Pediatric acute kidney injury: Indications, timing, and choice of modality for renal replacement therapy (RRT)
- Patrick D Brophy, MD
Patrick D Brophy, MD
- University of Iowa, Carver College of Medicine
- Jennifer G Jetton, MD
Jennifer G Jetton, MD
- Clinical Associate Professor
- University of Iowa, Carver College of Medicine
Acute kidney injury (AKI) is characterized by the acute failure of the kidneys to maintain adequate electrolyte, acid-base, and fluid homeostasis along with a reduction in glomerular filtration rate (GFR) [1,2]. Clinically, AKI is manifested by increases in nitrogenous waste products (blood urea nitrogen [BUN]) and serum creatinine (SCr), and, in some cases, a concomitant reduction in urine output (less than 0.5 to 1 mL/kg per hour) that may be refractory to diuretic therapy [1-3]. (See "Acute kidney injury in children: Clinical features, etiology, evaluation, and diagnosis".)
AKI is increasingly recognized as an important and independent risk factor of morbidity and mortality in critically ill children [4-7]. With at least 30 different definitions of AKI reported in the literature , generalizations across studies and comparisons of different data sets are challenging. As a result, the lack of evidence-based guidelines regarding the management of the pediatric patient with AKI has led to uncertainty and controversy regarding the appropriate timing for the initiation of renal replacement therapy (RRT), as well as the most appropriate RRT modality.
The indications, timing, and modalities for RRT for children with AKI will be reviewed here. RRT in adults is discussed separately. (See "Renal replacement therapy (dialysis) in acute kidney injury in adults: Indications, timing, and dialysis dose", section on 'Timing of elective initiation'.)
INDICATIONS FOR AND TIMING OF RRT
Retrospective reviews of large databases of critically ill children demonstrate that children tend to develop organ failure, including AKI, early in their hospital course, and children with AKI have a greater mortality risk and longer length of stay than those without AKI [9,10]. RRT may prevent and correct the adverse and potentially life-threatening complications of AKI including symptomatic uremia, metabolic and electrolyte imbalance, and severe fluid overload, thereby reducing the mortality and length of stay of children with AKI.
Indicators for the provision of RRT in pediatric AKI have been traditionally extrapolated from the following parameters used for dialysis initiation for end-stage renal disease (ESRD) :
- Benfield MR, Bunchman TE. Management of acute renal failure. In: Pediatric Nephrology, 5th ed, Avner ED, Harmon WE, Niaudet P (Eds), Lippincott Williams & Wilkins, Philadelphia 2004. p.1253.
- Andreoli SP. Acute renal failure in the newborn. Semin Perinatol 2004; 28:112.
- Maxvold NJ, Bunchman TE. Renal failure and renal replacement therapy. Crit Care Clin 2003; 19:563.
- Vachvanichsanong P, Dissaneewate P, Lim A, McNeil E. Childhood acute renal failure: 22-year experience in a university hospital in southern Thailand. Pediatrics 2006; 118:e786.
- Bunchman TE, McBryde KD, Mottes TE, et al. Pediatric acute renal failure: outcome by modality and disease. Pediatr Nephrol 2001; 16:1067.
- Symons JM, Chua AN, Somers MJ, et al. Demographic characteristics of pediatric continuous renal replacement therapy: a report of the prospective pediatric continuous renal replacement therapy registry. Clin J Am Soc Nephrol 2007; 2:732.
- Price JF, Mott AR, Dickerson HA, et al. Worsening renal function in children hospitalized with decompensated heart failure: evidence for a pediatric cardiorenal syndrome? Pediatr Crit Care Med 2008; 9:279.
- Bellomo R, Ronco C, Kellum JA, et al. Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care 2004; 8:R204.
- Proulx F, Gauthier M, Nadeau D, et al. Timing and predictors of death in pediatric patients with multiple organ system failure. Crit Care Med 1994; 22:1025.
- Schneider J, Khemani R, Grushkin C, Bart R. 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 2010; 38:933.
- Flynn JT. Choice of dialysis modality for management of pediatric acute renal failure. Pediatr Nephrol 2002; 17:61.
- Palevsky PM. Dialysis modality and dosing strategy in acute renal failure. Semin Dial 2006; 19:165.
- Ronco C, Bellomo R, Homel P, et al. Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial. Lancet 2000; 356:26.
- Devarajan P. Cellular and molecular derangements in acute tubular necrosis. Curr Opin Pediatr 2005; 17:193.
- Zappitelli M, Washburn KK, Arikan AA, et al. Urine neutrophil gelatinase-associated lipocalin is an early marker of acute kidney injury in critically ill children: a prospective cohort study. Crit Care 2007; 11:R84.
- Parikh CR, Mishra J, Thiessen-Philbrook H, et al. Urinary IL-18 is an early predictive biomarker of acute kidney injury after cardiac surgery. Kidney Int 2006; 70:199.
