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Pediatric Nephrology

, Volume 31, Issue 4, pp 651–659 | Cite as

Continuous renal replacement therapy in children: fluid overload does not always predict mortality

  • Lara de GalassoEmail author
  • Francesco Emma
  • Stefano Picca
  • Matteo Di Nardo
  • Emanuele Rossetti
  • Isabella Guzzo
Original Article

Abstract

Background

Mortality among critically ill children requiring continuous renal replacement therapy (CRRT) is high. Several factors have been identified as outcome predictors. Many studies have specifically reported a positive association between the fluid overload at CRRT initiation and the mortality of critically ill pediatric patients.

Methods

This study is a retrospective single-center analysis including all patients admitted to the pediatric intensive care unit (PICU) of our hospital who received CRRT between 2000 and 2012. One hundred thirty-one patients were identified and subsequently classified according to primary disease. Survival rates, severity of illness and fluid balance differed among subgroups. The primary outcome was patient survival to PICU discharge.

Results

Overall survival to PICU discharge was 45.8 %. Based on multiple regression analysis, mortality was independently associated with onco-hematological disease [odds ratio (OR) 11.7, 95 % confidence interval (CI) 1.3–104.7; p = 0.028], severe multiple organ dysfunction syndrome (MODS) (OR 5.1, 95 % CI 1.7–15; p = 0.003) and hypotension (OR 11.6, 95 % CI 1.4–93.2; p = 0.021). In the subgroup analysis, a fluid overload (FO) of more than 10 % (FO>10 %) at the beginning of CRRT seems to be a negative predictor of mortality (OR 10.9, 95 % CI 0.78–152.62; p = 0.07) only in children with milder disease (renal patients). Due to lack of statistical power, the independent effect of fluid overload on mortality could not be analyzed in all subgroups of patients.

Conclusions

In children treated with CRRT the underlying diagnosis and severity of illness are independent risk factors for mortality. The degree of FO is a negative predictor only in patients with milder disease.

Keywords

Acute renal failure CRRT Fluid overload Multiple organ dysfunction syndrome Underlying diseases Survival 

