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Deja A, Guzzo I, Cappoli A, Labbadia R, Bayazit AK, Yildizdas D, Schmitt CP, Tkaczyk M, Cvetkovic M, Kostic M, Hayes W, Shroff R, Jankauskiene A, Virsilas E, Longo G, Vidal E, Mir S, Bulut IK, Pasini A, Paglialonga F, Montini G, Yilmaz E, Costa LC, Teixeira A, Schaefer F. Factors influencing circuit lifetime in paediatric continuous kidney replacement therapies - results from the EurAKId registry. Pediatr Nephrol 2024; 39:3353-3362. [PMID: 39023538 DOI: 10.1007/s00467-024-06459-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 06/22/2024] [Accepted: 06/24/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Continuous kidney replacement therapy (CKRT) has recently become the preferred kidney replacement modality for children with acute kidney injury (AKI). We hypothesise that CKRT technical parameters and treatment settings in addition to the clinical characteristics of patients may influence the circuit lifetime in children. METHODS The study involved children included in the EurAKId registry (NCT02960867), who underwent CKRT treatment. We analysed patient characteristics and CKRT parameters. The primary end point was mean circuit lifetime (MCL). Secondary end points were number of elective circuit changes and occurrence of dialysis-related complications. RESULTS The analysis was composed of 247 children who underwent 37,562 h of CKRT (median 78, IQR 37-165 h per patient). A total of 1357 circuits were utilised (3, IQR 2-6 per patient). MCL was longer in regional citrate anticoagulation (RCA), compared to heparin (HA) and no anticoagulation (NA) (42, IQR 32-58 h; 24, IQR 14-34 h; 18, IQR 12-24 h, respectively, p < 0.001). RCA was associated with longer MCL regardless of the patient's age or dialyser surface. In multivariate analysis, MCL correlated with dialyser surface area (beta = 0.14, p = 0.016), left internal jugular vein vascular access site (beta = -0.37, p = 0.027), and the use of HA (beta = -0.14, p = 0.038) or NA (beta = -0.37, p < 0.001) vs. RCA. RCA was associated with the highest ratio of elective circuit changes and the lowest incidence of complications. CONCLUSION Anticoagulation modality, dialyser surface, and vascular access site influence MCL. RCA should be considered when choosing first-line anticoagulation for CKRT in children. Further efforts should focus on developing guidelines and clinical practice recommendations for paediatric CKRT.
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Affiliation(s)
- Anna Deja
- Department of Paediatrics and Nephrology, Medical University of Warsaw, Warsaw, Poland.
| | - Isabella Guzzo
- Division of Nephrology, Dialysis and Transplant Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Andrea Cappoli
- Division of Nephrology, Dialysis and Transplant Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Raffaella Labbadia
- Division of Nephrology, Dialysis and Transplant Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Aysun Karabay Bayazit
- Department of Pediatric Nephrology, Cukurova University, Faculty of Medicine, Adana, Turkey
| | - Dincer Yildizdas
- Department of Pediatric Nephrology, Cukurova University, Faculty of Medicine, Adana, Turkey
| | - Claus Peter Schmitt
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Marcin Tkaczyk
- Department of Pediatrics and Immunology, Nephrology Division, Polish Mothers Memorial Hospital Research Institute, Lodz, Poland
| | - Mirjana Cvetkovic
- Department of Nephrology, University Children Hospital, Belgrade, Serbia
| | - Mirjana Kostic
- Department of Nephrology, University Children Hospital, Belgrade, Serbia
| | - Wesley Hayes
- Department of Pediatric Nephrology, UCL Great Ormond Street Hospital and Institute of Child Health, London, UK
| | - Rukshana Shroff
- Department of Pediatric Nephrology, UCL Great Ormond Street Hospital and Institute of Child Health, London, UK
| | - Augustina Jankauskiene
- Clinic of Pediatrics, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
| | - Ernestas Virsilas
- Clinic of Pediatrics, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
| | - Germana Longo
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Woman's and Children's Health, University of Padua, Padua, Italy
| | - Enrico Vidal
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Woman's and Children's Health, University of Padua, Padua, Italy
| | - Sevgi Mir
- Department of Pediatric Nephrology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Ipek Kaplan Bulut
- Department of Pediatric Nephrology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Andrea Pasini
- Pediatric Nephrology and Dialysis, Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Fabio Paglialonga
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione Ca' Grande IRRCS, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanni Montini
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione Ca' Grande IRRCS, Ospedale Maggiore Policlinico, Milan, Italy
| | - Ebru Yilmaz
- Department of Pediatric Nephrology, Dr Behcet Children Research and Education Hospital, Izmir, Turkey
| | - Liane Correia Costa
- Department of Pediatric Nephrology, Centro Materno-Infantil Do Norte, Porto, Portugal
| | - Ana Teixeira
- Department of Pediatric Nephrology, Centro Materno-Infantil Do Norte, Porto, Portugal
| | - Franz Schaefer
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
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Stenson EK, Alhamoud I, Alobaidi R, Bottari G, Fernandez S, Fuhrman DY, Guzzi F, Haga T, Kaddourah A, Marinari E, Mohamed T, Morgan C, Mottes T, Neumayr T, Ollberding NJ, Raggi V, Ricci Z, See E, Stanski NL, Zang H, Zangla E, Gist KM. 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 Med 2024; 50:861-872. [PMID: 38436726 PMCID: PMC11164640 DOI: 10.1007/s00134-024-07336-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 01/25/2024] [Indexed: 03/05/2024]
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 0-25 years) treated with CRRT for AKI or FB disorders. Patients with previous dialysis dependence, tandem extracorporeal membrane oxygenation use, died within the first 72 h 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 72 h) vs. success (no receipt of dialysis for ≥ 72 h). 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.
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Affiliation(s)
- Erin K Stenson
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Issa Alhamoud
- Carver College of Medicine, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | | | | | - Sarah Fernandez
- School of Medicine, Gregorio Marañón University Hospital, Madrid, Spain
| | - Dana Y Fuhrman
- University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | | | - Taiki Haga
- Osaka City General Hospital, Osaka, Japan
| | | | | | - Tahagod Mohamed
- Nationwide Children's Hospital, The Kidney and Urinary Tract Center, The Ohio State University College of Medicine, Columbus, OH, USA
| | | | - Theresa Mottes
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Tara Neumayr
- St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO, USA
| | - Nicholas J Ollberding
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Valeria Raggi
- Bambino Gesù, Children's Hospital, IRCCS, Rome, Italy
| | - Zaccaria Ricci
- Department of Pediatrics, Pediatric Intensive Care Unit, Meyer Children's Hospital, IRCCS, Florence, Italy
| | - Emily See
- Royal Children's Hospital, Murdoch Children's Research Institute, University of Melbourne, Melbourne, VIC, Australia
| | - Natalja L Stanski
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Huaiyu Zang
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Katja M Gist
- St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO, USA
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Neumayr TM, Bayrakci B, Chanchlani R, Deep A, Morgan J, Arikan AA, Basu RK, Goldstein SL, Askenazi DJ. Programs and processes for advancing pediatric acute kidney support therapy in hospitalized and critically ill children: a report from the 26th Acute Disease Quality Initiative (ADQI) consensus conference. Pediatr Nephrol 2024; 39:993-1004. [PMID: 37930418 PMCID: PMC10817827 DOI: 10.1007/s00467-023-06186-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/24/2023] [Accepted: 09/25/2023] [Indexed: 11/07/2023]
Abstract
Pediatric acute kidney support therapy (paKST) programs aim to reliably provide safe, effective, and timely extracorporeal supportive care for acutely and critically ill pediatric patients with acute kidney injury (AKI), fluid and electrolyte derangements, and/or toxin accumulation with a goal of improving both hospital-based and lifelong outcomes. Little is known about optimal ways to configure paKST teams and programs, pediatric-specific aspects of delivering high-quality paKST, strategies for transitioning from acute continuous modes of paKST to facilitate rehabilitation, or providing effective short- and long-term follow-up. As part of the 26th Acute Disease Quality Initiative Conference, the first to focus on a pediatric population, we summarize here the current state of knowledge in paKST programs and technology, identify key knowledge gaps in the field, and propose a framework for current best practices and future research in paKST.
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Affiliation(s)
- Tara M Neumayr
- Department of Pediatrics, Divisions of Pediatric Critical Care Medicine and Pediatric Nephrology, Washington University School of Medicine, St. Louis, MO, USA
| | - Benan Bayrakci
- Department of Pediatric Intensive Care Medicine, The Center for Life Support Practice and Research, Hacettepe University, Ankara, Türkiye
| | - Rahul Chanchlani
- Department of Pediatrics, Division of Pediatric Nephrology, McMaster University, McMaster Children's Hospital, Hamilton, ON, Canada
| | - Akash Deep
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK.
- Pediatric Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK.
| | - Jolyn Morgan
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ayse Akcan Arikan
- Department of Pediatrics, Divisions of Critical Care Medicine and Nephrology, Baylor College of Medicine, Houston, TX, USA
| | - Rajit K Basu
- Department of Pediatrics, Division of Critical Care Medicine, Northwestern University Feinberg School of Medicine, Ann & Robert Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Stuart L Goldstein
- Department of Pediatrics, Division of Nephrology & Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David J Askenazi
- Department of Pediatrics, Division of Pediatric Nephrology, Pediatric and Infant Center for Acute Nephrology, Children's of Alabama, University of Alabama at Birmingham, Birmingham, AL, USA
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Raina R, Suchan A, Sethi SK, Soundararajan A, Vitale VS, Keller GL, Brown AM, Davenport A, Shih WV, Nada A, Irving SY, Mannemuddhu SS, Crugnale AS, Myneni A, Berry KG, Zieg J, Alhasan K, Guzzo I, Lussier NH, Yap HK, Bunchman TE. Nutrition in Critically Ill Children with AKI on Continuous RRT: Consensus Recommendations. KIDNEY360 2024; 5:285-309. [PMID: 38112754 PMCID: PMC10914214 DOI: 10.34067/kid.0000000000000339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 12/01/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Nutrition plays a vital role in the outcome of critically ill children, particularly those with AKI. Currently, there are no established guidelines for children with AKI treated with continuous RRT (CRRT). A thorough understanding of the metabolic changes and nutritional challenges in AKI and CRRT is required. Our objective was to create clinical practice points for nutritional assessment and management in critically ill children with AKI receiving CRRT. METHODS PubMed, MEDLINE, Cochrane, and Embase databases were searched for articles related to the topic. Expertise of the authors and a consensus of the workgroup were additional sources of data in the article. Available articles on nutrition therapy in pediatric patients receiving CRRT through January 2023. RESULTS On the basis of the literature review, the current evidence base was examined by a panel of experts in pediatric nephrology and nutrition. The panel used the literature review as well as their expertise to formulate clinical practice points. The modified Delphi method was used to identify and refine clinical practice points. CONCLUSIONS Forty-four clinical practice points are provided on nutrition assessment, determining energy needs, and nutrient intake in children with AKI and on CRRT on the basis of the existing literature and expert opinions of a multidisciplinary panel.
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Affiliation(s)
- Rupesh Raina
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio
- Akron Children's Hospital, Akron, Ohio
| | - Andrew Suchan
- Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Sidharth K. Sethi
- Department of Pediatric Nephrology, Kidney Institute, Medanta, The Medicity, Gurgaon, India
| | - Anvitha Soundararajan
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio
| | | | | | - Ann-Marie Brown
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
- Children's Healthcare of Atlanta, Atlanta, Georgia
- ECU Health, Greenville, North Carolina
| | - Andrew Davenport
- UCL Department of Renal Medicine, Royal Free Hospital, University College London, London, United Kingdom
| | - Weiwen V. Shih
- Section of Pediatric Nephrology, Children's Hospital Colorado, University of Colorado, Aurora, Colorado
| | - Arwa Nada
- Department of Pediatrics, Division of Pediatric Nephrology, Le Bonheur Children's & St. Jude Children's Research Hospitals, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Sharon Y. Irving
- Children's Hospital of Philadelphia, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Sai Sudha Mannemuddhu
- Division of Pediatric Nephrology, East Tennessee Children's Hospital, Knoxville, Tennessee
- Department of Medicine, University of Tennessee at Knoxville, Knoxville, Tennessee
| | - Aylin S. Crugnale
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio
| | - Archana Myneni
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio
| | - Katarina G. Berry
- Children's Hospital of Philadelphia, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Jakub Zieg
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Khalid Alhasan
- Pediatrics Department, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Isabella Guzzo
- Division of Nephrology and Dialysis, Department of Pediatrics, Bambino Gesù Children's Hospital and Research Institute, Rome, Italy
| | | | - Hui Kim Yap
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Timothy E. Bunchman
- Department of Pediatrics, Childrens Hospital of Richmond, Virginia Commonwealth University, Richmond, Virginia
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5
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Cortina G, Daverio M, Demirkol D, Chanchlani R, Deep A. Continuous renal replacement therapy in neonates and children: what does the pediatrician need to know? An overview from the Critical Care Nephrology Section of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC). Eur J Pediatr 2024; 183:529-541. [PMID: 37975941 PMCID: PMC10912166 DOI: 10.1007/s00431-023-05318-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/13/2023] [Accepted: 10/28/2023] [Indexed: 11/19/2023]
Abstract
Continuous renal replacement therapy (CRRT) is the preferred method for renal support in critically ill and hemodynamically unstable children in the pediatric intensive care unit (PICU) as it allows for gentle removal of fluids and solutes. The most frequent indications for CRRT include acute kidney injury (AKI) and fluid overload (FO) as well as non-renal indications such as removal of toxic metabolites in acute liver failure, inborn errors of metabolism, and intoxications and removal of inflammatory mediators in sepsis. AKI and/or FO are common in critically ill children and their presence is associated with worse outcomes. Therefore, early recognition of AKI and FO is important and timely transfer of patients who might require CRRT to a center with institutional expertise should be considered. Although CRRT has been increasingly used in the critical care setting, due to the lack of standardized recommendations, wide practice variations exist regarding the main aspects of CRRT application in critically ill children. Conclusion: In this review, from the Critical Care Nephrology section of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC), we summarize the key aspects of CRRT delivery and highlight the importance of adequate follow up among AKI survivors which might be of relevance for the general pediatric community. What is Known: • CRRT is the preferred method of renal support in critically ill and hemodynamically unstable children in the PICU as it allows for gentle removal of fluids and solutes. • Although CRRT has become an important and integral part of modern pediatric critical care, wide practice variations exist in all aspects of CRRT. What is New: • Given the lack of literature on guidance for a general pediatrician on when to refer a child for CRRT, we recommend timely transfer to a center with institutional expertise in CRRT, as both worsening AKI and FO have been associated with increased mortality. • Adequate follow-up of PICU patients with AKI and CRRT is highlighted as recent findings demonstrate that these children are at increased risk for adverse long-term outcomes.
