Elsevier

Seminars in Nephrology

Volume 28, Issue 5, September 2008, Pages 457-469
Seminars in Nephrology

Renal Supportive Therapy for Pediatric Acute Kidney Injury in the Setting of Multiorgan Dysfunction Syndrome/Sepsis

https://doi.org/10.1016/j.semnephrol.2008.05.005Get rights and content

Summary

In the setting of sepsis and multiorgan dysfunction syndrome, the development of acute kidney injury can be an ominous event, particularly in the pediatric patient. In this setting, rapid initiation of renal supportive therapy is likely to positively impact on mortality rates. Therapeutic initiation and choice of dialytic modality are dependent on physician beliefs, as well as patient and organizational characteristics. Patient-specific factors including adequacy of nutrition provision, acuity of acute kidney injury, degree of uremia, and severity of fluid overload all must be taken into account during the decision on whether or not to initiate renal supportive therapies. In addition to the utilization of classical renal supportive modalities such as acute hemodialysis, peritoneal dialysis, and continuous renal replacement therapies, the increasing use of plasma exchange therapies and other alternatives are actively being explored for use in sepsis-associated acute kidney injury. This article reviews these concepts and current literature in the context of pediatric specific sepsis-associated acute kidney injury.

Section snippets

Timing of Initiation of RST

Few topics in the pediatric RST realm have been as controversial as delineating the optimal timing of RST initiation. Over the past several years both pediatric and adult data have supported the implementation of RST earlier in the course of care4, 5, 6; such a strategy is particularly relevant in pediatric care because children tend to develop their maximal organ failures and die more rapidly than the adult population.7 Classically defined indicators for RST initiation in the setting of AKI

Modality Choice

A number of modalities are available for RST provision in the pediatric patient with MODS/sepsis-associated AKI. Intermittent hemodialysis (HD), peritoneal dialysis (PD), and CRRTs such as continuous venovenous hemodialysis (CVVHD) (predominantly diffusive clearance), CVVH (convective clearance), or continuous venovenous hemodiafiltration (CVVHDF) (both convective and diffusive clearance), may be used to provide enhanced solute clearance and ultrafiltration.33, 34 In addition to these classic

Conclusions

Significant questions remain with respect to the initiation timing, modality choice duration, and frequency of these therapies in the clinical setting.9 The variables impacting these decisions are numerous and significant. Wider approaches to blood purification in sepsis are promising and these techniques usually are well tolerated and are effective in clearing septic mediators with subsequent improvement in physiologic parameters. Direct demonstration in improvement in mortality rates has been

References (103)

  • R.J. Meyer et al.

    Hemodialysis followed by continuous hemofiltration for treatment of lithium intoxication in children

    Am J Kidney Dis

    (2001)
  • M.A. Nash et al.

    Neonatal lactic acidosis and renal failure: the role of peritoneal dialysis

    J Pediatr.

    (1977)
  • F. Fleming 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)
  • T.E. Bunchman et al.

    Pediatric convective hemofiltration: normocarb replacement fluid and citrate anticoagulation

    Am J Kidney Dis

    (2003)
  • C.D. Scheinkestel et al.

    Impact of increasing parenteral protein loads on amino acid levels and balance in critically ill anuric patients on continuous renal replacement therapy

    Nutrition

    (2003)
  • J.J. Payne-James et al.

    Artificial nutrition support in hospitals in the United Kingdom—1991: second national survey

    Clin Nutr

    (1992)
  • Walters S, Porter C, Brophy PD. Dialysis and pediatric acute kidney injury: choice of renal support modality. Pediatr...
  • J.T. Flynn

    Choice of dialysis modality for management of pediatric acute renal failure

    Pediatr Nephrol

    (2002)
  • S.L. Goldstein et al.

    Outcome in children receiving continuous venovenous hemofiltration

    Pediatrics

    (2001)
  • F. Proulx et al.

    Timing and predictors of death in pediatric patients with multiple organ system failure

    Crit Care Med

    (1994)
  • L. Cole et al.

    A prospective, multicenter study of the epidemiology, management, and outcome of severe acute renal failure in a “closed” ICU system

    Am J Respir Crit Care Med

    (2000)
  • P.M. Palevsky

    Clinical review: timing and dose of continuous renal replacement therapy in acute kidney injury

    Crit Care

    (2007)
  • F.G. Brivet et al.

    Acute renal failure in intensive care units—causes, outcome, and prognostic factors of hospital mortality; a prospective, multicenter study. French Study Group on Acute Renal Failure

    Crit Care Med

    (1996)
  • Z. Ricci et al.

    Practice patterns in the management of acute renal failure in the critically ill patient: an international survey

    Nephrol Dial Transplant

    (2006)
  • M.R. Benfield et al.

    Management of acute renal failure

  • R. Bellomo et al.

