Expanding role of renal replacement therapy in a tertiary care Picu : Unit experience

Abstract

Background : The role of renal replacement therapy (RRT) in critical care is expanding. It is the cornerstone in the management of critically ill children. Continuous RRT is a mainstay of treatment in PICU for acute kidney injury (AKI) due to well-maintained hemodynamic stability with slow predictable fluid and solute removal. Apart from the classic indications RRT plays a significant role in the treatment of many other disease conditions such as septic shock and other organ-supportive strategies. Methods : We conducted a retrospective analysis of all the children who underwent RRT for critical care indications over a period from July 2015 to July 2017 at Rainbow Children’s Hospital, Marathahalli, Bangalore. Results : A total of 24 children underwent RRT over a period of 2 years with 12 males (50%) and 12 females (50%). Out of these 5 children (20.8%) had background of chronic kidney disease. Mean age of children who underwent RRT was 6 years (range:4 months-16 years). Sepsis with septic shock was the diagnosis most commonly associated to needing RRT (58.3%). The most common clinical condition associated with acute kidney injury was hemodynamic instability (58%), followed by multi-organ dysfunction syndrome (41%). The most common indication for initiating RRT was Acute Kidney Injury stage 2 with fluid overload >10% (as defined by KDIGO criteria) in 50% of the cases followed by severe metabolic acidosis refractory to medical therapy (29%). Eleven (45.8%) children who underwent RRT had Multi-organ dysfunction. There were no significant complications associated to initiation of RRT. Fifty- four percent of children survived. Among the children who died 81% had Multi-organ dysfunction syndrome. Three children (23%) required intermittent hemodialysis on follow up for complete recovery. Continuous renal replacement Therapy (CRRT) was done in 11 children (45.8%). The median duration of CRRT was 30 hours with the longest duration being 194 hours. Most common mode of CRRT used was Continuous venovenous hemodiafiltration (CVVHDF) . Newer hybrid techniques like Sustained low efficiency dialysis (SLED) was used in 5 patients (20%) with complete recovery noted during PICU stay. Conclusion : We present a diverse population of pediatric patients requiring RRT. Sepsis with septic shock was the most common diagnosis requiring RRT in our study population. CVVHDF was the common mode of RRT we used in our unit followed by newer techniques like SLED. We noticed hemodynamic instability and multi-organ dysfunction syndrome are the most common clinical conditions associated with acute kidney injury in our population. We did not observe any significant complications associated with initiation for RRT which indicates CRRT is safe in hemodynamic unstable patients. We observed that new therapies and techniques can provide supportive treatment beyond the classic renal indications.