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Affiliation(s)
- Gerard Cortina
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Marco Daverio
- Pediatric Intensive Care Unit, University Hospital of Padua, Padua, Italy
| | - Demet Demirkol
- Pediatric Intensive Care Unit, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Rahul Chanchlani
- Division of Pediatric Nephrology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, ON, Canada
| | - Akash Deep
- Pediatric Intensive Care Unit, Kings College London, London, UK.
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6
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Ding JJ, Hsia SH, Jaing TH, Huang JL, Lin JJ, Chen SH, Lin SH, Tseng MH. Prognostic Factors in Children with Acute Kidney Injury Requiring Continuous Renal Replacement Therapy. Blood Purif 2024; 53:511-519. [PMID: 38185099 DOI: 10.1159/000536018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 12/11/2023] [Indexed: 01/09/2024]
Abstract
INTRODUCTION This study aimed to evaluate prognostic factors and outcomes in a single-center PICU cohort that received continuous renal replacement therapy (CRRT). METHODS This retrospective study analyzed clinical characteristics, laboratory data, and outcomes. Ninety-day mortality and advanced chronic kidney disease (CKD) (eGFR <60 mL/min/1.73 m2) were defined as primary and secondary outcomes, respectively. RESULTS Seventy-five patients were enrolled, all of whom received CRRT for indications including acute kidney injury with complicated refractory metabolic acidosis, electrolyte derangement, and existed or impending fluid overload. The 90-day mortality and advanced CKD were 53% and 29%, respectively. Multivariate Cox regression analysis demonstrated that only underlying bone marrow transplantation (BMT) (HR 4.58; 95% CI: 2.04-10.27) and a high pSOFA score (HR 1.12; 95% CI: 1.01-1.23) were independent risk factors for 90-day mortality. Among survivors, ten developed advanced CKD on the 90th day, and this group had a higher serum fibrinogen level (OR 1.01; 95% CI: 1.01-1.03) at the start of CRRT. CONCLUSION In critically ill children with AKI requiring CRRT, post-BMT and high pSOFA scores are independent risk factors for 90-day mortality. Additionally, a high serum fibrinogen level at the initiation of CRRT is associated with the development of advanced CKD.
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Affiliation(s)
- Jhao-Jhuang Ding
- Department of Pediatrics, New Taipei Municipal TuCheng Hospital, New Taipei City, Taiwan
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Shao-Hsuan Hsia
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Tang-Her Jaing
- Division of Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Jing-Long Huang
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- Division of Asthma, Allergy, and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Jainn-Jim Lin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Shih-Hsiang Chen
- Division of Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Shih-Hua Lin
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Min-Hua Tseng
- Division of Nephrology, Department of Pediatrics, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
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Gist KM, Menon S, Anton-Martin P, Bigelow AM, Cortina G, Deep A, De la Mata-Navazo S, Gelbart B, Gorga S, Guzzo I, Mah KE, Ollberding NJ, Shin HS, Thadani S, Uber A, Zang H, Zappitelli M, Selewski DT. Time to Continuous Renal Replacement Therapy Initiation and 90-Day Major Adverse Kidney Events in Children and Young Adults. JAMA Netw Open 2024; 7:e2349871. [PMID: 38165673 PMCID: PMC10762580 DOI: 10.1001/jamanetworkopen.2023.49871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 11/14/2023] [Indexed: 01/04/2024] Open
Abstract
Importance 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. Objective 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). Design, Setting, and Participants 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. Exposure The primary exposure was time to CRRT initiation from intensive care unit admission. Main Outcomes and measures The primary outcome was MAKE-90 (death, dialysis dependence, or persistent kidney dysfunction [>25% decline in estimated glomerular filtration rate from baseline]). Results 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]). Conclusions and Relevance 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.
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Affiliation(s)
- Katja M. Gist
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Shina Menon
- Seattle Children’s Hospital, University of Washington, Seattle
| | | | - Amee M. Bigelow
- Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus
| | | | - Akash Deep
- King’s College Hospital, London, England
| | - Sara De la Mata-Navazo
- Gregorio Marañón University Hospital; Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Ben Gelbart
- Royal Children’s Hospital, University of Melbourne, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
| | - Stephen Gorga
- University of Michigan Medical School, C.S. Mott Children’s Hospital, Ann Arbor
| | | | - Kenneth E. Mah
- Stanford University School of Medicine, Palo Alto, California
| | - Nicholas J. Ollberding
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - H. Stella Shin
- Children’s Healthcare of Atlanta, Emory University, Atlanta, Georgia
| | - Sameer Thadani
- Baylor College of Medicine, Texas Children’s Hospital, Houston
| | - Amanda Uber
- University of Nebraska Medical Center, Children’s Hospital & Medical Center, Omaha
- University of Utah, Primary Children’s Hospital, Salt Lake City
| | - Huaiyu Zang
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
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8
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Kedarnath M, Alexander EC, Deep A. Safety and efficacy of continuous renal replacement therapy for children less than 10 kg using standard adult machines. Eur J Pediatr 2023; 182:3619-3629. [PMID: 37233776 PMCID: PMC10460307 DOI: 10.1007/s00431-023-05007-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 04/25/2023] [Accepted: 04/27/2023] [Indexed: 05/27/2023]
Abstract
Continuous Renal Replacement Therapy (CRRT) machines are used off-label in patients less than 20 kg. Infant and neonates-dedicated CRRT machines are making their way into current practice, but these machines are available only in select centres. This study assesses the safety and efficacy of CRRT using adult CRRT machines in children ≤ 10 kg and to determines the factors affecting the circuit life in these children. DESIGN Retrospective cohort study of children ≤ 10 kg who received CRRT (January 2010-January 2018) at a PICU in a tertiary care centre in London, UK. Primary diagnosis, markers for illness severity, CRRT characteristics, length of PICU admission and survival to PICU discharge were collected. Descriptive analysis compared survivors and non-survivors. A subgroup analysis compared children ≤ 5 kg to children 5-10 kg. Fifty-one patients ≤ 10 kg received 10,328 h of CRRT, with median weight of 5 kg. 52.94% survived to hospital discharge. Median circuit life was 44 h (IQR 24-68). Bleeding episodes occurred with 6.7% of sessions and hypotension for 11.9%. Analysis of efficacy showed a reduction in fluid overload at 48 h (P = 0.0002) and serum creatinine at 24 and 48 h (P = 0.001). Blood priming was deemed to be safe as serum potassium decreased at 4 h (P = 0.005); there was no significant change in serum calcium. Survivors had a lower PIM2 score at PICU admission (P < 0.001) and had longer PICU length of stay (P < 0.001). Conclusion: Pending neonatal and infant dedicated CRRT machines, CRRT can be safely and effectively applied to children weighing ≤ 10 kg using adult-sized CRRT machines. WHAT IS KNOWN • Continuous Renal Replacement Therapy can be used for a variety of renal and non-renal indications to improve outcomes for children in the paediatric intensive care unit. These include, persistent oliguria, fluid overload, hyperkalaemia, metabolic acidosis, hyperlactatemia, hyperammonaemia, and hepatic encephalopathy. • Young children ≤ 10 kg are most often treated using standard adult machines, off-label. This potentially places them at risk of side effects due to high extracorporeal circuit volumes, relatively higher blood flows, and difficulty in achieving vascular access. WHAT IS NEW • This study found that standard adult machines were effective in reducing fluid overload and creatinine in children ≤ 10 kg. This study also assessed safety of blood priming in this group and found no evidence of an acute fall in haemoglobin or calcium, and a fall in serum potassium by a median of 0.3 mmol/L. The frequency of bleeding episodes was 6.7%, and hypotension requiring vasopressors or fluid resuscitation occurred with 11.9% of treatment sessions. • These findings suggest that adult CRRT machines are sufficiently safe and efficacious for routine use in PICU for children ≤ 10 kg and suggest that further research is undertaken, regarding the routine rollout of dedicated machines.
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Affiliation(s)
- Manju Kedarnath
- Paediatric Intensive Care Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Emma C Alexander
- Paediatric Intensive Care Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Akash Deep
- Paediatric Intensive Care Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK.
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK.
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9
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Lambert H, Hiu S, Coulthard MG, Matthews JNS, Holstein EM, Crosier J, Agbeko R, Brick T, Duncan H, Grant D, Mok Q, Nyman AG, Pappachan J, Boucher C, Bulmer J, Chisholm D, Cromie K, Emmet V, Feltbower RG, Ghose A, Grayling M, Harrison R, Kennedy CA, McColl E, Morris K, Norman L, Office J, Parslow R, Pattinson C, Sharma S, Smith J, Steel A, Steel R, Straker J, Vrana L, Walker J, Wellman P, Whitaker M, Wightman J, Wilson N, Wirz L, Wood R. The Infant KIdney Dialysis and Utrafiltration (I-KID) Study: A Stepped-Wedge Cluster-Randomized Study in Infants, Comparing Peritoneal Dialysis, Continuous Venovenous Hemofiltration, and Newcastle Infant Dialysis Ultrafiltration System, a Novel Infant Hemodialysis Device. Pediatr Crit Care Med 2023; 24:604-613. [PMID: 36892305 PMCID: PMC10317301 DOI: 10.1097/pcc.0000000000003220] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
OBJECTIVES Renal replacement therapy (RRT) options are limited for small babies because of lack of available technology. We investigated the precision of ultrafiltration, biochemical clearances, clinical efficacy, outcomes, and safety profile for a novel non-Conformité Européenne-marked hemodialysis device for babies under 8 kg, the Newcastle Infant Dialysis Ultrafiltration System (NIDUS), compared with the current options of peritoneal dialysis (PD) or continuous venovenous hemofiltration (CVVH). DESIGN Nonblinded cluster-randomized cross-sectional stepped-wedge design with four periods, three sequences, and two clusters per sequence. SETTING Clusters were six U.K. PICUs. PATIENTS Babies less than 8 kg requiring RRT for fluid overload or biochemical disturbance. INTERVENTIONS In controls, RRT was delivered by PD or CVVH, and in interventions, NIDUS was used. The primary outcome was precision of ultrafiltration compared with prescription; secondary outcomes included biochemical clearances. MEASUREMENTS AND MAIN RESULTS At closure, 97 participants were recruited from the six PICUs (62 control and 35 intervention). The primary outcome, obtained from 62 control and 21 intervention patients, showed that ultrafiltration with NIDUS was closer to that prescribed than with control: sd controls, 18.75, intervention, 2.95 (mL/hr); adjusted ratio, 0.13; 95% CI, 0.03-0.71; p = 0.018. Creatinine clearance was smallest and least variable for PD (mean, sd ) = (0.08, 0.03) mL/min/kg, larger for NIDUS (0.46, 0.30), and largest for CVVH (1.20, 0.72). Adverse events were reported in all groups. In this critically ill population with multiple organ failure, mortality was lowest for PD and highest for CVVH, with NIDUS in between. CONCLUSIONS NIDUS delivers accurate, controllable fluid removal and adequate clearances, indicating that it has important potential alongside other modalities for infant RRT.
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Affiliation(s)
- Heather Lambert
- Paediatric Nephrology Department, Great North Children's Hospital, Royal Victoria Infirmary, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom
| | - Shaun Hiu
- Biostatistics Research Group, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Malcolm G Coulthard
- Paediatric Nephrology Department, Great North Children's Hospital, Royal Victoria Infirmary, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom
| | - John N S Matthews
- Biostatistics Research Group, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, United Kingdom
- School of Mathematics, Statistics & Physics, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Eva-Maria Holstein
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Jean Crosier
- Paediatric Nephrology Department, Great North Children's Hospital, Royal Victoria Infirmary, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom
| | - Rachel Agbeko
- Paediatric Nephrology Department, Great North Children's Hospital, Royal Victoria Infirmary, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom
| | - Thomas Brick
- Cardiac Intensive Care Unit, Great Ormond Street Hospital NHS Trust, London, United Kingdom
| | - Heather Duncan
- Department of Paediatric Intensive Care, Birmingham Women's and Children's Hospital, Birmingham, United Kingdom
| | - David Grant
- Paediatric Intensive Care Unit, Bristol Royal Hospital for Children and University of Bristol Medical School, Bristol, United Kingdom
| | - Quen Mok
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Andrew Gustaf Nyman
- Paediatric Intensive Care Unit, Evelina London Children's Hospital, London, United Kingdom
| | - John Pappachan
- Paediatric Intensive Care Unit, Southampton Children's Hospital, Southampton NIHR Biomedical Centre, Southampton, United Kingdom
| | | | - Joe Bulmer
- Northern Medical Physics and Clinical Engineering, Royal Victoria Infirmary, Newcastle Upon Tyne, United Kingdom
| | - Denise Chisholm
- Paediatric Nephrology Department, Great North Children's Hospital, Royal Victoria Infirmary, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom
| | - Kirsten Cromie
- Leeds Institute for Data Analytics, School of Medicine, Leeds, United Kingdom
| | - Victoria Emmet
- Clinical Resource Building, Royal Victoria Infirmary, Newcastle Upon Tyne, United Kingdom
| | - Richard G Feltbower
- Clinical Resource Building, Royal Victoria Infirmary, Newcastle Upon Tyne, United Kingdom
| | - Arunoday Ghose
- Department of Paediatric Intensive Care, Birmingham Women's and Children's Hospital, Birmingham, United Kingdom
| | - Michael Grayling
- Biostatistics Research Group, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Rebecca Harrison
- Northern Medical Physics and Clinical Engineering, Royal Victoria Infirmary, Newcastle Upon Tyne, United Kingdom
| | - Ciara A Kennedy
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Elaine McColl
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Kevin Morris
- Department of Paediatric Intensive Care, Birmingham Women's and Children's Hospital, Birmingham, United Kingdom
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Lee Norman
- Clinical Resource Building, Royal Victoria Infirmary, Newcastle Upon Tyne, United Kingdom
| | - Julie Office
- Leeds Institute for Data Analytics, School of Medicine, Leeds, United Kingdom
| | - Roger Parslow
- Leeds Institute of Cardiovascular and Metabolic Medicine, School of Medicine, Leeds, United Kingdom
| | - Christine Pattinson
- Leeds Institute for Data Analytics, School of Medicine, Leeds, United Kingdom
| | - Shriya Sharma
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Jonathan Smith
- Paediatric Intensive Care Unit, Freeman Hospital, Newcastle Upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom
| | - Alison Steel
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Rachel Steel
- Leeds Institute for Data Analytics, School of Medicine, Leeds, United Kingdom
| | - Jayne Straker
- Leeds Institute for Data Analytics, School of Medicine, Leeds, United Kingdom
| | - Lamprini Vrana
- Paediatric Intensive Care Unit, Freeman Hospital, Newcastle Upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom
| | - Jenn Walker
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Paul Wellman
- Paediatric Intensive Care Unit, Evelina London Children's Hospital, London, United Kingdom
| | - Mike Whitaker
- Northern Medical Physics and Clinical Engineering, Royal Victoria Infirmary, Newcastle Upon Tyne, United Kingdom
| | - Jim Wightman
- Northern Medical Physics and Clinical Engineering, Royal Victoria Infirmary, Newcastle Upon Tyne, United Kingdom
| | - Nina Wilson
- Biostatistics Research Group, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Lucy Wirz
- Leeds Institute for Data Analytics, School of Medicine, Leeds, United Kingdom
| | - Ruth Wood
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle Upon Tyne, United Kingdom
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10
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Gün E, Gurbanov A, Nakip ÖS, Yöntem A, Aslan AD, Botan E, Kahveci F, Özcan S, Azapağası E, Emeksiz S, Yazıcı MU, Kesici S, Horoz ÖÖ, Erdeve Ö, Bayrakçı B, Yıldızdaş RD, Kendirli T. Clinical characteristics and outcomes of continuous renal replacement therapy performed on younger children weighing up to 10 kg. Turk J Med Sci 2023; 53:791-802. [PMID: 37476891 PMCID: PMC10388067 DOI: 10.55730/1300-0144.5642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 02/14/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND This study aimed to investigate the clinical features, modality, complications, and effecting factors on the survival of children weighing up to 10 kg who received continuous renal replacement therapy (CRRT). METHODS This study was a retrospective observational study conducted in five pediatric intensive care units in tertiary hospitals in Turkey between January 2015 and December 2019. RESULTS One hundred and forty-one children who underwent CRRT were enrolled in the study. The median age was 6 (range, 2-12)months, and 74 (52.5%) were male. The median weight of the patients was 6 (range, 4-8.35) kg and 52 (36.9%) weighed less than 5 kg. The most common indication for CRRT was fluid overload in 75 (53.2%) patients, and sepsis together with multiorgan failure in 62 (44%). The overall mortality was 48.2%. DISCUSSION Despite its complexity, CRRT in children weighing less than 10 kg is a beneficial, lifesaving extracorporeal treatment modality.
