Title: CRRT for Pediatric ARF
1CRRT for Pediatric ARF
- Stuart L. Goldstein, MD
- Assistant Professor of Pediatrics
- Baylor College of Medicine
2Ronco et al. Lancet 2000 351 26-30
3Ronco et al. Lancet 2000 351 26-30
- Conclusions
- Minimum UF rates should reach at least 35
ml/kg/hr - (2000/1.73m2/hr when adapted for children)
- Survivors in all their groups had lower BUNs than
non-survivors prior to commencement of
hemofiltration - Begs the question does early CRRT effect outcome?
4Pediatric ARFRRT Modalities
- PD most commonly used RRT modality until
mid-1990s - Ease of application
- Limited staffing requirements
- Unit experience
- Cost
5Pediatric ARFRRT Modality Preferences
- 92 pediatric centers
- Most frequently used ( of centers)
modality - 2003 was a projection
Warady and Bunchman Pediatr Nephrol 1511-13
(2000)
6Pediatric Acute Renal FailureIdeal 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
7Pediatric Acute Renal FailureIdeal 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!
8Renal Replacement Therapy in the PICUPediatric
Outcome Literature
- Few pediatric studies (all single center) use
severity of illness measure to evaluate outcomes
in pediatric RRT - Lane noted that mortality was greater after bone
marrow transplant who had gt 10 fluid overload at
the time of HD initiation - Smoyer2 found higher mortality in patients on
pressors - Faragson3 found PRISM to be a poor outcome
predictor in patients treated with HD - Zobel4 demonstrated that children who received
CRRT with worse illness severity by PRISM score
had increased mortality - Did not stratify by modality
1. Bone Marrow Transplant 13613-7, 1994 2. JASN
61401-9, 1995 3. Pediatr Nephrol 7703-7,
1994 4. Child Nephrol Urol 1014-7, 1990
9Pediatric ARF Modality and Survival
Plt0.01
Plt0.01
Survival
Bunchman TE et al Ped Neph 161067-1071, 2001
10Pediatric ARF Modality and Survival
- Patient survival on pressors (35) lower than
without pressors (89) (plt0.01) - Lower survival seen in CRRT than in patients who
received HD for all disease states
Bunchman TE et al Ped Neph 161067-1071, 2001
11CRRT and Outcome in Children
- 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
Jun107(6)1309-12
12Percent Fluid Overload Calculation
Fluid In - Fluid Out ICU Admit Weight
100
FO at CVVH initiation
Fluid In Total Input from ICU admit to CRRT
initiation Fluid Out Total Output from ICU
admit to CRRT initiation
Goldstein SL et al Pediatrics 2001
Jun107(6)1309-12
13CRRT and Outcome in Children
- 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)
Goldstein SL et al Pediatrics 2001 1071309-12
14CRRT and Outcome in Children
- 22 pt (12 male/10 female) received 23 courses
(3028 hrs) of CVVH (n10) or CVVHD (n12) 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
(pNS). - 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)
Goldstein SL et al Pediatrics 2001 1071309-12
15CRRT and Outcome in Children
- Survival curve demonstrates that nearly 75 of
deaths occurred less than 25 days into the ICU
course
Goldstein SL et al Pediatrics 2001 1071309-12
16CRRT and Outcome in Children
- Lesser FO at CVVH (D) initiation was associated
with improved outcome (p0.03) - Lesser FO at CVVH (D) initiation was also
associated with improved outcome when sample was
adjusted for severity of illness (p0.03
multiple regression analysis)
Goldstein SL et al Pediatrics 2001 1071309-12
17CRRT and Outcome in Children
Goldstein SL et al Pediatrics 2001 1071309-12
18Pediatric MODS and CRRT
Foland J et al Journal Society of Critical Care
Medicine (in press)
19Pediatric MODS and CRRT
p
Variable
