Time Of Continuous Renal Replacement Therapy Initiation Research Articles

The possibility of serum and urine cystatin C and NGAL as discriminative biomarkers for early stage AKI and CKD among hospitalized and renal outpatients

Although some studies have found that early initiation of continuous renal replacement therapy (CRRT) is associated with better prognosis, no consensus exists on the best timing to start CRRT. We investigated whether the timing of CRRT initiation was relevant to overall mortality and explored which factors at the time of CRRT initiation were associated with better outcomes in critically ill patients with acute kidney injury (AKI).A total of 361 patients who received CRRT for AKI between 2009 and 2011 were collected and divided into 2 groups based on the median blood urea nitrogen (BUN) levels or 6-hour urine output immediately before CRRT was started. The impact of the timing of CRRT initiation stratified by BUN concentration or urine output on 28-day all-cause mortality was compared between groups.When the timing of CRRT initiation was stratified by 6-hour urine output, 28-day all-cause mortality rates were significantly lower in the nonoliguric group compared with the oliguric group (P = .02). In contrast, clinical outcomes were not different between the low-BUN and the high-BUN groups (P = .30). Cox regression analysis revealed that 28-day all-cause mortality risk was significantly lower in the nonoliguric group stratified by 6-hour urine output, even after adjusting for age, sex, mean arterial pressure, Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores, and serum biomarkers (hazard ratio, 0.85; 95% confidence interval, 0.65-0.99; P = .04).Urine output but not BUN concentration was significantly associated with a better prognosis in critically ill patients with AKI requiring CRRT.

Process based quality improvement using a continuous renal replacement therapy dashboard

BackgroundThe prevalence of continuous renal replacement therapy (CRRT) utilization in critically ill patients with acute kidney is increasing. In comparison to published and on-going trials attempting to answer questions surrounding the optimal timing of CRRT initiation, anticoagulation, and modality, a paucity of literature describes the quality of the therapy delivered.MethodsWe conducted a single-center process improvement project to determine if a methodology to assess the quality of CRRT delivery could lead to improvement in CRRT delivery outcomes. We developed three broad categories of objective CRRT metrics to assess longitudinally, enabling creation of a CRRT Dashboard. Following the objective categories of “filter”, “prescription”, and “fluid balance” over time allowed us to perform quarterly analyses, target provider based CRRT education, and address variation from our standard of care. From 2012 to 2017, 184 critically ill patients received CRRT.ResultsWe report a mean filter life of 56 + 28.4 h, a 60-h filter life of 62%, and unplanned filter changes of 15%. Compared to a minimum target prescription of 2000 ml/1.73 m2/hour, we report the mean prescribed dose (2300 ml/1.73 m2/hour) and the rate of patients receiving at least the minimum prescription (98%). Finally, using a 10% deviation in the acceptable range of desired daily patient fluid balance, we report 83% CRRT patient days achieving an acceptable stipulated fluid goal.ConclusionWe report the implementation of a quality dashboard and adopting quality improvement strategies provided a platform for measuring adherence to our institutional standards and the delivery of CRRT, specifically on the process of the care.

Long-term outcomes in acute kidney injury patients who underwent continuous renal replacement therapy: a single-center experience.

Acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT) is the most severe form of AKI associated with poor short- and long-term patient outcomes. The aim of this study was to evaluate the variables associated with long-term patient survival in our clinic. This was a single-center retrospective study with AKI survivors who received CRRT from March 2011 to February 2015. During the study period, all consecutive AKI survivors who underwent CRRT were included. Patients on maintenance dialysis prior to CRRT were excluded. Data were collected by reviewing the patients' medical charts. Long-term follow-up data were gathered through February 2018. A total of 430 patients were included, and 62.8% of the patients were male. The mean age of the patients was 63.4 ± 14.6years. The mean serum creatinine level at the time of CRRT initiation was 3.5 ± 2.5mg/dL. At the time of discharge, the mean eGFR and serum creatinine levels were 58.4 ± 46.7 and 1.7 ± 1.6mg/dL, respectively. After 3years, 44.9% of the patients had survived. When we investigated the factors associated with long-term patient mortality, a longer stay in the ICU [OR 1.034 (1.016-1.053), p < 0.001], a history of cancer [OR 3.830 (1.037-3.308), p = 0.037], a prolonged prothrombin time [OR 1.852 (1.037-3.308), p = 0.037] and a lower eGFR at the time of discharge [OR 0.988 (0.982-0.995), p = 0.001] were independently associated with long-term patient mortality. Our study demonstrates that long-term mortality after CRRT is associated with longer ICU stays and lower eGFRs at the time of hospital discharge. Our data imply the importance of renal recovery for long-term survival of AKI patients treated with CRRT.

