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Time to Continuous Renal Replacement Therapy Initiation and 90-Day Major Adverse Kidney Events in Children and Young
Katja M Gist1, Shina Menon2, Pilar Anton-Martin3
1Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio.
Insights
Delaying continuous renal replacement therapy (CRRT) in children and young adults with acute kidney injury increases the risk of major adverse kidney events (MAKE-90), including mortality. Further research is needed to optimize CRRT timing.
Area of Science:
- Pediatric Nephrology
- Critical Care Medicine
- Renal Replacement Therapy
Background:
- Early continuous renal replacement therapy (CRRT) initiation in adults with acute kidney injury or volume overload has not shown survival benefits.
- The impact of CRRT initiation timing on outcomes in pediatric and young adult populations remains unknown.
Purpose of the Study:
- To investigate the association between CRRT initiation timing and major adverse kidney events at 90 days (MAKE-90) in children and young adults.
- To explore the role of volume overload (VO) in this association.
Main Methods:
- Multinational retrospective cohort study using the WE-ROCK registry (2015-2021).
- Included 969 patients (birth to 25 years) receiving CRRT for acute kidney injury or VO.
- Primary exposure: time from ICU admission to CRRT initiation. Primary outcome: MAKE-90 (death, dialysis dependence, or persistent kidney dysfunction).
Main Results:
- MAKE-90 occurred in 65.0% of patients; mortality was 58.4% among those with MAKE-90.
- Longer time to CRRT initiation was associated with a higher risk of MAKE-90 (median 3 days vs 2 days; P=.002).
- Each 1-day delay in CRRT initiation was associated with approximately 3% higher odds of MAKE-90 (OR, 1.03; 95% CI, 1.02-1.04).
Conclusions:
- Delayed CRRT initiation in children and young adults is linked to an increased risk of MAKE-90, particularly mortality.
- Findings highlight the need for prospective studies to determine optimal CRRT timing and its interaction with volume overload in this population.
- Optimizing CRRT initiation timing may improve survival and reduce morbidity in pediatric patients with acute kidney injury.
Importance:
In clinical trials, the early or accelerated continuous renal replacement therapy (CRRT) initiation strategy among adults with acute kidney injury or volume overload has not demonstrated a survival benefit. Whether the timing of initiation of CRRT is associated with outcomes among children and young adults is unknown.
Objective:
To determine whether timing of CRRT initiation, with and without consideration of volume overload (VO; <10% vs ≥10%), is associated with major adverse kidney events at 90 days (MAKE-90).
Design, Setting, And Participants:
This multinational retrospective cohort study was conducted using data from the Worldwide Exploration of Renal Replacement Outcome Collaborative in Kidney Disease (WE-ROCK) registry from 2015 to 2021. Participants included children and young adults (birth to 25 years) receiving CRRT for acute kidney injury or VO at 32 centers across 7 countries. Statistical analysis was performed from February to July 2023.
Exposure:
The primary exposure was time to CRRT initiation from intensive care unit admission.
Main Outcomes And Measures:
The primary outcome was MAKE-90 (death, dialysis dependence, or persistent kidney dysfunction [>25% decline in estimated glomerular filtration rate from baseline]).
Results:
Data from 996 patients were entered into the registry. After exclusions (n = 27), 969 patients (440 [45.4%] female; 16 (1.9%) American Indian or Alaska Native, 40 (4.7%) Asian or Pacific Islander, 127 (14.9%) Black, 652 (76.4%) White, 18 (2.1%) more than 1 race; median [IQR] patient age, 8.8 [1.7-15.0] years) with data for the primary outcome (MAKE-90) were included. Median (IQR) time to CRRT initiation was 2 (1-6) days. MAKE-90 occurred in 630 patients (65.0%), of which 368 (58.4%) died. Among the 601 patients who survived, 262 (43.6%) had persistent kidney dysfunction. Of patients with persistent dysfunction, 91 (34.7%) were dependent on dialysis. Time to CRRT initiation was approximately 1 day longer among those with MAKE-90 (median [IQR], 3 [1-8] days vs 2 [1-4] days; P = .002). In the generalized propensity score-weighted regression, there were approximately 3% higher odds of MAKE-90 for each 1-day delay in CRRT initiation (odds ratio, 1.03 [95% CI, 1.02-1.04]).
Conclusions And Relevance:
In this cohort study of children and young adults receiving CRRT, longer time to CRRT initiation was associated with greater risk of MAKE-90 outcomes, in particular, mortality. These findings suggest that prospective multicenter studies are needed to further delineate the appropriate time to initiate CRRT and the interaction between CRRT initiation timing and VO to continue to improve survival and reduce morbidity in this population.
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