Background
Methods
Retrospective chart review
• Equipment change from Prisma to Prismaflex | |
• Standard prescription changed from CVVHD to CVVHDF | |
• Standard anticoagulation changed from systemic heparin to regional citrate | |
• Filter change from mostly AN69 to HF2000 membranes | |
• Adoption of 24 h in-house dialysis nursing staff | |
• Introduction of emergency department sepsis protocola | |
• Establishment of a dedicated Renal ICU physician team | |
• Institutional CRRT Policies & Procedures manual written | |
• Creation of an institutional CRRT prospective database | |
• Creation of a prospective CRRT Quality Improvement Team |
Statistical analysis
Results
Characteristic, n (%) | All patients including ECMO | All patients excluding ECMO |
---|---|---|
Patients (n) | 311 | 273 |
Age (n) | ||
0 to 1 yr. | 73 (23%) | 56 (21%) |
1 to 3 yr | 37 (12%) | 34 (12%) |
3 to 5 yr | 23 (7%) | 23 (8%) |
5 to 10 yr | 41 (13%) | 38 (14%) |
10 to 15 yr | 63 (20%) | 57 (21%) |
15 to 21 yr | 64 (21%) | 55 (20%) |
> 21 yr | 10 (3%) | 10 (4%) |
Mean (SD) | 8.2 (7.0) | 8.4 (7.0) |
Weight (n) | ||
0 to 10 kg | 82 (26%) | 64 (23%) |
10 to 20 kg | 71 (23%) | 68 (25%) |
20 to 50 kg | 80 (26%) | 68 (25%) |
> 50 kg | 78 (25%) | 73 (27%) |
Mean (SD) | 33 (28.1) | 33.5 (27.2) |
Pre-existing end-stage renal disease | 13 (4%) | 13 (5%) |
Sepsis on admission | 36 (13%) | 34 (14%) |
Immunocompromised | ||
Solid organ transplant | 67 (22%) | 58 (21%) |
BMT | 33 (11%) | 31 (11%) |
Other immunocompromised | 54 (17%) | 51 (19%) |
Not immunocompromised | 156 (50%) | 132 (49%) |
% Fluid overload at CRRT Start a | 15 (7, 26) | 15 (8, 26) |
Hospital Unit of CRRT Start | ||
Pediatric Intensive Care Unit | 257 (83%) | 241 (89%) |
Neonatal Intensive Care Unit | 22 (7%) | 14 (5%) |
Cardiovascular Intensive Care Unit | 29 (9%) | 15 (6%) |
Bone Marrow Transplant Unit | 1 (0.3%) | 1 (0.4%) |
ICU survival | 154 (50%) | 145 (53%) |
28 day survival | 176 (57%) | 165 (60%) |
60 day survival | 156 (50%) | 146 (53%) |
Survival to discharge | 139 (45%) | 131 (48%) |
Outpatient Renal Follow-up b | 62 (45%) | 58 (44%) |
Characteristic, n (%) | 2004–2008 | 2009–2013 | p-value |
---|---|---|---|
Patients (n) | 129 | 144 | |
Age (n) | |||
0 to 1 yr. | 24 (19%) | 32 (22%) | |
1 to 3 yr | 15 (12%) | 19 (13%) | |
3 to 5 yr | 7 (5%) | 16 (11%) | |
5 to 10 yr | 19 (15%) | 19 (13%) | |
10 to 15 yr | 28 (22%) | 29 (20%) | |
15 to 21 yr | 29 (22%) | 26 (18%) | |
> 21 yr | 7 (5%) | 3 (2%) | |
Mean (SD) | 9.2 (7.2) | 7.7 (6.8) | 0.08 |
Weight (n) | |||
0 to 10 kg | 26 (20%) | 38 (26%) | |
10 to 20 kg | 29 (22%) | 39 (27%) | |
20 to 50 kg | 35 (27%) | 33 (23%) | |
> 50 kg | 39 (30%) | 34 (24%) | |
