Impact of continuous renal replacement therapy on oxygenation in children with acute lung injury after allogeneic hematopoietic stem cell transplantation

Abstract

Background Acute lung injury (ALI) continues to carry a high mortality rate in children after allogeneic hematopoietic stem cell transplant (HSCT). Continuous renal replacement therapy (CRRT) is often used for these patients for various indications including renal failure and fluid overload, and may have a beneficial effect on oxygenation and survival. Therefore, we sought to determine the effect of CRRT on oxygenation in mechanically ventilated pediatric allogeneic HSCT patients with ALI, and to document survival to intensive care unit discharge in this at-risk population receiving both mechanical ventilation and CRRT. Procedure Retrospective analysis of a pediatric allogeneic HSCT cohort admitted to intensive care unit of a single pediatric oncology center from 1994 to 2006 who received CRRT during a course of mechanical ventilation for ALI. Results Thirty post-HSCT mechanically ventilated children with ALI who underwent CRRT were included. There was a significant improvement in PaO2/FiO2 with median increase of 31 and 43 in the 24 and 48 hour intervals after initiation of CRRT compared with the 24 hour interval before CRRT (p = 0.0008 and 0.0062, respectively). This improvement in PaO2/FiO2 correlated significantly with reduction of fluid balance achieved after initiation of CRRT (p=0.0001). There was a trend not reaching statistical significance in improvement in mean airway pressure 48 hours after CRRT in survivors compared to non-survivors. Conclusions CRRT improved oxygenation in mechanically ventilated pediatric allogeneic HSCT patients with ALI.

The critically-ill pediatric hemato-oncology patient: epidemiology, management, and strategy of transfer to the pediatric intensive care unit

“…In addition, the conditioning regimen may be associated with renal toxicity and with some degree of systemic inflammatory response syndrome accompanied by a capillary leak syndrome [74]. …”

Early Initiation of Continuous Renal Replacement Therapy Improves Clinical Outcomes in Patients With Acute Respiratory Distress Syndrome

“…Although it has not become a standard protocol for ARDS treatment, using CRRT to support ARDS treatment has been studied and reported in several medical centers for the past decade. 22 However, Hoste et al 36 found neither benefit nor harm about CRRT on oxygenation in patients with ARDS and acute kidney injury (AKI). These studies showed the therapeutic benefits of CRRT in ARDS patients.…”

Nonpulmonary Treatments for Pediatric Acute Respiratory Distress Syndrome

“…The choice of fluid to administer in critically ill patients with ALI and ARDS has also been debated (118)(119)(120)(121). Adult studies have shown that hypoproteinemic patients may be twice as likely to develop ALI and three times more likely to die after its onset (122).…”

“…Greater fluid overload at the initiation of CRRT, after adjusting for illness severity, has been associated with increased mortality in critically ill children (113)(114)(115)(116)(117)(118). In a retrospective analysis of CRRT use in pediatric allogeneic hematopoietic stem cell transplantation patients requiring mechanical ventilation for ALI, CRRT significantly improved oxygenation which correlated with reduction in fluid balance (118). Further studies are needed to determine the role of CRRT in fluid management of PARDS.…”