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The effect of continuous venovenous hemodiafiltration on amino acid delivery, clearance, and removal in children

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Abstract

Background

In critically ill children with acute kidney injury (AKI), continuous kidney replacement therapy (CKRT) enables nutrition provision. The magnitude of amino acid loss during continuous venovenous hemodiafiltration (CVVHDF) is unknown and needs accurate quantification. We investigated the mass removal and clearance of amino acids in pediatric CVVHDF.

Methods

This is a prospective observational cohort study of patients receiving CVVHDF from August 2014 to January 2016 in the pediatric intensive care unit (PICU) of a tertiary children’s hospital.

Results

Fifteen patients (40% male, median age 2.0 (IQR 0.7, 8.0) years) were enrolled. Median PICU and hospital lengths of stay were 20 (9, 59) and 36 (22, 132) days, respectively. Overall survival to discharge was 66.7%. Median daily protein prescription was 2.00 (1.25, 2.80) g/kg/day. Median daily amino acid mass removal was 299.0 (174.9, 452.0) mg/kg body weight, and median daily amino acid mass clearance was 18.2 (13.5, 27.9) ml/min/m2, resulting in a median 14.6 (8.3, 26.7) % protein loss. The rate of amino acid loss increased with increasing dialysis dose and blood flow rate.

Conclusion

CVVHDF prescription and related amino acid loss impact nutrition provision, with 14.6% of the prescribed protein removed. Current recommendations for protein provision for children requiring CVVHDF should be adjusted to compensate for circuit-related loss.

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Abbreviations

ACD-A:

Anticoagulant citrate dextrose solution A

AKI:

Acute kidney injury

ARF:

Acute renal failure

BFR:

Blood flow rate

BSA:

Body surface area

BUN:

Blood urea nitrogen

CKRT:

Continuous kidney replacement therapy

CVVH:

Continuous venovenous hemofiltration

CVVHD:

Continuous venovenous hemodialysis

CVVHDF:

Continuous venovenous hemodiafiltration

ECMO:

Extracorporeal membrane oxygenation

FUN:

Fluid urea nitrogen

IQR:

Interquartile range

NPO:

Nil per os

PELOD:

Pediatric logistic organ dysfunction

PICU:

Pediatric intensive care unit

pRIFLE:

Pediatric version of RIFLE (Risk of renal dysfunction; Injury to kidney; Failure of kidney function; Loss of kidney function, End-stage renal disease)

PRISM-III:

Pediatric risk of mortality

REE:

Resting energy expenditure

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Acknowledgements

We would like to acknowledge the collaborative efforts of the Texas Children’s Hospital Pediatric Intensive Care Unit, the Nephrology Department Physician and Nursing Staff, and the Critical Care Research Team, in particular Nancy Jaimon and Daphne Peoples, without whom this study would not have been possible. We also would like to thank Mr. Uluc Arikan for his assistance with figures.

Availability of data and material

Deidentified data will be available from the authors by way of Baylor College of Medicine Institutional Review Board.

Code availability

Not applicable.

Funding

This study is supported by the Texas Children’s Hospital Pediatric Pilot Award.

Author information

Authors and Affiliations

  1. Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA

    Richard P Lion, Moreshwar S Desai, Jorge A Coss-Bu & Ayse Akcan Arikan

  2. Section of Nephrology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA

    Molly R Vega, Michael C Braun & Ayse Akcan Arikan

  3. Department of Pediatrics and Children’s Nutrition Research Center, Baylor College of Medicine, Houston, TX, USA

    E O’Brien Smith & Nathan S Bryan

  4. Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX, USA

    Sridevi Devaraj

  5. Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA

    Talat Alp Ikizler

  6. Texas Children’s Hospital, 6651 Main Street, Houston, TX, 77030, USA

    Ayse Akcan Arikan

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  1. Richard P Lion
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Correspondence to Ayse Akcan Arikan.

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Lion, R.P., Vega, M.R., Smith, E. et al. The effect of continuous venovenous hemodiafiltration on amino acid delivery, clearance, and removal in children. Pediatr Nephrol 37, 433–441 (2022). https://doi.org/10.1007/s00467-021-05162-0

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