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Pediatric Acute Renal Failure: CRRT/Dialysis Outcome Studies

Pediatric Acute Renal Failure: CRRT/Dialysis Outcome Studies. Stuart L. Goldstein, MD Assistant Professor of Pediatrics Baylor College of Medicine. Pediatric Acute Renal Failure: Ideal Study Design.

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Pediatric Acute Renal Failure: CRRT/Dialysis Outcome Studies

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  1. Pediatric Acute Renal Failure:CRRT/Dialysis Outcome Studies Stuart L. Goldstein, MD Assistant Professor of Pediatrics Baylor College of Medicine

  2. Pediatric Acute Renal Failure:Ideal Study Design • Prospective protocol driven entry criteria to ensure that patients and their respective disease receive similar treatment • Control for severity of illness, primary and co-morbid diseases • Adequate power to detect effect of an intervention on or an association of a clinical variable with outcome

  3. Pediatric Acute Renal Failure:Ideal Study Design • Prospective protocol driven entry criteria to ensure that patients and their respective disease receive similar treatment --- Do not exist! • Control for severity of illness, primary and co-morbid diseases --- Some information • Adequate power to detect effect of an intervention on or an association of a clinical variable with outcome --- Do not exist!

  4. Renal Replacement Therapy in the PICU:Pediatric Outcome Literature • Few pediatric studies (all single center) use a severity of illness measure to evaluate outcomes in pCRRT: • Lane noted that mortality was greater after bone marrow transplant who had > 10% fluid overload at the time of HD initiation • Smoyer2 found higher mortality in patients on pressors. • Faragson3 found PRISM to be a poor outcome predictor in patients treated with HD • Zobel4 demonstrated that children who received CRRT with worse illness severity by PRISM score had increased mortality • Did not stratify by modality 1. Bone Marrow Transplant 13:613-7, 1994 2. JASN 6:1401-9, 1995 3. Pediatr Nephrol 7:703-7, 1994 4. Child Nephrol Urol 10:14-7, 1990

  5. Renal Replacement Therapy in the PICU Pediatric Outcome Literature • 122 children studied • No PRISM scores • Most common diagnosis • IHD: primary renal failure • CRRT: sepsis • 31% survival • Conclusion: patients who receive CRRT are more ill Maxvold NJ et al: Am J Kidney Dis 1997 Nov;30(5 Suppl 4):S84-8

  6. Pediatric ARF: IHD and CRRT Bunchman TE et al: Ped Neph 16:1067-1071, 2001

  7. Pediatric ARF: Disease and Survival Bunchman TE et al: Ped Neph 16:1067-1071, 2001

  8. Pediatric ARF: Modality and Survival P<0.01 P<0.01 % Survival Bunchman TE et al: Ped Neph 16:1067-1071, 2001

  9. Pediatric ARF: Modality and Survival • Patient survival on pressors (35%) lower than without pressors (89%) (p<0.01) • Lower survival seen in CRRT than in patients who received HD for all disease states Bunchman TE et al: Ped Neph 16:1067-1071, 2001

  10. Renal Replacement Therapy in the PICU Pediatric Outcome Literature • Retrospective review of all patients who received CVVH(D) in the Texas Children’s Hospital PICU from February 1996 through September 1998 (32 months) • Pre-CVVH initiation data: • Age • Primary disease leading to need for CVVH • Co-morbid diseases • Reason for CVVH • Fluid intake (Fluid In) from PICU admission to CVVH initiation • Fluid output (Fluid Out) from PICU admission to CVVH initiation • GFR (Schwartz formula) at CVVH initiation Goldstein SL et al: Pediatrics 2001 Jun;107(6):1309-12

  11. Percent Fluid Overload Calculation [ ] Fluid In - Fluid Out ICU Admit Weight * 100% % FO at CVVH initiation = Goldstein SL et al: Pediatrics 2001 Jun;107(6):1309-12

  12. Renal Replacement Therapy in the PICU Pediatric Literature • PRISM scores at PICU admission and CVVH initiation calculated by same nurse • PICU Course Data: • Maximum number of pressors used • Pressors completely weaned (y/n) • Mean Airway Pressure (Paw) at CVVH initiation and termination • ICU length of stay (days) • CVVH complications • Outcome (death or survival) Goldstein SL et al: Pediatrics 2001 Jun;107(6):1309-12

  13. Pediatric RISk of Mortality (PRISM) Score • PRISM evaluates severity of illness by examining 14 clinical variables in 5 organ systems. • PRISM does not directly evaluate renal function--only BUN and potassium levels. • Higher PRISM scores (>10) on admission to the PICU have been associated with poorer prognosis. • The mean PRISM score at admission to the Texas Children’s Hospital PICU is 14.

