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

Emanuele Buccione,Stefano Romagnoli,Manuela L'Erario,Denise Colosimo,Gianluca Villa,Zaccaria Ricci,Brigida Tedesco,Francesco Guzzi

doi:10.3389/fped.2021.696798

Abstract

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.

Highlights

Severe acute kidney injury is a common finding in the Pediatric Intensive Care Unit (PICU), Continuous Renal Replacement Therapy (CRRT) is rarely applied in this setting
Patients’ PICU mortality rate was high and survival often complicated by chronic kidney disease (CKD) development
In line with previous experiences reported in the literature [36, 37], we found that dimension of vascular access and anticoagulation strategy were independent predictors for circuit clotting

Summary

Introduction

Severe acute kidney injury is a common finding in the Pediatric Intensive Care Unit (PICU), Continuous Renal Replacement Therapy (CRRT) is rarely applied in this setting. Acute kidney injury (AKI) is a common complication in the Pediatric Intensive Care Unit (PICU), involving approximately one third of critically ill neonates and children [1, 2]. Continuous Renal Replacement Therapy (CRRT) is usually applied in critically ill adult patients with severe AKI and/or multiple organ dysfunction syndrome (MODS) in order to support kidney function [3,4,5], this technique is uncommonly used in the PICU [6]. Uncertainties exist on long-term kidney and global outcomes of critically ill pediatric patients who underwent CRRT. CRRT has been recognized as a strong predictor of short-term mortality, 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]

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