Mean (SD) | 36.0 (28.6) | 31.3 (25.7) | 0.15 |
Pre-existing end-stage renal disease | 8 (6%) | 5 (3%) | 0.40 |
Sepsis on admission a | 21 (20%) | 13 (9%) | 0.02 |
Immunocompromised | 0.74 | ||
Solid organ transplant | 25 (20%) | 33 (23%) | |
BMT | 17 (13%) | 14 (10%) | |
Not immunocompromised | 61 (48%) | 71 (49%) | |
Other immunocompromised | 25 (20%) | 26 (18%) | |
% Fluid overload at CRRT Start b | 17 (10, 26) | 14 (6, 26) | 0.19 |
Hospital Unit at CRRT Start | 0.85 | ||
Pediatric Intensive Care Unit | 115 (91%) | 126 (88%) | |
Neonatal Intensive Care Unit | 6 (5%) | 8 (6%) | |
Cardiovascular Intensive Care Unit | 6 (5%) | 9 (6%) | |
Bone Marrow Transplant Unit | 0 | 1 (1%) | |
ICU survival | 68 (53%) | 77 (53%) | 0.90 |
28 day survival | 79 (61%) | 86 (60%) | 0.81 |
60 day survival | 68 (53%) | 78 (54%) | 0.90 |
Survival to discharge | 60 (47%) | 71 (49%) | 0.72 |
Outpatient Renal Follow-up c | 20 (33%) | 38 (54%) | 0.02 |
Diagnosis, n (%) | 0.06 | ||
Cardiac | 13 (10%) | 11 (8%) | |
Renal | 9 (7%) | 19 (13%) | |
Liver | 19 (15%) | 37 (26%) | |
Hematology/Oncology | 18 (14%) | 17 (12%) | |
Post-Bone Marrow Transplant | 18 (14%) | 15 (10%) | |
Pulmonary | 11 (9%) | 4 (3%) | |
Inborn error of metabolism | 5 (4%) | 10 (7%) | |
Sepsis | 10 (8%) | 5 (4%) | |
Neonates | 10 (8%) | 13 (9%) | |
Other d | 16 (12%) | 13 (9%) | |
Cause of acute kidney injury a, e | (n = 113) | (n = 124) | 0.04 |
Multifactorial | 50 (44%) | 69 (56%) | |
Septic shock | 24 (21%) | 14 (11%) | |
Renal | 10 (9%) | 7 (6%) | |
Poor cardiac function | 5 (5%) | 6 (5%) | |
Hepatorenal syndrome | 5 (4%) | 8 (6%) | |
Nephrotoxic drugs | 4 (3%) | 5 (4%) | |
Abdominal compartment syndrome | 1 (1%) | 8 (6%) | |
Other f | 16 (13%) | 7 (6%) | |
Indication for CRRT | (n = 129) | (n = 144) | 0.41 |
Fluid overload | 74 (57%) | 71 (49%) | |
Electrolyte management | 7 (5%) | 9 (6%) | |
Fluid overload and electrolyte management | 28 (22%) | 42 (29%) | |
Prevent fluid overload/provide nutrition | 6 (5%) | 3 (2%) | |
Other | 14 (11%) | 19 (13%) | |
Hemodynamic instability | 3 (21%) | 4 (21%) | |
Hyperammonemia | 6 (43%) | 12 (63%) | |
Ingestion | 3 (21%) | 3 (16%) | |
End-stage renal disease | 2 (14%) | 0 |
2004–2008 | 2009–2013 |
2004–2013
| |||||||
---|---|---|---|---|---|---|---|---|---|
Time Variable (days) | All Patients | Survivors | Non-survivors | All Patients | Survivors | Non-survivors |
All Patients
|
Survivors
|
Non-survivors
|
Time from Hospital Admit to CRRT Start | 8 (2, 22) | 4 (2, 9) | 18 a (4, 36) | 7 (3, 22) | 4 (1, 11) | 14 a (4, 32) |
8 (2, 22)
|
4 (1, 10)
|
16
a
(4, 35)
|
Time from ICU Admit to CRRT Start | 4 (1, 10) | 3 (1, 6) | 9 a (2, 19) | 5 (2, 12) | 2 (1, 5) | 4.5 a (3, 14) |
