Continuous Kidney Replacement Therapy Practices in Pediatric Intensive Care Units Across Europe

Abstract

ImportanceContinuous kidney replacement therapy (CKRT) is the preferred method of kidney support for children with critical illness in pediatric intensive care units (PICUs). However, there are no data on the current CKRT management practices in European PICUs.ObjectiveTo describe current CKRT practices across European PICUs.Design, Setting, and ParticipantsThis cross-sectional survey of PICUs in 20 European countries was conducted by the Critical Care Nephrology Section of the European Society of Pediatric and Neonatal Intensive Care from April 1, 2020, to May 31, 2022. Participants included intensivists and nurses working in European PICUs. The survey was developed in English and distributed using SurveyMonkey. One response from each PICU that provided CKRT was included in the analysis. Data were analyzed from June 1 to June 30, 2022.Main Outcome and MeasuresDemographic characteristics of European PICUs along with organizational and delivery aspects of CKRT (including prescription, liberation from CKRT, and training and education) were assessed.ResultsOf 283 survey responses received, 161 were included in the analysis (response rate, 76%). The attending PICU consultant (70%) and the PICU team (77%) were mainly responsible for CKRT prescription, whereas the PICU nurses were responsible for circuit setup (49%) and bedside machine running (67%). Sixty-one percent of permanent nurses received training to use CKRT, with no need for certification or recertification in 36% of PICUs. Continuous venovenous hemodiafiltration was the preferred dialytic modality (51%). Circuit priming was performed with normal saline (67%) and blood priming in children weighing less than 10 kg (56%). Median (IQR) CKRT dose was 35 (30-50) mL/kg/h in neonates and 30 (30-40) mL/kg/h in children aged 1 month to 18 years. Forty-one percent of PICUs used regional unfractionated heparin infusion, whereas 35% used citrate-based regional anticoagulation. Filters were changed for filter clotting (53%) and increased transmembrane pressure (47%). For routine circuit changes, 72 hours was the cutoff in 62% of PICUs. Some PICUs (34%) monitored fluid removal goals every 4 hours, with variation from 12 hours (17%) to 24 hours (13%). Fluid removal goals ranged from 1 to 3 mL/kg/h. Liberation from CKRT was performed with a diuretic bolus followed by an infusion (32%) or a diuretic bolus alone (19%).Conclusions and RelevanceThis survey study found a wide variation in current CKRT practice, including organizational aspects, education and training, prescription, and liberation from CKRT, in European PICUs. This finding calls for concerted efforts on the part of the pediatric critical care and nephrology communities to streamline CKRT education and training, research, and guidelines to reduce variation in practice.

Epoprostenol (Prostacyclin Analog) as a Sole Anticoagulant in Continuous Renal Replacement Therapy for Critically Ill Children With Liver Disease: Single-Center Retrospective Study, 2010–2019*

“…Clotting is one of the key complications of CRRT, with downtime reducing the positive benefits of CRRT. A 2022 survey of CRRT practice among PICUs across Europe described catheter and circuit thrombosis as the most common complication encountered when anticoagulating for CRRT (20). A meta-analysis of clotting events in pediatric circuits anticoagulated with citrate or heparin reported 28.4% of circuits clotted with citrate and 39.3% with heparin (14).…”

Standardizing Care in Pediatric Continuous Kidney Replacement Therapy—Can We Reach Consensus Without Adequate Evidence?

“…This study by Daverio and colleagues may not capture actual practice patterns as only 1 person per PICU was surveyed, potentially introducing confirmation bias and availability heuristic. Indeed, this situation might explain the surprisingly short time reported between the decision to initiate and initiating CKRT (2 hours) as it is not quite clear how this data point was collected and may be biased by recall or optimism.…”

“…There are several issues with this survey study that should be underscored. This report encompassed only European PICUs 1 and could not glean global variation in practice. Moreover, of the 161 responses from 211 PICUs analyzed, 52% of them came from the UK, Germany, Turkey, and Italy, so there may be substantial intracountry and intercountry heterogeneity, or even homogeneity, that has not been identified by this study.…”

“…Continuous kidney replacement therapy (CKRT) is the predominant extracorporeal support for management of acute kidney injury, fluid overload, and metabolic derangements. Daverio and colleagues surveyed professionals from pediatric intensive care units (PICUs) in 20 countries across Europe. The study covered various domains of center and respondent characteristics, organizational aspects for education and training, CKRT duration, vascular access, approach to CKRT termination, anticoagulation, and fluid-removal strategies.…”

“…Before we can establish consensus, we need to understand the current practice. Daverio and colleagues have provided an important first step; however, there was insufficient granularity to truly get a scope of practice patterns across all European PICUs. Most pediatric CKRT knowledge has originated from adult studies, single-center pediatric reports, and a multicenter registry with selective enrollment of children from the US, making it especially challenging to identify which practice approach is likely to be associated with the best patient outcome.…”