Continuous renal replacement therapy for septic shock: practicalities for a pediatric intensivist

Area of Science:

• Pediatric critical care medicine
• Extracorporeal therapies
• Sepsis management

Background:

• High-volume hemofiltration (HVHF) is proposed for pediatric sepsis to reduce inflammatory mediators.
• The 2026 Surviving Sepsis Campaign guidelines conditionally recommend HVHF for pediatric sepsis requiring CRRT.
• This recommendation is based on limited evidence.

Purpose of the Study:

• To critically review the biological rationale, evidence, and limitations of HVHF in pediatric septic shock.
• To evaluate the clinical applicability of HVHF in pediatric intensive care settings.
• To inform clinical practice regarding the use of HVHF in pediatric sepsis.

Main Methods:

• Narrative review of biological rationale and existing pediatric and adult evidence.
• Critical examination of clinical trial data and observational studies.
• Analysis of practical limitations and pediatric-specific factors.

Main Results:

• HVHF's biological premise is plausible, but clinical benefits remain uncertain.
• Pediatric evidence consists of small trials with heterogeneous data; larger datasets show no clear dose-outcome link.
• Adult trials and systematic reviews do not consistently support survival benefits from higher-volume strategies.

Conclusions:

• HVHF is biologically plausible but clinically unproven in pediatric septic shock.
• Potential risks, including dialytrauma and nutrient losses, warrant caution.
• Routine adoption of HVHF in pediatric sepsis should be tempered by current evidence and specific patient factors.