At the present time there have been no randomized clinical trails comparing PD vs IHD vs CRRT for treatment of children with AKI. To date only one randomized clinical study of adults, comparing CRRT with PD, has been published. This study was performed in a developing country in terms of resources. Phu et al. [
87] made an open randomized comparison of PD vs CRRT in patients with infection-related AKI. This 70-patient study (
n = 34 on CRRT,
n = 36 on PD) found that for all their primary end points (i.e. resolution of acidosis, reduction of creatinine), CRRT was significantly superior to PD. Additionally, they noted as secondary outcomes a significant survival difference between modalities, with CRRT resulting in an 85% survival rate and PD associated with a 53% survival rate. They also noted an overall cost reduction for patient care with the use of CRRT, despite the higher technical costs of this therapy. This was due to savings in duration of therapy and overall reduction in total resource requirements per patient. Their overwhelming conclusion was that CRRT was superior to PD for the treatment of AKI associated with infection. Their study has been criticized for the prescription delivered with PD and other methodological issues leading to potential selection bias [
87,
88], but, nonetheless, the study provides the first randomized comparison of these modalities. More recently, a pediatric-based retrospective analysis [
49] of 118 infants and children treated either with PD (
n = 82) or CRRT (
n = 36) (followed by extended daily dialysis in those showing signs of recovery) demonstrated that, while there was no difference in mortality rates between modalities, CRRT provided better fluid control and was the modality of choice for hypercatabolic AKI associated with sepsis. Main CRRT complications were access and circuit clotting. The patients’ conditions and modality choices were quite different, with smaller patients with more stable conditions receiving PD, while hemodynamically unstable, somewhat larger, patients received CRRT. These data support, in part, the conclusions reached by Fleming et al. [
82]. They retrospectively compared PD (
n = 21) and CRRT (
n = 21) in 42 children following repair of congenital heart disease lesions. The common indications for RRT implementation included fluid overload, electrolyte abnormalities, provision of total parenteral nutrition (TPN), and oliguria. No standardized initiation criteria were utilized, and this varied significantly among patients. Additionally, nine patients in the CRRT group received arteriovenous CRRT. Most of the patients (90%) required pressor support. While there was no difference noted in terms of mortality rate between modalities (62% for both), CRRT was superior to PD for ultrafiltration, solute clearance and nutritional provision. From these data, the authors concluded that CRRT was superior to PD in this clinical setting. The conclusions of their study must be guarded, as patient care was not standardized in terms of modality initiation criterion. Also, the patient group was rather homogeneous, making generalizability difficult, and no apparent survival benefit was noted with improved solute and ultrafiltration in the CRRT group. Bunchman et al. [
75] reviewed survival outcome in 226 pediatric patients receiving various forms of RRT, including PD, IHD and CRRT, over a 7-year period from 1992–1998. Patients were treated with CRRT (
n = 106), IHD (
n = 61) or PD (
n = 59). Factors influencing patient survival included: (1) low blood pressure (BP) at the initiation of RRT (33% survival, low BP; 61%, normal BP; 100%, high BP;
P < 0.05); (2) pressor use anytime during RRT (35% survival on pressors; 89% survival not requiring pressors;
P < 0.01); (3) diagnosis (improved outcome in those with primary renal failure compared to those with secondary renal failure;
P < 0.05); (4) RRT modality (40% survival, CRRT; 49% survival, PD; 81% survival, IHD; P < 0.01 IHD vs PD or CRRT), and (5) pressor support was significantly higher in children on CRRT (74%) and PD (81%) vs IHD (33%) (
P < 0.05 IHD vs CRRT or PD). The authors concluded that hemodynamic support (sicker patients) with pressors imparted a greater prediction of mortality, rather than RRT modality, and that survival of children, as of adults, is best predicted by the underlying diagnosis and hemodynamic stability. Interestingly, modality choice was determined, in part, by patient status. That is, patients with greater hemodynamic instability were preferentially treated with PD or CRRT, and many of these patients required pressor support.