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Continuous renal replacement therapy: mechanism of clearance, fluid removal, indications and outcomes
1University of Cincinnati College of Medicine, The Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45206, USA. stuart.goldstein@cchmc.org
Insights
Continuous renal replacement therapy (CRRT) is effective for critically ill children with acute kidney injury (AKI). Early CRRT initiation to manage fluid overload may improve survival, but further trials are needed.
Area of Science:
- Pediatric Nephrology
- Critical Care Medicine
- Renal Replacement Therapy
Background:
- Continuous renal replacement therapy (CRRT) is the primary dialysis method for critically ill children with acute kidney injury (AKI).
- Optimal CRRT use across pediatric age groups and disease spectrums remains unclear.
- Standardized terminology for CRRT in pediatrics is needed.
Purpose of the Study:
- To review the current evidence on CRRT in critically ill pediatric patients.
- To clarify CRRT terminology and optimal application in pediatric AKI.
- To assess the association between fluid accumulation and mortality in pediatric CRRT patients.
Main Methods:
- Review of single-center and multicenter pediatric studies on CRRT.
- Analysis of data on CRRT effectiveness across pediatric age ranges.
- Examination of the relationship between fluid accumulation at CRRT initiation and patient outcomes.
Main Results:
- CRRT is effective for all pediatric patients, from infants to young adults.
- Greater fluid accumulation at CRRT initiation is independently associated with increased mortality in critically ill children with AKI.
- CRRT efficiently clears exogenous and endogenous toxins without rebound, unlike intermittent hemodialysis.
Conclusions:
- CRRT is an indispensable tool for pediatric nephrologists managing critically ill children.
- Early CRRT initiation to prevent fluid overload may enhance survival in pediatric AKI.
- Prospective trials are necessary to confirm the survival benefits of early CRRT initiation.
Purpose Of Review:
Continuous renal replacement therapy (CRRT) is the most common dialysis modality provided to critically ill children with acute kidney injury (AKI). However, confusion still exists with respect to CRRT terminology and the optimal use of this modality across the entire pediatric disease and age spectrum.
Recent Findings:
Data from both single-center and multicenter pediatric studies demonstrate that CRRT can be provided effectively to all pediatric patients, from infants to young adult aged patients. Furthermore, these data demonstrate a consistent and independent association between the degree of patient fluid accumulation at the initiation of a CRRT course and mortality in critically ill children with AKI. In addition, CRRT has been successfully utilized for rapid clearance of both exogenous and endogenous (e.g., ammonia) toxins without the concentration rebound that characterizes toxin removal by intermittent hemodialysis.
Summary:
CRRT represents an essential dialytic modality for the pediatric nephrologist caring for critically ill children. Current data suggest that earlier initiation of CRRT to prevent excessive fluid accumulation may lead to improved survival in critically ill children, but prospective trials are required to test this hypothesis directly.
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