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Current practices in pediatric continuous kidney replacement therapy: a systematic review-guided multinational
Dana Y Fuhrman1,2,3, Katja M Gist4, Ayse Akcan-Arikan5,6
1Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA. dana.fuhrman@chp.edu.
Insights
Current pediatric continuous kidney replacement therapy (CKRT) practices largely mirror adult care, with consensus on initiation, dosing, and anticoagulation but variability in monitoring and quality assessment. Further research is needed to optimize pediatric CKRT outcomes.
Area of Science:
- Pediatric Nephrology
- Critical Care Medicine
- Renal Replacement Therapy
Background:
- Continuous kidney replacement therapy (CKRT) is vital for critically ill children, yet current prescribing and delivery practices lack clarity.
- This study aimed to define contemporary pediatric CKRT practices.
Approach:
- A systematic literature review (2012-2022) identified CKRT data on initiation, dosing, anticoagulation, fluid removal, and quality monitoring.
- A multinational, two-round modified Delphi survey of 147/126 pediatric CKRT prescribers refined practice insights.
Key Points:
- Consensus was reached on 26 statements regarding CKRT initiation, dosing, anticoagulation methods, and fluid removal.
- Significant variability exists in anticoagulation monitoring and treatment quality assessment methods among practitioners.
- Pediatric CKRT practices appear heavily influenced by adult patient care protocols.
Conclusions:
- Current pediatric CKRT practices largely reflect a decade of literature, predominantly based on adult data.
- This study establishes a foundation for investigating best practices to enhance outcomes for pediatric CKRT patients.
Background:
Continuous kidney replacement therapy (CKRT) has become an integral part of the care of critically ill children. However, uncertainty exists regarding the current state of how CKRT is prescribed and delivered in children. The main objective of this study was to identify the current practices for pediatric CKRT.
Methods:
We conducted a systematic review of the literature from 2012 to 2022 to identify data regarding CKRT timing of initiation, dosing, anticoagulation, fluid removal, and quality monitoring. Using this data, we then performed a two-round modified Delphi process using a multinational internet-assisted survey of prescribers of CKRT.
Results:
The survey was constructed using 172 articles that met inclusion criteria (12% of studies were pediatric focused). A total of 147 and 126 practitioners completed the survey in rounds 1 and 2, respectively. Participants represented Europe (9.5-11.6%) and North America including pediatric intensivists, nephrologists, and advance practice providers. Consensus (defined as a ≥ 75% participant response of "sometimes" or "always") was achieved for 26 statements. There was consensus in the practices of CKRT initiation, dosing, method of anticoagulation, and fluid removal. In contrast, there appears to be greater variability in the methods used for monitoring anticoagulation and the quality of the delivered treatment.
Conclusions:
Our study results suggest that the current state of pediatric CKRT practice is reflective of the literature over the last 10 years, which is largely based on the care of adult patients. This data provides a framework to study best practices to further improve outcomes for children receiving CKRT. A higher resolution version of the Graphical abstract is available as Supplementary information.
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