3 (1, 10)
|
3 (1, 6)
|
7
a
(2, 16)
|
Total CRRT time | 8 (4, 16) | 7 (4, 13) | 8 (4, 19) | 8 (4, 18) | 8 (4, 17) | 8 (4, 18) |
8 (4, 17)
|
7 (4, 15)
|
8 (4, 18)
|
Ventilation time | 21 (9, 35) | 19 (6, 31) | 21 (11, 37) | 12 (5, 29) | 11 (4, 25) | 13b (7, 30) |
16 (7, 31)
|
13 (4, 28)
|
18
a
(8, 33)
|
ICU LOS | 22 (13, 36) | 21 (13, 34) | 22 (13, 38) | 19 (11, 33) | 20 (11, 33) | 19 (10, 33) |
21 (12, 34)
|
21 (12, 34)
|
21 (11, 36)
|
Hospital LOS | 39 (24, 63) | 43 (31, 77) | 36 a (19, 59) | 35 (23, 60) | 41 (26, 71) | 31 a (20, 51) |
38 (23, 61)
|
42 (28, 71)
|
32
a
(19, 54)
|
2004–2008 | 2009–2013 |
2004–2013
| |
---|---|---|---|
Survivor n (%) | Survivor n (%) |
Survivor
n (%)
| |
Principal Diagnosis Category | |||
Cardiac | 7 (54%) | 3 (27%) |
10 (42%)
|
Renal | 4 (44%) | 14 (74%) |
18 (64%)
|
Liver | 6 (32%) | 17 (46%) |
23 (41%)
|
Hematology/Oncology a | 10 (56%) | 3 (18%) |
13 (37%)
|
Bone marrow transplant | 3 (17%) | 5 (33%) |
8 (24%)
|
Pulmonary | 4 (36%) | 2 (50%) |
6 (40%)
|
Inborn error of metabolism | 5 (100%) | 7 (70%) |
12 (80%)
|
Sepsis | 3 (30%) | 2 (40%) |
5 (33%)
|
Neonates | 8 (80%) | 8 (62%) |
16 (70%)
|
Other b | 10 (63%) | 10 (77%) |
20 (69%)
|
Weight | |||
0-10 kg | 9 (35%) | 19 (50%) |
28 (44%)
|
10-25 kg | 13 (45%) | 22 (56%) |
35 (51%)
|
25-50 kg | 17 (49%) | 13 (39%) |
30 (44%)
|
> 50 kg | 21 (54%) | 17 (50%) |
38 (52%)
|
Indications for CRRT | |||
Fluid overload | 31 (42%) | 35 (49%) |
66 (46%)
|
Fluid overload & electrolyte management | 12 (43%) | 17 (41%) |
29 (41%)
|
Prevent fluid overload/provide nutrition | 3 (50%) | 2 (67%) |
5 (56%)
|
Electrolyte management | 4 (57%) | 4 (44%) |
8 (50%)
|
Other c | 10 (71%) | 13 (68%) |
23 (70%)
|
Days on CRRT | |||
1 day | 8 (47%) | 5 (55%) |
12 (50%)
|
2–7 days | 24 (42%) | 34 (45%) |
58 (44%)
|
8–14 days | 18 (50%) | 12 (36%) |
30 (43%)
|
15–21 days | 10 (53%) | 11 (48%) |
21 (50%)
|
22–28 days | 1 (17%) | 7 (50%) |
8 (40%)
|
> 28 days | 3 (25%) | 7 (50%) |
10 (38%)
|
Immune Status | |||
Solid organ transplant | 11 (44%) | 17 (52%) |
28 (48%)
|
Bone marrow transplant | 5 (29%) | 5 (36%) |
10 (32%)
|
Other immunocompromised | 12 (48%) | 11 (42%) |
23 (45%)
|
Not immunocompromised | 32 (52%) | 38 (54%) |
70 (53%)
|
Principal Diagnosis | 2004–2008 | 2009–2013 |
2004–2013
| ||||||
---|---|---|---|---|---|---|---|---|---|
All Patients | Survivors | Non-survivors | All Patients | Survivors | Non-survivors |
All Patients
|
Survivors
|
Non-survivors
| |
Cardiac | 19 (2, 26) | 5 (2, 22) | 20 (19, 33) | 4 (3, 11) | 12 (3,29) | 4 (0, 7) |
7 (2, 22)
|
9 (3, 24)
|
7 (0, 20)
|
Renal | 10 (6, 30) | 10 (6, 30) | – | 23 (13, 30) | 17 (13, 30) | 28 (28,28) |
20 (12, 30)
|
17 (11, 30)
|
28 (28, 28)
