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Experience of continuous kidney replacement therapy in a tertiary care unit of a lower-middle-income country
Madhileti Sravani1, Sudarsan Krishnasamy2, Bobbity Deepthi1
1Pediatric Nephrology Services, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006, India.
Insights
Continuous kidney replacement therapy (CKRT) is feasible in critically ill children in lower-middle-income countries (LMIC), despite challenges like malnutrition. High mortality rates necessitate further research into modifiable risk factors.
Area of Science:
- Pediatric Critical Care Medicine
- Nephrology
- Global Health
Background:
- Limited data exists on pediatric continuous kidney replacement therapy (CKRT) in lower-middle-income countries (LMIC).
- Critically ill children in LMICs often present with significant undernutrition and multi-organ dysfunction.
Purpose of the Study:
- To evaluate the clinical characteristics, machine-related factors, and outcomes of children undergoing CKRT in a tertiary care pediatric intensive care unit (PICU) in an LMIC setting.
- To assess the feasibility and safety of CKRT in this vulnerable population.
Main Methods:
- Retrospective analysis of consecutive children (1 month to 18 years) who underwent CKRT between January 2016 and January 2024.
- Data collected included clinical parameters, PRISM III scores, diagnoses, CKRT indications, modality used (Continuous veno-venous hemodiafiltration - CVVHDF), effluent dose, anticoagulation, circuit events, and outcomes.
Main Results:
- 102 children received CKRT, with a median age of 4 years; 51% weighed less than 15 kg, and 36.3% were underweight.
- Common indications included fluid overload and inborn errors of metabolism; septic shock was the most frequent diagnosis.
- Overall mortality was 75%, with circuit clot occurring in 28% of patients, leading to CKRT termination in 17.6%.
Conclusions:
- Continuous kidney replacement therapy (CKRT) can be safely implemented in critically ill children in lower-middle-income countries (LMIC), even with severe undernutrition.
- The high mortality rate underscores the need for further investigation into modifiable risk factors in similar resource-limited settings.
Background:
Information on the clinical characteristics and outcomes of children undergoing continuous kidney replacement therapy (CKRT) from lower-middle-income countries (LMIC) is limited.
Methods:
Records of consecutive children 1 month to 18 years of age who underwent CKRT from Jan 2016 to Jan 2024 in a tertiary care pediatric intensive care unit (PICU) were retrospectively reviewed and analyzed for clinical and machine-related characteristics, and outcomes.
Results:
Over the 8-year period, 102 patients (61.8% boys) with median age 4 (1.5-9) years underwent CKRT. Among these, 52 (51%) weighed < 15 kg, 37 (36.3%) were underweight, and 27 (26.5%) were stunted. Mean (SD) PRISM III score at admission was 17 (6.8), with 94.1% of patients ventilated and 90.2% on two or more inotropes at CKRT initiation. Septic shock (28.4%) and inborn errors of metabolism with acute decompensation (23.5%) were the most common diagnoses at PICU admission. Indications for CKRT were fluid overload, hyperammonemia or inborn errors of metabolism with acute decompensation, dyselectrolytemia, or their combination in 33.3%, 32.4%, 5.9%, and 19.6% patients, respectively. Continuous veno-venous hemodiafiltration (CVVHDF) was the most common (60.8%) modality employed, with an effluent dose of 32.8 ± 7.3 ml/kg/h. Despite heparin anticoagulation in 87.2% patients, circuit clot occurred in 28 patients, 18 (17.6%) of which led to termination of CKRT session. Overall mortality was 75%.
Conclusions:
CKRT can be safely performed in critically ill children from LMIC despite the presence of significant undernutrition and multi-organ dysfunction. Further studies from similar settings are required to evolve strategies to identify modifiable risk factors for the observed high mortality.
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