Pediatric acute renal failure: outcome by modality and disease

Abstract

Two hundred and twenty-six children who underwent renal replacement therapy (RRT) from 1992 to 1998 were retrospectively reviewed. The mean age, at the onset of RRT, was 74+/-11.7 months and weight was 25.3+/-9.7 kg. RRT therapies included hemofiltration (HF; n=106 children for an average of 8.7+/-2.3 days), hemodialysis (HD; n=61 children for an average of 9.5+/-1.7 days), and peritoneal dialysis (PD; n=59 children for an average of 9.6+/-2.1 days). Factors influencing patient survival included: (1) low blood pressure (BP) at onset of RRT (33% survival with low BP, vs. 61% with normal BP, vs 100% with high BP; P<0.05), (2) use of pressors anytime during RRT (35% survival in those on pressors vs. 89% survival in those not requiring pressors; P<0.01), (3) diagnosis (primary renal failure with a high likelihood of survival vs secondary renal failure; P<0.05), (4) RRT modality (40% survival with HF, vs. 49% survival with PD, vs. 81% survival with HD; P<0.01 HD vs PD or HF), and (5) pressor use was significantly higher in children on HF (74%) vs HD (33%) or PD (81%; P<0.05 HD vs HF or PD). In conclusion, pressor use has the greatest prediction of survival, rather than RRT modality. Patient survival in children with the need for RRT for ARF is similar to in adults and, as in adults, is best predicted by the underlying diagnosis and hemodynamic stability.

Peritoneal Dialysis for Acute Kidney Injury

“…5 PDI The etiology of AKI is different between children from developed and developing countries. Whereas ischemic/hypoxic and nephrotoxic injury secondary to prematurity, post-cardiac surgery, or bone marrow transplantation are common in the former, infectionrelated causes (especially malaria), gastroenteritis and primary renal diseases are common in the latter (68)(69)(70). Renal replacement therapy in the form of PD, HD or continuous renal replacement therapy (CRRT) is frequently needed and the decision to use any of these modalities should not be delayed; higher survival rates in neonates and infants have been associated with early initiation of PD (71,72).…”

“…Finally, there have been improvements in dialysate solutions with the use of low glucose degradation products (GDP), bicarbonate-buffered solutions which are asso-, bicarbonate-buffered solutions which are associated with reduced inflow pain; unfortunately, these solutions are not available in many countries. (68,(77)(78)(79). However, in 1 study, CVVH was associated with better fluid control and was superior to PD in the management of hypercatabolic AKI due to sepsis (79).…”

“…However, in none of these studies was there a survival benefit associated with the use of CVVH. In 1 study in which the 3 modalities were compared in children, it was concluded that the underlying clinical diagnosis, hemodynamic stability and the use of pressor agents were the key predictors of mortality rather than the type of RRT (68). As is characteristic of many pediatric investigations, these studies were all hampered by the small number of patients, a lack of standardization of the therapy provided, variability in terms of the modalities available, and additional variability regarding expertise and experience with the different modalities, such that the effect of bias could not be eliminated.…”

AKI in Hospitalized Children

“…Most pediatric studies have been from single centers and are limited by small sample size and a propensity to focus only on critical care populations or children who require dialysis (2,(14)(15)(16)(17)(18)(19)(20)(21)(22). Studies have suggested that the epidemiology of pediatric AKI has changed dramatically over the past few decades, noting that sepsis, congenital heart disease, and oncologic illness have replaced hemolytic uremic syndrome, GN, and primary renal diseases as the most common causes of AKI in hospitalized children (14,23).…”

Serum neutrophil gelatinase-associated lipocalin (NGAL) as a marker of acute kidney injury in critically ill children with septic shock

“…Shock and subsequent multiple organ dysfunction remain significant risk factors for mortality in these patients . Sepsis remains a significant risk factor and one of the leading causes of AKI in critically ill children (3)(4)(5)(6)13,14,(18)(19)(20)(21).…”