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Affiliation(s)
- Emrah Gün
- Department of Pediatric Intensive Care, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Anar Gurbanov
- Department of Pediatric Intensive Care, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Özlem Saritaş Nakip
- Department of Pediatric Intensive Care, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Ahmet Yöntem
- Department of Pediatric Intensive Care, Faculty of Medicine, Çukurova University, Adana, Turkey
| | - Ayşen Durak Aslan
- Department of Pediatric, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Edin Botan
- Department of Pediatric Intensive Care, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Fevzi Kahveci
- Department of Pediatric Intensive Care, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Serhan Özcan
- Department of Pediatric Intensive Care, Faculty of Medicine, Ankara City Hospital, Ankara, Turkey
| | - Ebru Azapağası
- Department of Pediatric Intensive Care, Faculty of Medicine, Dr. Sami Ulus Gynecology Obstetrics and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Serhat Emeksiz
- Department of Pediatric Intensive Care, Faculty of Medicine, Ankara City Hospital, Ankara, Turkey
| | - Mutlu Uysal Yazıcı
- Department of Pediatric Intensive Care, Faculty of Medicine, Dr. Sami Ulus Gynecology Obstetrics and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Selman Kesici
- Department of Pediatric Intensive Care, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Özden Özgür Horoz
- Department of Pediatric Intensive Care, Faculty of Medicine, Çukurova University, Adana, Turkey
| | - Ömer Erdeve
- Department of Neonatology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Benan Bayrakçı
- Department of Pediatric Intensive Care, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Rıza Dinçer Yıldızdaş
- Department of Pediatric Intensive Care, Faculty of Medicine, Çukurova University, Adana, Turkey
| | - Tanil Kendirli
- Department of Pediatric Intensive Care, Faculty of Medicine, Ankara University, Ankara, Turkey
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11
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Vestal ML, Liu B, Heath TS. Evaluation of Dosing Regimens of Vancomycin and Aminoglycosides in Pediatric Patients on Continuous Renal Replacement Therapy. J Pediatr Pharmacol Ther 2023; 28:143-148. [PMID: 37139253 PMCID: PMC10150899 DOI: 10.5863/1551-6776-28.2.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 05/11/2022] [Indexed: 05/05/2023]
Abstract
OBJECTIVE To determine the optimal empiric dosing regimen to achieve therapeutic serum concentrations of vancomycin and aminoglycosides in pediatric patients who are receiving continuous renal replacement therapy (CRRT). METHODS This retrospective study investigated pediatric patients (<18 years old) who received at least one dose of an aminoglycoside and/or vancomycin while on CRRT and who had at least one serum concentration assessed during the study period. Rates of culture clearance and discontinuation of renal replacement therapy, pharmacokinetic variables (i.e., volume of distribution [Vd], half-life [t½], rate of elimination [ke]), and correlations between patient's age and weight in regard to the empiric dosing regimen were evaluated. RESULTS Forty-three patients were included in this study. The median dose required to reach therapeutic serum concentrations for vancomycin was 17.6 mg/kg (12.8-20.4 mg/kg) every 12 hours (6-30 hours) in continuous venovenous hemodialysis (CVVHD) patients and 16.3 mg/kg (13.9-21.4 mg/kg) every 12 hours (6-24 hours) in continuous venovenous hemodiafiltration (CVVHDF) patients. The median dose for aminoglycosides was unable to be determined. In CVVHD patients, the median vancomycin ke was 0.04 hr-1, t½ was 18 hours, and Vd was 1.6 L/kg. In CVVHDF patients, the median vancomycin ke was 0.05 hr-1, t½ was 14 hours, and Vd was 0.6 L/kg. No correlation was found between age and weight with regard to effective dosing regimen. CONCLUSIONS To achieve therapeutic trough concentrations in pediatric patients on CRRT, vancomycin should be dosed at approximately 17.5 mg/kg administered every 12 hours.
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Affiliation(s)
- Mark L Vestal
- Department of Pharmacy (MV, TSH), Duke University Medical Center, Durham, NC
| | - Beiyu Liu
- Department of Pharmacy (MV, TSH), Duke University Medical Center, Durham, NC
| | - Travis S Heath
- Department of Pharmacy (MV, TSH), Duke University Medical Center, Durham, NC
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12
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Zama D, Mondardini MC, Petris MG, Amigoni A, Carraro F, Zanaroli A, dell'Orso G, Faraci M, Spaggiari S, Muggeo P, Perruccio K, Mura R, Barone A, Muratore E, Cesaro S. Pediatric cancer and hematopoietic stem cell transplantation patients requiring renal replacement therapy: results of the retrospective nationwide AIEOP study. Leuk Lymphoma 2022; 63:2923-2930. [PMID: 35819873 DOI: 10.1080/10428194.2022.2095628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In children affected by malignancies and/or who received hematopoietic stem cell transplantation (HSCT), acute kidney injury (AKI) may occur causing a high mortality rate, despite the implementation of renal replacement therapy (RRT). We performed a nationwide, multicenter, retrospective, observational cohort study including consecutive patients between January 2010 and December 2019. One hundred and fourteen episodes of AKI requiring RRT coming from nine different Italian centers were included. The overall mortality rate was 61.4%. At the 3-month follow-up, the mortality rate was 47.4%. The mortality rate was higher in transplanted patients than those receiving chemotherapy. In particular, HSCT (p = 0.048) and invasive mechanical ventilation (p = 0.040) were significantly associated with death at three months after the end of dialysis in the multivariate analysis. Pediatric patients affected by malignancies complicated by AKI requiring RRT have a high mortality. The main factors associated to death are respiratory failure and having received HSCT.
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Affiliation(s)
- Daniele Zama
- Pediatric Oncology and Hematology Unit "Lalla Seràgnoli", IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Maria Grazia Petris
- Women's and Children's Health, Clinic of Pediatric Hemato-Oncology, University of Padua, Padua, Italy
| | - Angela Amigoni
- Pediatric Intensive Care Unit, Woman and Child's Health Department, University Hospital of Padova, Padova, Italy
| | - Francesca Carraro
- Pediatric Hematology and Oncology Department, Stem Cell Transplantation and Cell Therapy Division, "Regina Margherita" Pediatric Hospital, Torino, Italy
| | - Andrea Zanaroli
- Residency School in Pediatrics, University of Bologna, Bologna, Italy
| | - Gianluca dell'Orso
- Pediatric Hemato-oncology Department, Hematopoietic Stem Cell Transplantation Unit, IRCSS G. Gaslini, Genova, Italy
| | - Maura Faraci
- Pediatric Hemato-oncology Department, Hematopoietic Stem Cell Transplantation Unit, IRCSS G. Gaslini, Genova, Italy
| | - Stefania Spaggiari
- Pediatric Hematology and Oncology, Mother and Child's Health Department, University Hospital of Verona, Verona, Italy
| | - Paola Muggeo
- Pediatric Hematology and Oncology Department, University of Bari, Bari, Italy
| | - Katia Perruccio
- Pediatric Hematology and Oncology Department, "Santa Maria della Misericordia" Hospital, Perugia, Italy
| | - Rosamaria Mura
- Pediatric Hematology and Oncology Department, "A Cao" Microcitemic Pediatric Hospital, "Botzu" Medical Center, Cagliari, Italy
| | - Angelica Barone
- Pediatric Oncohematology Unit, University Hospital of Parma, Parma, Italy
| | - Edoardo Muratore
- Pediatric Oncology and Hematology Unit "Lalla Seràgnoli", IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Simone Cesaro
- Pediatric Hematology and Oncology, Mother and Child's Health Department, University Hospital of Verona, Verona, Italy
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13
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Buccione E, Bambi S, Rasero L, Tofani L, Piazzini T, Della Pelle C, El Aoufy K, Ricci Z, Romagnoli S, Villa G. Regional Citrate Anticoagulation and Systemic Anticoagulation during Pediatric Continuous Renal Replacement Therapy: A Systematic Literature Review. J Clin Med 2022; 11:jcm11113121. [PMID: 35683511 PMCID: PMC9181744 DOI: 10.3390/jcm11113121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 05/24/2022] [Accepted: 05/30/2022] [Indexed: 12/20/2022] Open
Abstract
Background: Clotting is a major drawback of continuous renal replacement therapy (CRRT) performed on critically ill pediatric patients. Although anticoagulation is recommended to prevent clotting, limited results are available on the effect of each pharmacological strategy in reducing filter clotting in pediatric CRRT. This study defines which anticoagulation strategy, between regional citrate anticoagulation (RCA) and systemic anticoagulation with heparin, is safer and more efficient in reducing clotting, patient mortality, and treatment complications during pediatric CRRT. Methods: A systematic literature review was run considering papers published in English until December 2021 and describing patients’ and treatments’ complications in CRRT performed with heparin and RCA on patients aged less than 18 years. Results: Eleven studies were considered, cumulatively comprising 1.706 CRRT sessions (62% with systemic anticoagulation and 38% with RCA). Studies have consistently identified RCA’s superiority over systemic anticoagulation with heparin in prolonging circuit life. The pooled estimate (95% CI) of filter clotting risk showed that RCA is a protective factor for clotting risk (RR = 0.204). Conclusions: RCA has a potential role in prolonging circuit life and seems superior to systemic anticoagulation with heparin in decreasing the risk of circuit clotting during CRRT performed in critically ill pediatric patients.
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Affiliation(s)
- Emanuele Buccione
- Neonatal Intensive Care Unit, 65124 Pescara, Italy
- Correspondence: ; Tel.: +39-349-809-8954
| | - Stefano Bambi
- Health Sciences Department, University of Florence, 50139 Florence, Italy; (S.B.); (L.R.)
| | - Laura Rasero
- Health Sciences Department, University of Florence, 50139 Florence, Italy; (S.B.); (L.R.)
| | - Lorenzo Tofani
- Section of Anesthesiology, Intensive Care and Pain Medicine, Department of Health Sciences, University of Florence, 50139 Florence, Italy; (L.T.); (T.P.); (Z.R.); (S.R.); (G.V.)
| | - Tessa Piazzini
- Section of Anesthesiology, Intensive Care and Pain Medicine, Department of Health Sciences, University of Florence, 50139 Florence, Italy; (L.T.); (T.P.); (Z.R.); (S.R.); (G.V.)
| | | | - Khadija El Aoufy
- Department of Experimental and Clinical Medicine, Azienda Ospedaliero Universitaria Careggi, 50134 Florence, Italy;
| | - Zaccaria Ricci
- Section of Anesthesiology, Intensive Care and Pain Medicine, Department of Health Sciences, University of Florence, 50139 Florence, Italy; (L.T.); (T.P.); (Z.R.); (S.R.); (G.V.)
- Pediatric Intensive Care Unit, Meyer Children’s University Hospital, 50139 Florence, Italy
| | - Stefano Romagnoli
- Section of Anesthesiology, Intensive Care and Pain Medicine, Department of Health Sciences, University of Florence, 50139 Florence, Italy; (L.T.); (T.P.); (Z.R.); (S.R.); (G.V.)
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Careggi, 50139 Florence, Italy
| | - Gianluca Villa
- Section of Anesthesiology, Intensive Care and Pain Medicine, Department of Health Sciences, University of Florence, 50139 Florence, Italy; (L.T.); (T.P.); (Z.R.); (S.R.); (G.V.)