Heart rate is associated with mortality in patients undergoing continuous renal replacement therapy.

BackgroundHeart rate (HR) is an essential vital sign based on the finding that HR beyond its normal range is associated with several conditions or diseases, including high mortality in several clinical settings. Nevertheless, the clinical implications of HR remain unresolved in patients undergoing continuous renal replacement therapy (CRRT).MethodsThis retrospective cohort study included 828 patients who underwent CRRT due to acute kidney injury between 2010 and 2014. HR and other baseline parameters at the time of CRRT initiation were retrieved. The odds ratio (OR) of 30-day mortality was calculated using a multivariate logistic model.ResultsCRRT significantly lowered the HR of patients such that the pre- and post-CRRT HRs (average 6 hours) were 107 beats/min and 103 beats/min, respectively (P < 0.001). When we explored the relationship with 30-day mortality, only HR at the time of CRRT initiation, but not pre- or post-CRRT HR, had a significant relationship with mortality outcome. Based on this result, we divided patients into quartiles of HR at the time of CRRT initiation. Mortality OR in the 4th quartile HR group was 2.6 (1.78–3.92) compared with the 1st quartile HR group. This relationship remained consistent despite adjusting for 28 baseline covariates: OR, 1.7 (1.09–2.76); P = 0.020. However, HR was not associated with the weaning rate from CRRT.ConclusionHigh HR at the time of CRRT initiation is subsequently related with high mortality. These results can be a basis for a future predictive model of CRRT-related mortality.

Clinical variables associated with poor outcome from sepsis-associated acute kidney injury and the relationship with timing of initiation of renal replacement therapy

PurposeIdentify clinical variables associated with mortality in patients with sepsis-associated acute kidney injury (SA-AKI) receiving continuous renal replacement therapy (CRRT) and examine timing of initiation of CRRT in reference to those variables identified. MethodsRetrospective study conducted at two tertiary care hospitals including 939 septic shock patients with SA-AKI who received CRRT in the intensive care unit (ICU). Cox regression models were used to identify variables associated with 90-day mortality. Timing of CRRT initiation was assessed in relationship to significant clinical variables identified. ResultsOverall 90-day mortality was 62.9%. Variables prior to CRRT associated with 90-day mortality included: age (aHR, 1.02; 95%CI, 1.01–1.02, p<000.1), APS-III score (1.01, 1.0–1.0, p<0.048), days from hospital admission to CRRT initiation (1.01, 1.0–1.0, p<0.01), blood urea nitrogen (1.01, 1.0–1.0, p<0.04), medical admission (1.76, 1.5–2.1, p<0.0001), creatinine (0.99, 0.9–1.0, p<0.001), and urine output (0.77, 0.6–0.9, p=0.049). In patients with advanced SA-AKI at ICU admission receiving CRRT within the first 5days (n=433), urine output during the 24h prior to CRRT initiation was a strong predictor of survival (2.6, 1.6–4.3, p<0.001). ConclusionsIn patients with SA-AKI, survival is lower when CRRT is started in the setting of low urine output.

Derivation and Validation of a Search Algorithm to Retrospectively Identify CRRT Initiation in the ECMO Patients.

