Pediatric continuous renal replacement therapy: have practice changes changed outcomes? A large single-center ten-year retrospective evaluation

Riley, Alyssa A.; Watson, Mary N; Smith, Caroline J.; Guffey, Danielle; Minard, Charles G.; Currier, Helen; Akcan-Arikan, Ayse

doi:10.1186/s12882-018-1068-1

Cited by 30 publications

(28 citation statements)

References 55 publications

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“…This study also showed the dramatic increase in morbidity and mortality in patients who required CRRT which has been previously reported [7,14,15]. As expected by PRISM-III scores, the overall mortality and morbidity rates in this study were high overall, but CRRT patients had signi icant morbidity burden and mortality rates as compared to patients who did not require CRRT.…”

Section: Discussionsupporting

confidence: 85%

Modification of the Renal Angina Index for identifying the need for renal replacement therapy in critically ill pediatric patients

Stenson¹,

Brinton²,

Beil³

et al. 2020

J Clini Nephrol

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Severe Acute Kidney Injury (AKI) is a common, serious problem affecting critically ill children that lacks effective treatment options. Currently, there are no treatment options for AKI other than supportive care. Continuous renal replacement therapy (CRRT) is employed to reduce Fluid Overload (FO) burden and treat metabolic disturbances in AKI. Identifying patients upon admission who may require CRRT has potential clinical care implications. The aim of this study was to determine if the RAI had diagnostic capabilities to identify patients who would require CRRT. The analytic cohort consisted of patients who required CRRT and illness severity score matched controls who did not require CRRT at a single center. Patients who required CRRT had higher mortality rates, length of stay, and use of ventilatory and inotropic support. Sensitivity, specificity and area under the receiver operating characteristic curve (AUC) assessed and compared the discriminatory accuracy of three scores: 1) the renal angina index (RAI), 2) serum-creatinine (sCr) based AKI on day 0 and 3) modified RAI created with an additional RAI injury tranche that corresponded to severe stage 3 AKI sCr elevation. Compared to Day0AKI (AUC 0.78, 0.70-0.87; sensitivity 0.63, 0.45-0.79; specificity 0.93, 0.870.97) and RAI (AUC 0.76, 0.69-0.82; sensitivity 0.94, 0.81-0.99; specificity 0.57, 0.47-0.66), the modified RAI had the highest AUC (0.79; 0.72-0.85) with a high sensitivity (0.91; 0.77-0.98) and moderate specificity (0.65; 0.56-0.75) for prediction of CRRT requirements. As a more accurate tool for discriminating patients in need of CRRT, a modified RAI has numerous potential implications. Identifying patients who ultimately require CRRT at an earlier timepoint may influence timing of CRRT initiation in an attempt to avoid further FO, or may influence nephrotoxin administration. The diagnostic capabilities of the modified RAI may be refined by the addition of urinary biomarkers. These findings should be validated in a larger cohort.

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Section: Discussionsupporting

confidence: 85%

Modification of the Renal Angina Index for identifying the need for renal replacement therapy in critically ill pediatric patients

Stenson¹,

Brinton²,

Beil³

et al. 2020

J Clini Nephrol

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“…In a large multicenter observational study, only 1.5% of critically ill children underwent CRRT (2). A knowledge gap exists regarding clinical and technical peculiarities of CRRT in the pediatric population (7), and several researchers in the field encourage the sharing of experiences and clinical and technical data (8)(9)(10)(11). Predictors for circuit clotting are mostly unknown and originate from large cohorts of adult patients (12,13).…”

Section: Introductionmentioning

confidence: 99%

“…Uncertainties also exist on long-term kidney and global outcomes of critically ill pediatric patients who underwent CRRT. Although CRRT has been recognized as a strong predictor of short-term mortality, particularly when associated with fluid overload (FO) and MODS (14)(15)(16)(17), pediatric AKI patients undergoing CRRT often encounter delays in referral to the nephrology unit or are lost to long-term follow-up (10,18).…”