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Careggi, 50139 Florence, Italy
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14
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Duyu M, Turkozkan C. Clinical features and risk factors associated with mortality in critically ill children requiring continuous renal replacement therapy. Ther Apher Dial 2022; 26:1121-1130. [PMID: 35129292 DOI: 10.1111/1744-9987.13811] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 12/07/2021] [Accepted: 02/05/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The aims of this study were to describe the demographic characteristics of critically ill children requiring continuous renal replacement therapy (CRRT) at our pediatric intensive care unit (PICU) and to explore risk factors associated with mortality. METHODS A retrospective cohort of 121 critically ill children who received CRRT from May 2015 to May 2020 in the PICU of a tertiary healthcare institution was evaluated. RESULTS Overall mortality was 29.8%. In patients diagnosed with sepsis, time until CRRT initiation was significantly shorter in survivors compared to non-survivors (p = 0.036). Based on multivariate logistic regression, presence of comorbidity (OR: 5.71), diagnoses of pneumonia/respiratory failure at admission (OR:16.16), and high lactate level at CRRT initiation (OR:1.43) were independently associated with mortality. CONCLUSION In the context of the population studied, mortality rate was lower than previously reported. Despite having a large series, heterogenous characteristics and limitations in subgroups may have influenced results and survival. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Muhterem Duyu
- Department of Pediatrics, Pediatric Intensive Care Unit, Istanbul Medeniyet University Prof. Dr. Suleyman Yalcin City Hospital, Istanbul, Turkey
| | - Ceren Turkozkan
- Department of Pediatrics, Istanbul Medeniyet University Prof. Dr. Suleyman Yalcin City Hospital, Istanbul, Turkey
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15
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Szeps I, Östlund Å, Norberg Å, Fläring U, Andersson A. Thromboembolic Complications of Vascular Catheters Used for Pediatric Continuous Renal Replacement Therapy: Prevalence in a Single-Center, Retrospective Cohort. Pediatr Crit Care Med 2021; 22:743-752. [PMID: 33950886 DOI: 10.1097/pcc.0000000000002754] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Pediatric venous thromboembolic events are commonly associated with in situ central venous catheters. The risk for severe venous thromboembolism increases if a larger portion of the vessel lumen is occupied by the central venous catheter. A functioning vascular catheter is required when the continuous renal replacement therapy is used in critically ill children. Due to the high blood flow required for continuous renal replacement therapy, the external diameter of the catheter needs to be larger than a conventional central venous catheter used for venous access, potentially increasing the risk of venous thromboembolism. However, children on continuous renal replacement therapy often receive systemic anticoagulation to prevent filter clotting, possibly also preventing venous thromboembolism. The frequency of catheter-related venous thromboembolic events in this setting has not been described. Our main objective was to determine the prevalence of catheter-related venous thromboembolism in pediatric continuous renal replacement therapy. DESIGN Retrospective cohort study. SETTING Tertiary multidisciplinary academic pediatric hospital. PATIENTS Patients 0-18 years old with a vascular catheter used for continuous renal replacement therapy. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS In our series of 80 patients, we used 105 vascular catheters. The median age of the patients was 10 months and PICU mortality rate was 21%. Venous thromboembolic events were considered to be catheter related if located in the same vein as the vascular catheter and radiologically verified. Six (5.7%) catheter-related venous thromboembolic events were found. The clinically relevant complications of venous thromboembolism included superior vena cava syndrome and catheter dysfunction. In one patient, severe and life-threatening pulmonary embolism occurred. In comparison with patients without venous thromboembolism, venous thromboembolic events were associated with lower body weight (p = 0.03) and longer durations of continuous renal replacement therapy (p < 0.01), mechanical ventilation (p = 0.03), and PICU stay (p < 0.01). Five out of six venous thromboembolisms appeared in neonates. CONCLUSIONS Catheter-related venous thromboembolism is a clinically relevant complication of pediatric continuous renal replacement therapy, with a prevalence of 5.7% in our cohort. Clinicians involved in pediatric continuous renal replacement therapy need to be vigilant for symptoms of venous thromboembolisms and initiate appropriate treatment as soon as possible.
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Affiliation(s)
- Isabelle Szeps
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Huddinge, Stockholm, Sweden
- Department of Physiology and Pharmacology, Section of Anaesthesia and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Åsa Östlund
- Department of Physiology and Pharmacology, Section of Anaesthesia and Intensive Care, Karolinska Institutet, Stockholm, Sweden
- Department of Pediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Åke Norberg
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Huddinge, Stockholm, Sweden
- Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Urban Fläring
- Department of Physiology and Pharmacology, Section of Anaesthesia and Intensive Care, Karolinska Institutet, Stockholm, Sweden
- Department of Pediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Andreas Andersson
- Department of Physiology and Pharmacology, Section of Anaesthesia and Intensive Care, Karolinska Institutet, Stockholm, Sweden
- Department of Pediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
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16
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Lambert HJ, Sharma S, Matthews JNS. I-KID study protocol: evaluation of efficacy, outcomes and safety of a new infant haemodialysis and ultrafiltration machine in clinical use: a randomised clinical investigation using a cluster stepped-wedge design. BMJ Paediatr Open 2021; 5:e001224. [PMID: 34734128 PMCID: PMC8524285 DOI: 10.1136/bmjpo-2021-001224] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 07/30/2021] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION The I-KID study aims to determine the clinical efficacy, outcomes and safety of a novel non-CE-marked infant haemodialysis machine, the Newcastle Infant Dialysis Ultrafiltration System (NIDUS), compared with currently available therapy in the UK. NIDUS is specifically designed for renal replacement therapy in small babies between 0.8 and 8 kg. METHODS AND ANALYSIS The clinical investigation is taking place in six UK centres. This is a randomised clinical investigation using a cluster stepped-wedge design. The study aims to recruit 95 babies requiring renal replacement therapy in paediatric intensive care units over 20 months. ETHICS AND DISSEMINATION The study has high parent and public involvement at all stages in its design and parents will be involved in dissemination of results to parents and professionals via publications, conference proceedings and newsletters. The study has has ethics permissions from Tyne and Wear South Research Ethics Committee. TRIAL REGISTRATION NUMBERS IRAS ID number: 170 481MHRA Reference: CI/2017/0066ISRCT Number: 13 787 486CPMS ID number: 36 558NHS REC reference: 16/NE/0008Eudamed number: CIV-GB-18-02-023105Link to full protocol v6.0: https://fundingawards.nihr.ac.uk/award/14/23/26.
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Affiliation(s)
- Heather J Lambert
- Paediatric Nephrology, Great North Children's Hospital, Newcastle Upon Tyne, UK.,Department of Child Health, Newcastle University, Newcastle upon Tyne, UK
| | - Shriya Sharma
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
| | - John N S Matthews
- Department of Mathematics, Statistics & Physics and Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
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17
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Abstract
Acute kidney injury (AKI) is a highly prevalent disease entity in the NICU, affecting nearly one-quarter of critically ill neonates by some reports. Though medical management remains the mainstay in the treatment of AKI, renal replacement therapy (RRT) is indicated when conservative measures are unable to maintain electrolytes, fluid balance, toxins, or waste products within a safe margin. Several modalities of RRT exist for use in neonatal populations, including peritoneal dialysis, hemodialysis, and continuous RRT. It is the aim of this review to introduce each of these RRT modalities, as well as to discuss their technical considerations, benefits, indications, contraindications, and complications.
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Affiliation(s)
| | - Jason M Misurac
- Division of Nephrology, Dialysis, and Transplantation, University of Iowa Stead Family Children's Hospital, Iowa City, IA
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18
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Abstract
PURPOSE OF REVIEW Pediatric acute kidney injury (AKI) in critically ill patients is associated with increased morbidity and mortality. Emerging data support that the incidence of pediatric AKI in the ICU is rising. For children with severe AKI, renal replacement therapy (RRT) can provide a lifesaving supportive therapy. The optimal timing to deliver and modality by which to deliver RRT remain a point of discussion within pediatric (and adult) literature. This review discusses the use of RRT for pediatric patients in the ICU. We discuss the most recent evidence-based methods for RRT with a focus on continuous RRT. RECENT FINDINGS The feasibility of dialyzing the smallest infants and more medically complex children in the ICU is dependent on the advancements in dialysis access and circuit technology. At present, data indicate that upward of 27% of children in the ICU develop AKI and 6% require RRT. Newer dialysis modalities including prolonged intermittent hemodialysis and continuous flow peritoneal dialysis as well as newer dialysis technologies such as the smaller volume circuits (e.g., Cardio-Renal Pediatric Dialysis Emergency Machine, Newcastle Infant Dialysis and Ultrafiltration System) have made the provision of dialysis safer and more effective for pediatric patients of a variety of sizes. SUMMARY Renal replacement in the ICU requires a multidisciplinary team approach that is facilitated by a pediatric nephrologist in conjunction with intensivists and skilled nursing staff. Although mortality rates for children on dialysis remain high, outcomes are improving with the support of the multidisciplinary team and dialysis technology advancements.
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The Effect of Patient- and Treatment-Related Factors on Circuit Lifespan During Continuous Renal Replacement Therapy in Critically Ill Children. Pediatr Crit Care Med 2020; 21:578-585. [PMID: 32343111 DOI: 10.1097/pcc.0000000000002305] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To examine the effects of patient and treatment variables on circuit lifespan in critically ill children requiring continuous renal replacement therapy. DESIGN Retrospective observational study based on a prospective registry. SETTING Tertiary referral 30-bed PICU. PATIENTS One hundred sixty-one critically ill children undergoing continuous renal replacement therapy during an 8-year period (2007-2014) were included in the study. INTERVENTIONS Continuous renal replacement therapy. MEASUREMENTS AND MAIN RESULTS During the study period, 161 patients received a total of 22,190 hours of continuous renal replacement therapy, with a median duration of 74.75 hours (interquartile range, 32-169.5) per patient. Of the 572 filter circuits used, 276 (48.3%) were changed due to circuit clotting and 262 (45.8%) were electively changed. Median circuit life was 24.62 hours (interquartile range, 10.6-55.3) for all filters and significantly longer for those electively removed as compared to those prematurely removed because of clotting (35.50 hr [interquartile range, 16.9-67.6] vs 22.00 hr [interquartile range, 13.8-42.5]; p < 0.001). Multivariate regression analyses revealed that admission diagnosis (p < 0.001), anticoagulation type (p < 0.001), access type (p = 0.016), and circuit size (p = 0.027) were associated with prolonged circuit life, as well as, in patients on heparin anticoagulation, with higher doses of heparin (p < 0.001) and a prolonged activated partial thromboplastin time (p < 0.001). CONCLUSIONS In this study, circuit lifespan in pediatric continuous renal replacement therapy was low and appeared to depend upon the patient's diagnosis, the type of access and anticoagulation used as well as the size of the circuit used.
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20
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Dialysis modalities for the management of pediatric acute kidney injury. Pediatr Nephrol 2020; 35:753-765. [PMID: 30887109 DOI: 10.1007/s00467-019-04213-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 01/19/2019] [Accepted: 02/08/2019] [Indexed: 01/11/2023]
Abstract
Acute kidney injury (AKI) is an increasingly frequent complication among hospitalized children. It is associated with high morbidity and mortality, especially in neonates and children requiring dialysis. The different renal replacement therapy (RRT) options for AKI have expanded from peritoneal dialysis (PD) and intermittent hemodialysis (HD) to continuous RRT (CRRT) and hybrid modalities. Recent advances in the provision of RRT in children allow a higher standard of care for increasingly ill and young patients. In the absence of evidence indicating better survival with any dialysis method, the most appropriate dialysis choice for children with AKI is based on the patient's characteristics, on dialytic modality performance, and on the institutional resources and local practice. In this review, the available dialysis modalities for pediatric AKI will be discussed, focusing on indications, advantages, and limitations of each of them.
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21
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Zhang WF, Chen DM, Wu LQ, Wang RQ. [Clinical effect of continuous blood purification in treatment of multiple organ dysfunction syndrome in neonates]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2020; 22:31-36. [PMID: 31948521 PMCID: PMC7389716 DOI: 10.7499/j.issn.1008-8830.2020.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 12/12/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To study the clinical effect and complications of continuous blood purification (CBP) in the treatment of multiple organ dysfunction syndrome (MODS) in neonates. METHODS A retrospective analysis was performed for the clinical data of 21 neonates with MODS who were admitted to the neonatal intensive care unit from November 2015 to April 2019 and were treated with CBP. Clinical indices were observed before treatment, at 6, 12, 24, and 36 hours of CBP treatment, and at the end of treatment to evaluate the clinical effect and safety of CBP treatment. RESULTS Among the 21 neonates with MODS undergoing CBP, 17 (81%) had response to treatment. The neonates with response to CBP treatment had a significant improvement in oxygenation index at 6 hours of treatment, a significant increase in urine volume at 24 hours of treatment, a stable blood pressure within the normal range at 24 hours of treatment, and significant reductions in the doses of the vasoactive agents epinephrine and dopamine at 6 hours of treatment (P<0.05), as well as a significant reduction in serum K+ level at 6 hours of treatment, a significant improvement in blood pH at 12 hours of treatment, and significant reductions in blood lactic acid, blood creatinine, and blood urea nitrogen at 12 hours of treatment (P<0.05). Among the 21 neonates during CBP treatment, 6 experienced thrombocytopenia, 1 had membrane occlusion, and 1 experienced bleeding, and no hypothermia, hypotension, or infection was observed. CONCLUSIONS CBP is a safe, feasible, and effective method for the treatment of MODS in neonates, with few complications.
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Affiliation(s)
- Wei-Feng Zhang
- Department of Neonatology, Quanzhou Children's Hospital, Quanzhou, Fujian 362000, China.
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22
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Serial measurement of electrolyte and citrate concentrations in blood-primed continuous hemodialysis circuits during closed-circuit dialysis. Pediatr Nephrol 2020; 35:127-133. [PMID: 31372760 DOI: 10.1007/s00467-019-04318-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 07/17/2019] [Accepted: 07/23/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND For continuous renal replacement therapy in small infants, due to the large extracorporeal volume involved, blood priming can be necessary to prevent hypotension and hemodilution. Because packed red blood cells (RBCs) have high levels of potassium and citrate, closed-circuit dialysis is often performed. We assessed the metrics of closed-circuit dialysis and serial citrate concentration changes. METHODS We performed dialysis of closed circuits primed with expired human packed RBC solution and 5% albumin. Blood and dialysate flow rates were 70 and 33.3 mL/min, respectively. The extracorporeal volume was 70 mL. We measured pH, electrolytes, and citrate in the closed circuit every 3 min for 15 min. We also assessed the adequacy of closed-circuit dialysis using the formula: [dialysate flow rate (mL/min) × time of dialysis (min)]/extracorporeal volume (mL) and we assessed the correlation between citrate and ionized calcium concentrations. RESULTS To reach normal concentrations of sodium, potassium, and chloride, 2.4 times as much dialysate fluid as extracorporeal volume was needed. In contrast, for ionized calcium, bicarbonate, and citrate, 3.8 times as much dialysate fluid as extracorporeal volume was required. By simple linear regression analysis, the concentration of citrate was significantly correlated with that of ionized calcium. CONCLUSIONS For closed-circuit dialysis using an RBC solution, the formula [dialysate flow rate (mL/min) × time of dialysis (min)]/extracorporeal volume (mL) would be a better parameter to estimate efficacy, compared with other metrics. Additionally, the citrate concentration can be readily estimated from the ionized calcium concentration during closed-circuit dialysis.
