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Continuous Renal Replacement Therapy in Pediatric Severe Sepsis: A Propensity Score-Matched Prospective Multicenter
Huijie Miao1, Jingyi Shi1, Chunxia Wang1
1Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China.
Insights
Continuous renal replacement therapy (CRRT) reduces mortality in critically ill children with severe sepsis. This therapy is particularly beneficial for pediatric patients experiencing acute respiratory distress syndrome.
Area of Science:
- Pediatric Critical Care Medicine
- Nephrology
- Intensive Care Medicine
Background:
- Severe sepsis poses a significant mortality risk in critically ill children.
- The role of continuous renal replacement therapy (CRRT) in improving outcomes for pediatric severe sepsis patients remains debated.
- Existing research lacks consistent conclusions regarding CRRT's impact on mortality rates in this population.
Purpose of the Study:
- To evaluate the effect of CRRT on hospital mortality in pediatric patients diagnosed with severe sepsis.
- To identify specific subgroups of pediatric severe sepsis patients who may benefit most from CRRT.
- To analyze the association between CRRT initiation timing and patient outcomes.
Main Methods:
- A propensity score-matched cohort study was conducted using data from four tertiary university children's hospitals in China.
- Data were prospectively collected over two years (2016-2018) from pediatric intensive care units (PICUs).
- Patients were divided into CRRT and conventional (non-CRRT) groups, with propensity score adjustment applied to mitigate confounding factors.
Main Results:
- The study included 324 pediatric patients with severe sepsis.
- After propensity score adjustment, the hospital mortality rate was significantly lower in the CRRT group (21.3%) compared to the non-CRRT group (32.4%).
- CRRT demonstrated a significant mortality benefit specifically in patients with acute respiratory distress syndrome (ARDS), with a relative risk of dying of 0.447. No significant benefit was observed in patients with shock, acute kidney injury, acute liver dysfunction, encephalopathy, or significant fluid overload.
- Biomarkers showed decreased interleukin-6 levels and improved natural killer cell percentages in the CRRT group.
- CRRT was identified as an independent protective factor against hospital mortality, while the timing of CRRT initiation relative to PICU admission was an independent risk factor for mortality in the CRRT group.
Conclusions:
- Continuous renal replacement therapy, particularly with an ultrafiltration rate of 50 mL/kg/hr, is associated with decreased hospital mortality in pediatric patients with severe sepsis.
- The benefits of CRRT are most pronounced in pediatric severe sepsis patients who also have acute respiratory distress syndrome.
- Optimizing the timing of CRRT initiation is crucial for maximizing its survival benefit in critically ill children.
Objectives:
Continuous renal replacement therapy becomes available utilization for pediatric critically ill, but the impact of mortality rate in severe sepsis remains no consistent conclusion. The aim of the study is to assess the effect of continuous renal replacement therapy in pediatric patients with severe sepsis and the impact this therapy may have on their mortality.
Design:
Propensity score-matched cohort study analyzing data prospectively collected by the PICUs over 2 years (2016-2018).
Setting:
Four PICUs of tertiary university children's hospital in China.
Patients:
The consecutive patients with severe sepsis admitted to study PICUs were enrolled from July 2016 to June 2018.
Interventions:
The patients were divided into the continuous renal replacement therapy group and the conventional (noncontinuous renal replacement therapy) group.
Measurements And Main Results:
A total of 324 patients with severe sepsis were enrolled. The hospital mortality rate was 35.6% (64/180) in the continuous renal replacement therapy group and 47.9% (69/144) in the noncontinuous renal replacement therapy group. After propensity score adjustment, the hospital mortality rate was 21.3% (29/136) in the continuous renal replacement therapy group and 32.4% (44/136) in the noncontinuous renal replacement therapy group. In subgroup analysis, the relative risk of dying was 0.447 (95% CI, 0.208-0.961) only in patients complicated by acute respiratory distress syndrome (p = 0.037), but not in patients with shock, acute kidney injury, acute liver dysfunction, encephalopathy, and fluid overload greater than 10%. The mean duration of continuous renal replacement therapy was 45 hours (26-83 hr) with an ultrafiltration rate of 50 mL/kg/hr. The level of interleukin-6 was decreased, and the percent of natural killer cells (%) was improved in the continuous renal replacement therapy group compared with the noncontinuous renal replacement therapy group. Furthermore, continuous renal replacement therapy was an independently significant risk factor for hospital mortality in pediatric patients with severe sepsis, and the interval between continuous renal replacement therapy initiation and PICU admission was an independent risk factor for hospital mortality in patients receiving continuous renal replacement therapy.
Conclusions:
Continuous renal replacement therapy with an ultrafiltration rate of 50 mL/kg/hr decreases hospital mortality rate in pediatric severe sepsis, especially in patients with acute respiratory distress syndrome.
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