Notes

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

References

  1. 1.
    Hui-Stickle S, Brewer ED, Goldstein SL (2005) Pediatric ARF epidemiology at a tertiary care center from 1999 to 2001. Am J Kid Dis 45:96–101CrossRefPubMedGoogle Scholar
  2. 2.
    Askenazi D (2011) Evaluation and management of critically ill children with acute kidney injury. Curr Opin Pediatr 23(2):201–207PubMedCentralCrossRefPubMedGoogle Scholar
  3. 3.
    Williams DM, Sreedhar SS, Mickell JJ, Chan JC (2002) Acute kidney failure: a pediatric experience over 20 years. Arch Pediatr Adolesc Med 156:893–900CrossRefPubMedGoogle Scholar
  4. 4.
    Proulx F, Gauthier M, Nadeau D, Lacroix J, Farrell CA (1994) Timing and predictors of death in pediatric patients with multiple organ system failure. Crit Care Med 22(6):1025–1031Google Scholar
  5. 5.
    Warady BA, Bunchman T (2000) Dialysis therapy for children with acute renal failure: survey results. Pediatr Nephrol 15(1–2):11–13Google Scholar
  6. 6.
    Schneider J, Khemani R, Grushkin C, Bart R (2010) Serum creatinine as stratified in the RIFLE score for acute kidney injury is associated with mortality and length of stay for children in the pediatric intensive care unit. Crit Care Med 38:933–939CrossRefPubMedGoogle Scholar
  7. 7.
    Akcan-Arikan A, Zappitelli M, Loftis LL, Washburn KK, Jefferson LS, Goldstein SL (2007) Modified RIFLE criteria in critically ill children with acute kidney injury. Kidney Int 71:1028–1035CrossRefPubMedGoogle Scholar
  8. 8.
    Goldstein SL, Currier H, Cd G, Cosio CC, Brewer ED, Sachdeva R (2001) Outcome in children receiving continuous venovenous hemofiltration. Pediatrics 107:1309–1312CrossRefPubMedGoogle Scholar
  9. 9.
    Symons JM, Brophy PD, Gregory MJ, McAfee N, Somers MJ, Bunchman TE, Goldstein SL (2003) Continuous renal replacement therapy in children up to 10 kg. Am J Kidney Dis 41:984–989CrossRefPubMedGoogle Scholar
  10. 10.
    Foland JA, Fortenberry JD, Warshaw BL, Pettignano R, Merritt RK, Heard ML, Rogers K, Reid C, Tanner AJ, Easley KA (2004) Fluid overload before continuous hemofiltration and survival in critically ill children: a retrospective analysis. Crit Care Med 32:1771–1776CrossRefPubMedGoogle Scholar
  11. 11.
    Gillespie RS, Seidel K, Symons JM (2004) Effect of fluid overload and dose of replacement fluid on survival in hemofiltration. Pediatr Nephrol 19:1394–1399CrossRefPubMedGoogle Scholar
  12. 12.
    Goldstein SL, Somers MJ, Baum MA, Symons JM, Brophy PD, Blowey D, Bunchman TE, Baker C, Mottes T, McAfee N, Barnett J, Morrison G, Rogers K, Fortenberry JD (2005) Pediatric patients with multi-organ dysfunction syndrome receiving continuous renal replacement. Kidney Int 67:653–658CrossRefPubMedGoogle Scholar
  13. 13.
    Fernandez C, Lopez-Herce J, Flores JC, Galaviz D, Ruperez M, Brandstrup KB, Bustiniza A (2005) Prognosis in critically ill children requiring continuous renal replacement therapy. Pediatr Nephrol 20:1473–1477CrossRefPubMedGoogle Scholar
  14. 14.
    Symons JM, Chua AN, Somers MJ, Baum MA, Bunchman TE, Benfield MR, Brophy PD, Blowey D, Fortenberry JD, Chand D, Flores FX, Hackbarth R, Alexander SR, Mahan J, McBryde KD, Goldstein SL (2007) Demographic characteristics of pediatric continuous renal replacement therapy: a report of the prospective pediatric continuous renal replacement therapy registry. Clin J Am Soc Nephrol 2(4):732–738CrossRefPubMedGoogle Scholar
  15. 15.
    Flores FX, Brophy PD, Symons JM, Fortenberry JD, Chua AN, Alesander SR, Mahan JD, Bunchman TE, Blowey D, Somers MJ, Baum M, Hackbarth R, Chand D, Benfield M, Goldstein SL (2008) Continuous renal replacement therapy (CRRT) after stem cell transplantation. A report from the prospective pediatric CRRT Registry Group. Pediatr Nephrol 23(4):625–630CrossRefPubMedGoogle Scholar
  16. 16.
    Hayes LW, Oster RA, Tofil NM, Tolwani AJ (2009) Outcomes of critically ill children requiring continuous renal replacement therapy. J Crit Care 24(3):394–400CrossRefPubMedGoogle Scholar
  17. 17.
    Sutherland SM, Zappitelli M, Alexander SR, Chua AN, Brophy PD, Bunchman TE, Hackbarth R, Somers MJ, Baum M, Symons JM, Flores FX, Benfield M, Askenazi D, Chand D, Fortnberry JD, McBryde K, Blowey D, Goldstein SL (2010) Fluid overload and mortality in children receiving continuous renal replacement therapy: the prospective pediatric continuous renal replacement therapy registry. Am J Kidney Dis 55(2):316–325CrossRefPubMedGoogle Scholar
