Pediatric Acute Renal Failure: CRRT/Dialysis Outcome Studies

1
Pediatric Acute Renal FailureCRRT/Dialysis
Outcome Studies

• Stuart L. Goldstein, MD
• Assistant Professor of Pediatrics
• Baylor College of Medicine

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Pediatric Acute Renal FailureIdeal Study Design

• Prospective protocol driven entry criteria to
  ensure that patients and their respective disease
  receive similar treatment
• Control for severity of illness, primary and
  co-morbid diseases
• Adequate power to detect effect of an
  intervention on or an association of a clinical
  variable with outcome

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Pediatric Acute Renal FailureIdeal Study Design

• Prospective protocol driven entry criteria to
  ensure that patients and their respective disease
  receive similar treatment --- Do not exist!
• Control for severity of illness, primary and
  co-morbid diseases --- Some information
• Adequate power to detect effect of an
  intervention on or an association of a clinical
  variable with outcome --- Do not exist!

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Renal Replacement Therapy in the PICUPediatric
Outcome Literature

• Few pediatric studies (all single center) use a
  severity of illness measure to evaluate outcomes
  in pCRRT
• Lane noted that mortality was greater after bone
  marrow transplant who had gt 10 fluid overload at
  the time of HD initiation
• Smoyer2 found higher mortality in patients on
  pressors.
• Faragson3 found PRISM to be a poor outcome
  predictor in patients treated with HD
• Zobel4 demonstrated that children who received
  CRRT with worse illness severity by PRISM score
  had increased mortality
• Did not stratify by modality

1. Bone Marrow Transplant 13613-7, 1994 2. JASN
61401-9, 1995 3. Pediatr Nephrol 7703-7,
1994 4. Child Nephrol Urol 1014-7, 1990
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Renal Replacement Therapy in the PICU Pediatric
Outcome Literature

• 122 children studied
• No PRISM scores
• Most common diagnosis
• IHD primary renal failure
• CRRT sepsis
• 31 survival
• Conclusion patients who receive CRRT are more ill

Maxvold NJ et al Am J Kidney Dis 1997 Nov30(5
Suppl 4)S84-8
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Pediatric ARF IHD and CRRT
Bunchman TE et al Ped Neph 161067-1071, 2001
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Pediatric ARF Disease and Survival
Bunchman TE et al Ped Neph 161067-1071, 2001
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Pediatric ARF Modality and Survival
Plt0.01
Plt0.01
Survival
Bunchman TE et al Ped Neph 161067-1071, 2001
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Pediatric ARF Modality and Survival

• Patient survival on pressors (35) lower than
  without pressors (89) (plt0.01)
• Lower survival seen in CRRT than in patients who
  received HD for all disease states

Bunchman TE et al Ped Neph 161067-1071, 2001
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Renal Replacement Therapy in the PICU Pediatric
Outcome Literature

• Retrospective review of all patients who received
  CVVH(D) in the Texas Childrens Hospital PICU
  from February 1996 through September 1998 (32
  months)
• Pre-CVVH initiation data
• Age
• Primary disease leading to need for CVVH
• Co-morbid diseases
• Reason for CVVH
• Fluid intake (Fluid In) from PICU admission to
  CVVH initiation
• Fluid output (Fluid Out) from PICU admission to
  CVVH initiation
• GFR (Schwartz formula) at CVVH initiation

Goldstein SL et al Pediatrics 2001
Jun107(6)1309-12

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Percent Fluid Overload Calculation


Fluid In - Fluid Out ICU Admit Weight
100
FO at CVVH initiation
Goldstein SL et al Pediatrics 2001
Jun107(6)1309-12
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Renal Replacement Therapy in the PICU Pediatric
Literature

• PRISM scores at PICU admission and CVVH
  initiation calculated by same nurse
• PICU Course Data
• Maximum number of pressors used
• Pressors completely weaned (y/n)
• Mean Airway Pressure (Paw) at CVVH initiation and
  termination
• ICU length of stay (days)
• CVVH complications
• Outcome (death or survival)

Goldstein SL et al Pediatrics 2001
Jun107(6)1309-12
13
Pediatric RISk of Mortality (PRISM) Score

• PRISM evaluates severity of illness by examining
  14 clinical variables in 5 organ systems.
• PRISM does not directly evaluate renal
  function--only BUN and potassium levels.
• Higher PRISM scores (gt10) on admission to the
  PICU have been associated with poorer prognosis.
• The mean PRISM score at admission to the Texas
  Childrens Hospital PICU is 14.