  14. RESULTS • 22 pt (12 male/10 female) received 23 courses (3028 hrs) of CVVH (n=10) or CVVHD (n=12) over study period. • Overall survival was 41% (9/22). • Survival in septic patients was 45% (5/11). • PRISM scores at ICU admission and CVVH initiation were 13.5 +/- 5.7 and 15.7 +/- 9.0, respectively (p=NS). • Conditions leading to CVVH (D) • Sepsis (11) • Cardiogenic shock (4) • Hypovolemic ATN (2) • End Stage Heart Disease (2) • Hepatic necrosis, viral pneumonia, bowel obstruction and End-Stage Lung Disease (1 each) Goldstein SL et al: Pediatrics 2001 Jun;107(6):1309-12

  15. Renal Replacement Therapy in the PICU Pediatric Literature • Survival curve demonstrates that nearly 75% of deaths occurred less than 25 days into the ICU course Goldstein SL et al: Pediatrics 2001 Jun;107(6):1309-12

  16. Renal Replacement Therapy in the PICU Pediatric Literature • Lesser % FO at CVVH (D) initiation was associated with improved outcome (p=0.03) • Lesser % FO at CVVH (D) initiation was also associated with improved outcome when sample was adjusted for severity of illness (p=0.03; multiple regression analysis) Goldstein SL et al: Pediatrics 2001 Jun;107(6):1309-12

  17. Renal Replacement Therapy in the PICU Pediatric Outcome Literature Goldstein SL et al: Pediatrics 2001 Jun;107(6):1309-12

  18. Neonatal CRRT • 36 critically ill neonates • mean age 9.8 + 1.5 days • mean weight 3.0 + 0.1 kg • CAVH (17) • CVVH (15) • SCUF/ECMO (4) • Therapeutic Intervention Scoring System (TISS) • Acute Physiologic Scoring System for Children (APSC) Zobel G et al: Kid Int 53:S169-S173, 1998

  19. Neonatal CRRT • Mean CRRT duration of 97 + 20 hours • Mean filter life-span 40.7 + 6.1 hours • Overall survival of 66% • No difference between survivors and non-survivors with respect to • number of failed organs • TISS points • Significant difference between S and NS with respect to • MAP (49.2 mmHg versus 38.3 mmHg) • APSC 24 hours after starting CRRT Zobel G et al: Kid Int 53:S169-S173, 1998

  20. Neonatal/Infant CRRT Outcome • Multicenter retrospective review of CRRT in neonates/infants (n=85) less than 10kg • 655 patient-days (7.6+8.6 days/pt) • Mean weight 5.3 + 2.8kg (16 pt < 3 kg) • Mean Qb of 9.5 + 4.2ml/min/kg Symons JM et al: CRRT meeting 2002

  21. Neonatal/Infant CRRT Outcome Symons JM et al: CRRT meeting 2002

  22. Neonatal/Infant CRRT Outcome Symons JM et al: CRRT meeting 2002

  23. Neonatal/Infant CRRT Outcome Symons JM et al: CRRT meeting 2002

  24. Pediatric CRRT Outcome Literature:Summary • Children with ARF requiring CRRT exhibit 40-50% survival • PRISM score not predictive • Infants >3kg have similar survival rates as older children • Most mortality occurs within 3 weeks of ICU admission • Children with increased degrees of fluid overload at CRRT initiation may have increased mortality

  25. Pediatric CRRT Outcome Literature:Conclusions • Earlier might be better • Early mortality • Prevent fluid overload • Allow nutrition, blood product administration • Single center data are limited • No differences with respect to • initiation protocols • anticoagulation • machines • nutrition • data assessed

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