The role of extracorporeal membrane oxygenation (ECMO) in refractory cardiorespiratory failure is gaining momentum with recent advancements in technology. However, the need for dialysis modes such as continuous renal replacement therapy (CRRT) has also increased in the management for acute kidney injury. Establishing the exact timing of CRRT initiation in these patients from the electronic medical record is vital for automated data extraction for research and quality improvement efforts. We aimed to derive and validate an automated Electronic Health Records (EHR) search strategy for CRRT initiation in patients receiving ECMO. We screened 488 patients who received ECMO and a total of 213 patients underwent CRRT. We evaluated random 120 patients, 60 for derivation and 60 for validation cohorts. Following implementation of eligibility criteria, the algorithm was derived in 55 out of 120 ECMO/CRRT patients. The search algorithm was developed using first-time chart entry of 'access pressure drop' at CRRT initiation. The algorithm was then validated in an independent subset of 52 patients from the same time period. The overall agreement between electronic search algorithm and a comprehensive manual medical record review in the derivation and validation subsets, using 'access pressure drop' as the reference standard, was compared to assess CRRT initiation time. In the derivation subset (N=55), the automated electronic search strategy achieved an excellent agreement with manual search (κ =0.99, 54 were identified electronically, and 55 upon manual review). There was no time difference observed in 49/54(89%) patients, while in the remaining 5 (9%) patients time difference was within 15 minutes. In the validation cohort (N=52), agreement was 100 % (κ = 1.0, both methods identified 52 patients). Out of 52 patients, 47 (90%) had no time difference between the methods, for the remaining 5 (10%) patients, differences were within 15 minutes. The use of an electronic search strategy resulted in determining an accurate CRRT initiation time among ECMO patients.

Fluid overload and outcomes in neonates receiving continuous renal replacement therapy.

Continuous renal replacement therapy (CRRT) has emerged as the modality of choice for the management of high-risk neonates with acute kidney injury (AKI), inborn errors of metabolism and multi-organ dysfunction. The aim of this study was to evaluate fluid overload (FO) and investigate the factors associated with outcomes in neonates undergoing CRRT. We retrospectively reviewed the medical records of 34 neonates with AKI who were admitted to the neonatal intensive care unit (NICU) of Samsung Medical Center, Seoul, Republic of Korea between January 2007 and December 2014 where they underwent at least 24 h of CRRT. The survival rates of patients with an FO of ≥30% at the time of CRRT initiation were lower than those of patients with an FO of <30% at the same time-point. Univariate Cox regression analysis revealed that a higher percentage FO at CRRT initiation and decreased urine output at the end of CRRT were associated with mortality, and multivariate Cox regression analysis indicated that mortality was associated with decreased urine output at the end of CRRT. Univariate linear regression analysis revealed that the length of hospital stay was associated with higher levels of serum creatinine at CRRT initiation, longer stay in the NICU prior to initiation of CRRT, longer duration of CRRT and lower body weight at the time of NICU admission. Neonates with a higher percentage FO and higher levels of serum creatinine at CRRT initiation showed poor outcomes. Early initiation of CRRT before the development of severe FO or azotemia might improve the outcomes of neonates requiring CRRT.

Continuous renal replacement therapy in children with severe sepsis and multiorgan dysfunction - A pilot study on timing of initiation.

Objective:Scanty literature is available regarding continuous renal replacement therapy (CRRT) utility in severe sepsis with multiorgan dysfunction syndrome (MODS) from developing countries. Author unit's experience in pediatric CRRT is described and outcome of early initiation of CRRT with sepsis and MODS is assessed.Materials and Methods:Children aged <16 years with sepsis and MODS who required CRRT from September 2010 to February 2015 were analyzed on demographic factors, timing of initiation of CRRT, mode of CRRT, effect of CRRT onhemodynamics, oxygenation parameters, and outcome.Results:Twenty-seven children required CRRT (male - 16). The median age was 11 years (range 1.1–16). Twenty-one had severe sepsis with MODS. Eighteen patients were given CRRT within 48 h of admission to Intensive Care Unit (ICU). Statistically significant improvement in the P/F ratio, decrement in plateau pressure and vasoactive-inotropic score were noted in survivor group compared to nonsurvivor group (P = 0.022, 0.00, and 0.03, respectively). There was no statistically significant difference in duration of ICU stay, fluid overload, CRRT duration, PRISM score at 12 and 24 h, percentage of decrease in inotrope score, plateau pressure, and percentage of increase in P/F ratio in relation to timing of CRRT initiation. However, the survival rate was 61.1% (11/18) who received CRRT within 48 h of ICU admission compared to 33.3% (3/9) who received after 48 h (P = 0.0001).Conclusion:Our study emphasizes the CRRT role in improving the oxygenation status and hemodynamics. Survival benefit may be expected in those children who receive CRRT early in the course of sepsis. However, multicenter RCTs are required to prove mortality benefit.