Section: Introductionmentioning

confidence: 99%

Continuous Renal Replacement Therapy in Critically Ill Children in the Pediatric Intensive Care Unit: A Retrospective Analysis of Real-Life Prescriptions, Complications, and Outcomes

et al. 2021

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Introduction: Severe acute kidney injury is a common finding in the Pediatric Intensive Care Unit (PICU), however, Continuous Renal Replacement Therapy (CRRT) is rarely applied in this setting. This study aims to describe our experience in the rate of application of CRRT, patients' clinical characteristics at admission and CRRT initiation, CRRT prescription, predictors of circuit clotting, short- and long-term outcomes.Methods: A 6-year single center retrospective study in a tertiary PICU.Results: Twenty-eight critically ill patients aged 0 to 18 years received CRRT between January 2012 and December 2017 (1.4% of all patients admitted to PICU). Complete clinical and CRRT technical information were available for 23/28 patients for a total of 101 CRRT sessions. CRRT was started, on average, 40 h (20–160) after PICU admission, mostly because of fluid overload. Continuous veno-venous hemodiafiltration and systemic heparinization were applied in 83.2 and 71.3% of sessions, respectively. Fifty-nine sessions (58.4%) were complicated by circuit clotting. At multivariate Cox-regression analysis, vascular access caliber larger than 8 Fr [HR 0.37 (0.19–0.72), p = 0.004] and regional citrate anticoagulation strategy [HR 0.14 (0.03–0.60), p = 0.008] were independent protective factors for clotting. PICU mortality rate was 42.8%, and six survivors developed chronic kidney disease (CKD), within an average follow up of 3.5 years.Conclusions: CRRT is uncommonly applied in our PICU, mostly within 2 days after admission and because of fluid overload. Larger vascular access and citrate anticoagulation are independent protective factors for circuit clotting. Patients' PICU mortality rate is high and survival often complicated by CKD development.

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“…Interestingly, in our cohort, there was a significant protective effect from having pre-existing kidney disease against developing moderate to severe disability at discharge. We did not compare the severity of illness for the eleven survivors with pre-existing renal disease to the remainder of the cohort, but good global outcomes have been demonstrated in children receiving CKRT primarily for a renal indication in other cohorts [ 15 , 16 ]. Although not examined separately, there were more patients who received intermittent HD after CKRT in the worse FSS group compared to intact survival; whether this reflects the adverse impact of delayed kidney recovery on functional outcomes remains speculative and should be further investigated.…”

Section: Discussionmentioning

confidence: 99%

Patient-centered outcomes in pediatric continuous kidney replacement therapy: new morbidity and worsened functional status in survivors

et al. 2021

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Background Ongoing measures to improve pediatric continuous kidney replacement therapy (CKRT) have lowered mortality rates, shifting the focus to survivor functional status. While septic acute kidney injury generates new morbidity in pediatric critically ill patients, acquired morbidities and functional status of CKRT population are unknown. We predicted that CKRT survivors are at risk for new morbidity and would have worse functional status at PICU discharge compared to baseline, and aimed to describe associated factors. Methods Retrospective cohort study over 24 months of CKRT patients surviving to PICU discharge in a quaternary children’s hospital. Functional outcome was determined by Functional Status Scale (FSS). Results FSS scores were higher at PICU and hospital discharge compared to baseline. Of 45 CKRT survivors, 31 (69%) had worse FSS score at PICU discharge and 51% had new morbidity (≥3 increase in FSS); majority qualified as moderate to severe disability (FSS ≥10). Four patients (9%) had new tracheostomy, 3 (7%) were ventilator dependent, and 10 (22%) were dialysis dependent. Most (23/45, 51%) required outpatient rehabilitation. Cumulative days on sedation, controlled for illness severity, were independently associated with worse FSS at PICU discharge (aOR 25.18 (3.73, 169.92)). In adjusted analyses, duration of sedation was associated with new morbidity, while neurologic comorbidity, percent fluid overload at CKRT start, and nonrenal comorbidity were associated with moderate to severe disability at PICU discharge when controlled for baseline FSS. Conclusions CKRT survivors, with new morbidity and worse functional outcomes at PICU discharge, are a newly described vulnerable population requiring targeted follow-up. Deliberate decrease of sedation exposure in patients with decreased clearance due to organ dysfunction needs to be studied as a modifiable risk factor. Supplementary Information The online version contains supplementary material available at 10.1007/s00467-021-05177-7.

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Pediatric continuous renal replacement therapy: have practice changes changed outcomes? A large single-center ten-year retrospective evaluation

Cited by 30 publications

References 55 publications

Modification of the Renal Angina Index for identifying the need for renal replacement therapy in critically ill pediatric patients

Modification of the Renal Angina Index for identifying the need for renal replacement therapy in critically ill pediatric patients

Continuous Renal Replacement Therapy in Critically Ill Children in the Pediatric Intensive Care Unit: A Retrospective Analysis of Real-Life Prescriptions, Complications, and Outcomes

Patient-centered outcomes in pediatric continuous kidney replacement therapy: new morbidity and worsened functional status in survivors

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