Neonatal extracorporeal renal replacement therapy—a routine renal support modality?

Abstract

Peritoneal dialysis (PD) is generally considered the preferred extracorporeal therapy for neonates with acute kidney injury (AKI). However, there are situations when PD is not suitable, such as in patients with previous abdominal surgery, hyperammonemia and significant ascites or anasarca. Additionally, with a need to start PD soon after catheter placement, there is increased risk of PD catheter leak and infection. Extracorporeal continuous renal replacement therapy (CRRT) is challenging in severely ill neonates as it requires obtaining adequately sized central venous access to accommodate adequate blood flow rates and also adaptation of a CRRT machine meant for older children and adults. In addition, ultrafiltration often cannot be set in sufficiently small increments to be suitable for neonates. Although CRRT practices can be modified to fit the needs of infants and neonates, there is a need for a device designed specifically for this population. Until that becomes available, providing the highest level of care for neonates with AKI is dependent on the shared experiences of members of the pediatric nephrology community.Keywords Extracorporeal continuous renal replacement therapy . Acute kidney injury . Neonates . nRIFLE . Continuous venovenous hemodiafiltrationIn a recent article in Pediatric Nephrology, Lee and Cho review their continuous renal replacement therapy (CRRT) experience in 34 neonates with acute kidney injury (AKI) [1]. Although single center and retrospective, there are several noteworthy characteristics of this study. The authors standardize neonatal AKI using the neonatal RIFLE (nRIFLE) criteria to define and stratify severity of AKI. Of the 34 neonates included in the study, 44 % were born preterm (25-36 weeks), with 60 % of these preterm infants being either extremely or very low birth weight. All patients had AKI, and 24 patients met the nRIFLE class F (Failure) criterion. Survival was 50 %. Continuous venovenous hemodiafiltration (CVVHDF) with Prisma or Prismaflex (Gambro/Baxter Int., Lund, Sweden) dialysis machines and M10 (50 ml) or HF20 (55 ml) filters was used for all CRRT treatments. Access was via internal jugular 6.5-French (Fr) hemodialysis catheters. Mean filter life was 51.1 h. Similar to other studies in pediatric CRRT patients [2-4, 5], fluid overload (FO), defined by the percentage weight gain over weight at admission to the neonatal intensive care unit (NICU), was independently associated with mortality [6]. Neonatal studies have reported an FO of >15-20 % to be associated with poor outcome defined as need for CRRT, prolonged NICU stay, time to extubation or death within 30 days postcardiothoracic surgery [7,8]. Interestingly, this study by Lee and Cho [1] reports a much higher FO cut-off of 30 % being associated with poor outcomes, including 100 % mortality for patients reaching an FO of >30 %. The authors propose higher body surface area, calorie consumption and insensible water loss in neonates as a possible explanation. They address this issue by using actual weig...

Renal replacement therapy in the neonatal intensive care unit

“…6 Although different types of CRRT are available (HD, hemofiltration, or both), hemofiltration still remains the key mode of CRRT in neonatal patients. 7 With the use of CRRT, continuous ultrafiltration and solute clearance can be achieved even in a hemodynamically unstable patient. 8 However, despite current advancements, CRRT in neonatal patients continues to encounter limitations from vascular access, bleeding complications, and a lack of neonatalspecific hemofiltration devices.…”

Challenges of acute peritoneal dialysis in extremely-low-birth-weight infants: a retrospective cohort study

“…These include vascular access, bleeding complications, and lack of neonate-specific devices. An adequately-sized central venous access is needed to accommodate adequate blood flow rates and a CRRT machine meant for neonates should be adapted [ 25 , 26 ]. A few studies have reported the use of CRRT in the NICU [ 25 – 27 ].…”

Challenges of acute peritoneal dialysis in extremely-low-birth-weight infants: a retrospective cohort study

“…These include vascular access, bleeding complications, and lack of neonate-speci c devices. An adequately-sized central venous access is needed to accommodate adequate blood ow rates and a CRRT machine meant for neonates should be adapted [26,27]. A few studies have reported the use of CRRT in the NICU [25][26][27].…”

“…An adequately-sized central venous access is needed to accommodate adequate blood ow rates and a CRRT machine meant for neonates should be adapted [26,27]. A few studies have reported the use of CRRT in the NICU [25][26][27]. Although CRRT practices can be modi ed to t the needs of neonates including preterms, there is a need for a device designed speci cally for this population [25][26][27].…”