Assessing continuous renal replacement therapy as a rescue strategy in cardiorenal syndrome 1.

BackgroundPatients with acute decompensated heart failure (ADHF) and cardiorenal syndrome (CRS) 1 have poor outcomes. Ultrafiltration (UF) is used to mechanically remove salt and water in ADHF patients with diuretic resistance. However, little is known about the outcomes of ADHF patients on inotropes and/or vasopressors who require continuous renal replacement therapy (CRRT) for both UF and solute clearance in severe acute kidney injury.MethodsWe retrospectively analyzed 37 consecutive critically ill patients who were admitted for ADHF from 2005–13 and were on inotropes and/or vasopressors at the time of CRRT initiation. The primary outcome was in-hospital mortality.ResultsIn-hospital mortality rate was 62%. Median survival was 15.5 days after CRRT initiation, and 10 months following hospital discharge. When comparing renal and cardiovascular variables for survivors and non-survivors at baseline, admission and CRRT initiation, survivors were less likely to need vasopressors. After controlling for multiple predictors, vasopressor use remained associated with time to death (HR 9.9; 95% CI 2.3–43.3; P = 0.002). Patients with isolated right ventricular dysfunction had an in-hospital mortality of 45% compared with 69% in those with left ventricular dysfunction (P = 0.27). Age of >70 years was associated with 100% in-hospital mortality.ConclusionsRescue therapy using CRRT in refractory CRS1 was associated with high in-hospital mortality, especially when vasopressors were used and when patient age exceeded 70 years. Additionally, survivors had a poor long-term prognosis.

Mean platelet volume is a prognostic factor in patients with acute kidney injury requiring continuous renal replacement therapy

PurposePlatelet size has been demonstrated to reflect platelet activity and to predict poor clinical outcomes in patients with cardiovascular disease. However, the prognostic value of platelet size for mortality has not been studied in patients with acute kidney injury (AKI). Materials and methodsA total of 349 patients who received continuous renal replacement therapy (CRRT) for AKI between August 2009 and October 2011 were divided into 2 groups based on the median mean platelet volume (MPV) at the time of CRRT initiation. Twenty-eight-day mortality rate was determined using Kaplan-Meier plots and time-dependent receiver operating characteristic curves were constructed. In addition, multivariate Cox analysis for mortality was used to evaluate the independent prognostic value of MPV. ResultsThe mean age was 61.3 years, and 218 patients (62.5%) were male. At the initiation of CRRT, MPV level was inversely correlated with platelet count, whereas it was positively associated with Acute Physiology and Chronic Health Evaluation II scores. During the study period, 231 deaths (66.2%) occurred. Kaplan-Meier curve showed that 28-day all-cause mortality was significantly higher in patients with MPV ≥ 10.2 fL compared with those with MPV < 10.2 fL (P < .001). Moreover, Cox regression analysis revealed that MPV was an independent predictor for 28-day all-cause mortality after adjustment of age, age-adjusted Charlson Comorbidity Index, cause of AKI, platelet count, Acute Physiology and Chronic Health Evaluation II score, presence of malignancy, albumin, and C-reactive protein (hazard ratio, 1.080; 95% confidence interval, 1.010-1.155; P = .023). ConclusionMean platelet volume at the time of CRRT initiation may be an inexpensive and useful predictor for 28-day all-cause mortality in patients with AKI requiring CRRT.

Urine output is associated with prognosis in patients with acute kidney injury requiring continuous renal replacement therapy

