Cr Rt Dialysis Out Come

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Pediatric Acute Renal Failure:

CRRT/Dialysis Outcome Studies

Stuart L. Goldstein, MD

Assistant Professor of Pediatrics

Baylor College of Medicine


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Ideal Study Design Prospective protocol driven entry criteria to ensure

that patients and their respective disease receive

similar treatment Control for severity of illness, primary and co-

morbid diseases

Adequate power to detect effect of an intervention

on or an association of a clinical variable with

outcome


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Ideal Study Design Prospective protocol driven entry criteria to ensure

that patients and their respective disease receive

similar treatment --- Do not exist! Control for severity of illness, primary and co-

morbid diseases --- Some information

Adequate power to detect effect of an intervention

on or an association of a clinical variable with

outcome --- Do not exist!


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Renal Replacement Therapy in the PICU:

Pediatric Outcome Literature

Few pediatric studies (all single center) use a severity of

illness measure to evaluate outcomes in pCRRT:

Lane noted that mortality was greater after bone marrow transplant

who had > 10% fluid overload at the time of HD initiation

Smoyer2found higher mortality in patients on pressors.

Faragson3found PRISM to be a poor outcome predictor in patients

treated with HD

Zobel4demonstrated that children who received CRRT with worse

illness severity by PRISM score had increased mortality Did not stratify by modality

1. Bone Marrow Transplant13:613-7, 1994

2.JASN6:1401-9, 1995

3.Pediatr Nephrol 7:703-7, 1994

4. Child Nephrol Urol 10:14-7, 1990


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Renal Replacement Therapy in the PICU Pediatric

Outcome Literature

122 children studied

No PRISM scores

Most common diagnosis

IHD: primary renal failure

CRRT: sepsis

31% survival

Conclusion: patients whoreceive CRRT are more ill

0

10

20

30

40

50

6070

80

90

Patients % Pressors % Survival

IHD

CRRT

Maxvold NJ et al: Am J Kidney Dis 1997 Nov;30(5 Suppl 4):S84-8


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Pediatric ARF: IHD and CRRT

0

20

40

60

80

100

120

CRRT IHD PD

Bunchman TE et al: Ped Neph 16:1067-1071, 2001


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Pediatric ARF: Disease and Survival

Diagnosis N Survival Diagnosis N %Survival

BMT 26 42% HUS 16 94%

TLS/Malig 17 58% ATN 46 67%

CHD 47 39% Liver Tx 22 17%

Heart Tx 13 67% Sepsis 39 33%



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Pediatric ARF: Modality and Survival

0

10

20

30

40

50

60

70

80

90

IHD PD CRRT

% Survival


P


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Pediatric ARF: Modality and Survival

Patient survival on pressors (35%) lower than

without pressors (89%) (p


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Outcome Literature

Retrospective review of all patients who received CVVH(D) in the

Texas Childrens Hospital PICU from February 1996 through

September 1998 (32 months)

Pre-CVVH initiation data:

Age

Primary disease leading to need for CVVH

Co-morbid diseases

Reason for CVVH

Fluid intake (Fluid In) from PICU admission to CVVH initiation Fluid output (Fluid Out) from PICU admission to CVVH initiation

GFR (Schwartz formula) at CVVH initiation

Goldstein SL et al: Pediatrics 2001 Jun;107(6):1309-12


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Percent Fluid Overload Calculation

% FO at CVVH initiation =[ Fluid In - Fluid OutICU Admit Weight ] * 100%



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Literature

PRISM scores at PICU admission and CVVH initiation calculated by

same nurse

PICU Course Data:

Maximum number of pressors used Pressors completely weaned (y/n)

Mean Airway Pressure (Paw) at CVVH initiation and termination

ICU length of stay (days)

CVVH complications

Outcome (death or survival)



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Pediatric RISk of Mortality (PRISM) Score

PRISM evaluates severity of illness by examining 14 clinical variables

in 5 organ systems.

PRISM does not directly evaluate renal function--only BUN andpotassium levels.

Higher PRISM scores (>10) on admission to the PICU have been

associated with poorer prognosis.

