Continuous Renal Replacement Therapy for Children <= 10 kg: A Report from the Prospective Pediatric Continuous Renal Replacement Therapy Registry

ArticleinThe Journal of pediatrics 162(3) · October 2012with62 Reads
Impact Factor: 3.79 · DOI: 10.1016/j.jpeds.2012.08.044 · Source: PubMed
Abstract

Objective: To report circuit characteristics and survival analysis in children weighing ≤10 kg enrolled in the Prospective Pediatric Continuous Renal Replacement Therapy (ppCRRT) Registry. Study design: We conducted prospective cohort analysis of the ppCRRT Registry to: (1) evaluate survival differences in children ≤10 kg compared with other children; (2) determine demographic and clinical differences between surviving and non-surviving children ≤10 kg; and (3) describe continuous renal replacement therapy (CRRT) circuit characteristics differences in children ≤5 kg versus 5-10 kg. Results: The ppCRRT enrolled 84 children ≤10 kg between January 2001 and August 2005 from 13 US tertiary centers. Children ≤10 kg had lower survival rates than children >10 kg (36/84 [43%] versus 166/260 [64%]; P < .001). In children ≤10 kg, survivors were more likely to have fewer days in intensive care unit prior to CRRT, lower Pediatric Risk of Mortality 2 scores at intensive care unit admission and lower mean airway pressure (P(aw)), higher urine output, and lower percent fluid overload (FO) at CRRT initiation. Adjusted regression analysis revealed that Pediatric Risk of Mortality 2 scores, FO, and decreased urine output were associated with mortality. Compared with circuits from children 5-10 kg at CRRT initiation, circuits from children ≤5 kg more commonly used blood priming for initiation, heparin anticoagulation, and higher blood flows/effluent flows for body weight. Conclusion: Mortality is more common in children who are ≤10 kg at the time of CRRT initiation. Like other CRRT populations, urine output and FO at CRRT initiation are independently associated with mortality. CRRT prescription differs in small children.

    • "However, in newborns, the technical limitations (lack of approved dialysis machines and devices specifically designed for low or very low weights), frequently limits the possibility of a widespread use of this intensive approach. This fact allows treatment only in experienced and specialized pediatric nephrology centers, with the use of custom off-label adapted machinery and circuits [15, 16]. "
    [Show abstract] [Hide abstract] ABSTRACT: Neonatal sepsis due to E. coli is often complicated by multiple organ failure (MOF) and a high mortality risk. We report the case of a term newborn discharged in good condition who suddenly fell into septic shock after 11 days and required immediate resuscitation, volume expansion and a high-dosage amine infusion. Extremely severe metabolic acidosis, disseminated intravascular coagulation (DIC) with diffuse bleeding, and unstable hemodynamic status with oliguria turned into strict anuria, and the patient became anuric. The presence of DIC, with gastric and intestinal bleeding, rendered peritoneal dialysis impossible. Continuous renal replacement therapy (CRRT) was started with the new dialysis machine CARPEDIEM(®) (Cardio-Renal Pediatric Dialysis Emergency Machine), available on a trial-basis in our center, after the surgical placement of jugular double-lumen central venous catheters. A 'ready to use' neonatal kit with a low-priming volume of the extracorporeal circuit allowed a prompt hemofiltration start. The filtration CRRT was continuously performed for 48 h, then intermittently (12 h/day) for 2 more days and interrupted on day 5 for diuresis reprisal. Acute kidney injury and multi-organ failure resolved after 5 days. The child survived without neurological damage, with a normal renal function and a normal development at 9 months follow-up. In conclusion, a prompt CRRT start with this specifically designed neonatal device allowed a progressive stabilization of hemodynamics, a better control of acidosis, a reduction of amine requirement, a gradual control of fluid overload and a rapid improvement of MOF, DIC as well as a resolution of the acute kidney injury. The device also allowed the extension of CRRT in the neonatal age.
    Full-text · Article · May 2014
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    • "In children, the relevancy of these thresholds remains to be confirmed. With respect to age, even though regional citrate anticoagulation has already been used in newborns without obvious side effects [8], data remain sparse for children with a body weight of <10 kg [6, 9, 20]. In our study, the phosphate-containing post-dilution solution prevented the occurrence of hypophosphatemia. "
    [Show abstract] [Hide abstract] ABSTRACT: In continuous renal replacement therapy (CRRT), regional citrate anticoagulation offers an attractive alternative to heparinization, especially for children with a high bleeding risk. We report on a new management approach to CRRT using integrated citrate software and physiological sodium concentration solutions. Convective filtration was performed with pre-filter citrate anticoagulation using an 18 mmol/L citrate solution and a post-filter replacement fluid. The citrate flow rate was automatically adjusted to the blood flow rate by means of integrated citrate software. Similarly, calcium was automatically infused into children to maintain their blood calcium levels within normal range. Eleven CRRT sessions were performed (330 h) in seven critically ill children aged 3-15 years (extreme values 15-66 kg). Disease categories included sepsis with multiorgan dysfunction (n = 2) and hemolytic uremic syndrome (n = 5). Median effluent dose was 2.1 (extreme values 1.7-3.3) L/h/1.73 m(2). No session had to be stopped because of metabolic complications. Calcium levels, both in the circuits and in the circulating blood of the children, remained stable and secure. Regional citrate anticoagulation can be used in children with a body weight of >15 kg using integrated citrate software and commercially available solutions with physiological sodium concentrations in a safe, effective and convenient procedure.
    Full-text · Article · Feb 2014 · Pediatric Nephrology
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    • "The cumulative internal diameter of both sheaths is similar to that of much larger 9-or 10-French dialysis catheters. Half of our patients had initial circuit survival beyond 60 h, which is similar to that seen with 9-and 10-French dialysis catheters in children (51 and 53 %, respectively) [9]. Also, according to the CRRT registry, infants less than 5 kg had much lower circuit survival (average of 28 h) than those between 5 and 10 kg. "
    [Show abstract] [Hide abstract] ABSTRACT: Acute kidney injury (AKI) frequently occurs in neonates and infants after cardiopulmonary bypass (CPB) and may require renal replacement therapy (RRT). Peritoneal dialysis (PD) is the RRT modality of choice in neonates with AKI after CPB, but continuous renal replacement therapy (CRRT) may be necessary if PD is ineffective or contraindicated. Vascular access is challenging in this population, in part, due to small central vein size that may preclude placement. The risk of malfunction or morbidity associated with standard dialysis catheters may be excessive in neonates with congenital heart disease. We describe a unique approach to vascular access for CRRT in six small patients with AKI. This is a retrospective review of six patients with fluid overload and AKI that received CRRT because PD was contraindicated. In all cases, CRRT was performed via two hemostasis valve sheaths placed into separate veins for dialysis access and return. The low-resistance sheaths provided excellent blood flow with normalization of metabolic derangements and significant fluid removal (median negative 167 ml/kg at 72 h). Mean circuit life before the first change was 55.2 ± 30.4 h. The use of two small single-lumen catheters in separate veins enables consistent and effective hemodiafiltration in neonates and infants with challenging vascular access.
    Full-text · Article · Sep 2013 · Pediatric Nephrology
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