Abstract
Objective
To study the clinical course in children requiring continuous renal replacement therapy (CRRT) and to analyse factors associated with mortality.
Design
Prospective observational study.
Setting
Paediatric intensive care department of a tertiary university hospital.
Patients
Critically ill children with CRRT were included in the study.
Intervention
Continuous renal replacement therapy.
Measurements and results
Univariate and multivariate analyses were performed to analyse the influence of each factor on mortality. The ability of the PRISM, PIM II and PELOD severity of illness scores to predict mortality was tested using receiver-operating characteristic curve statistics. A total of 174 children aged between 1 month and 22 years were treated with CRRT. Mortality was 35.6%, and multiorgan failure and haemodynamic disturbances were the principal causes of death. Mortality was higher in children less than 12 months of age (44.7%; P = 0.037) and in patients with a diagnosis of sepsis (44.1%; P = 0.001). Haemodynamic disturbances at the time of starting CRRT (hypotension or need for adrenaline >0.6 µg/kg/min) and the presence of multiorgan failure were the factors associated with an increased risk of mortality. The PRISM scale was the severity score with the best predictive capacity, although all three scales underestimated the actual mortality.
Conclusions
Mortality in children who require CRRT is high. Haemodynamic disturbances and the presence of multiorgan failure at the time of starting the technique are the factors associated with a higher mortality. The clinical severity scores underestimate mortality in children requiring CRRT.
Similar content being viewed by others
References
Barletta GM, Bunchman TE (2004) Acute renal failure in children and infants. Curr Opin Crit Care 10:499–504
Medina A, López-Herce J, López Y, Antón M, Concha A, Rey C, Santos F (2004) Insuficiencia renal aguda en niños criticamente enfermos. Estudio preliminar. An Pediatr (Barc) 61:509–514
Williams DM, Sreedhar SS, Mickell JJ, Chan JC (2002) Acute kidney failure: a pediatric experience over 20 years. Arch Pediatr Adolesc Med 156:893–900
Uchino S, Kellum JA, Bellomo R, Doig GS, Morimatsu H, Morgera S, Schetz M, Tan I, Bouman C, Macedo E, Gibney N, Tolwani A, Ronco C, Beginning and Ending Supportive Therapy for the Kidney (BEST Kidney) Investigators (2005) Acute renal failure in critically ill patients: a multinational, multicenter study. JAMA 294:813–818
Azcan-Arikan A, Zapitelli M, Loftis LL, Washburn KK, Jefferson LS, Goldstein SL (2007) Modified RIFLE criteria in critically ill children with acute renal injury. Kidney Int 71:1028–1035
Palmieri T, Lavrentieva A, Greenhalgh D (2009) An assessment of acute kidney injury with modified RIFLE criteria in pediatric patients with severe burns. Intensive Care Med 35:2125–2129
Plötz FB, Bouma AB, van Wijk JA, Kneyber MC, Bökenkamp A (2008) Pediatric acute kidney injury in the ICU: an independent evaluation of pRIFLE criteria. Intensive Care Med 34:1713–1717
Goldstein SL (2009) Overview of pediatric renal replacement therapy in acute renal failure. Semin Dial 22:180–184
Strazdins V, Watson AR, Harvey B (2004) Renal replacement therapy for acute renal failure: European guidelines. Pediatr Nephrol 19:199–207
Walters S, Porter C, Brophy PD (2009) Dialysis and pediatric acute kidney injury: choice of renal support modality. Pediatr Nephrol 24:37–48
Pichler G, Rodl S, Mache C, Trop M, Ring E, Zobel G (2007) Two decades’ experience of renal replacement therapy in paediatric patients with acute renal failure. Eur J Pediatr 166:139–144
Foland JA, Fortenberry JD, Warshaw BL, Pettignano R, Merritt RK, Heard ML, Rogers K, Reid C, Tanner AJ, Easley KA (2004) Fluid overload before continuous hemofiltration and survival in critically ill children: a retrospective analysis. Crit Care Med 32:1771–1776