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23
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Antimicrobial Disposition During Pediatric Continuous Renal Replacement Therapy Using an Ex Vivo Model. Crit Care Med 2019; 47:e767-e773. [DOI: 10.1097/ccm.0000000000003895] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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24
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Menon S, Broderick J, Munshi R, Dill L, DePaoli B, Fathallah-Shaykh S, Claes D, Goldstein SL, Askenazi DJ. Kidney Support in Children using an Ultrafiltration Device: A Multicenter, Retrospective Study. Clin J Am Soc Nephrol 2019; 14:1432-1440. [PMID: 31462396 PMCID: PMC6777586 DOI: 10.2215/cjn.03240319] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 07/17/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Provision of kidney replacement therapy (KRT) to manage kidney injury and volume overload in critically ill neonates and small children is technically challenging. The use of machines designed for adult-sized patients, necessitates large catheters, a high extracorporeal volume relative to patient size, and need for blood priming. The Aquadex FlexFlow System (CHF Solutions Inc., Eden Prairie, MN) is an ultrafiltration device designed for fluid removal in adults with diuretic resistant heart failure. It has an extracorporeal volume of 33 ml, which can potentially mitigate some complications seen at onset of KRT in smaller infants. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In this multicenter, retrospective case series of children who received KRT with an ultrafiltration device (n=119 admissions, 884 circuits), we report demographics, circuit characteristics, complications, and short- and long-term outcomes. Patients were grouped according to weight (<10, 10-20, and >20 kg), and received one of three modalities: slow continuous ultrafiltration, continuous venovenous hemofiltration (CVVH), or prolonged intermittent KRT. Our primary outcome was survival to end of KRT. RESULTS Treatment patterns and outcomes varied between the groups. In patients who weighed <10 kg, the primary indication was AKI in 40%, volume overload in 46%, and ESKD in 14%. These patients primarily received CVVH (66%, n=48) and prolonged intermittent KRT (21%, n=15). In the group weighing >20 kg, volume overload was the primary indication in 91% and slow continuous ultrafiltration was the most common modality. Patients <10 kg had lower KRT survival than those >20 kg (60% versus 97%), more volume overload at onset, and received KRT for a longer duration. Cardiovascular complications at initiation were seen in 3% of treatments and none were severe. Complications during therapy were seen in 15% treatments and most were vascular access-related. CONCLUSIONS We report the first pediatric experience using an ultrafiltration device to provide a range of therapies, including CVVH, prolonged intermittent KRT, and slow continuous ultrafiltration. We were able to initiate KRT with minimal complications, particularly in critically ill neonates. There is an unmet need for devices specifically designed for younger patients. Having size-appropriate machines will improve the care of smaller children who require kidney support.
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Affiliation(s)
- Shina Menon
- Division of Pediatric Nephrology, Seattle Children's Hospital, University of Washington, Seattle, Washington;
| | - John Broderick
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; and
| | - Raj Munshi
- Division of Pediatric Nephrology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Lynn Dill
- Division of Pediatric Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Bradley DePaoli
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Sahar Fathallah-Shaykh
- Division of Pediatric Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Donna Claes
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; and
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; and
| | - David J Askenazi
- Division of Pediatric Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
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25
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Guzzo I, de Galasso L, Mir S, Bulut IK, Jankauskiene A, Burokiene V, Cvetkovic M, Kostic M, Bayazit AK, Yildizdas D, Schmitt CP, Paglialonga F, Montini G, Yilmaz E, Oh J, Weber L, Taylan C, Hayes W, Shroff R, Vidal E, Murer L, Mencarelli F, Pasini A, Teixeira A, Afonso AC, Drozdz D, Schaefer F, Picca S. Acute dialysis in children: results of a European survey. J Nephrol 2019; 32:445-451. [PMID: 30949986 DOI: 10.1007/s40620-019-00606-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 03/28/2019] [Indexed: 12/21/2022]
Abstract
The number of children with acute kidney injury (AKI) requiring dialysis is increasing. To date, systematic analysis has been largely limited to critically ill children treated with continuous renal replacement therapy (CRRT). We conducted a survey among 35 European Pediatric Nephrology Centers to investigate dialysis practices in European children with AKI. Altogether, the centers perform dialysis in more than 900 pediatric patients with AKI per year. PD and CRRT are the most frequently used dialysis modalities, accounting for 39.4% and 38.2% of treatments, followed by intermittent HD (22.4%). In units treating more than 25 cases per year and in those with cardiothoracic surgery programs, PD is the most commonly chosen dialysis modality. Also, nearly one quarter of centers, in countries with a gross domestic product below $35,000/year, do not utilize CRRT at all. Dialysis nurses are exclusively in charge of CRRT management in 45% of the cases and pediatric intensive care nurses in 25%, while shared management is practiced in 30%. In conclusion, this survey indicates that the choice of treatment modalities for dialysis in children with AKI in Europe is affected by the underlying ethiology of the disease, organization/set-up of centers and socioeconomic conditions. PD is utilized as often as CRRT, and also intermittent HD is a commonly applied treatment option. A prospective European AKI registry is planned to provide further insights on the epidemiology, management and outcomes of dialysis in pediatric AKI.
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Affiliation(s)
- Isabella Guzzo
- Nephrology and Dialysis Unit, Pediatric Subspecialties Department, Institute for Scientific Research, Bambino Gesù Children's Hospital, Piazza S. Onofrio 4, 00165, Rome, Italy.
| | - Lara de Galasso
- Nephrology and Dialysis Unit, Pediatric Subspecialties Department, Institute for Scientific Research, Bambino Gesù Children's Hospital, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Sevgi Mir
- Ege University Faculty of Medicine, Izmir, Turkey
| | | | - Augustina Jankauskiene
- Clinic of Children Diseases, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
| | - Vilmanta Burokiene
- Children Hospital, Affiliate of Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | | | | | - Aysun Karabay Bayazit
- Department of Pediatric Nephrology, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Dincer Yildizdas
- Department of Pediatric Nephrology, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Claus Peter Schmitt
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Fabio Paglialonga
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanni Montini
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Jun Oh
- University Children's Hospital, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lutz Weber
- Children's and Adolescents' Hospital, University Hospital of Cologne, Cologne, Germany
| | - Christina Taylan
- Children's and Adolescents' Hospital, University Hospital of Cologne, Cologne, Germany
| | - Wesley Hayes
- Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Rukshana Shroff
- Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Enrico Vidal
- Azienda Ospedaliera-University of Padua, Padua, Italy
| | - Luisa Murer
- Azienda Ospedaliera-University of Padua, Padua, Italy
| | | | | | - Ana Teixeira
- Centro Materno-Infantil do Norte, Porto, Portugal
| | | | - Dorota Drozdz
- Jagiellonian University Medical College, Krakow, Poland
| | - Franz Schaefer
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Stefano Picca
- Nephrology and Dialysis Unit, Pediatric Subspecialties Department, Institute for Scientific Research, Bambino Gesù Children's Hospital, Piazza S. Onofrio 4, 00165, Rome, Italy
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Mortality of Critically Ill Children Requiring Continuous Renal Replacement Therapy: Effect of Fluid Overload, Underlying Disease, and Timing of Initiation. Pediatr Crit Care Med 2019; 20:314-322. [PMID: 30431556 DOI: 10.1097/pcc.0000000000001806] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To identify risk factors associated with mortality in critically ill children requiring continuous renal replacement therapy. DESIGN Retrospective observational study based on a prospective registry. SETTING Tertiary and quaternary referral 30-bed PICU. PATIENTS Critically ill children undergoing continuous renal replacement therapy were included in the study. INTERVENTIONS Continuous renal replacement therapy. MEASUREMENTS AND MAIN RESULTS Overall mortality was 36% (n = 58) among the 161 patients treated with continuous renal replacement therapy during the study period and was significantly higher in patients on extracorporeal membrane oxygenation (47.5%, 28 of 59) than in patients not requiring extracorporeal membrane oxygenation (28.4%, 29 of 102; p = 0.022). According to the admission diagnosis, we found the highest mortality in patients with onco-hematologic disease (77.8%) and the lowest in patients with renal disease (5.6%). Based on multivariate logistic regression analysis, the presence of higher severity of illness score at admission (adjusted odds ratio, 1.49; 95% CI, 1.18-1.89; p < 0.001), onco-hematologic disease (odds ratio, 17.10; 95% CI, 4.10-72.17; p < 0.001), fluid overload 10%-20% (odds ratio, 3.83; 95% CI, 1.33-11.07; p = 0.013), greater than 20% (odds ratio, 15.03; 95% CI, 4.03-56.05; p < 0.001), and timing of initiation of continuous renal replacement therapy (odds ratio, 1.01; 95% CI, 1.00-1.01; p = 0.040) were independently associated with mortality. In our population, the odds of dying increases by 1% for every hour of delay in continuous renal replacement therapy initiation from ICU admission. CONCLUSIONS Mortality in children requiring continuous renal replacement therapy remains high and seems to be related to the underlying disease, the severity of illness, and the degree of fluid overload. In critically ill children at high risk for developing acute kidney injury and fluid overload, earlier initiation of continuous renal replacement therapy might result in decreased mortality.
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Choice of Catheter Size for Infants in Continuous Renal Replacement Therapy: Bigger Is Not Always Better. Pediatr Crit Care Med 2019; 20:e170-e179. [PMID: 30531553 DOI: 10.1097/pcc.0000000000001825] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Renal replacement therapy in infants and small children is the treatment of choice for severe oligoanuric renal dysfunction, with an increasing consensus that early initiation might contribute to preventing acute kidney injury complications. Safer renal replacement therapy devices specifically designed for neonates may contribute to ameliorating outcomes and increasing chances of survival. One of the crucial factors to achieve an effective renal replacement therapy in small infants is adequate vascular access. The interaction of small size central vascular catheters with renal replacement therapy devices has never been investigated. The aim of this study was to characterize both the operating conditions and performance of three different central vascular catheters sizes (4F, 5F, and 7F) connected to two different extracorporeal blood circulation models (adult and pediatric). The rheologic performance of each vascular access size in combination with the adult and pediatric renal replacement therapy models was described. DESIGN Series of experimental extracorporeal circulation circuit tests were conducted with different setups. A two-roller pump was used to simulate a standard adult dialysis machine, whereas a small three-roller pump served as pediatric renal replacement therapy device. SETTING A pressure-flow setup aimed to collect pressure and flow values under different test conditions. A second experiment focused on hemolysis estimation induced by the extracorporeal system. Hemolysis exclusively induced by the 4F catheter was also evaluated. Finally, our data were applied to estimate the optimal catheter size theoretically capable of delivering adequate doses basing on anthropometric data (patient weight and cannulation site) in absence of direct ultrasound vessel measurement. SUBJECTS In vitro tests conducted on simulated extracorporeal circuit models of continuous pediatric and neonatal renal replacement therapy. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS When 4F and 5F catheters are used, maximal blood flows within safe circuit pressures can be set at the values of 13 and 29 mL/min, respectively, when a small pump is used. Differently, when using adult roller pumps, only maximal flows of 10 and 20 mL/min are reached. However, hemolysis is higher when using a three-roller pump compared with the two-roller. The clinical impact of this increased hemolytic burden is likely not relevant. CONCLUSIONS Small size central vascular catheters display optimal rheologic performances in terms of pressures and flows particularly when the renal replacement therapy device is equipped with pumps proportional to central vascular catheters sizes, and even when relatively high blood flows are set. This is achieved at the risk of a higher hemolysis rate.
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Sethi SK, Agrawal G, Wazir S, Rohatgi S, Iyengar A, Chakraborty R, Jain R, Nair N, Sinha R, Chakrabarti R, Kumar D, Raina R. Neonatal Acute Kidney Injury: A Survey of Perceptions and Management Strategies Amongst Pediatricians and Neonatologists. Front Pediatr 2019; 7:553. [PMID: 32010651 PMCID: PMC6972501 DOI: 10.3389/fped.2019.00553] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 12/19/2019] [Indexed: 01/06/2023] Open
Abstract
Background: Neonatal Acute Kidney Injury (AKI) occurs in 40-70% of critically ill newborn infants and is independently associated with increased morbidity and mortality. Understanding the practice patterns of physicians (neonatologists and pediatricians), caring for neonates in India is important to optimize care and outcomes in neonatal AKI. Aim: The aim of this study was to identify differences in physician's perception and practice variations of diagnosis, management, and follow-up of newborn infants with AKI in India. Methods: An online survey of neonatologists and pediatricians in India caring for newborn infants with AKI. Results: Out of 800 correspondents, 257 (135 neonatologists and 122 pediatricians) completed the survey, response rate being 32.1%. Resources available to the respondents included level III NICU (59%), neonatal surgery (60%), dialysis (11%), and extracorporeal membrane oxygenation (ECMO, 3%). Most respondents underestimated the risk of AKI due to various risk factors such as prematurity, asphyxia, sepsis, cardiac surgery, and medications. Less than half the respondents were aware of the AKIN or KDIGO criteria, which are the current standard criteria for defining neonatal AKI. Only half of the respondents were aware of the risk of CKD in preterm neonates and nearly half were unaware of the need to follow up with a pediatric nephrologist. Conclusions: Similar to other regions worldwide, there exists a knowledge gap in early recognition, optimal management and follow up of newborn infants with AKI amongst Indian physicians.
