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Timing of continuous renal replacement therapy and mortality in critically ill children*
Vinai Modem1, Marita Thompson, Diane Gollhofer
11Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX. 2Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO. 3Pediatric Intensive Care Unit, Children's Medical Center, Dallas, TX.
Insights
Starting continuous renal replacement therapy earlier in critically ill children with acute kidney injury or fluid overload is linked to reduced intensive care unit mortality. Early intervention improves survival outcomes in pediatric critical care.
Area of Science:
- Pediatric Critical Care Medicine
- Nephrology
- Renal Replacement Therapy
Background:
- Acute kidney injury and fluid overload are common in critically ill children.
- Continuous renal replacement therapy (CRRT) is often required for these conditions.
- The optimal timing for initiating CRRT remains a critical question in pediatric intensive care.
Purpose of the Study:
- To investigate the impact of CRRT initiation timing on intensive care unit (ICU) mortality in children.
- To determine if earlier CRRT initiation is associated with improved survival in pediatric patients with acute kidney injury and/or fluid overload.
Main Methods:
- Retrospective cohort study design.
- Inclusion of pediatric patients who received CRRT for acute kidney injury or fluid overload between 2000 and 2009.
- Exclusion of patients on extracorporeal life support or with other CRRT indications.
Main Results:
- Overall ICU mortality was 47% in the study population.
- Median CRRT initiation time was significantly higher in non-survivors (3.4 days) compared to survivors (2.0 days).
- Earlier CRRT initiation (≤ 5 days) was associated with lower mortality (HR 1.56), with timing identified as an independent predictor of mortality.
Conclusions:
- Earlier initiation of CRRT is associated with reduced mortality in critically ill children.
- Further research should focus on identifying children who would benefit from early CRRT intervention.
- Timely CRRT management is crucial for improving outcomes in pediatric critical care.
Objectives:
Acute kidney injury and fluid overload frequently necessitate initiation of continuous renal replacement therapy in critically ill patients admitted to the ICU. In this study, our primary objective was to determine the effect of timing of initiation of continuous renal replacement therapy on ICU mortality in children requiring renal support for management of acute kidney injury and/or fluid overload.
Design:
Retrospective cohort study.
Setting:
Tertiary level, multidisciplinary PICU.
Patients:
Children who received continuous renal replacement therapy for management of acute kidney injury and/or fluid overload from January 2000 through July 2009 were included in the study. Patients requiring extracorporeal life support and patients initiated on continuous renal replacement therapy for indications other than acute kidney injury and/or fluid overload were excluded.
Interventions:
None.
Measurements And Main Results:
Timing of initiation was defined chronologically as time from ICU admission to continuous renal replacement therapy initiation. Three hundred eighty treatments were performed during the study period, of which 190 were eligible and included in the study. Overall ICU mortality was 47% among the study population. Median timing of initiation was higher among nonsurvivors compared with survivors (3.4 vs 2.0 d, p = 0.001). Multivariable logistic regression analysis identified timing of initiation as an independent predictor of mortality with an adjusted odds ratio of 1.05 (95% CI, 1.01, 1.11). Fluid overload, indication for continuous renal replacement therapy initiation, severity of illness at ICU admission, and active oncologic diagnosis were the other independent predictors of mortality that were identified in the final regression model. In the survival analysis, late initiators (> 5 d) had higher mortality than early initiators (≤ 5 d) with a hazard ratio of 1.56 (95% CI, 1.02, 2.37).
Conclusions:
Earlier initiation of continuous renal replacement therapy was associated with lower mortality in this cohort of critically ill children. Future studies should focus on early identification of such children who may benefit from early continuous renal replacement therapy initiation.
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