Renal Replacement Therapy Modalities in Critically Ill Children*

Abstract

Objectives: The objective of this study is to describe the relative frequency of use of continuous renal replacement therapy, intermittent hemodialysis, and peritoneal dialysis and to analyze characteristics and outcomes of critically ill children receiving renal replacement therapies admitted to PICUs that participate in the Virtual PICU (VPS LLC, Los Angeles, CA) registry. Design: Retrospective, database analysis. Setting: PICUs that participate in the Virtual PICU (VPS LLC) registry. Patients: Critically ill children admitted to PICUs that participate in the Virtual PICU (VPS LLC) registry and received renal replacement therapy from January 1, 2009, to December 31, 2015. Interventions: None. Measurements and Main Results: A total of 7,109 cases (53% males) received renal replacement therapy during the study period. The median age was 72.3 months (interquartile range, 8.4–170 mo) and median length of stay was 8.7 days (interquartile range, 3.3–21.2 d). Caucasians comprised 42% of the cohort and blacks and Hispanics were 16% each. Continuous renal replacement therapy was used in 46.5%, hemodialysis in 35.5% and peritoneal dialysis in 18%. Of the 7,109 cases, 1,852 (26%) were postoperative cases (68% cardiac surgical) and 981 (14%) had a diagnosis of cancer. Conventional mechanical ventilation was used in 64%, high-frequency oscillatory ventilation in 12%, noninvasive ventilation in 24%, and extracorporeal membrane oxygenation in 5.8%. The overall mortality was 22.3%. Patients who died were younger 40.8 months (interquartile range, 1.5–159.4 mo) versus 79.9 months (interquartile range, 12.6–171.7 mo), had a longer length of stay 15 days (interquartile range, 7–33 d) versus 7 days (interquartile range, 3–18 d) and higher Pediatric Index of Mortality 2 score –2.84 (interquartile range, –3.5 to –1.7) versus –4.2 (interquartile range, –4.7 to –3.0) (p < 0.05). On multivariate logistic regression analysis, higher mortality was associated with the presence of cancer (32.7%), previous ICU admission (32%), requiring mechanical ventilation (33.7%), receiving high-frequency oscillatory ventilation (67%), or extracorporeal membrane oxygenation (58.4%), admission following cardiac surgical procedure (29.4%), and receiving continuous renal replacement therapy (38.8%), and lower mortality was associated with hemodialysis (9.8%), and peritoneal dialysis (12.3%) (p < 0.0001). Conclusions: Continuous renal replacement therapy is an increasingly prevalent renal replacement therapy modality used in critically ill children admitted to an ICU. Higher mortality rate with the use of continuous renal replacement therapy should be interpreted with caution.

Renal replacement therapies for infants and children in the ICU

“…CRRT is often the preferred modality for management of the critically ill, hemodynamically unstable patient needing dialysis in the ICU [35]. CRRT shares many principles of solute clearance and ultrafiltration with IHD but at much lower flow rates [21].…”

Population Pharmacokinetics of Phenobarbital in Neonates and Infants on Extracorporeal Membrane Oxygenation and the Influence of Concomitant Renal Replacement Therapy

“…Moreover, as CVVHDF was the only RRT modality used in our population, the effect may be different in children supported by other RRT modalities. CVVH, intermittent hemodialysis, and peritoneal dialysis are also frequently used in children on ECMO 43,44 . Their effectiveness in treating phenobarbital intoxication suggests that those modalities are associated with an increase in phenobarbital clearance, although the extent of this effect remain to be characterized 45–48 .…”

“…CVVH, intermittent hemodialysis, and peritoneal dialysis are also frequently used in children on ECMO. 43,44 Their effectiveness in treating phenobarbital intoxication suggests that those modalities are associated with an increase in phenobarbital clearance, although the extent of this effect remain to be characterized. [45][46][47][48] Therefore, we suggest routine TDM use in children on RRT (excluding slow continuous ultrafiltration).…”

Terapia de reemplazo renal continua en niños: de los conceptos a la prescripción

“…Es una entidad frecuente en pacientes en estado crítico, que puede ser o no reversible (5,6). Aunque existen múltiples causas de Lesión renal aguda (LRA), estas varían de acuerdo a las características clínicas y demográficas de cada paciente, comorbilidades como sepsis, hipotensión, deshidratación y tratamientos como ventilación mecánica, terapia vasoactiva, trasplantes de órganos y cirugía cardiovascular (4,6,7).…”

“…En 1977, Peter Kramer cambió la hemodiálisis intermitente tradicional por un nuevo tratamiento llamado hemofiltrado continuo arteriovenoso, procedimiento basado en una membrana (filtro) altamente permeable, conectado a una arteria y a una vena mediante accesos vasculares de hemodiálisis modificada, logrando la producción lenta de un ultrafiltrado y la sustitución de líquidos para mantener un adecuado balance. En años recientes, la técnica se ha modificado y se han introducido diferentes innovaciones que conforman las actuales modalidades de TRRC (1,4).…”