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Acute kidney injury in pediatric toxic shock syndrome is associated with worse clinical course in the intensive care unit

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Abstract

To explore the prevalence, severity, nature, and significance of acute kidney injury (AKI) among children admitted to the pediatric intensive care unit (PICU) with toxic shock syndrome (TSS). Bi-center, retrospective observational study. Children admitted for TSS to two intensive care units from 2009–2022 were included. We identified 41 children (median age 5 years, 46% females) who met the Centers for Disease Control and Prevention (CDC) definitions of TSS. Staphylococcal TSS accounted for 63% of the patients and Streptococcal TSS accounted for the remaining 37%. AKI was diagnosed in 24 (59%) (stage 1: n = 6 [15% of total], stage 2: n = 10 [24%], and stage 3: n = 8 [20%]). The worst creatinine level was measured during the first day of admission in 34 (83%) patients. The median duration of AKI was 2 days. Creatinine normalized by hospital discharge in all cases. Patients with AKI had a longer intensive care unit stay than those without AKI (6 vs. 3 days, respectively, p = 0.01), needed more respiratory support (87% vs. 47%, p = 0.002), had fewer 28 ventilation-free days (25 vs. 28, p = 0.01), fewer vasopressor-free days (25 vs. 28, p = 0.001), and received more blood products (p = 0.03).

   Conclusion: Children admitted to the PICU with TSS, show a high prevalence of AKI at presentation. Creatinine levels and clearance normalize by hospital discharge in most cases. AKI in the setting of TSS could be used as an early marker for illness severity and a predictor of a more complex course.

What is Known:

• TSS is characterized according to the CDC by specific sets of clinical signs and symptoms in conjunction with specific laboratory findings one of which is AKI.

• AKI is associated with worse outcomes in critically ill patients in general and in septic patients in particular.

What is New:

• AKI is found in about 60% of all patients admitted to the PICU with a diagnosis of TSS and hence is an important defining criteria.

• AKI in the setting of TSS is associated with a more complex illness course and can serve as an early marker predicting such a course.

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Abbreviations

AKI:

Acute kidney injury

AKIN:

Acute Kidney Injury Network

ALT:

ALanine amino Transferase

ARDS:

Acute Respiratory Distress Syndrome

CDC:

Centers for Disease Control and Prevention

CPK:

Creatine PhosphoKinase

CRP:

C-Reactive Protein

eGFR:

Estimated Glomerular Filtration Rate

ICU:

Intensive Care Unit

INR:

International Normalized Ratio

KDIGO:

Kidney Disease Improving Global Outcomes

PICU:

Pediatric Intensive Care Unit

PIM3:

Pediatric Index of Mortality 3

PTT:

Partial Thromboplastin Time

RIFLE:

Risk, Assessment, Failure, Loss, and End Stage Renal Failure

RRT:

Renal Replacement Therapy

SCR:

Serum Creatinine

SD:

Standard Deviation

TSS:

Toxic Shock Syndrome

UO:

Urinary Output

VIS:

Vasoactive Inotropic Score

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Funding

All authors declare that they received no financial support for the research, authorship, and/or publication of this article.

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Authors and Affiliations

  1. Pediatric Intensive Care Unit, Schneider Children’s Medical Center of Israel, Petach Tikva, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 4920235, Israel

    Avichai Weissbach, Eytan Kaplan, Gili Kadmon & Elhanan Nahum

  2. The Department of Nursing, School of Health Sciences, Ariel University, Ariel, Israel

    Yulia Gendler

  3. Pediatric Intensive Care Unit, Dana-Dwek Children’s Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 4920235, Israel

    Barak Meidan, Shirley Friedman, Efraim Sadot & Itay Ayalon

Authors
  1. Avichai Weissbach
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Contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by A.W and I.A. All statistical analyses were reviewed by Y.G. The first draft of the manuscript was written by A.W and I.A and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Avichai Weissbach.

Ethics declarations

Ethics approval

This retrospective chart review study involving human participants was in accordance with the ethical standards of the institutional and with the 1964 Helsinki declaration and its later amendments. It was approved by the ethics committees of both participating sites (RMC-21-0713 date of approval 01/12/2021 and TLV 0727-21 date of approval 04/01/2022) and both waived the requirement of obtaining informed consent.

Consent to participate and publish

Due to retrospective nature of this observational study, ethic committees of both participating sites approved a waiver to obtain informed consent from participants (RMC-21-0713 date of approval 01/12/2021 and TLV 0727-21 date of approval 04/01/2022).

Competing interests

All authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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Communicated by Piet Leroy

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Weissbach, A., Kaplan, E., Kadmon, G. et al. Acute kidney injury in pediatric toxic shock syndrome is associated with worse clinical course in the intensive care unit. Eur J Pediatr 182, 4253–4261 (2023). https://doi.org/10.1007/s00431-023-05109-7

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