Fluid Overload in Children Following Hematopoietic Cell Transplant: A Comprehensive Review

Area of Science:

• Pediatric critical care medicine
• Hematology/Oncology
• Nephrology

Background:

• Fluid overload (FO) is a significant risk factor for morbidity and mortality in critically ill children, particularly those undergoing hematopoietic cell transplant (HCT).
• Children post-HCT face high risks of fluid accumulation due to necessary medical treatments and complications like sinusoidal obstruction syndrome, engraftment syndrome, sepsis, and acute kidney injury (AKI).
• Fluid overload exceeding 10% affects nearly half of pediatric HCT patients, correlating with reduced Pediatric Intensive Care Unit (PICU) survival and worsening AKI.

Purpose of the Study:

• To highlight the critical impact of fluid overload on outcomes in children following HCT.
• To emphasize the need for early detection, prevention, and intervention strategies for fluid overload in this vulnerable population.
• To discuss current management approaches for fluid overload in pediatric HCT patients.

Main Methods:

• Review of existing literature and clinical data concerning fluid overload in pediatric HCT recipients.
• Analysis of the association between fluid overload, complications (e.g., AKI, respiratory failure), and mortality.
• Evaluation of diagnostic tools (renal angina index, urinary biomarkers like NGAL) for risk identification.
• Assessment of management strategies including fluid restriction, diuretics, and continuous kidney replacement therapy (CKRT).

Main Results:

• Fluid overload (>10%) occurs in approximately 50% of pediatric HCT patients, linked to decreased PICU survival.
• Each 1% increase in cumulative fluid balance on day 3 post-HCT in children with acute respiratory failure increases PICU mortality odds by 3%.
• Fluid overload exacerbates acute kidney injury, underscoring the importance of renal monitoring.

Conclusions:

• Fluid overload is a major determinant of poor outcomes in pediatric HCT patients.
• Utilizing tools like the renal angina index and urinary biomarkers can aid in identifying at-risk individuals for AKI and FO.
• Prompt and effective management, including fluid restriction, diuretics, and CKRT when indicated, is essential for improving survival and mitigating complications.