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Affiliation(s)
| | - Gopal Agrawal
- Department of Pediatrics and Neonatology, Cloudnine Hospital, Gurgaon, India
| | - Sanjay Wazir
- Department of Pediatrics and Neonatology, Cloudnine Hospital, Gurgaon, India
| | - Smriti Rohatgi
- Department of Pediatric Nephrology, Medanta the Medicity, Gurgaon, India
| | - Arpana Iyengar
- Department of Pediatrics, St. John's National Academy of Health Sciences, Bengaluru, India
| | - Ronith Chakraborty
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, United States
| | - Rahul Jain
- Saint Ignatius High School, Cleveland, OH, United States
| | - Nikhil Nair
- Department of Chemistry, Case Western Reserve University, Cleveland, OH, United States
| | - Rajiv Sinha
- Department of Pediatric Medicine, Institute of Child Health, Kolkata, India
| | - Raktima Chakrabarti
- Department of Pediatrics and Neonatology, Cloudnine Hospital, Gurgaon, India
| | - Deepak Kumar
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States
| | - Rupesh Raina
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, United States.,Department of Nephrology, Akron Children's Hospital, Akron, OH, United States
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Jonckheer J, Vergaelen K, Spapen H, Malbrain MLNG, De Waele E. Modification of Nutrition Therapy During Continuous Renal Replacement Therapy in Critically Ill Pediatric Patients: A Narrative Review and Recommendations. Nutr Clin Pract 2018; 34:37-47. [PMID: 30570180 PMCID: PMC7379206 DOI: 10.1002/ncp.10231] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Introduction Nutrition is an important part of treatment in critically ill children. Clinical guidelines for nutrition adaptations during continuous renal replacement therapy (CRRT) are lacking. We collected and evaluated current knowledge on this topic and provide recommendations. Methods Questions were produced to guide the literature search in the PubMed database. Results Evidence is scarce and extrapolation from adult data was often required. CRRT has a direct and substantial impact on metabolism. Indirect calorimetry is the preferred method to assess resting energy expenditure (REE). Moderate underestimation of REE is common but not clinically relevant. Formula‐based calculation of REE is inaccurate and not validated in critically ill children on CRRT. The nutrition impact of nonintentional calories delivered as citrate, lactate, and glucose during CRRT must be considered. Quantifying nitrogen balance is not feasible during CRRT. Protein delivery should be increased by 25% to compensate for losses in the effluent. Fats are not removed by CRRT and should not be adapted during CRRT. Electrolyte disturbances are frequently present and should be treated accordingly. Vitamins B1, B6, B9, and C are lost in the effluent and should be adapted to the effluent dose. Trace elements, with the exception of selenium, are not cleared in relevant quantities. Manganese accumulation is of concern because of potential neurotoxicity. Conclusion Current recommendations regarding nutrition support in pediatric CRRT must be extrapolated from adult studies. Recommendations are provided, based on the weak level of evidence. Additional research on this topic is warranted.
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Affiliation(s)
- Joop Jonckheer
- Intensive Care Department, University Hospital Brussels, Brussels, Belgium
| | - Klaar Vergaelen
- Pediatric Intensive Care Unit, University Hospital Brussels, Brussels, Belgium
| | - Herbert Spapen
- Intensive Care Department, University Hospital Brussels, Brussels, Belgium
| | - Manu L N G Malbrain
- Intensive Care Department, University Hospital Brussels, Brussels, Belgium.,Pediatric Intensive Care Unit, University Hospital Brussels, Brussels, Belgium
| | - Elisabeth De Waele
- Intensive Care Department, University Hospital Brussels, Brussels, Belgium.,Department of Nutrition, University Hospital Brussels, Brussels, Belgium
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Sinha R, Sethi SK, Bunchman T, Lobo V, Raina R. Prolonged intermittent renal replacement therapy in children. Pediatr Nephrol 2018; 33:1283-1296. [PMID: 28721515 DOI: 10.1007/s00467-017-3732-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 05/22/2017] [Accepted: 05/31/2017] [Indexed: 12/15/2022]
Abstract
Wide ranges of age and weight in pediatric patients makes renal replacement therapy (RRT) in acute kidney injury (AKI) challenging, particularly in the pediatric intensive care unit (PICU), wherein children are often hemodynamically unstable. Standard hemodialysis (HD) is difficult in this group of children and continuous veno-venous hemofiltration/dialysis (CVVH/D) has been the accepted modality in the developed world. Unfortunately, due to cost constraints, CVVH/D is often not available and peritoneal dialysis (PD) remains the common mode of RRT in resource-poor facilities. Acute PD has its drawbacks, and intermittent HD (IHD) done slowly over a prolonged period has been explored as an alternative. Various modes of slow sustained IHD have been described in the literature with the recently introduced term prolonged intermittent RRT (PIRRT) serving as an umbrella terminology for all of these modes. PIRRT has been widely accepted in adults with studies showing it to be as effective as CVVH/D but with an added advantage of being more cost-effective. Pediatric data, though scanty, has been promising. In this current review, we elaborate on the practical aspects of undertaking PIRRT in children as well as summarize its current status.
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Affiliation(s)
- Rajiv Sinha
- Institute of Child Health and AMRI Hospital, 37, G Bondel Road, Kolkata, West Bengal, 700019, India.
| | - Sidharth Kumar Sethi
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Timothy Bunchman
- Pediatric Nephrology, Children's Hospital of Richmond at VCU, Richmond, VA, USA
| | - Valentine Lobo
- Department of Nephrology, KEM Hospital, Pune, Maharashtra, India
| | - Rupesh Raina
- Pediatric Nephrology, Akron Children's Hospital, Cleveland, OH, USA
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31
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Murphy HJ, Finch CW, Taylor SN. Neonatal Extracorporeal Life Support: A Review of Nutrition Considerations. Nutr Clin Pract 2018; 33:625-632. [PMID: 30004582 DOI: 10.1002/ncp.10111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Critically ill neonates who require extracorporeal life support have particular nutrition needs. These infants require prescription of aggressive, early nutrition support by knowledge providers. Understanding the unique metabolic demands and nutrition requirements of these fragile patients is paramount, particularly if additional therapies such as aggressive diuretic regimens or continuous renal replacement therapy are used concurrently. Although the American Society for Parenteral and Enteral Nutrition has published guidelines for this population, a review of each nutrition component is warranted because few studies exist specific to this population. Long-term complications in survivors of neonatal extracorporeal life support, particularly in patients with select diagnoses such as congenital diaphragmatic hernia, can be significant and must be recognized and anticipated. This review focuses on recognizing the nutrition needs of neonatal patients requiring extracorporeal life support, appraising the available data to guide selection of an appropriate mode of nutrition delivery, and describing the anticipated long-term nutrition implications of extracorporeal life support provision during the neonatal period.
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Affiliation(s)
- Heidi J Murphy
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Carolyn W Finch
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Sarah N Taylor
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
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Al-Ayed T, Rahman NU, Alturki A, Aljofan F. Outcome of continuous renal replacement therapy in critically ill children: a retrospective cohort study. Ann Saudi Med 2018; 38:260-268. [PMID: 30078024 PMCID: PMC6086670 DOI: 10.5144/0256-4947.2018.260] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Continuous renal replacement therapy (CRRT) has become the preferred mode of dialysis to support critically ill children with acute kidney injury. However, there are limited pediatric data on CRRT use, especially in our region. OBJECTIVE Determine the outcome of CRRT among critically ill children. DESIGN Retrospective cohort study. SETTING Pediatric intensive care unit. PATIENTS AND METHODS The study included critically ill children 1-14 years of age who underwent CRRT from July 2009 to June 2015. We report the underlying diagnosis, demographics, indications and modality of CRRT, and associated risk factors. Statistical analyses were used to identify risk factors associated with mortality. MAIN OUTCOME MEASURES Mortality and associated risk factors with use of CRRT. SAMPLE SIZE 96 RESULTS: The mean age was 6.0 (standard deviation, 4.4) years, with a male preponderance in the age group from 1-10 years which comprised almost 60% of the study group. The most common primary diagnoses were malignancies [37.5% (36/96)] followed by primary renal diseases [19.8% (19/96)], and immunodeficiency [16.7% (16/96)]. The most common indication for CRRT was fluid overload [67.2% (65/96)] followed by tumor lysis syndrome [18.8%(18/96)], and metabolic encephalopathy [9.4%(9/96)]. The median length of CRRT was 66 hours (IQR, 35.5-161.4), with a median average circuit life of 30.9 hours (IQR, 16.4-45.0). The most common CRRT catheter site was the internal jugular vein [77.1% (74/96)], followed by the femoral vein [18.8%(18/96)] with continuous venovenous hemodiafiltration [82.3%(79/96)] being the most common CRRT modality used. The mortality rate among critically ill children requiring CRRT was 50% (48/96). There was an increased mortality rate among children with hematological diseases (100%, 10/10), immunodeficiency (86.6%, 13/16) and in children who had undergone stem cell transplantation (90.0%, 27/30), with the least mortality in primary renal disease (15.8% (3/19). We identified septic shock and use of inotropic support as being independently associated with mortality in a multivariate analysis. CONCLUSION The overall mortality rate among critically ill children who un.derwent CRRT was 50% with significantly increased mortality among patients with hematological diseases, immunodeficiency, and in children who had undergone stem cell transplantation. Septic shock and use of inotropic support were associated with mortality. LIMITATIONS Retrospective and single center data that is not generalizable. CONFLICT OF INTEREST None.
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Affiliation(s)
- Tareq Al-Ayed
- Dr. Tareq Al-Ayed, Department of Pediatrics, King Faisal Specialist Hospital and Research Centre,, PO Box 3354, Riyadh 11211, Saudi Arabia, T: +96614427763 F: +96614427784, , ORCID: http://orcid.org/0000-0001-7525-3529
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Sethi SK, Bansal SB, Khare A, Dhaliwal M, Raghunathan V, Wadhwani N, Nandwani A, Yadav DK, Mahapatra AK, Raina R. Heparin free dialysis in critically sick children using sustained low efficiency dialysis (SLEDD-f): A new hybrid therapy for dialysis in developing world. PLoS One 2018; 13:e0195536. [PMID: 29698409 PMCID: PMC5919674 DOI: 10.1371/journal.pone.0195536] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 03/23/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In critically sick adults, sustained low efficiency dialysis [SLED] appears to be better tolerated hemodynamically and outcomes seem to be comparable to CRRT. However, there is paucity of data in critically sick children. In children, two recent studies from Taiwan (n = 11) and India (n = 68) showed benefits of SLED in critically sick children. AIMS AND OBJECTIVES The objective of the study was to look at the feasibility and tolerability of sustained low efficiency daily dialysis-filtration [SLEDD-f] in critically sick pediatric patients. MATERIAL AND METHODS Design: Retrospective study Inclusion criteria: All pediatric patients who had undergone heparin free SLEDD-f from January 2012 to October 2017. Measurements: Data collected included demographic details, vital signs, PRISM III at admission, ventilator parameters (where applicable), number of inotropes, blood gas and electrolytes before, during, and on conclusion of SLED therapy. Technical information was gathered regarding SLEDD-f prescription and complications. RESULTS Between 2012-2017, a total of 242 sessions of SLEDD-f were performed on 70 patients, out of which 40 children survived. The median age of patients in years was 12 (range 0.8-17 years), and the median weight was 39 kg (range 8.5-66 kg). The mean PRISM score at admission was 8.77±7.22. SLEDD-f sessions were well tolerated, with marked improvement in fluid status and acidosis. Premature terminations had to be done in 23 (9.5%) of the sessions. There were 21 sessions (8.6%) terminated due to hypotension and 2 sessions (0.8%) terminated due to circuit clotting. Post- SLEDD-f hypocalcemia occurred in 15 sessions (6.2%), post- SLEDD-f hypophosphatemia occurred in 1 session (0.4%), and post- SLEDD-f hypokalemia occurred in 17 sessions (7.0%). CONCLUSIONS This study is the largest compiled data on pediatric SLEDD-f use in critically ill patients. Our study confirms the feasibility of heparin free SLEDD-f in a larger pediatric population, and even in children weighing <20 kg on inotropic support.
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Affiliation(s)
| | - Shyam B. Bansal
- Kidney Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Anshika Khare
- Northeast Ohio Medical University, Rootstown, Ohio, United States of America
| | - Maninder Dhaliwal
- Pediatric Critical Care, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Veena Raghunathan
- Pediatric Critical Care, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Nikita Wadhwani
- Kidney Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Ashish Nandwani
- Kidney Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | | | | | - Rupesh Raina
- Pediatric Nephrology, Akron Children’s Hospital, Akron, Ohio, United States of America
- * E-mail:
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Abstract
OBJECTIVES Although renal replacement therapy is widely used in critically ill children, there have been few comprehensive population-based studies of its use. This article describes renal replacement therapy use, and associated outcomes, in critically ill children across the United Kingdom in the largest cohort study of this patient group. DESIGN A retrospective observational study using prospectively collected data. SETTING Data from the Pediatric Intensive Care Audit Network database which collects data on all children admitted to U.K. PICUs. PATIENTS Children (< 16 yr) in PICU who received renal replacement therapy between January 1, 2005, and December 31, 2012, were identified. INTERVENTIONS Individual-level data including age, underlying diagnosis, modality (peritoneal dialysis and continuous extracorporeal techniques [continuous renal replacement therapy]), duration of renal replacement therapy, PICU length of stay, and survival were extracted. MEASUREMENTS AND MAIN RESULTS Three-thousand eight-hundred twenty-five of 129,809 PICU admissions (2.9%) received renal replacement therapy in 30 of 33 centers. Volumes of renal replacement therapy varied considerably from 0% to 8.6% of PICU admissions per unit, but volume was not associated with patient survival. Overall survival to PICU discharge (73.8%) was higher than previous reports. Mortality risk was related to age, with lower risk in older children compared with neonates (odds ratio, 0.6; 95% CI, 0.5-0.8) although mortality did not increase over the age of 1 year; mode of renal replacement therapy, with lower risk in peritoneal dialysis than continuous renal replacement therapy methodologies (odds ratio, 0.7; 0.5-0.9); duration of renal replacement therapy (odds ratio, 1.02/d; 95% CI, 1.01-1.04); and primary diagnosis, with the lowest survival in liver disease patients (53.9%). CONCLUSIONS This study describes current renal replacement therapy use across the United Kingdom and associated outcomes. We describe a number of factors associated with outcome, including age, underlying diagnosis, and renal replacement therapy modality which will need to be factored into future trial design.
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Dirkes S, Wonnacott R. Continuous Renal Replacement Therapy and Anticoagulation: What Are the Options? Crit Care Nurse 2018; 36:34-41. [PMID: 27037337 DOI: 10.4037/ccn2016623] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Continuous renal replacement therapy is currently used as a standard treatment for acute kidney injury in the intensive care unit, particularly for patients with unstable hemodynamic status. Because this therapy is continuous, for days or weeks, and the extracorporeal blood circuit is large, the circuit is prone to clotting. Several methods of keeping the extracorporeal circuit patent are available, including heparin infusion, flushes with physiological saline, use of thrombin inhibitors, and citrate. This article reviews methods for continuous renal replacement therapy, anticoagulation, efficacy, and implications for bedside critical care.
