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Updated: May 21, 2025
Long-Term Continuous Measurement of Renal Blood Flow in Conscious Rats
Published on: February 8, 2022
Net Fluid Balance Impacts Pediatric Continuous Renal Replacement Therapy Liberation
Sameer Thadani1,2, Harsha V Jujjavarapu3, Christin Silos2
1Department of Pediatrics, Division of Critical Care Medicine, Baylor College of Medicine, Houston, TX.
Insights
Fluid management in pediatric continuous renal replacement therapy (CRRT) is key. A net fluid balance (NFB) between -4.46 and -0.305 mL/kg/hr in critically ill children on CRRT is linked to better kidney recovery.
Area of Science:
- Pediatric Nephrology
- Critical Care Medicine
- Renal Replacement Therapy
Background:
- Optimal fluid management strategies for pediatric continuous renal replacement therapy (CRRT) remain unclear.
- The impact of ultrafiltration rates (UFRs) on CRRT-induced dialytrauma in children is undetermined.
- While fluid overload (FO) at CRRT initiation is linked to adverse outcomes, the role of net fluid balance (NFB) during CRRT in predicting renal recovery is not well-established.
Purpose of the Study:
- To investigate the association between net fluid balance (NFB) during CRRT and renal recovery in critically ill children.
- To explore the relationship between preserved urine output (UOP) and outcomes in pediatric CRRT patients.
- To compare pediatric CRRT fluid management practices with those in adult cohorts.
Main Methods:
- Retrospective cohort study including children and young adults who received CRRT at two quaternary pediatric intensive care units (PICUs).
- Data collected on patient demographics, acute kidney injury status, fluid overload (FO), net fluid balance (NFB), and urine output (UOP).
- Statistical analysis to determine associations between NFB, UOP, and outcomes like CRRT-free days and major adverse kidney events at 30 days (MAKE-30).
Main Results:
- A total of 371 patients were analyzed, with 96% having acute kidney injury at CRRT initiation and 28% experiencing FO > 15%.
- Patients with preserved UOP (> 0.3 mL/kg/hr) experienced 5.6 more CRRT-free days and had reduced odds of MAKE-30.
- A NFB between -4.46 and -0.305 mL/kg/hr was independently associated with significantly more CRRT-free days (β 2.90) and decreased odds of MAKE-30 (aOR 0.41).
Conclusions:
- Pediatric CRRT ultrafiltration practices differ significantly from adult protocols.
- A more positive NFB during CRRT was associated with fewer CRRT-free days in children.
- Further research is needed to determine if excessive UFR causes dialytrauma in critically ill children, aiming for personalized CRRT prescriptions to enhance outcomes.
Objectives:
The optimal fluid management strategy on continuous renal replacement therapy (CRRT) is unknown for critically ill children. The pace of ultrafiltration has been highlighted as a risk predictor for adverse outcomes in adult cohorts. Whether CRRT can cause dialytrauma through excessive ultrafiltration rates (UFRs) in children is undetermined. Although fluid overload (FO) at CRRT start has been associated with adverse outcomes, net fluid balance (NFB) on CRRT has not been investigated as a predictor for renal recovery.
Design:
Retrospective cohort study.
Setting:
Two quaternary PICUs.
Patients Or Subjects:
Children and young adults admitted between 2/2014 and 2/2020 at two quaternary pediatric hospitals who received CRRT.
Interventions:
None.
Measurements And Main Results:
Three hundred and seventy-one patients were included in this study with the median age of 85 months (interquartile range [IQR] 17-172), 180 (50%) were female. Three hundred and forty-five (96%) had acute kidney injury at CRRT start, 102 (28%) patients had FO > 15%. The median NFB on day 1 was 0.33 mL/kg/hr (-0.43 to 1.18), day 2 was -0.14 mL/kg/hr (-0.72 to 0.52), and day 3 was -0.24 mL/kg/hr (-0.85 to 0.42). Patients with a preserved urine output (UOP) greater than 0.3 mL/kg/hr over the study period had 5.6 more CRRT-free days and had decreased odds of major adverse kidney events at 30 days (MAKE-30). A NFB between -4.46 and -0.305 mL/kg/hr was independently associated with more CRRT-free days (β 2.90 [0.24-5.56]) and decreased odds of MAKE-30 (adjusted odds ratio 0.41 [0.22-0.79]).
Conclusions:
Ultrafiltration practices in children receiving CRRT are substantially different compared to adult cohorts. Patients with a more positive NFB had fewer CRRT-free days. Preservation of UOP was associated with more CRRT-free days. Whether UFR causes direct dialytrauma in critically ill children through impairment of organ perfusion and hemodynamics require further study to allow personalization of CRRT prescriptions to improve outcomes.
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