Renal Replacement Therapy in Pediatric Acute Kidney Injury


Acute kidney injury (AKI) is common in critically ill children and affects nearly 30–40% of patients admitted to the pediatric intensive care unit (ICU). Even with technological advances in critical care and dialysis, there is a high mortality rate of 66.8% to 90% in ICU patients. Renal replacement therapy (RRT) is often performed to treat patients with AKI. However, for optimal RRT treatment, it is crucial to consider the indications, modes of access, and prescription of each RRT method. Therefore, this review aims to discuss the various modalities of RRT in pediatric patients, which include peritoneal dialysis (PD), hemodialysis (HD), continuous RRT (CRRT), and sustained low-efficiency dialysis (SLED).

This is a preview of subscription content, log in to check access.

Access options

Buy single article

Instant unlimited access to the full article PDF.

US$ 39.95

Price includes VAT for USA

Subscribe to journal

Immediate online access to all issues from 2019. Subscription will auto renew annually.

US$ 99

This is the net price. Taxes to be calculated in checkout.

Fig. 1
Fig. 2


  1. 1.

    Sethi SK, Bunchman T, Raina R, Kher V. Unique considerations in renal replacement therapy in children: core curriculum 2014. Am J Kidney Dis. 2014;63:329–45.

  2. 2.

    Li PK, Burdmann EA, Mehta RL. World kidney day 2013: acute kidney injury—global health alert. Am J Kidney Dis. 2013;61:359–63.

  3. 3.

    Jetton JG, Askenazi DJ. Update on acute kidney injury in the neonate. Curr Opin Pediatr. 2012;24:191–6.

  4. 4.

    Krishnappa V, Hein W, DelloStritto D, Gupta M, Raina R. Palliative care for acute kidney injury patients in the intensive care unit. World J Nephrol. 2018;7:148–54.

  5. 5.

    Sutherland SM, Ji J, Sheikhi FH, et al. AKI in hospitalized children: epidemiology and clinical associations in a national cohort. Clin J Am Soc Nephrol. 2013;8:1661–9.

  6. 6.

    Pathak S, Pandey SS, Lazarus M, Mudey A, Nagrale A. Incidences and clinical outcomes of acute kidney injury in PICU: a prospective observational study. Int J Med Health Sci. 2017;6:101–5.

  7. 7.

    Macedo E, Cerdá J, Hingorani S, et al. Recognition and management of acute kidney injury in children: the ISN 0by25 global snapshot study. PLoS One. 2018;13:e0196586.

  8. 8.

    Sethi SK, Raghunathan V, Shah S, et al. Fluid overload and renal angina index at admission are associated with worse outcomes in critically ill children. Front Pediatr. 2018;6:118.

  9. 9.

    Raina R, Chauvin AM, Bunchman T, et al. Treatment of AKI in developing and developed countries: an international survey of pediatric dialysis modalities. PLoS One. 2017;12:e0178233.

  10. 10.

    Carmody JB, Swanson JR, Rhone ET, Charlton JR. Recognition and reporting of AKI in very low birth weight infants. Clin J Am Soc Nephrol. 2014;9:2036–43.

  11. 11.

    Sutherland SM, Byrnes JJ, Kothari M, et al. AKI in hospitalized children: comparing the pRIFLE, AKIN, and KDIGO definitions. Clin J Am Soc Nephrol. 2015;10:554–61.

  12. 12.

    Kaddourah A, Basu RK, Bagshaw SM, Goldstein SL. Epidemiology of acute kidney injury in critically ill children and young adults. New Engl J Med. 2017;376:11–20.

  13. 13.

    Jetton JG, Boohaker LJ, Sethi SK, et al. Incidence and outcomes of neonatal acute kidney injury (AWAKEN): a multicentre, multinational, observational cohort study. Lancet Child Adolesc Health. 2017;1:184–94.

  14. 14.

    Pandey V, Kumar D, Vijayaraghavan P, Chaturvedi T, Raina R. Non-dialytic management of acute kidney injury in newborns. J Renal Inj Prev. 2016;6:1–11.

  15. 15.

    Kwiatkowski DM, Menon S, Krawczeski CD, et al. Improved outcomes with peritoneal dialysis catheter placement after cardiopulmonary bypass in infants. J Thorac Cardiovasc Surg. 2015;149:230–6.

  16. 16.

    Bojan M, Gioanni S, Vouhe PR, Journois D, Pouard P. Early initiation of peritoneal dialysis in neonates and infants with acute kidney injury following cardiac surgery is associated with a significant decrease in mortality. Kidney Int. 2012;82:474–81.

  17. 17.

    Alparslan C, Yavascan O, Bal A, et al. The performance of acute peritoneal dialysis treatment in neonatal period. Ren Fail. 2012;34:1015–20.

  18. 18.

    Kim YH, Resontoc LPR. Peritoneal dialysis in critically ill children. In: Deep A, Goldstein SL, editors. Critical Care Nephrology and Renal Replacement Therapy in Children. New York: SpringerLink: Springer, Cham; 2018. p. 307–23.

  19. 19.

    Palevsky PM, Zhang JH, O'Connor TZ, et al; VA/NIH Acute Renal Failure Trial Network. Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med. 2008;359:7–20.

  20. 20.

    Paganini EP, Tapolyai M, Goormastic M, et al. Establishing a dialysis therapy/patient outcome link in intensive care unit acute dialysis for patients with acute renal failure. Am J Kidney Dis. 1996;28:581–9.

  21. 21.