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RESULTS

• 22 pt (12 male/10 female) received 23 courses
  (3028 hrs) of CVVH (n10) or CVVHD (n12) over
  study period.
• Overall survival was 41 (9/22).
• Survival in septic patients was 45 (5/11).
• PRISM scores at ICU admission and CVVH initiation
  were 13.5 /- 5.7 and 15.7 /- 9.0, respectively
  (pNS).
• Conditions leading to CVVH (D)
• Sepsis (11)
• Cardiogenic shock (4)
• Hypovolemic ATN (2)
• End Stage Heart Disease (2)
• Hepatic necrosis, viral pneumonia, bowel
  obstruction and End-Stage Lung Disease (1 each)

Goldstein SL et al Pediatrics 2001
Jun107(6)1309-12
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Renal Replacement Therapy in the PICU Pediatric
Literature

• Survival curve demonstrates that nearly 75 of
  deaths occurred less than 25 days into the ICU
  course

Goldstein SL et al Pediatrics 2001
Jun107(6)1309-12
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Renal Replacement Therapy in the PICU Pediatric
Literature

• Lesser FO at CVVH (D) initiation was associated
  with improved outcome (p0.03)
• Lesser FO at CVVH (D) initiation was also
  associated with improved outcome when sample was
  adjusted for severity of illness (p0.03
  multiple regression analysis)

Goldstein SL et al Pediatrics 2001
Jun107(6)1309-12
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Renal Replacement Therapy in the PICU Pediatric
Outcome Literature
Goldstein SL et al Pediatrics 2001
Jun107(6)1309-12
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Neonatal CRRT

• 36 critically ill neonates
• mean age 9.8 1.5 days
• mean weight 3.0 0.1 kg
• CAVH (17)
• CVVH (15)
• SCUF/ECMO (4)
• Therapeutic Intervention Scoring System (TISS)
• Acute Physiologic Scoring System for Children
  (APSC)

Zobel G et al Kid Int 53S169-S173, 1998
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Neonatal CRRT

• Mean CRRT duration of 97 20 hours
• Mean filter life-span 40.7 6.1 hours
• Overall survival of 66
• No difference between survivors and non-survivors
  with respect to
• number of failed organs
• TISS points
• Significant difference between S and NS with
  respect to
• MAP (49.2 mmHg versus 38.3 mmHg)
• APSC 24 hours after starting CRRT

Zobel G et al Kid Int 53S169-S173, 1998
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Neonatal/Infant CRRT Outcome

• Multicenter retrospective review of CRRT in
  neonates/infants (n85) less than 10kg
• 655 patient-days (7.68.6 days/pt)
• Mean weight 5.3 2.8kg (16 pt lt 3 kg)
• Mean Qb of 9.5 4.2ml/min/kg

Symons JM et al CRRT meeting 2002
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Neonatal/Infant CRRT Outcome
Symons JM et al CRRT meeting 2002
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Neonatal/Infant CRRT Outcome
Symons JM et al CRRT meeting 2002
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Neonatal/Infant CRRT Outcome
Symons JM et al CRRT meeting 2002
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Pediatric CRRT Outcome LiteratureSummary

• Children with ARF requiring CRRT exhibit 40-50
  survival
• PRISM score not predictive
• Infants gt3kg have similar survival rates as older
  children
• Most mortality occurs within 3 weeks of ICU
  admission
• Children with increased degrees of fluid overload
  at CRRT initiation may have increased mortality

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Pediatric CRRT Outcome LiteratureConclusions

• Earlier might be better
• Early mortality
• Prevent fluid overload
• Allow nutrition, blood product administration
• Single center data are limited
• No differences with respect to
• initiation protocols
• anticoagulation
• machines
• nutrition
• data assessed