Two decades’ experience of renal replacement therapy in paediatric patients with acute renal failure

Abstract

During the past 20 years, childhood renal replacement therapy (RRT) and the treatment of underlying diseases experienced extensive advances. We reviewed the data of our critically ill patients with acute renal failure (ARF) and RRT, comparing two decades from 1985 to 1994 and from 1995 to 2004. There were 87 patients with a mortality rate of 45% in the first decade, decreasing to 28 patients with a mortality rate of 39% in the second decade. The mortality rate decreased from 51% to 20% in patients older than one year, while the mortality rate in patients younger than one year increased from 38% to 88%. Yet, the absolute number of these non-survivors younger than one year decreased from 16 to seven patients. The decrease of RRT was mainly caused by a decrease of ARF secondary to heart surgery, oncologic disorders and sepsis. Whereas the majority of patients (75%) were treated with continuous haemofiltration in the first decade, 75% of patients were treated with continuous haemodiafiltration in the second decade. In conclusion, advances in the diagnosis and treatment of underlying disorders have reduced the need for RRT in critically ill paediatric patients during the past 20 years. In addition, there was a tendency for a decrease in the overall mortality, which might be caused by changing treatment policies and advances in RRT technology. Nevertheless, the high mortality rate in small infants is challenging.

Clinical course of children requiring prolonged continuous renal replacement therapy

“…Factors associated with a higher mortality rate are clinical severity, underlying disease, and-above all-the hemodynamic status at the start of therapy [4][5][6][7][8][9][10][11]. Some studies have found a higher mortality rate among children with heart disease than among other patients requiring CRRT, particularly in those undergoing cardiac surgery [5,8].…”

“…A number of studies have analyzed prognostic factors in critically ill children who develop renal failure and/or require RRT. Clinical severity, hemodynamic disturbances, number of organ failures, and a positive fluid balance before starting treatment are the main factors determining the prognosis in these patients [4][5][6][7][8][9][10][11]14]. Critically ill children treated using RRT often require relatively prolonged treatment.…”

“…Though renal replacement therapy (RRT) is only required by a small percentage of these patients, the mortality rate in this group is high [4][5][6][7][8][9][10][11]. Continuous renal replacement therapy (CRRT) has become the most widely used renal support modality in critically ill children, as it allows continuous and programmed removal of fluids and is better tolerated hemodynamically [4,12,13].…”

Incidence of Adverse Events during Continuous Renal Replacement Therapy

“…Various studies have described the individual AEs, safety and usefulness of CRRT in critically ill patients over the last decade [15,17,18] , especially in children [17,[19][20][21] . However, very few studies systematically investigated the incidence of CRRT-related AEs in adult populations, including hemodynamic instability, electrolyte disturbances, coagulopathy and others [15][16][17]22] . It is also often difficult to distinguish between AEs related to CRRT and those related to comorbid conditions or the critical illness itself [23].…”

Continuous Flow Peritoneal Dialysis

“…Mortality rates stratified by dialysis modality in children have remained fairly constant in the past decades, with an overall mortality rate of around 45%, ranging from 27 to 62% (1)(2)(3)(4). The better survival rate for hemodialysis (HD) found in the study by Bunchman et al (1) was attributed to a preselection of more hemodynamically stable patients for HD.…”