Prolonged intermittent renal replacement therapy in children

Abstract

Wide ranges of age and weight in pediatric patients makes renal replacement therapy (RRT) in acute kidney injury (AKI) challenging, particularly in the pediatric intensive care unit (PICU), wherein children are often hemodynamically unstable. Standard hemodialysis (HD) is difficult in this group of children and continuous veno-venous hemofiltration/dialysis (CVVH/D) has been the accepted modality in the developed world. Unfortunately, due to cost constraints, CVVH/D is often not available and peritoneal dialysis (PD) remains the common mode of RRT in resource-poor facilities. Acute PD has its drawbacks, and intermittent HD (IHD) done slowly over a prolonged period has been explored as an alternative. Various modes of slow sustained IHD have been described in the literature with the recently introduced term prolonged intermittent RRT (PIRRT) serving as an umbrella terminology for all of these modes. PIRRT has been widely accepted in adults with studies showing it to be as effective as CVVH/D but with an added advantage of being more cost-effective. Pediatric data, though scanty, has been promising. In this current review, we elaborate on the practical aspects of undertaking PIRRT in children as well as summarize its current status.

Pediatric Continuous Renal Replacement Therapy (PCRRT) expert committee recommendation on prescribing prolonged intermittent renal replacement therapy (PIRRT) in critically ill children

“…Another study from Taiwan by Lee et al used the following operational definition of SLED‐F; wherein the therapy lasted for 8 to 10 hours, blood flow rates were set at 5 mL/kg/min for bodyweight up to 40 kg or 200 mL/min for bodyweight >40 kg, counter current dialysate flow to 260 mL/min, and filtration rate to 35 ml/kg/h in predilution mode. Table illustrates Sinha et al's recommendation for blood flow in children with weight of 5 to 20 kg, 20 to 40 kg, >40 kg necessitating 30 to 75 mL/min, 75 to 125 mL/min, and > 150 mL/min of blood flow, respectively . These terminologies and their operational definitions are detailed in Table .…”

“…Any extracorporeal mode of RRT given intermittently over a prolonged session (i.e ≥ 6 hours) can be defined as PIRRT …”

“…Children who are on more than two inotropes should be started on CRRT, rather than PIRRT. The indications for RRT may be as follows: nonobstructive oliguria with fluid overload, refractory metabolic acidosis, hyperkalemia, uremic organ involvement (pericarditis, encephalopathy, neuropathy, myopathy), severe refractory dysnatremia, dialyzable drug overdose, neonatal hyperammonemia, and other inborn errors of metabolism, coagulopathy requiring large amounts of blood products in patients at risk of pulmonary edema or acute respiratory distress syndrome (ARDS), and refractory edema not responding to high dose diuretics . In the above situations, PIRRT may be used as the primary modality if the child is hemodynamically unstable and less likely to tolerate intermittent hemodialysis.…”

“…Some of the currently used single‐pass machines include the Fresenius 2008, Fresenius 4008, and Fresenius 5008 series. Currently used batch dialysate machine include the Genius Machine from Gambro, Althin from Tina and Diamax …”

“…Prolonged renal replacement therapies that offer a conceptual hybrid of continuous renal replacement therapies (CRRT) and intermittent hemodialysis therapies (IHD) have emerged as cost‐effective alternatives to conventional CRRT . These therapies were widely applied to hemodynamically unstable adults that required inotropic support.…”