PurposeAlthough some studies have found that early initiation of continuous renal replacement therapy (CRRT) is associated with better prognosis, no consensus exists on the best timing to start CRRT. We investigated whether the timing of CRRT initiation was relevant to overall mortality and explored which factors at the time of CRRT initiation were associated with better outcomes in critically ill patients with acute kidney injury (AKI). Materials and MethodsA total of 361 patients who received CRRT for AKI between 2009 and 2011 were collected and divided into 2 groups based on the median blood urea nitrogen (BUN) levels or 6-hour urine output immediately before CRRT was started. The impact of the timing of CRRT initiation stratified by BUN concentration or urine output on 28-day all-cause mortality was compared between groups. ResultsWhen the timing of CRRT initiation was stratified by 6-hour urine output, 28-day all-cause mortality rates were significantly lower in the nonoliguric group compared with the oliguric group (P = .02). In contrast, clinical outcomes were not different between the low-BUN and the high-BUN groups (P = .30). Cox regression analysis revealed that 28-day all-cause mortality risk was significantly lower in the nonoliguric group stratified by 6-hour urine output, even after adjusting for age, sex, mean arterial pressure, Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores, and serum biomarkers (hazard ratio, 0.85; 95% confidence interval, 0.65-0.99; P = .04). ConclusionsUrine output but not BUN concentration was significantly associated with a better prognosis in critically ill patients with AKI requiring CRRT.

Continuous renal replacement therapy outcomes in acute kidney injury and end-stage renal disease: a cohort study

IntroductionContinuous renal replacement therapy (CRRT) is a widely used but resource-intensive treatment. Despite its broad adoption in intensive care units (ICUs), it remains challenging to identify patients who would be most likely to achieve positive outcomes with this therapy and to provide realistic prognostic information to patients and families.MethodsWe analyzed a prospective cohort of all 863 ICU patients initiated on CRRT at an academic medical center from 2008 to 2011 with either new-onset acute kidney injury (AKI) or pre-admission end-stage renal disease (ESRD). We examined in-hospital and post-discharge mortality (for all patients), as well as renal recovery (for AKI patients). We identified prognostic factors for both in-hospital and post-discharge mortality separately in patients with AKI or ESRD.ResultsIn-hospital mortality was 61% for AKI and 54% for ESRD. In patients with AKI (n = 725), independent risk factors for mortality included age over 60 (OR 1.9, 95% CI 1.3, 2.7), serum lactate over 4 mmol/L (OR 2.2, 95% CI 1.5, 3.1), serum creatinine over 3 mg/dL at time of CRRT initiation (OR 0.63, 95% CI 0.43, 0.92) and comorbid liver disease (OR 1.75, 95% CI 1.1, 2.9). Among patients with ESRD (n = 138), liver disease was associated with increased mortality (OR 3.4, 95% CI 1.1, 11.1) as was admission to a medical (vs surgical) ICU (OR 2.2, 95% CI 1.1, 4.7). Following discharge, advanced age became a predictor of mortality in both groups (AKI: HR 1.9, 95% CI 1.2, 3.0; ESRD: HR 4.1, 95% CI 1.5, 10.9). At the end of the study period, only 25% (n = 183) of patients with AKI achieved dialysis-free survival.ConclusionsAmong patients initiating CRRT, risk factors for mortality differ between patients with underlying ESRD or newly acquired AKI. Long-term dialysis-free survival in AKI is low. Providers should consider these factors when assessing prognosis or appropriateness of CRRT.

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

To report circuit characteristics and survival analysis in children weighing ≤10 kg enrolled in the Prospective Pediatric Continuous Renal Replacement Therapy (ppCRRT) Registry. 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. 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. 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.

Outcomes of critically ill children requiring continuous renal replacement therapy

Purpose Acute kidney injury in the pediatric intensive care unit (PICU) is associated with significant morbidity, with continued mortality greater than 50%. Previous studies have described an association between percentage of fluid overload (%FO) less than 20% and improved survival. We reviewed our continuous renal replacement therapy (CRRT) experience to evaluate for factors associated with mortality as well as secondary outcomes. Materials and Methods This is a retrospective chart review of pediatric CRRT intensive care unit patients from January 2000 to September 2005. Results Seventy-six admissions required CRRT during the study period. Overall survival was 55.3%. Median patient age was 5.8 years (range, 0-18.9). Median %FO at the time of CRRT initiation was 7.3% in survivors vs 22.3% in nonsurvivors ( P = .0001). Presence of sepsis was significantly associated with mortality ( P = .0001). All nonsurvivors had multiple organ dysfunction syndrome (MODS); only 69% of survivors had MODS ( P = .0003). For survivors, there was a significant relationship between %FO and time to renal recovery ( P = .0038). Greater %FO was also associated with significantly prolonged days of mechanical ventilation ( P = .0180), PICU stay ( P = .0425), and duration of hospitalization ( P = .0123). Conclusions For patients with acute kidney injury who require CRRT, the presence of sepsis, MODS, and FO greater than 20% at the time of CRRT initiation are significantly associated with higher mortality. In addition, we report that duration of mechanical ventilation, PICU stay, hospitalization, and time to renal recovery were all significantly prolonged for survivors who had FO greater than 20%.