- Han WK, Bailly V, Abichandani R, et al. Kidney Injury Molecule-1 (KIM-1): a novel biomarker for human renal proximal tubule injury. Kidney Int 2002; 62:237.
- Goldstein SL, Somers MJ, Baum MA, et al. Pediatric patients with multi-organ dysfunction syndrome receiving continuous renal replacement therapy. Kidney Int 2005; 67:653.
- Goldstein SL, Currier H, Graf Cd, et al. Outcome in children receiving continuous venovenous hemofiltration. Pediatrics 2001; 107:1309.
- Foland JA, Fortenberry JD, Warshaw BL, et al. Fluid overload before continuous hemofiltration and survival in critically ill children: a retrospective analysis. Crit Care Med 2004; 32:1771.
- Gillespie RS, Seidel K, Symons JM. Effect of fluid overload and dose of replacement fluid on survival in hemofiltration. Pediatr Nephrol 2004; 19:1394.
- Sutherland SM, Zappitelli M, Alexander SR, et al. Fluid overload and mortality in children receiving continuous renal replacement therapy: the prospective pediatric continuous renal replacement therapy registry. Am J Kidney Dis 2010; 55:316.
- Flores FX, Brophy PD, Symons JM, et al. Continuous renal replacement therapy (CRRT) after stem cell transplantation. A report from the prospective pediatric CRRT Registry Group. Pediatr Nephrol 2008; 23:625.
- Brierley J, Carcillo JA, Choong K, et al. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med 2009; 37:666.
- Goldstein SL, Chawla LS. Renal angina. Clin J Am Soc Nephrol 2010; 5:943.
- Basu RK, Chawla LS, Wheeler DS, Goldstein SL. Renal angina: an emerging paradigm to identify children at risk for acute kidney injury. Pediatr Nephrol 2012; 27:1067.
- Parakininkas D, Greenbaum LA. Comparison of solute clearance in three modes of continuous renal replacement therapy. Pediatr Crit Care Med 2004; 5:269.
- Bunchman TE, Maxvold NJ, Brophy PD. Pediatric convective hemofiltration: Normocarb replacement fluid and citrate anticoagulation. Am J Kidney Dis 2003; 42:1248.
- Bunchman TE, Smoyer WE, Valentini RP, et al. Modality and mortality in pediatric renal replacement therapy (abstract). J Am Soc Nephrol 1994; 5:436.
- Arora P, Kher V, Rai PK, et al. Prognosis of acute renal failure in children: a multivariate analysis. Pediatr Nephrol 1997; 11:153.
- Kandoth PW, Agarwal GJ, Dharnidharka VR. Acute renal failure in children requiring dialysis therapy. Indian Pediatr 1994; 31:305.
- Wong W, McCall E, Anderson B, et al. Acute renal failure in the paediatric intensive care unit. N Z Med J 1996; 109:459.
- Blowey DL, McFarland K, Alon U, et al. Peritoneal dialysis in the neonatal period: outcome data. J Perinatol 1993; 13:59.
- Gong WK, Tan TH, Foong PP, et al. Eighteen years experience in pediatric acute dialysis: analysis of predictors of outcome. Pediatr Nephrol 2001; 16:212.
- Alarabi AA, Petersson T, Danielson BG, Wikström B. Continuous peritoneal dialysis in children with acute renal failure. Adv Perit Dial 1994; 10:289.
- Kohli HS, Arora P, Kher V, et al. Daily peritoneal dialysis using a surgically placed Tenckhoff catheter for acute renal failure in children. Ren Fail 1995; 17:51.
- Flynn JT, Kershaw DB, Smoyer WE, et al. Peritoneal dialysis for management of pediatric acute renal failure. Perit Dial Int 2001; 21:390.
- Anochie IC, Eke FU. Paediatric acute peritoneal dialysis in southern Nigeria. Postgrad Med J 2006; 82:228.
- Bandeira MF, Gam A, Zagury A, et al. Renal Replacement Therapy (RRT) in Acute Renal Failure (ARF) in Critically Ill Children Under 10 kg. Poster/Abstract Annual Dialysis Conference Tampa, FL, 2005.
- Phadke KD, Dinakar C. The challenges of treating children with renal failure in a developing country. Perit Dial Int 2001; 21 Suppl 3:S326.
- Auron A, Warady BA, Simon S, et al. Use of the multipurpose drainage catheter for the provision of acute peritoneal dialysis in infants and children. Am J Kidney Dis 2007; 49:650.
- Bunchman TE. Acute peritoneal dialysis access in infant renal failure. Perit Dial Int 1996; 16 Suppl 1:S509.
- Nash MA, Russo JC. Neonatal lactic acidosis and renal failure: the role of peritoneal dialysis. J Pediatr 1977; 91:101.