Symons JM, Chua AN, Somers MJ, Baum MA, Bunchman TE, Benfield MR, Brophy PD, Blowey D, Fortenberry JD, Chand D, Flores FX, Hackbarth R, Alexander SR, Mahan J, McBryde KD, Goldstein SL (2007) Demographic characteristics of pediatric continuous renal replacement therapy: a report of the prospective pediatric continuous renal replacement therapy registry. Clin J Am Soc Nephrol 2:732–738
Bresolin N, Silva C, Halllal A, Toporovski J, Fernandes V, Góes J, Carvalho FL (2009) Prognosis for children with acute kidney injury in the intensive care unit. Pediatr Nephrol 24:537–544
Ball EF, Kara T (2008) Epidemiology and outcome of acute kidney injury in New Zealand children. J Paediatr Child Health 44:642–646
Cappi SB, Sakr Y, Vincent JL (2006) Daily evaluation of organ function during renal replacement therapy in intensive care unit patients with acute renal failure. J Crit Care 21:179–183
Payen D, de Pont AC, Sakr Y, Spies C, Reinhart K, Vincent JL (2008) A positive fluid balance is associated with a worse outcome in patients with acute renal failure. Crit Care 12:R74
Schiffl H (2006) Renal recovery from acute tubular necrosis requiring renal replacement therapy: a prospective study in critically ill patients. Nephrol Dial Transplant 21:1248–1252
Brivet FG, Kleinknecht DJ, Loirat P, Landais PJ (1996) 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 24:192–198
Bell M, Liljestam E, Granath F, Fryckstedt J, Ekbom A, Martling CR (2005) Optimal follow-up time after continuous renal replacement therapy in actual renal failure patients stratified with the RIFLE criteria. Nephrol Dial Transplant 20:354–360
Clermont G, Acker CG, Angus DC, Sirio CA, Pinsky MR, Johnson JP (2002) Renal failure in the ICU: comparison of the impact of acute renal failure and end-stage renal disease on ICU outcomes. Kidney Int 62:986–996
Metnitz PG, Krenn CG, Steltzer H, Lang T, Ploder J, Lenz K, Le Gall JR, Druml W (2002) Effect of acute renal failure requiring renal replacement therapy on outcome in critically ill patients. Crit Care Med 30:2051–2058
Batista PB, Cendorogolo Neto M, dos Santos OF, Carvalho Bacelar AC, Batista Campos G, dos Santos ES (2004) Evaluation of prognostic indexes in critical acute renal failure patients. Ren Fail 26:545–552
Sasaki S, Gando S, Kobayashi S, Nanzaki S, Ushitani T, Morimoto Y, Demmotsu O (2001) Predictors of mortality in patients treated with continuous hemodiafiltration for acute renal failure in an intensive care setting. ASAIO J 47:86–91
Lima EQ, Dirce MT, Castro I, Yu L (2005) Mortality risk factors and validation of severity scoring systems in critically ill patients with acute renal failure. Ren Fail 27:547–556
Guerin C, Girard R, Selli JM, Perdrix JP, Ayzac L (2000) Initial versus delayed acute renal failure in the intensive care unit. A multicenter prospective epidemiological study. Rhone-Alpes Area Study Group on acute renal failure. Am J Respir Crit Care Med 161:872–879
Silvester W, Bellomo R, Cole L (2001) Epidemiology, management, and outcome of severe acute renal failure of critical illness in Australia. Crit Care Med 29:1910–1915
Ympa YP, Sakr Y, Reinhart K, Vincent JL (2005) Has mortality from acute renal failure decreased? A systematic review of the literature. Am J Med 118:827–832
Elsurer R, Sezer S, Ozdemir NF, Akgul A, Arat Z, Haberal M (2006) Acute renal failure in intensive care unit: which factors predict future dialysis dependency? J Nephrol 19:634–639
Delannoy B, Floccard B, Thiolliere T, Kaaki M, Badet M, Rosselli S, Ber CE, Saez A, Flandreau G, Guérin C (2009) Six-month outcome in acute kidney injury requiring renal replacement therapy in the ICU: a multicentre prospective study. Intensive Care Med 35:1907–1915