Hazard Ratio
95 CI
Percent fluid overload
1.5
High (
gt
10)
3.02
-
6.10
0.002
Low (lt10)
1
Dose of replacement fluid
High (
gt
gt25.6 ml/kg/h)
1.23
0.63
7-
2.39
0.533
Low (lt25.6 ml/kg/h)
1
PRISM
-
2 Score
High (
gt
11)
1.67
0.855
-
3.25
0.133
Low (lt11)
1
Number of pressors
High 3-5
-
2.03
0.65
8-
6.30
0.658
None
1
Number of pressors
Low (1
-
1-2)
2.13
1.05-
4.32
0.036
None
1
Gillespie R et al ASN 2003 abstract
20Prospective Pediatric CRRT (ppCRRT ) Registry
Registry Phase 1 Design
- Collect prospective data from 10 pediatric
centers treating 15 to 20 patients annually
(200-300 patients over 4 years) - Each center follows own institutional practice
- Patient selection
- Initiation and termination
- Anti-coagulation protocols
- Convection versus diffusion versus
hemodiafiltration - Fluid composition
- Cytokine clearance study
21ppCRRT Experience
- First patient enrolled on 1/1/01
- 231 patients entered into database as of 05/31/04
- Currently 12 active participating pediatric
centers, 11 have entered at least one patient
- Texas Childrens
- Boston Childrens
- Seattle Childrens
- UAB
- University of Michigan
- Mercy Childrens, KC
- Egleston Childrens, Atlanta
- All Childrens, St. Petersburg
- DC Childrens
- Columbus Childrens
- Packard Childrens, Palo Alto
- DeVos Childrens, Grand Rapids
22Patient Demographics
- Newborn to 25 years
- 59 males
- Weights 1.3 160kg (mean 33.5 kg)
- Mean 6.5 days in ICU prior to CRRT
- (range 0 135 days, median 2)
- Modality
- CVVH (33)
- CVVHD (54)
- CVVHDF (13)
23ppCRRT Data Size Distribution
24Indications for CRRT and Survival
25ppCRRT MODS Data
- BASELINE DEMOGRAPHICS
- 231 patients entered (1/1/2001 to 5/31/04)
- 169/231 (73) with MODS (2 organs involved)
- Mean age 8.6 6.9 years (2 days to 25.1 years)
- Mean weight 33.7 25.1 kg (1.9 to 160 kg)
- Mean GFR 37.9 31.1 at CRRT initiation
- Median 3 ICU days prior to CRRT initiation
- Range 0 to 103 days
- 114/169 (67) less than 7 days
26ppCRRT MODS Data Survival
27ppCRRT MODS Data Clinical Variables
28ppCRRT MODS Data Other Analyses
- FO associated with outcome when CRRT initiation
PRISM 2 controlled in multiple regression
analysis - Survival rates similar by CRRT modality
- Survival rates similar for patients on 0-1
(54), 2 (54) or 3 (44) pressors - Survival rates better for patients with lt20 FO
(61) versus gt20 FO (35) at CRRT initiation
(plt0.001)
29CRRT for Pediatric ARF Summary
- CRRT is the most popular therapy for critically
ill children with ARF - Single center data and multi-center data show
that worse fluid overload is associated with
worse outcome - Would early initiation of CRRT to prevent
worsening fluid overload improve survival? - Prospective randomized controlled trials do not
exist (and could be unethical) - Medication adjustment based on volume status?
30Acknowledgements The ppCRRT Group
Boston Childrens Michael Somers, MD Michelle
Baum, MD Seattle Childrens Jordan Symons,
MD Nancy Hawkins-McAfee, RN CS Mott
Childrens Patrick Brophy, MD Theresa Mottes,
RN UAB Gloria Morrison, RN Joni Barnett,
RN Childrens Mercy Douglas Blowey,
MD Eggleston, Atlanta James Fortenberry,
MD Kristine Rogers, RN
Devos Childrens Timothy Bunchman, MD Richard
Hackbarth, MD Stanford Annabelle Chua,
MD Steven Alexander, MD All Childrens Francis
co Flores, MD Columbus Childrens John Mahan,
MD Texas Childrens Cheryl Baker, RN Leisha
Sanders, RN David Wilson, RN Helen Currier,
RN DC Childrens Kevin McBryde, MD
31Acknowledgement ppCRRT Sponsors
Gambro Renal Products (Cathy DiMuzio) Dialysis
Solutions, Incorporated (Walter ORourke) Baxter
Healthcare (Joseph Villanova)