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Affiliation(s)
- Susan Dirkes
- Susan Dirkes is a staff nurse in the surgical intensive care unit and the progressive care unit at the University of Michigan Health System, Ann Arbor, Michigan.Rob Wonnacott is the clinical educator in the surgical intensive care unit and lead instructor for the adult CRRT program at the University of Michigan Health System.
| | - Rob Wonnacott
- Susan Dirkes is a staff nurse in the surgical intensive care unit and the progressive care unit at the University of Michigan Health System, Ann Arbor, Michigan.Rob Wonnacott is the clinical educator in the surgical intensive care unit and lead instructor for the adult CRRT program at the University of Michigan Health System
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Aygun F, Aygun D, Erbek Alp F, Zubarıoglu T, Zeybek C, Cam H. The impact of continuous renal replacement therapy for metabolic disorders in infants. Pediatr Neonatol 2018; 59:85-90. [PMID: 28778517 DOI: 10.1016/j.pedneo.2017.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Revised: 02/19/2017] [Accepted: 04/12/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND While Continuous Renal Replacement Therapy (CRRT) is a well established treatment modality for patients with acute kidney insufficiency (AKI), it is now also being used for the management of various illnesses such as acute metabolic disorders presenting with hyperammonemia and elevated leucine levels. Herein, we aimed to describe our experience with CRRT in treatment of acute decompensation of 14 patients with a diagnosis of metabolic disorder who has been admitted to our pediatric intensive care unit (PICU) in the last year. METHODS Patients who have had life threatening acute metabolic crisis due to various metabolic disorders and were treated with continuous renal replacement therapy (CRRT) were evaluated retrospectively. RESULTS Between November 2014 and December 2015, 14 patients were found to have received CRRT for various metabolic disorders in the PICU. Ten patients had hyperammonemia and four patients had elevated leucine levels. Nine patients were male and five were female. The age interval was between 2 days and 18 months, with a mean of 5.5 ± 7.4 months. The weight distribution was between 2.5 and 18 kg, with a mean of 7.3 ± 5.6 kg. Eleven patients received continuous veno-venous hemodiafiltration (CVVHDF), and 3 patients with MSUD received continuous veno-venous hemodialysis (CVVHD). All patients have received high throughput hemodialysis and hemofiltration. The dialyzate rate was set to be minimum 4042 ml/h/1.73 m2, and maximum 12,900 ml/h/1.73 m2. Hemofiltration was performed with a replacement rate of 40-76 ml/kg/h. The average CRRT duration was 16.6 ± 15.6 h. CONCLUSIONS We suggest that CRRT is an efficient method that can be used in hyperammonemia and elevated leucine levels which are metabolic emergencies.
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Affiliation(s)
- Fatih Aygun
- Istanbul University, Cerrahpasa Medical Faculty, Department of Pediatric Intensive Care Unit, Istanbul, Turkey.
| | - Deniz Aygun
- Istanbul University, Cerrahpasa Medical Faculty, Department of Pediatric Infectious Disease, Istanbul, Turkey.
| | - Firuze Erbek Alp
- Istanbul University, Cerrahpasa Medical Faculty, Department of Pediatrics, Istanbul, Turkey.
| | - Tanyel Zubarıoglu
- Istanbul University, Cerrahpasa Medical Faculty, Department of Pediatric Nutrition and Metabolism, Istanbul, Turkey.
| | - Cigdem Zeybek
- Istanbul University, Cerrahpasa Medical Faculty, Department of Pediatric Nutrition and Metabolism, Istanbul, Turkey.
| | - Halit Cam
- Istanbul University, Cerrahpasa Medical Faculty, Department of Pediatric Intensive Care Unit, Istanbul, Turkey.
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Abstract
Acute kidney injury (AKI) has become one of the more common complications seen among hospitalized children. The development of a consensus definition has helped refine the epidemiology of pediatric AKI, and we now have a far better understanding of its incidence, risk factors, and outcomes. Strategies for diagnosing AKI have extended beyond serum creatinine, and the most current data underscore the diagnostic importance of oliguria as well as introduce the concept of urinary biomarkers of kidney injury. As AKI has become more widespread, we have seen that it is associated with a number of adverse consequences including longer lengths of stay and greater mortality. Though effective treatments do not currently exist for AKI once it develops, we hope that the diagnostic and definitional strides seen recently translate to the testing and development of more effective interventions.
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Acute kidney injury in pediatric patients. Best Pract Res Clin Anaesthesiol 2017; 31:427-439. [DOI: 10.1016/j.bpa.2017.08.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 08/17/2017] [Indexed: 01/09/2023]
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Membrane pressures predict clotting of pediatric continuous renal replacement therapy circuits. Pediatr Nephrol 2017; 32:1251-1261. [PMID: 28247082 PMCID: PMC5441937 DOI: 10.1007/s00467-017-3601-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 01/17/2017] [Accepted: 01/17/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Clotting of continuous renal replacement therapy (CRRT) circuits leads to inadequate clearance, decreased ultrafiltration, and increased resource use. We identified factors associated with premature clotting of circuits during CRRT in children. METHODS In a retrospective cohort of 26 children (median age 11.8 years) receiving 79 CRRT circuits (51 heparin, 22 citrate, 6 using no anticoagulation), we captured hourly pressure, flow, and fluid removal rates along with all activated clotting time (ACT) and circuit ionized calcium measurements. Cox and logistic regression models were used to examine factors associated with premature circuit clotting before the scheduled 3-day circuit change. RESULTS Of the 79 circuits, 51 (64.6%) underwent unplanned filter change due to filter clotting (median duration 18.25 h, interquartile range [IQR] 9.25, 33.5 h), and 28 (35.4%) underwent scheduled change (median duration 66 h, IQR 61.00, 69.00 h). Patient age, catheter size and location, blood flow rate, and the percentage of pre-filter replacement fluid were not associated with premature clotting. Heparin circuits were less likely than citrate circuits to clot prematurely. Each 1-mmHg increase in the transmembrane or filter pressure was independently associated with a 1.5% (95% confidence interval [CI] 1.0-2.0%) and 1.5% (95% CI 1.0-2.0%) higher risk of clotting, respectively. Higher ACTs were associated with lower transmembrane (p = 0.03) and filter (p < 0.001) pressures. CONCLUSIONS The majority of circuits in our cohort were subject to unplanned filter changes. Elevated transmembrane and filter pressures were associated with clotting. Our results suggest that maintaining higher ACT may decrease the risk of circuit clotting. Larger studies are needed to examine other factors that may prolong the lifespan of the CRRT circuit in this high-risk population.
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Profeta E, Shank K, Wang S, O'Connor C, Kunselman AR, Woitas K, Myers JL, Ündar A. Evaluation of Hemodynamic Performance of a Combined ECLS and CRRT Circuit in Seven Positions With a Simulated Neonatal Patient. Artif Organs 2017. [PMID: 28621839 DOI: 10.1111/aor.12907] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
As it is common for patients treated with extracorporeal life support (ECLS) to subsequently require continuous renal replacement therapy (CRRT), and neonatal patients encounter limitations due to lack of access points, inclusion of CRRT in the ECLS circuit could provide advanced treatment for this population. The objective of this study was to evaluate an alternative neonatal ECLS circuit containing either a Maquet RotaFlow centrifugal pump or Maquet HL20 roller pump with one of seven configurations of CRRT using the Prismaflex 2000 System. All ECLS circuit setups included a Quadrox-iD Pediatric diffusion membrane oxygenator, a Better Bladder, an 8-Fr arterial cannula, a 10-Fr venous cannula, and 6 feet of ¼-inch diameter arterial and venous tubing. The circuit was primed with lactated Ringer's solution and packed human red blood cells resulting in a total priming volume of 700 mL for both the circuit and the 3-kg pseudopatient. Hemodynamic data were recorded for ECLS flow rates of 200, 400, and 600 mL/min and a CRRT flow rate of 50 mL/min. When a centrifugal pump is used, the hemodynamic performance of any combined ECLS and CRRT circuit was not significantly different than that of the circuit without CRRT, thus any configuration could potentially be used. However, introduction of CRRT to a circuit containing a roller pump does affect performance properties for some CRRT positions. The circuits with CRRT positions B and G demonstrated decreased total hemodynamic energy (THE) levels at the post-arterial cannula site, while positions D and E demonstrated increased post-arterial cannula THE levels compared to the circuit without CRRT. CRRT positions A, C, and F did not have significant changes with respect to pre-arterial cannula flow and THE levels, compared to the circuit without CRRT. Considering hemodynamic performance, for neonatal combined extracorporeal membrane oxygenation (ECMO) and CRRT circuits with both blood pumps, we recommend the use of CRRT position A due to its hemodynamic similarities to the ECMO circuit without CRRT.
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Affiliation(s)
- Elizabeth Profeta
- Department of Pediatrics, Penn State Health Pediatric Cardiovascular Research Center, Hershey, PA, USA
| | - Kaitlyn Shank
- Department of Pediatrics, Penn State Health Pediatric Cardiovascular Research Center, Hershey, PA, USA
| | - Shigang Wang
- Department of Pediatrics, Penn State Health Pediatric Cardiovascular Research Center, Hershey, PA, USA
| | - Christian O'Connor
- Department of Pediatrics, Penn State Health Pediatric Cardiovascular Research Center, Hershey, PA, USA
| | - Allen R Kunselman
- Department of Public Health and Sciences, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Karl Woitas
- Penn State Heart and Vascular Institute, Penn State Health Children's Hospital, Hershey, PA, USA
| | - John L Myers
- Department of Pediatrics, Penn State Health Pediatric Cardiovascular Research Center, Hershey, PA, USA.,Department of Surgery, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Akif Ündar
- Department of Pediatrics, Penn State Health Pediatric Cardiovascular Research Center, Hershey, PA, USA.,Department of Surgery, Penn State Health Children's Hospital, Hershey, PA, USA.,Department of Bioengineering, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, USA
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Rico MP, Fernández Sarmiento J, Rojas Velasquez AM, González Chaparro LS, Gastelbondo Amaya R, Mulett Hoyos H, Tibaduiza D, Quintero Gómez AM. Regional citrate anticoagulation for continuous renal replacement therapy in children. Pediatr Nephrol 2017; 32:703-711. [PMID: 27896442 DOI: 10.1007/s00467-016-3544-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Revised: 10/24/2016] [Accepted: 10/27/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND Anticoagulation of the continuous renal replacement therapy (CRRT) circuit is an important technical aspect of this medical procedure. Most studies evaluating the efficacy and safety of citrate use have been carried out in adults, and little evidence is available for the pediatric patient population. The aim of this study was to compare regional citrate anticoagulation versus systemic heparin anticoagulation in terms of the lifetime of hemofilters in a pediatric population receiving CRRT at a pediatric center in Bogota, Colombia. METHODS This was an analytical, observational, retrospective cohort study in which we assessed the survival of 150 hemofilters (citrate group 80 hemofilters, heparin group 70 hemofilters) used in a total of 3442 hours of CCRT (citrate group 2248 h, heparin group 1194 h). Hemofilter survival was estimated beginning at placement and continuing until filter replacement due to clotting or high trans-membrane pressures. RESULTS Hemofilter survival was higher in the citrate group than in the heparin group (72 vs. 18 h; p <0.0001). Bivariate analysis showed that the hemofilter coagulation risk was significantly increased when heparin was used, regardless of hemofilter size and pump flow (hazard ratio 3.70, standard error 0.82, 95% confidence interval 2.39-5.72; p <0.00001). CONCLUSIONS Regional citrate anticoagulation could be more effective than heparin systemic anticoagulation in terms of prolonging the hemofilter lifetime in patients with acute renal injury who require CRRT.
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Affiliation(s)
- Mayerly Prada Rico
- Division of Pediatric Nephrology, Department of Pediatrics, Fundación Cardioinfantil IC, Instituto de Cardiologia, Bogota, Cundinamarca, Colombia
| | - Jaime Fernández Sarmiento
- Division of Pediatric Critical Care, Department of Pediatrics, Fundación Cardio-infantil IC, Universidad de la Sabana, Campus Universitario del Puente del Común, Km 7 Autopista Norte de Bogota, Chía, Cundinamarca, Colombia.
| | - Ana María Rojas Velasquez
- Division of Pediatric Gastroenterology, Pediatric Gastroenterology, Hepatology and Nutrition Unit, GASTRONUTRIPED, Bogota, Cundinamarca, Colombia
| | - Luz Stella González Chaparro
- Division of Pediatric Nephrology, Department of Pediatrics, Fundación Cardioinfantil IC, Instituto de Cardiologia, Bogota, Cundinamarca, Colombia
| | - Ricardo Gastelbondo Amaya
- Division of Pediatric Nephrology, Department of Pediatrics, Fundación Cardioinfantil IC, Instituto de Cardiologia, Bogota, Cundinamarca, Colombia
| | - Hernando Mulett Hoyos
- Division of Pediatric Critical Care, Department of Pediatrics, Fundación Cardio-infantil IC, Universidad de la Sabana, Campus Universitario del Puente del Común, Km 7 Autopista Norte de Bogota, Chía, Cundinamarca, Colombia
| | - Daniel Tibaduiza
- Division of Pediatric Critical Care, Department of Pediatrics, Fundación Cardio-infantil IC, Universidad de la Sabana, Campus Universitario del Puente del Común, Km 7 Autopista Norte de Bogota, Chía, Cundinamarca, Colombia
| | - Ana Maria Quintero Gómez
- Division of Pediatric Nephrology, Department of Pediatrics, Fundación Cardioinfantil IC, Instituto de Cardiologia, Bogota, Cundinamarca, Colombia
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Continuous Venovenous Hemofiltration in Children Less Than or Equal to 10 kg: A Single-Center Experience. Pediatr Crit Care Med 2017; 18:e70-e76. [PMID: 27977538 DOI: 10.1097/pcc.0000000000001030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of this study was to review the data from patients with a body weight less than or equal to 10 kg who required continuous venovenous hemofiltration, to assess the feasibility and problems associated with continuous venovenous hemofiltration in this population and compare the results with the current literature. DESIGN Retrospective study design. SETTING PICU in a single tertiary pediatric referral center. PATIENTS Children less than or equal to 10 kg who received continuous venovenous hemofiltration between January 2008 and July 2014 were included in the study. INTERVENTIONS Clinical data from these children were analyzed, and the differences between survivors and nonsurvivors were evaluated and compared with results from current literature. In a subgroup analysis of children less than or equal to 5 kg compared with children between 5 and 10 kg, the survival rate, indications for continuous venovenous hemofiltration, and continuous venovenous hemofiltration characteristics were assessed. MEASUREMENTS AND MAIN RESULTS In total, 71 continuous renal replacement therapy episodes in 70 children were included in the study. Children in our cohort had a survival rate of 57.7% (41/71). Survivors had less frequent need for vasopressor support prior to continuous venovenous hemofiltration, lower oxygen requirement and percent fluid overload at continuous venovenous hemofiltration initiation. Survival rate was not significantly different in children less than or equal to 5 kg compared with 5-10 kg. However, in children less than or equal to 5 kg, metabolic manipulation was a significantly more frequent indication for continuous venovenous hemofiltration, heparin use was lower and maximal blood flow rate was higher. CONCLUSIONS We have shown that continuous venovenous hemofiltration can be performed with good outcomes in children less than or equal to 10 kg using relatively high blood flow rates and with the current equipment available.
