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Effect of Continuous Renal Replacement Therapy on Outcome in Pediatric Acute Liver Failure
Akash Deep1, Claire E Stewart, Anil Dhawan
11Pediatric Intensive Care Unit, King's College Hospital, London, United Kingdom.2Pediatric Hepatology, Gastroenterology and Nutrition Center, King's College Hospital, London, United Kingdom.3Department of Primary Care and Public Health Sciences, NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, King's College, London, United Kingdom.
Insights
Continuous renal replacement therapy (CRRT) significantly improves survival in pediatric acute liver failure by reducing ammonia levels. Early initiation of CRRT is crucial for better outcomes and bridging patients to liver transplantation or recovery.
Area of Science:
- Pediatric critical care medicine
- Hepatology
- Nephrology
Background:
- Pediatric acute liver failure (PALF) is a critical condition with high mortality.
- Management strategies aim to support organ function and bridge patients to recovery or transplantation.
- Continuous renal replacement therapy (CRRT) is an extracorporeal technique used in critically ill patients.
Purpose of the Study:
- To evaluate the impact of continuous renal replacement therapy (CRRT) on survival outcomes in children with acute liver failure.
- To determine the efficacy of CRRT in managing hyperammonemia and supporting critically ill pediatric liver failure patients.
Main Methods:
- Retrospective cohort study of 136 children (0-18 years) with PALF admitted to a pediatric intensive care unit (PICU) between 2003 and 2013.
- Analysis of outcomes for 45 patients who received CRRT prior to liver transplantation or recovery.
- Cox proportional hazards regression models were used to assess survival predictors.
Main Results:
- CRRT use was associated with improved survival in children with PALF, particularly those not receiving a liver transplant (HR, 4; P = 0.006).
- Reducing hyperammonemia by 48 hours after initiating CRRT significantly improved survival (HR, 1.04; P = 0.004).
- Earlier initiation of CRRT correlated with better survival, with a notable increase in survival rates observed within the first 14 days of practice change (HR, 3; P = 0.063).
Conclusions:
- Continuous renal replacement therapy is a safe and effective supportive measure for critically ill children with acute liver failure.
- Early implementation of CRRT is recommended to manage hyperammonemia, prevent further deterioration, and improve the chances of recovery or successful liver transplantation.
- Failure to reduce ammonia levels within 48 hours of CRRT initiation indicates a poor prognosis.
Objectives:
To establish the effect of continuous renal replacement therapy on outcome in pediatric acute liver failure.
Design:
Retrospective cohort study.
Setting:
Sixteen-bed PICU in a university-affiliated tertiary care hospital and specialist liver centre.
Patients:
All children (0-18 yr) admitted to PICU with pediatric acute liver failure between January 2003 and December 2013.
Interventions:
Children with pediatric acute liver failure were managed according to a set protocol. The guidelines for continuous renal replacement therapy in pediatric acute liver failure were changed in 2011 following preliminary results to indicate the earlier use of continuous renal replacement therapy for both renal dysfunction and detoxification.
Measurements And Main Results:
Of 165 children admitted with pediatric acute liver failure, 136 met the inclusion criteria and 45 of these received continuous renal replacement therapy prior to transplantation or recovery. Of the children managed with continuous renal replacement therapy, 26 (58%) survived: 19 were successfully bridged to liver transplantation and 7 spontaneously recovered. Cox proportional hazards regression model clearly showed reducing hyperammonemia by 48 hours after initiating continuous renal replacement therapy significantly improved survival (HR, 1.04; 95% CI, 1.013-1.073; p = 0.004). On average, for every 10% decrease in ammonia from baseline at 48 hours, the likelihood of survival increased by 50%. Time to initiate continuous renal replacement therapy from PICU admission was lower in survivors compared to nonsurvivors (HR, 0.96; 95% CI, 0.916-1.007; p = 0.095). Change in practice to initiate early and high-dose continuous renal replacement therapy led to increased survival with maximum effect being visible in the first 14 days (HR, 3; 95% CI, 1.0-10.3; p = 0.063). Among children with pediatric acute liver failure who did not receive a liver transplant, use of continuous renal replacement therapy significantly improved survival (HR, 4; 95% CI, 1.5-11.6; p = 0.006).
Conclusion:
Continuous renal replacement therapy can be used successfully in critically ill children with pediatric acute liver failure to provide stability and bridge to transplantation. Inability to reduce ammonia by 48 hours confers poor prognosis. Continuous renal replacement therapy should be considered at an early stage to help prevent further deterioration and buy time for potential spontaneous recovery or bridge to liver transplantation.
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