Successful use of intra‐operative continuous renal replacement therapy in pediatric liver transplant recipients: Single center case series

Abstract

Background Acute kidney injury (AKI) is common in pediatric patients undergoing liver transplantation (LT), with an incidence 17%–55%. Fluid, metabolic, and acid–base aberrancies are often pronounced pre‐operatively and further worsened by events during LT, making intra‐operative continuous renal replacement therapy (CRRT) an option for critically ill LT recipients. Methods All pediatric LT performed at our institution who underwent intra‐operative CRRT between January 2017 and August 2021 were included. Patient demographics and clinical data including graft outcomes, intra‐operative findings, and timing and indications for CRRT were collected from the electronic medical record. Results CRRT was used in nine of the 76 (12%) pediatric LT performed at our center during the study period. Ages at LT ranged from 39 to 17.7 years. Recipients requiring CRRT were more likely to have acute liver failure, status 1A, and higher calculated MELD/PELD scores. CRRT was initiated pre‐transplant in three recipients and continued post‐transplant in six recipients. Median duration of CRRT was two (range 0–14) days. Indications included hyperammonemia (3/9), acidosis (3/9), fluid overload (6/9), and hyperkalemia (2/9). The CRRT group had a significantly longer post‐transplant intensive care unit length of stay in comparison to those that did not require CRRT (median 6, range 3–40 days vs. median 3, range 0–121 days, p = .02], but there were no significant differences in reoperations, hospital length of stay, or recipient or graft survival. Conclusions We demonstrate that CRRT can be safely performed in pediatric LT recipients, including young infants through adolescents.

Intraoperative renal replacement therapy during liver transplantation in children: Safety, efficacy and impact on survival

“…Blanchette et al. were the first to our knowledge to report successful use of iCRRT in nine patients 20 . This study, first in pediatric LT, demonstrated feasibility and safety of iCRRT.…”

“…Blanchette et al were the first to our knowledge to report successful use of iCRRT in nine patients. 20 This study, first in pediatric LT, demonstrated feasibility and safety of iCRRT. Recipients in this study requiring iCRRT were more likely to have acute liver failure, had a significantly longer post-transplant intensive care unit length of stay in comparison to the rest of the cohort, with no significant differences in reoperations, hospital length of stay, or recipient or graft survival.…”

“…In our study, the frequency of those needing CRRT pre-LT was 10%, which is in line with most adult data yet higher than the current pediatric case series. 16,20 It is important to note that a unique patient population who received dual liver/kidney transplants are not included in this study. In the time period of our study, there were 14 patients who received liver/kidney transplantation.…”

“…Thus, it is imperative to identify if there is a subset of highrisk pediatric LT patients who might benefit from iCRRT among the associated risks. To our knowledge, current data on iCRRT in children is limited to only one recent case series describing safety of iCRRT in pediatric LT. 20 The purpose of this study is to evaluate safety and efficacy of iCRRT in children receiving OLT at our institution among two matched cohort groups: (a) iCRRT group (those who received CRRT before OLT as well as during the intraoperative phase; and (b) non-iCRRT group (those who received CRRT before OLT but not during the intraoperative phase). We hypothesized that iCRRT in children receiving OLT is safe and efficacious in preserving intraoperative homeostasis and can improve post-transplant outcomes.…”

“…Thus, it is imperative to identify if there is a subset of high‐risk pediatric LT patients who might benefit from iCRRT among the associated risks. To our knowledge, current data on iCRRT in children is limited to only one recent case series describing safety of iCRRT in pediatric LT 20 …”