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What is this chocolate milk in my circuit? A cause of acute clotting of a continuous renal replacement circuit: Answers. Pediatr Nephrol 2016; 31:2253-2255. [PMID: 26817475 PMCID: PMC6033319 DOI: 10.1007/s00467-016-3318-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 12/10/2015] [Accepted: 12/11/2015] [Indexed: 10/22/2022]
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Abstract
Most babies with chronic renal failure are identified antenatally, and over half that are treated with peritoneal dialysis receive kidney transplants before school age. Most infants that develop acute renal failure have hypotension following cardiac surgery, or multiple organ failure. Sometimes the falls in glomerular filtration and urine output are physiological and reversible, and sometimes due to kidney injury, but (illogically) it is now common to define them all as having 'acute kidney injury'. Contrary to widespread opinion, careful interpretation of the plasma creatinine concentrations can provide sensitive evidence of early acute renal failure. Conservative management frequently leads to under-nutrition or fluid overload. Acute peritoneal dialysis is often technically fraught in very small patients, and haemotherapies have been limited by vascular access and anticoagulation requirements, the need to blood-prime circuits, and serious limitations in regulating fluid removal. Newer devices, including the Nidus, have been specifically designed to reduce these difficulties.
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Gulla KM, Sachdev A, Gupta D, Gupta N, Anand K, Pruthi PK. Continuous renal replacement therapy in children with severe sepsis and multiorgan dysfunction - A pilot study on timing of initiation. Indian J Crit Care Med 2015; 19:613-7. [PMID: 26628828 PMCID: PMC4637963 DOI: 10.4103/0972-5229.167044] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Objective: Scanty literature is available regarding continuous renal replacement therapy (CRRT) utility in severe sepsis with multiorgan dysfunction syndrome (MODS) from developing countries. Author unit's experience in pediatric CRRT is described and outcome of early initiation of CRRT with sepsis and MODS is assessed. Materials and Methods: Children aged <16 years with sepsis and MODS who required CRRT from September 2010 to February 2015 were analyzed on demographic factors, timing of initiation of CRRT, mode of CRRT, effect of CRRT onhemodynamics, oxygenation parameters, and outcome. Results: Twenty-seven children required CRRT (male - 16). The median age was 11 years (range 1.1–16). Twenty-one had severe sepsis with MODS. Eighteen patients were given CRRT within 48 h of admission to Intensive Care Unit (ICU). Statistically significant improvement in the P/F ratio, decrement in plateau pressure and vasoactive-inotropic score were noted in survivor group compared to nonsurvivor group (P = 0.022, 0.00, and 0.03, respectively). There was no statistically significant difference in duration of ICU stay, fluid overload, CRRT duration, PRISM score at 12 and 24 h, percentage of decrease in inotrope score, plateau pressure, and percentage of increase in P/F ratio in relation to timing of CRRT initiation. However, the survival rate was 61.1% (11/18) who received CRRT within 48 h of ICU admission compared to 33.3% (3/9) who received after 48 h (P = 0.0001). Conclusion: Our study emphasizes the CRRT role in improving the oxygenation status and hemodynamics. Survival benefit may be expected in those children who receive CRRT early in the course of sepsis. However, multicenter RCTs are required to prove mortality benefit.
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Affiliation(s)
- Krishna Mohan Gulla
- Division of Pediatric Emergency and Critical Care, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
| | - Anil Sachdev
- Division of Pediatric Emergency and Critical Care, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
| | - Dhiren Gupta
- Division of Pediatric Emergency and Critical Care, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
| | - Neeraj Gupta
- Division of Pediatric Emergency and Critical Care, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
| | - Kanav Anand
- Division of Pediatric Nephrology, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
| | - P K Pruthi
- Division of Pediatric Nephrology, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
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Vinsonneau C, Allain-Launay E, Blayau C, Darmon M, Ducheyron D, Gaillot T, Honore PM, Javouhey E, Krummel T, Lahoche A, Letacon S, Legrand M, Monchi M, Ridel C, Robert R, Schortgen F, Souweine B, Vaillant P, Velly L, Osman D, Van Vong L. Renal replacement therapy in adult and pediatric intensive care : Recommendations by an expert panel from the French Intensive Care Society (SRLF) with the French Society of Anesthesia Intensive Care (SFAR) French Group for Pediatric Intensive Care Emergencies (GFRUP) the French Dialysis Society (SFD). Ann Intensive Care 2015; 5:58. [PMID: 26714808 PMCID: PMC4695466 DOI: 10.1186/s13613-015-0093-5] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 11/27/2015] [Indexed: 12/12/2022] Open
Abstract
Acute renal failure (ARF) in critically ill patients is currently very frequent and requires renal replacement therapy (RRT) in many patients. During the last 15 years, several studies have considered important issues regarding the use of RRT in ARF, like the time to initiate the therapy, the dialysis dose, the types of catheter, the choice of technique, and anticoagulation. However, despite an abundant literature, conflicting results do not provide evidence on RRT implementation. We present herein recommendations for the use of RRT in adult and pediatric intensive care developed with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system by an expert group of French Intensive Care Society (SRLF), with the participation of the French Society of Anesthesia and Intensive Care (SFAR), the French Group for Pediatric Intensive Care and Emergencies (GFRUP), and the French Dialysis Society (SFD). The recommendations cover 4 fields: criteria for RRT initiation, technical aspects (access routes, membranes, anticoagulation, reverse osmosis water), practical aspects (choice of the method, peritoneal dialysis, dialysis dose, adjustments), and safety (procedures and training, dialysis catheter management, extracorporeal circuit set-up). These recommendations have been designed on a practical point of view to provide guidance for intensivists in their daily practice.
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Affiliation(s)
| | | | | | | | | | | | - Patrick M Honore
- Intensive Care Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium.
| | - Etienne Javouhey
- Réanimation pédiatrique spécialisée, CHU Lyon, 69677, Bron, France.
| | | | | | | | | | - Mehran Monchi
- Réanimation polyvalente, CH Melun, 77000, Melun, France.
| | | | | | | | | | | | | | - David Osman
- CHU Bicêtre, 94, Le Kremlin Bicêtre, France.
| | - Ly Van Vong
- Réanimation polyvalente, CH Melun, 77000, Melun, France.
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Cavagnaro Santa María F, Roque Espinosa J, Guerra Hernández P, Smith Torres M, González Largo I, Ronco Macchiavello R. [Continuous renal replacement therapy in newborns: Experience of a single centre]. REVISTA CHILENA DE PEDIATRIA 2015:S0370-4106(15)00183-7. [PMID: 26460084 DOI: 10.1016/j.rchipe.2015.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 07/24/2015] [Accepted: 07/27/2015] [Indexed: 06/05/2023]
Affiliation(s)
- Felipe Cavagnaro Santa María
- Departamento de Pediatría, Clínica Alemana de Santiago, Santiago de Chile, Chile; Facultad de Medicina, Clínica Alemana - Universidad del Desarrollo, Santiago de Chile, Chile.
| | - Jorge Roque Espinosa
- Departamento de Pediatría, Clínica Alemana de Santiago, Santiago de Chile, Chile; Facultad de Medicina, Clínica Alemana - Universidad del Desarrollo, Santiago de Chile, Chile; Unidad de Cuidados Intensivos Pediátricos, Departamento de Pediatría, Clínica Alemana de Santiago, Santiago de Chile, Chile
| | - Pamela Guerra Hernández
- Unidad de Cuidados Intensivos Pediátricos, Departamento de Pediatría, Clínica Alemana de Santiago, Santiago de Chile, Chile
| | - Marta Smith Torres
- Departamento de Pediatría, Clínica Alemana de Santiago, Santiago de Chile, Chile; Unidad de Cuidados Intensivos Pediátricos, Departamento de Pediatría, Clínica Alemana de Santiago, Santiago de Chile, Chile
| | - Isabel González Largo
- Departamento de Pediatría, Clínica Alemana de Santiago, Santiago de Chile, Chile; Unidad de Cuidados Intensivos Pediátricos, Departamento de Pediatría, Clínica Alemana de Santiago, Santiago de Chile, Chile
| | - Ricardo Ronco Macchiavello
- Departamento de Pediatría, Clínica Alemana de Santiago, Santiago de Chile, Chile; Facultad de Medicina, Clínica Alemana - Universidad del Desarrollo, Santiago de Chile, Chile
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Khandelwal P, Sharma S, Bhardwaj S, Thergaonkar RW, Sinha A, Hari P, Lodha R, Bagga A. Experience with Continuous Renal Replacement Therapy. Indian J Pediatr 2015; 82:752-4. [PMID: 25776002 DOI: 10.1007/s12098-015-1743-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 03/02/2015] [Indexed: 11/29/2022]
Abstract
Information on provision of continuous renal replacement therapy (CRRT) in critically ill children from developing countries is limited. The authors describe their experience in 17 children with hypotension and acute kidney injury (AKI) with fluid overload or electrolyte imbalance managed by 20 sessions of CRRT. The median (range) age and weight were 6 y (0.75-18) and 20 kg (6.2-42), respectively. All patients were receiving inotropic agents; nine had fluid overload (19 %, range 11-34.1 %) and ten had severe AKI. Median clearance and filter-life were 2171.4 ml/1.73 m(2)/h (1730.6-4405.8) and 69.7 h (2.8-98.3), respectively. Complications were catheter flow related (n = 1), filter clotting (n = 3), hemorrhage (n = 3), hypokalemia (n = 16) and hypophosphatemia (n = 11). Eight patients (47.1 %) survived; the median PRISM III score of survivors was significantly lower than non survivors (10.5 vs.17.0; P 0.02). Renal function recovered in the survivors emphasizing the role of this modality in managing critically ill patients.
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Affiliation(s)
- Priyanka Khandelwal
- Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
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Shin HS, Oh JY, Park SJ, Kim JH, Lee JS, Shin JI. Outcomes of Hemodialysis in Children: A 35-Year Experience at Severance Hospital. Yonsei Med J 2015; 56:1007-14. [PMID: 26069124 PMCID: PMC4479829 DOI: 10.3349/ymj.2015.56.4.1007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE The aim of this study was to analyze the results of children treated with hemodialysis (HD) at Severance Hospital over 35 years in terms of incidence, etiologies, characteristics, complications, and clinical outcomes. MATERIALS AND METHODS We analyzed 46 children admitted to Severance Hospital who had undergone HD between January 1979 and December 2013. RESULTS The main etiologies of the 23 end-stage renal disease (ESRD) patients who had received HD were chronic glomerulonephritis (7 patients, 30.4%) and congenital anomalies of the kidney and urinary tract (7 patients, 30.4%), whereas the etiology of the 23 acute kidney injury (AKI) patients was hemolytic uremic syndrome (6 patients, 26.1%). Compared with ESRD patients, hemocatheter placement in the femoral vein was preferred over the subclavian or internal jugular vein in the AKI patients (p=0.012). The most common complication was catheter related complication (10 patients, 21.7%). The site of hemocatheter insertion was not related to the frequency of oozing. Placing the hemocatheter in the femoral vein resulted in significantly more events of catheter obstruction than insertion in the internal jugular vein or the subclavian vein (p=0.001). Disequilibrium syndrome occurred more frequently in older patients (p=0.004), as well as patients with a greater body weight (p=0.008) and a higher systolic and diastolic blood pressure before HD (systolic: p=0.021; diastolic: p=0.040). CONCLUSION Based on the 35 years of experience in our center, HD can be sufficiently and safely carried out even in children without significant complications.
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Affiliation(s)
- Hyun-Seung Shin
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Young Oh
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Se Jin Park
- Department of Pediatrics, Daewoo General Hospital, Ajou University School of Medicine, Geoje, Korea
| | - Ji Hong Kim
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Seung Lee
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Il Shin
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea.
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Zhang YL, Hu WP, Zhou LH, Wang Y, Cheng A, Shao SN, Hong LL, Chen QY. Continuous renal replacement therapy in children with multiple organ dysfunction syndrome: a case series. Int Braz J Urol 2015; 40:846-52. [PMID: 25615255 DOI: 10.1590/s1677-5538.ibju.2014.06.18] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Accepted: 04/06/2014] [Indexed: 11/22/2022] Open
Abstract
There is a lack of definitive information regarding the precise indications, implementation, and outcomes of continuous renal replacement therapy (CRRT) for the treatment of critically ill children. Six children (three boys, three girls) aged from 3 days to 8 years, all of whom had multiple organ failure, were submitted to bedside CRRT using M60 filter membranes. Modified Port carbonate formula was used and clotting time was maintained between 20 and 30 minutes. Activated partial thromboplastin time was 1.5- to 2-fold normal. One patient discontinued treatment due to family decision. Marked improvements were seen in the remaining five patients, including normalization of blood urea nitrogen and creatinine levels, stabilization of electrolytes, and improvements in markers of organ function. Of note, one patient (a six-year-old male) underwent the treatment for 241 hours. All five patients were subsequently discharged and recovered uneventfully. CRRT is effective for the management of children who are critically ill due to multiple organ failure.
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Affiliation(s)
- Yan-lin Zhang
- Department of Nephrology, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen 361003, People's Republic of China and Department of Nephrology, The First Hospital of Xiamen, Fujian Medical University, Xiamen 361003, People's Republic of China
| | - Wei-ping Hu
- Department of Nephrology, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen 361003, People's Republic of China and Department of Nephrology, The First Hospital of Xiamen, Fujian Medical University, Xiamen 361003, People's Republic of China
| | - Ling-hui Zhou
- Department of Nephrology, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen 361003, People's Republic of China and Department of Nephrology, The First Hospital of Xiamen, Fujian Medical University, Xiamen 361003, People's Republic of China
| | - Yin Wang
- Department of Nephrology, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen 361003, People's Republic of China and Department of Nephrology, The First Hospital of Xiamen, Fujian Medical University, Xiamen 361003, People's Republic of China
| | - Ao Cheng
- Department of Nephrology, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen 361003, People's Republic of China and Department of Nephrology, The First Hospital of Xiamen, Fujian Medical University, Xiamen 361003, People's Republic of China
| | - Si-nan Shao
- Department of Nephrology, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen 361003, People's Republic of China and Department of Nephrology, The First Hospital of Xiamen, Fujian Medical University, Xiamen 361003, People's Republic of China
| | - Ling-Ling Hong
- Department of Nephrology, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen 361003, People's Republic of China and Department of Nephrology, The First Hospital of Xiamen, Fujian Medical University, Xiamen 361003, People's Republic of China
| | - Qiu-yue Chen
- Department of Nephrology, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen 361003, People's Republic of China and Department of Nephrology, The First Hospital of Xiamen, Fujian Medical University, Xiamen 361003, People's Republic of China
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