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Renal Replacement Therapy Modalities in Critically Ill Children*

Beltramo, Fernando, MD1; DiCarlo, Joseph, MD1; Gruber, Joshua B., MSPH3; Taylor, Thom, PhD3; Totapally, Balagangadhar R., MD2

Pediatric Critical Care Medicine: January 2019 - Volume 20 - Issue 1 - p e1–e9
doi: 10.1097/PCC.0000000000001754
Online Clinical Investigations

Objectives: The objective of this study is to describe the relative frequency of use of continuous renal replacement therapy, intermittent hemodialysis, and peritoneal dialysis and to analyze characteristics and outcomes of critically ill children receiving renal replacement therapies admitted to PICUs that participate in the Virtual PICU (VPS LLC, Los Angeles, CA) registry.

Design: Retrospective, database analysis.

Setting: PICUs that participate in the Virtual PICU (VPS LLC) registry.

Patients: Critically ill children admitted to PICUs that participate in the Virtual PICU (VPS LLC) registry and received renal replacement therapy from January 1, 2009, to December 31, 2015.

Interventions: None.

Measurements and Main Results: A total of 7,109 cases (53% males) received renal replacement therapy during the study period. The median age was 72.3 months (interquartile range, 8.4–170 mo) and median length of stay was 8.7 days (interquartile range, 3.3–21.2 d). Caucasians comprised 42% of the cohort and blacks and Hispanics were 16% each. Continuous renal replacement therapy was used in 46.5%, hemodialysis in 35.5% and peritoneal dialysis in 18%. Of the 7,109 cases, 1,852 (26%) were postoperative cases (68% cardiac surgical) and 981 (14%) had a diagnosis of cancer. Conventional mechanical ventilation was used in 64%, high-frequency oscillatory ventilation in 12%, noninvasive ventilation in 24%, and extracorporeal membrane oxygenation in 5.8%. The overall mortality was 22.3%. Patients who died were younger 40.8 months (interquartile range, 1.5–159.4 mo) versus 79.9 months (interquartile range, 12.6–171.7 mo), had a longer length of stay 15 days (interquartile range, 7–33 d) versus 7 days (interquartile range, 3–18 d) and higher Pediatric Index of Mortality 2 score –2.84 (interquartile range, –3.5 to –1.7) versus –4.2 (interquartile range, –4.7 to –3.0) (p < 0.05). On multivariate logistic regression analysis, higher mortality was associated with the presence of cancer (32.7%), previous ICU admission (32%), requiring mechanical ventilation (33.7%), receiving high-frequency oscillatory ventilation (67%), or extracorporeal membrane oxygenation (58.4%), admission following cardiac surgical procedure (29.4%), and receiving continuous renal replacement therapy (38.8%), and lower mortality was associated with hemodialysis (9.8%), and peritoneal dialysis (12.3%) (p < 0.0001).

Conclusions: Continuous renal replacement therapy is an increasingly prevalent renal replacement therapy modality used in critically ill children admitted to an ICU. Higher mortality rate with the use of continuous renal replacement therapy should be interpreted with caution.

1Department of Critical Care Medicine, Children’s Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA.

2Division of Critical Care Medicine, Nicklaus Children’s Hospital, Florida International University, Herbert Wertheim College of Medicine, Miami, FL.

3Research Data & Analytics Department, Miami Children’s Health Care System & Research Institute, Miami, FL.

*See also p. 87.

Dr. Totapally’s institution received funding from the Department of Defense. The remaining authors have disclosed that they do not have any potential conflict of interest.

This analysis was performed at Nicklaus Children’s Hospital.

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©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies