Pediatric Bone Marrow Transplant (BMT) Recipients with Acute Renal Failure (ARF): Assessment of an Algorithm to Prevent Fluid Overload including Early Initiation of Renal Replacement Therapy (RRT)

Abstract

Objective: ARF with fluid overload (FO) occurs often in BMT recipients. We have demonstrated increasing %FO prior to CRRT initiation is associated with mortality in children with ARF. Based on these data, we devised a protocol for FO prevention in BMT pts with ARF. BMT pts with ARF and 5% FO were started on furosemide and low-dose dopamine. To allow for nutrition, medication and blood product administration, RRT was initiated for pts with ≥ 10% FO. We reviewed the course and outcome for pediatric BMT pts with ARF and fluid overload managed with this protocol. Subjects: Medical records of 29 BMT pts with 33 ARF episodes from Jan 99 to Jan 02 were reviewed. Mean pt age was 12.8 ± 5 yrs (2–23.5 yrs). Outcome: 14/29 (48%) pts survived an initial ARF episode. 0/4 pts survived a second ARF episode. 14/14 survivors (S) either maintained ≤10% FO during course or re-attained ≤10%FO with RRT treatment. Max %FO for S was 17%. 7/19 non-survivors (NS) were 1 pressors were associated with lower survival (p < 0.05). Neither GVHD nor septic shock correlated with survival. Conclusion: Our data demonstrate that maintenance of euvolemia (%FO ≤10% is critical for S in BMT patients with ARF as all non-euvolemic pts died. We suggest that aggressive management with diuretics and earlier RRT initiation in pts not responsive to diuretics may improve BMT pt survival.