Neonatal Hemodialysis and Continuous Renal Replacement Therapy

After completing this article, readers should be able to: 1. Describe catheters, dialyzers, and blood lines in hemodialysis for neonates. 2. Explain the blood prime and hemodialysis prescription in hemodialysis for neonates. 3. List potential complications of hemodialysis for neonates. 4. Identify the types of continuous renal replacement therapy (CRRT) in neonates. 5. Explain the dialysis prescription and anticoagulation options for CRRT in neonates. 6. List potential complications of CRRT in neonates. Since the mid-1980s, when dialysis manufacturers began making dialyzers and blood circuit paths that required smaller extracorporeal volumes, hemodialysis has been used successfully to manage renal failure in neonates and infants. Compared with peritoneal dialysis (PD), which is analogous to the “family sedan” in the world of dialysis (slower, more predictable, easier to operate), hemodialysis is the “race car.” Hemodialysis is capable of removing fluids and solutes much more rapidly than is PD. Unlike PD, hemodialysis uses catheters that access the intravascular space directly. Despite the advantages of hemodialysis, the process in neonates is technically more challenging than PD due to the very attributes that make it so effective. Rapid removal of intravascular fluids, exceeding the rate of refill from the extravascular space, causes problems with hypotension due to direct reduction in intravascular volume. Similarly, rapid rates of solute clearance can cause problems with increased intracranial pressure. Catheter placement and maintenance of catheter function can constitute a significant obstacle to hemodialysis. Hemofiltration is very similar to hemodialysis in that patient blood is circulated through an artificial kidney. However, hemofiltration differs from hemodialysis in three significant aspects. First, the hemofilter has larger pore sizes than the standard dialyzer, which allows for excellent fluid removal, even with low blood flow rates, and better larger molecule clearance. Second, hemofiltration runs continuously without the continuous presence of a dialysis nurse. Third, typical hemofiltration uses a pre- or postdilution …

Continuous renal replacement therapy in children up to 10 kg

Background:There is growing use of continuous renal replacement therapy (CRRT) for pediatric patients, but no large studies reporting CRRT use and outcome in young children. We describe a cohort of patients weighing 10 kg or less who underwent CRRT at five US children's hospitals between 1993 and 2001. Methods:We reviewed records of 85 patients weighing 10 kg or less who underwent at least 24 hours of CRRT. We evaluated weight, diagnosis, pressor number, CRRT characteristics, days on CRRT, and outcome (survival to leave intensive care unit versus death). Results:Patients weighed 1.5 to 10 kg (mean, 5.3 ± 2.8 kg; 16 patients ≤ 3 kg). Sixty-nine percent of patients were being administered pressors at the time of CRRT initiation, 88% of patients were administered heparin, and the others were administered citrate or no anticoagulation. Mean blood flow was 48 ± 24 mL/min (range, 15 to 106 mL/min) or 9.5 ± 4.2 mL/min/kg. Six hundred fifty-five patient-days of therapy were studied (mean, 7.6 ± 8.6 d/patient; range, 1 to 46 d/patient). Thirty-two patients (38%) survived; 4 of 16 patients (25%) weighing 3 kg or less survived. The smallest survivor weighed 2.3 kg. Overall, survivors and nonsurvivors showed no significant difference in weight, days on CRRT, or pressor number. However, for patients weighing more than 3 kg, 28 of 69 patients (41%) survived, and mean pressor number was lower for survivors versus nonsurvivors (0.96 ± 1.1 versus 1.6 ± 1.0 pressors; P < 0.03). Conclusion:CRRT is feasible and useful in children weighing 10 kg or less. Hemodynamic instability requiring pressor support neither precludes successful CRRT nor adversely affects survival. After CRRT, the survival rate in children who weigh 3 to 10 kg is similar to that in older children and adolescents.