    Cullis B, Abdelraheem M, Abrahams G, et al. Peritoneal dialysis for acute kidney injury. Perit Dial Int. 2014;34:494–517.

  22. 22.

    Fischbach M, Edefonti A, Schroder C, Watson A; The European Pediatric Dialysis Working Group. Hemodialysis in children: general practical guidelines. Pediatr Nephrol. 2005;20:1054–66.

  23. 23.

    Akaraborworn O. A review in emergency central venous catheterization. Chin J Traumatol. 2017;20:137–40.

  24. 24.

    Schillinger F, Schillinger D, Montagnac R, et al. Post catheterisation vein stenosis in haemodialysis: comparative angiographic study of 50 subclavian and 50 internal jugular accesses. Nephrol Dial Transplant. 1991;6:722–4.

  25. 25.

    National Kidney Foundation. KDOQI clinical practice guidelines for vascular access, 2000. Am J Kidney Dis. 2001;37:S137–81.

  26. 26.

    Preka E, Rukshana S. Haemodialysis. In: Deep A, Goldstein SL, editors. Critical Care Nephrology and Renal Replacement Therapy in Children. New York: SpringerLink: Springer, Cham; 2018. p. 271–89.

  27. 27.

    Raina R, Vijayaraghavan P, Kapur G, et al. Hemodialysis in neonates and infants: a systematic review. Semin Dial. 2017;31:289–99.

  28. 28.

    Brophy PD, Somers MJ, Baum MA, et al. Multi-centre evaluation of anticoagulation in patients receiving continuous renal replacement therapy (CRRT). Nephrol Dial Transplant. 2005;20:1416–21.

  29. 29.

    Kozek-Langenecker SA, Spiss CK, Michalek-Sauberer A, Felfernig M, Zimpfer M. Effect of prostacyclin on platelets, polymorphonuclear cells, and heterotypic cell aggregation during hemofiltration. Crit Care Med. 2003;31:864–8.

  30. 30.

    Goldstein SL. Acute kidney injury in children and its potential consequences in adulthood. Blood Purif. 2012;33:131–7.

  31. 31.

    Hackbarth R, Bunchman TE, Chua AN, et al. The effect of vascular access location and size on circuit survival in pediatric continuous renal replacement therapy: a report from the pPCRRT registry. Int J Artif Organs. 2007;30:1116–21.

  32. 32.

    Menon S, Symons JM. CRRT: technology and basic concepts. In: Deep A, Goldstein SL, editors. Critical Care Nephrology and Renal Replacement Therapy in Children. New York: SpringerLink: Springer, Cham; 2018. p. 211–21.

  33. 33.

    Bunchman TE, Brophy PD, Goldstein SL. Technical considerations for renal replacement therapy in children. Semin Nephrol. 2008;28:488–92.

  34. 34.

    Hothi DK, St George-Hyslop C, Geary D, Bohn D, Harvey E. Continuous renal replacement therapy (CRRT) in children using the AQUARIUS. Nephrol Dial Transplant. 2006;21:2296–300.

  35. 35.

    Davenport A, Will EJ, Davison AM. Hyperlactataemia and metabolic acidosis during haemofiltration using lactate-buffered fluids. Nephron. 1991;59:461–5.

  36. 36.

    Symons JM, Brophy PD, Gregory MJ, et al. Continuous renal replacement therapy in children up to 10 kg. Am J Kidney Dis. 2003;41:984–9.

  37. 37.

    Eding DM, Jelsma LR, Metz CJ, Steen VS, Wincek JM. Innovative techniques to decrease blood exposure and minimize interruptions in pediatric continuous renal replacement therapy. Crit Care Nurse. 2011;31:64–71.

  38. 38.

    Verma AK, Levine M, Shalansky SJ, Carter CJ, Kelton JG. Frequency of heparin-induced thrombocytopenia in critical care patients. Pharmacotherapy. 2003;23:745–53.

  39. 39.

    Bellomo R, Cass A, Cole L, et al; RENAL Replacement Therapy Study Investigators. Intensity of continuous renal-replacement therapy in critically ill patients. N Engl J Med. 2009;361:1627–38.

  40. 40.

    The VA/NIH Acute Renal Failure Trial Network. Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med. 2008;359:7–20.

  41. 41.

    Prowle JR, Bellomo R. Continuous renal replacement therapy: recent advances and future research. Nat Rev Nephrol. 2010;6:521–9.

  42. 42.

    Sethi SK, Sinha R, Jha P, et al. Feasibility of sustained low efficiency dialysis in critically sick pediatric patients: a multicentric retrospective study. Hemodial Int. 2018;22:228–34.

  43. 43.

    Sethi SK, Bansal SB, Khare A, et al. Heparin free dialysis in critically sick children using sustained low efficiency dialysis (SLEDD-f): a new hybrid therapy for dialysis in developing world. PLoS One. 2018;13:e0195536.

Download references


The authors thank Ms. Jennifer L. Clark, Grant/Medical Writer, Rebecca D. Considine Clinical Research Institute and Akron Children’s Hospital for her assistance in language editing. They also thank Lena Nemer for her contributions in compiling and reviewing the manuscript.

Author information

Each author has contributed equally to this article. RR will act as guarantor for this paper.

Correspondence to Rupesh Raina.

Ethics declarations

Conflict of Interest


Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Sethi, S.K., Chakraborty, R., Joshi, H. et al. Renal Replacement Therapy in Pediatric Acute Kidney Injury. Indian J Pediatr (2020) doi:10.1007/s12098-019-03150-9

Download citation


  • Acute kidney injury
  • Renal replacement therapy
  • Pediatric
  • Dialysis