|
Liver | 20 (15, 31) | 37 (17, 42) | 18 (14, 24) | 20 (12, 30) | 19 (12, 30) | 20 (12, 30) |
20 (12, 30)
|
20 (12, 35)
|
19 (13, 27)
|
Hematology/ Oncology | 15 (8, 22) | 20 (12, 22) | 12 (8, 15) | 17 (5, 29) | 14 (0, 29) | 21 (5, 29) |
17 (8, 28)
|
17 (8, 22)
|
16 (8, 29)
|
Bone marrow transplant | 16 (10, 20) | 15 (9,20) | 16 (10, 20) | 10 a (7, 12) | 9 (7, 11) | 10 (7, 13) |
11 (9, 18)
|
10 (8, 12)
|
11 (10, 19)
|
Pulmonary | 15 (9, 18) | 20 (5, 26) | 15 (11, 15) | 13 (4, 22) | 13 (8, 18) | 13 (0, 25) |
15 (7, 19)
|
18 (8, 20)
|
15 (7, 16)
|
Inborn Error of Metabolism | 0 (0, 0) | 0 (0, 0) | – | 0 (0, 16) | 0 (0, 0) | 17 (0, 35) |
0 (0, 16)
|
0 (0, 0)
|
17 (0, 35)
|
Sepsis | 20 (9, 28) | 8 (0, 21) | 25 (13, 30) | 22 (20, 38) | 17 (12, 22) | 38 (20, 46) |
21 (12, 30)
|
12 (8, 21)
|
27
b
(19, 34)
|
Neonates | 20 (9, 32) | 21 (8, 39) | 20 (20, 20) | 14 (0, 26) | 6 (0, 14) | 26 b (14, 37) |
14 (6, 29)
|
10 (0, 15)
|
23 (14, 37)
|
Other c | 21 (13, 40) | 21 (13, 28) | 28 (12, 48) | 11 (4, 21) | 17 (5, 21) | 4 (0, 12) |
17 (8, 30)
|
17 (10, 28)
|
12 (4, 36)
|
Discussion
Our Study | ppCRRT Registry a, b | Spain c, d | Birmingham e | Alberta (CRRT only) f | |
---|---|---|---|---|---|
N | 273 | 344 | 174 | 76 | 49 |
Weight | |||||
Mean/Median Wt (kg) | 33.5 | 34.3 | 19.5(2.5–150) | 19.5 (5.5–45) | |
Less than 10 kg (%) | 23 | 24 | 43 | ||
10 to 20 kg (%) | 25 | 20 | |||
20 to 50 kg (%) | 25 | 29 | |||
> 50 kg (%) | 27 | 27 | |||
Age | |||||
Mean / Median Age (yr) | 8.4 | 8.5 | 4.3 (±5.3) | 5.8 (0–17.8) | 5.4 (0.3–13.8) |
0 to 1 yr. (%) | 21 | 20 | 43.7 | ||
1 to 3 yr. (%) | 12 | 13 | |||
3 to 5 yr. (%) | 8 | 8 | |||
5 to 10 yr. (%) | 14 | 17 | |||
10 to 15 yr. (%) | 21 | 19 | |||
15 to 21 yr. (%) | 20 | 20 | |||
> 21 yr. (%) | 4 | 3 | |||
Survival to discharge (%) | 48 | 58 | 64 | 55 | 67 |
Principle diagnosis (%) | |||||
Sepsis | 5 | 24 | 20 | 12 | |
BMT | 12 | 16 | 16 | ||
Cardiac | 9 | 12 | 56 | 9 | |
Renal | 10 | 9 | 10 | 20 | |
Liver | 21 | 8 | 6 | ||
Malignancy | 13 | 8 | 8 | ||
Ischemia/shock | 6 | ||||
Inborn error of metabolism | 5 | 4 | 7 | ||
Drug intoxication | 4 | 2 | |||
Tumor lysis syndrome | 3 | 3 | 14 | ||
Pulmonary | 5 | 3 | |||
Other | 11 | 2 | 05 | 14 | |
Survival on CRRT by Weight (N (%)) | |||||
< 10 kg | 28 (43%) | 36 (43%) | 57% | ||
> 10 kg | 105 (49%) | 165 (63%) | 73% | ||
ICU days before CRRT | 4 (1,10) | 2 | 2 (1–5) | ||
Days on CRRT | 8 (4,16) | 7 (3–18) | |||
% FO | 15 (8, 26) | 12.9 (0–66.4) | 20.1 (5.4–32.5) | ||
Indication for CRRT & survival (%) | |||||
FO and EM | 29 (41%) | 15 | 32g | ||
FO | 67 (45%) | 18 | |||
EM | 8(50%) | 20 | 42h | ||
Prevent FO /provide nutrition | 5(56%) | 20 | |||
Other | 24 (55%) | 21 |