  18. 18.
    Santiago MJ, Lopez-Herce J, Urbano J, Solana MJ, del Castillo J, Ballestero Y, Botran M, Bellon JM (2010) Clinical course and mortality risk factors in critically ill children requiring continuous renal replacement therapy. Intensive Care Med 36(5):843–849CrossRefPubMedGoogle Scholar
  19. 19.
    Askenazi DJ, Goldstein SL, Koralkar R, Fortenberry J, Baum M, Hackbarth R, Blowey D, Bunchman TE, Brophy PD, Symons J, Chua A, Flores F, Somers MJ (2013) Continuous Renal Replacement Therapy for Children ≤10 kg: a report from the prospective pediatric continuous renal replacement therapy registry. J Pediatr 162(3):587–592CrossRefPubMedGoogle Scholar
  20. 20.
    DiCarlo JV, Alexander SR, Agarwal R, Schiffman JD (2003) Continuous veno-venous hemofiltration may improve survival from acute respiratory syndrome after bone marrow transplantation or chemotherapy. J Pediatr Hematol Oncol 25(10):801–805CrossRefPubMedGoogle Scholar
  21. 21.
    Santiago MJ, López-Herce J, Urbano J, Solana MJ, del Castillo J, Sánchez A, Bellón JM (2013) Continuous renal replacement therapy in children after cardiac surgery. J Thorac Cardiovasc Surg 146(2):448–454CrossRefPubMedGoogle Scholar
  22. 22.
    Bunchman TE, McBryde KD, Mottes TE, Gardner JJ, Maxyold NY, Brophy PD (2001) Pediatric acute renal failure: out come by modality and disease. Pediatr Nephrol 16(12):1067–1071CrossRefPubMedGoogle Scholar
  23. 23.
    Selewski DT, Cornell TT, Lombel RM, Blatt NB, Han YY, Mottes T, Kommareddi M, Kershaw DB, Shanley TP, Heung M (2011) Weight-based determination of fluid overload status and mortality in pediatric intensive care unit patients requiring continuous renal replacement therapy. Intensive Care Med 37(7):1166–1673PubMedCentralCrossRefPubMedGoogle Scholar
  24. 24.
    Boschee ED, Cave DA, Garros D, Lequier L, Granoski DA, Guerra GG, Ryerson LM (2014) Indications and outcomes in children receiving renal replacement therapy in pediatric intensive care. J Crit Care 29(1):37–42CrossRefPubMedGoogle Scholar
  25. 25.
    Schwartz GJ, Brion LP, Spitzer A (1987) The use of plasma creatinine concentration for estimating glomerular filtration rate in infants, children, and adolescents. Pediatr Clin North Am 34(3):571–590PubMedGoogle Scholar
  26. 26.
    Slater A, Shann F, Pearson G, Paediatric Index of Mortality (PIM) Study Group (2003) PIM2: a revised version of the Pediatric Index of Mortality. Intensive Care Med 29(2):278–285PubMedGoogle Scholar
  27. 27.
    Goldstein B, Giroir B, Randolph A, International Consensus Conference on Pediatric Sepsis (2005) International pediatric sepsis consensus conference: definition for sepsis and organ dysfunction inpediatrics. Pediatr Crit Care Med 6(1):2–8CrossRefPubMedGoogle Scholar
  28. 28.
    Davison D, Basu RK, Goldstein SL, Chawla LS (2014) Fluid management in adults and children: core curriculum 2014. Am J Kidney Dis 63(4):700–712CrossRefPubMedGoogle Scholar
  29. 29.
    Prowle JR, Chua HR, Bagshaw SM, Bellomo R (2012) Clinical review: volume of fluid resuscitation and the incidence of acute kidney injury—a systematic review. Crit Care 16(4):230PubMedCentralCrossRefPubMedGoogle Scholar
  30. 30.
    Akech S, Ledermann H, Maitland K (2010) Choice of fluids for resuscitation in children with severe infection and shock: systematic review. BMJ 341:c4416PubMedCentralCrossRefPubMedGoogle Scholar
  31. 31.
    Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA (2011) Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med 39(2):259–265CrossRefPubMedGoogle Scholar

Copyright information

© IPNA 2015

Authors and Affiliations

  • Lara de Galasso
    • 1
    Email author
  • Francesco Emma
    • 2
  • Stefano Picca
    • 2
  • Matteo Di Nardo
    • 3
  • Emanuele Rossetti
    • 3
  • Isabella Guzzo
    • 2
  1. 1.Nephrology and Dialysis A Unit“Sapienza” University of RomeRomeItaly
  2. 2.Department of Nephrology and UrologyBambino Gesù Children’s Hospital—IRCCSRomeItaly
  3. 3.Pediatric Intensive Care UnitBambino Gesù Children’s Hospital—IRCCSRomeItaly

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