    Acute renal failure—definition, outcome measures, animal models, fluid therapy and information technology needs: 2nd Int Consensus Conf Acute Dialysis Quality Initiative (ADQI) Group

    Crit Care

    (2004)
  • P.M. Palevsky

    Dialysis modality and dosing strategy in acute renal failure

    Semin Dial

    (2006)
  • L.G. Gettings et al.

    Outcome in post-traumatic acute renal failure when continuous renal replacement therapy is applied early vs. late

    Intensive Care Med

    (1999)
  • K.D. Liu et al.

    Timing of initiation of dialysis in critically ill patients with acute kidney injury

    Clin J Am Soc Nephrol

    (2006)
  • S.R. Mendley et al.

    Acute renal failure in the pediatric patient

    Adv Ren Replace Ther

    (1997)
  • A. Sehic et al.

    Acute renal failure: therapy

    Pediatr Rev

    (1995)
  • T.E. Bunchman et al.

    Modality and mortality in pediatric renal replacement therapy [abstract]

    J Am Soc Nephrol

    (1994)
  • P. Arora et al.

    Prognosis of acute renal failure in children: a multivariate analysis

    Pediatr Nephrol

    (1997)
  • P.W. Kandoth et al.

    Acute renal failure in children requiring dialysis therapy

    Indian Pediatr

    (1994)
  • W. Wong et al.

    Acute renal failure in the paediatric intensive care unit

    N Z Med J

    (1996)
  • U.T. Acharya et al.

    Outcome of dialysed patients with acute renal failure

    Indian Pediatr

    (1996)
  • J.M. Symons 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)
  • R.L. Mehta et al.

    Diuretics, mortality, and nonrecovery of renal function in acute renal failure

    JAMA

    (2002)
  • J.A. Foland et al.

    Fluid overload before continuous hemofiltration and survival in critically ill children: a retrospective analysis

    Crit Care Med

    (2004)
  • R.S. Gillespie et al.

    Effect of fluid overload and dose of replacement fluid on survival in hemofiltration

    Pediatr Nephrol

    (2004)
  • R.P. Dellinger et al.

    International guidelines for management of severe sepsis and septic shock: 2008

    Crit Care Med

    (2008)
  • D. Parakininkas et al.

    Comparison of solute clearance in three modes of continuous renal replacement therapy

    Pediatr Crit Care Med

    (2004)
  • S.M. Bagshaw et al.

    Clinical characteristics and outcomes beginning and ending supportive therapy for the kidney (BEST kidney) investigators

    Clin J Am Soc Nephrol

    (2007)
  • C. Ronco

    Recent evolution of renal replacement therapy in the critically ill patient

    Crit Care

    (2006)
  • C. Ronco et al.

    Extracorporeal therapies in non-renal disease: treatment of sepsis and the peak concentration hypothesis

    Blood Purif

    (2004)
  • P.M. Honoré et al.

    Blood and plasma treatments: the rationale of high-volume hemofiltration

    Contrib Nephrol

    (2007)
  • T.A. Ikizler et al.

    Nutrition in acute renal failure patients

    Adv Ren Replace Ther

    (1997)
  • M.C. Riella

    Nutrition in acute renal failure

    Ren Fail

    (1997)
  • D.L. Blowey et al.

    Peritoneal dialysis in the neonatal period: outcome data

    J Perinatol

    (1993)
  • W.-K. Gong et al.

    Eighteen years experience in pediatric acute dialysis: analysis of predictors of outcome

    Pediatr Nephrol

    (2001)
  • Cited by (24)

    • Acute Kidney Injury in Children. An Update on Diagnosis and Treatment.

      2013, Pediatric Clinics of North America
      Citation Excerpt :

      Reported mortality in children with AKI receiving continuous renal replacement therapies (CRRTs) has ranged from 32.1% to 58.9% in studies since 2000.29 AKI synergistically increases morbidity and mortality in children with multiple organ failure, hematopoietic stem cell transplantation, trauma, and extracorporeal membrane oxygenation, independent of severity of illness scoring.32–35 Effects of AKI are also long lasting in survivors, with chronic renal insufficiency in almost half of patients at 3-year to 5-year follow-up, suggesting permanent alteration of the renal parenchyma.36

    • An update and review of acute kidney injury in pediatrics

      2011, Pediatric Critical Care Medicine
      Citation Excerpt :

      In a study of nearly 4,000 critically ill children, AKI increased mortality and lengthened intensive care stay four-fold (48). AKI increases mortality with multi-organ failure, marrow or solid organ transplantation, extracorporeal membrane oxygenation, or acute respiratory distress syndrome from 10% to 57.1% (12, 50–51). AKI has a high risk of death independent of Pediatric Risk of Mortality II scores in these patients (49).

    • Fluid balance

      2021, The Great Ormond Street Hospital: Manual of Children and Young People’s Nursing Practices: Second Edition
    View all citing articles on Scopus
    View full text