The mean PRISM score at admission to the Texas Childrens Hospital

PICU is 14.


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RESULTS

22 pt (12 male/10 female) received 23 courses (3028 hrs) of CVVH

(n=10) or CVVHD (n=12) over study period. Overall survival was 41% (9/22).

Survival in septic patients was 45% (5/11).

PRISM scores at ICU admission and CVVH initiation were 13.5 +/-

5.7 and 15.7 +/- 9.0, respectively (p=NS).

Conditions leading to CVVH (D)

Sepsis (11)

Cardiogenic shock (4)

Hypovolemic ATN (2)

End Stage Heart Disease (2) Hepatic necrosis, viral pneumonia, bowel obstruction and End-

Stage Lung Disease (1 each)



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Literature

Survival curvedemonstrates that nearly

75% of deaths occurred

less than 25 days into the

ICU course

Survival Time(days)

umua

veroporonurvvng

0.4

0.6

0.8

1.0

0 20 40 60 80 100



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Literature

Lesser % FO at CVVH (D)

initiation was associated with

improved outcome (p=0.03)

Lesser % FO at CVVH (D)initiation was also associated

with improved outcome when

sample was adjusted for severity

of illness (p=0.03; multiple

regression analysis)Mean+SE

Mean-SE

Mean

OUTCOME

a

naon

0

5

10

15

20

25

30

35

40

45

Death Survival

p=0.0



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Outcome Literature

-5

0

5

10

15

20

25

Max Pressor GFR Paw Change

Survivor

Non-Survivor



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Neonatal CRRT

36 critically ill neonates mean age 9.8 + 1.5 days

mean weight 3.0 + 0.1 kg

CAVH (17) CVVH (15)

SCUF/ECMO (4)

Therapeutic Intervention Scoring System (TISS)

Acute Physiologic Scoring System for Children

(APSC)

Zobel G et al: Kid Int 53:S169-S173, 1998


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Neonatal CRRT

Mean CRRT duration of 97 + 20 hours

Mean filter life-span 40.7 + 6.1 hours

Overall survival of 66%

No difference between survivors and non-survivors withrespect to

number of failed organs

TISS points

Significant difference between S and NS with respect to

MAP (49.2 mmHg versus 38.3 mmHg)

APSC 24 hours after starting CRRT

Zobel G et al: Kid Int 53:S169-S173, 1998


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Neonatal/Infant CRRT Outcome

Multicenter retrospective review of CRRT in

neonates/infants (n=85) less than 10kg

655 patient-days (7.6+8.6 days/pt)

Mean weight 5.3 + 2.8kg (16 pt < 3 kg)

Mean Qb of 9.5 + 4.2ml/min/kg

Symons JM et al: CRRT meeting 2002


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N Percent

Diagnosis

Congenital heart disease 14 16.5

Metabolic disorder 14 16.5Multiorgan dysfunction 13 15.3

Sepsis syndrome 12 14.1

Liver failure 9 10.5

Congenital nephrotic syndrome 7 8.2

Malignancy 5 5.9

Congenital diaphragmatic hernia 3 3.5

Heart failure 2 2.4

Other 6 7.1

Table 1. Patient diagnoses at CRRT initiation



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01

2

3

4

56

7

8

1 5 913

17

21

25

29

33

37

41

45

49

Days on CRRT

No.ofPatients

Survivors

Non-Survivors

Figure 2. Days on CRRT, survivors and non-survivors



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38

24

41

0

20

40

6080

100

All Patients 3kg

%Surv

ivors

Figure 3. Percent survival



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Pediatric CRRT Outcome Literature:

Summary

Children with ARF requiring CRRT exhibit 40-50%

survival

PRISM score not predictive Infants >3kg have similar survival rates as older

children

Most mortality occurs within 3 weeks of ICU admission

Children with increased degrees of fluid overload at CRRTinitiation may have increased mortality


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Pediatric CRRT Outcome Literature:

Conclusions

Earlier might be better

Early mortality

Prevent fluid overload

Allow nutrition, blood product administration

Single center data are limited

No differences with respect to

initiation protocols

anticoagulation

machines

nutrition

data assessed

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