Goldstein SL, Currier H, Graf C, Cosio CC, Brewer ED, Sachdeva R (2001) Outcome in children receiving continuous venovenous hemofiltration. Pediatrics 107:1309–1312
Fernandez C, Lopez-Herce J, Flores JC, Galaviz D, Rupérez M, Brandstrup KB, Bustinza A (2005) Prognosis in critically ill children requiring continuous renal replacement therapy. Pediatr Nephrol 20:1473–1477
Baskin E, Saygili A, Harmanci K, Agras PI, Ozdemir FN, Mercan S, Tokel K, Saatci U (2005) Acute renal failure and mortality after open-heart surgery in infants. Ren Fail 27:557–560
Goldstein SL, Somers MJ, Baum MA, Symons JM, Brophy PD, Blowey D, Bunchman TE, Baker C, Mottes T, McAfee N, Barnett J, Morrison G, Rogers K, Fortenberry JD (2005) Pediatric patients with multi-organ dysfunction syndrome receiving continuous renal replacement therapy. Kidney Int 67:653–658
Symons JM, Brophy PD, Gregory MJ, McAfee N, Somers MJ, Bunchman TE, Goldstein SL (2003) Continuous renal replacement therapy in children up to 10 kg. Am J Kidney Dis 41:984–989
Flynn JT (1998) Causes, management approaches, and outcome of acute renal failure in children. Curr Opin Pediatr 10:184–189
Hayes LW, Oster RA, Tofil NM, Tolwani AJ (2009) Outcomes of critically ill children requiring continuous renal replacement therapy. J Crit Care 24:394–400
Goldstein B, Giroir B, Randolph A, International Consensus Conference on Pediatric Sepsis (2005) International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med 6:2–8
Ponikvar R, Kandus A, Urbancic A, Kornhauser AG, Primozic J, Ponikvar JB (2002) Continuous renal replacement therapy and plasma exchange in newborns and infants. Artif Organs 26:163–168
Shiga H, Hirasawa H, Oda S, Matsuda K, Ueno H, Nakamura M (2004) Continuous hemodiafiltration in pediatric critical care patients. Ther Apher Dial 8:390–397
Jander A, Tkaczyk M, Pagowska-Klimek I, Pietrzykowski W, Moll J, Krajewski W, Nowicki M (2007) Continuous veno-venous hemodiafiltration in children after cardiac surgery. Eur J Cardiothorac Surg 31:1022–1028
Bouchard J, Soroko SB, Chertow GM, Himmelfarb J, Ikizler TA, Paganini EP, Mehta RL (2009) Fluid accumulation, survival and recovery of kidney function in critically ill patients with acute kidney injury. Kidney Int 76:422–427
Bunchman TE, McBryde KD, Mottes TE, Gardner JJ, Maxvold NJ, Brophy PD (2001) Pediatric acute renal failure: outcome by modality and disease. Pediatr Nephrol 16:1067–1071
Smoyer WE, McAdams C, Kaplan BS, Sherbotie JR (1995) Determinants of survival in pediatric continuous hemofiltration. J Am Soc Nephrol 6:1401–1409
Zobel G, Kuttnig M, Ring E, Grubbauer HM (1990) Clinical scoring systems in children with continuous extracorporeal renal support. Child Nephrol Urol 10:14–17
Martin C, Saran R, Leavey S, Swartz R (2002) Predicting the outcome of renal replacement therapy in severe acute renal failure. ASAIO J 48:640–644
Fargason CA, Langman CB (1993) Limitations of the pediatric risk of mortality score in assessing children with acute renal failure. Pediatr Nephrol 7:703–707
Acknowledgments
We thank the nurses and doctors of the Paediatric Intensive Care Department of the Hospital General Universitario Gregorio Marañón for their collaboration in performing this study. This study was partially supported by the grant N. RD08/0072: Maternal, Child Health and Development Network) within the framework of the VI National I+D+i Research Program (2008–2011).
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Santiago, M.J., López-Herce, J., Urbano, J. et al. Clinical course and mortality risk factors in critically ill children requiring continuous renal replacement therapy. Intensive Care Med 36, 843–849 (2010). https://doi.org/10.1007/s00134-010-1858-9
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00134-010-1858-9