- Grodstein GP, Blumenkrantz MJ, Kopple JD, et al. Glucose absorption during continuous ambulatory peritoneal dialysis. Kidney Int 1981; 19:564.
- Barletta JF, Barletta GM, Brophy PD, et al. Medication errors and patient complications with continuous renal replacement therapy. Pediatr Nephrol 2006; 21:842.
- Podel J, Hodelin-Wetzel R, Saha DC, Burns G. Glucose absorption in acute peritoneal dialysis. J Ren Nutr 2000; 10:93.
- Reznik VM, Griswold WR, Peterson BM, et al. Peritoneal dialysis for acute renal failure in children. Pediatr Nephrol 1991; 5:715.
- McBryde KD, Kershaw DB, Bunchman TE, et al. Renal replacement therapy in the treatment of confirmed or suspected inborn errors of metabolism. J Pediatr 2006; 148:770.
- Brophy PD, Flynn JT, Kershaw DB, et al. Pediatric overdose: effective treatment with high-efficiency hemodialysis (abstract). J Am Soc Neprhol 1999; 10:137A.
- Bunchman TE, Gardner JJ, Kershaw DB, Maxvoid JN. Vascular access for hemodialysis or CVVH(D) in infants and children. Dial Transplant 1994; 23:314.
- Coulthard MG, Crosier J, Griffiths C, et al. Haemodialysing babies weighing <8 kg with the Newcastle infant dialysis and ultrafiltration system (Nidus): comparison with peritoneal and conventional haemodialysis. Pediatr Nephrol 2014; 29:1873.
- Arieff AI. Dialysis disequilibrium syndrome: current concepts on pathogenesis and prevention. Kidney Int 1994; 45:629.
- Bunchman TE, Donckerwolcke RA. Continuous arterial-venous diahemofiltration and continuous veno-venous diahemofiltration in infants and children. Pediatr Nephrol 1994; 8:96.
- Forni LG, Hilton PJ. Continuous hemofiltration in the treatment of acute renal failure. N Engl J Med 1997; 336:1303.
- Maxvold NJ, Smoyer WE, Custer JR, Bunchman TE. Amino acid loss and nitrogen balance in critically ill children with acute renal failure: a prospective comparison between classic hemofiltration and hemofiltration with dialysis. Crit Care Med 2000; 28:1161.
- Fleming F, Bohn D, Edwards H, et al. Renal replacement therapy after repair of congenital heart disease in children. A comparison of hemofiltration and peritoneal dialysis. J Thorac Cardiovasc Surg 1995; 109:322.
- Clark WR, Mueller BA, Alaka KJ, Macias WL. A comparison of metabolic control by continuous and intermittent therapies in acute renal failure. J Am Soc Nephrol 1994; 4:1413.
- Swartz RD, Bustami RT, Daley JM, et al. Estimating the impact of renal replacement therapy choice on outcome in severe acute renal failure. Clin Nephrol 2005; 63:335.
- McBryde KD, Bunchman TE, Kudelka TL, et al. Hyperosmolar solutions in continuous renal replacement therapy for hyperosmolar acute renal failure: a preliminary report. Pediatr Crit Care Med 2005; 6:220.
- 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.
- Askenazi DJ, Goldstein SL, Koralkar R, et al. Continuous renal replacement therapy for children ≤10 kg: a report from the prospective pediatric continuous renal replacement therapy registry. J Pediatr 2013; 162:587.
- Ronco C, Garzotto F, Brendolan A, et al. Continuous renal replacement therapy in neonates and small infants: development and first-in-human use of a miniaturised machine (CARPEDIEM). Lancet 2014; 383:1807.
- Askenazi D, Ingram D, White S, et al. Smaller circuits for smaller patients: improving renal support therapy with Aquadex™. Pediatr Nephrol 2016; 31:853.
- Troyanov S, Cardinal J, Geadah D, et al. Solute clearances during continuous venovenous haemofiltration at various ultrafiltration flow rates using Multiflow-100 and HF1000 filters. Nephrol Dial Transplant 2003; 18:961.
- Chawla LS, Kellum JA, Ronco C. Permissive hypofiltration. Crit Care 2012; 16:317.
- Hui-Stickle S, Brewer ED, Goldstein SL. Pediatric ARF epidemiology at a tertiary care center from 1999 to 2001. Am J Kidney Dis 2005; 45:96.
- Choi SJ, Ha EJ, Jhang WK, Park SJ. Factors Associated With Mortality in Continuous Renal Replacement Therapy for Pediatric Patients With Acute Kidney Injury. Pediatr Crit Care Med 2017; 18:e56.
- INDICATIONS FOR AND TIMING OF RRT
- Severity of AKI
- Fluid overload
- Renal angina
- Our approach
- MODALITY CHOICE
- Peritoneal dialysis
- - Contraindications and complications
- Intermittent hemodialysis
- Continuous renal replacement therapy
- Comparisons of modalities
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS