13 (13%), and 1 (1%) had microalbuminuria, an eGFR less than 90 mL/min/1.73 m2, and an eGFR less than 60 mL/min/1.73 m2, respectively. Twenty-one children (18%) had chronic kidney disease. Only 5 children (4%) had been seen by a nephrologist during follow-up. There was no significant difference in renal outcomes between children with and without postoperative AKI.

Conclusions and Relevance  Chronic kidney disease and hypertension are common 5 years after pediatric cardiac surgery. Perioperative AKI is not associated with these complications. Longer follow-up is needed to ascertain resolution or worsening of chronic kidney disease and hypertension.

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Figure 1.
TRIBE-AKI Study Population.

Translational Research Investigating Biomarker Endpoints in Acute Kidney Injury (TRIBE-AKI) long-term follow-up cohort selection process.

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Figure 2.
Hypertension Prevalence Among Pediatric Center Cohorts Included in the TRIBE-AKI Study

Comparison of hypertension prevalence in 4 pediatric cohorts from the Translational Research Investigating Biomarker Endpoints in Acute Kidney Injury (TRIBE-AKI) pediatric cohort 5 years after cardiac surgery, the National Health and Nutrition Examination Survey (NHANES), the Kaiser Permanente health care system, and a large urban medical system in Northeast Ohio (eTable 3 in the Supplement). The NHANES, Kaiser, and Northeast Ohio cohorts were identified through a literature review.

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