12 Goldstein Pediatric Crrt Dialysis Outcome

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12 Goldstein Pediatric Crrt Dialysis Outcome

  1. 1. Pediatric Acute Renal Failure: CRRT/Dialysis Outcome Studies Stuart L. Goldstein, MD Assistant Professor of Pediatrics Baylor College of Medicine
  2. 2. Pediatric Acute Renal Failure: Ideal Study Design <ul><li>Prospective protocol driven entry criteria to ensure that patients and their respective disease receive similar treatment </li></ul><ul><li>Control for severity of illness, primary and co-morbid diseases </li></ul><ul><li>Adequate power to detect effect of an intervention on or an association of a clinical variable with outcome </li></ul>
  3. 3. Pediatric Acute Renal Failure: Ideal Study Design <ul><li>Prospective protocol driven entry criteria to ensure that patients and their respective disease receive similar treatment --- Do not exist! </li></ul><ul><li>Control for severity of illness, primary and co-morbid diseases --- Some information </li></ul><ul><li>Adequate power to detect effect of an intervention on or an association of a clinical variable with outcome --- Do not exist! </li></ul>
  4. 4. Renal Replacement Therapy in the PICU: Pediatric Outcome Literature <ul><li>Few pediatric studies (all single center) use a severity of illness measure to evaluate outcomes in pCRRT: </li></ul><ul><ul><li>Lane noted that mortality was greater after bone marrow transplant who had > 10% fluid overload at the time of HD initiation </li></ul></ul><ul><ul><li>Smoyer 2 found higher mortality in patients on pressors. </li></ul></ul><ul><ul><li>Faragson 3 found PRISM to be a poor outcome predictor in patients treated with HD </li></ul></ul><ul><ul><li>Zobel 4 demonstrated that children who received CRRT with worse illness severity by PRISM score had increased mortality </li></ul></ul><ul><ul><ul><li>Did not stratify by modality </li></ul></ul></ul>1 . Bone Marrow Transplant 13:613-7, 1994 2 . JASN 6:1401-9, 1995 3. Pediatr Nephrol 7:703-7, 1994 4. Child Nephrol Urol 10:14-7, 1990
  5. 5. Renal Replacement Therapy in the PICU Pediatric Outcome Literature <ul><li>122 children studied </li></ul><ul><li>No PRISM scores </li></ul><ul><li>Most common diagnosis </li></ul><ul><ul><li>IHD: primary renal failure </li></ul></ul><ul><ul><li>CRRT: sepsis </li></ul></ul><ul><ul><ul><li>31% survival </li></ul></ul></ul><ul><li>Conclusion: patients who receive CRRT are more ill </li></ul>Maxvold NJ et al: Am J Kidney Dis 1997 Nov;30(5 Suppl 4):S84-8
  6. 6. Pediatric ARF: IHD and CRRT Bunchman TE et al: Ped Neph 16:1067-1071, 2001
  7. 7. Pediatric ARF: Disease and Survival Bunchman TE et al: Ped Neph 16:1067-1071, 2001
  8. 8. Pediatric ARF: Modality and Survival % Survival Bunchman TE et al: Ped Neph 16:1067-1071, 2001 P<0.01 P<0.01
  9. 9. Pediatric ARF: Modality and Survival <ul><li>Patient survival on pressors (35%) lower than without pressors (89%) (p<0.01) </li></ul><ul><li>Lower survival seen in CRRT than in patients who received HD for all disease states </li></ul>Bunchman TE et al: Ped Neph 16:1067-1071, 2001
  10. 10. Renal Replacement Therapy in the PICU Pediatric Outcome Literature <ul><li>Retrospective review of all patients who received CVVH(D) in the Texas Children’s Hospital PICU from February 1996 through September 1998 (32 months) </li></ul><ul><li>Pre-CVVH initiation data: </li></ul><ul><ul><li>Age </li></ul></ul><ul><ul><li>Primary disease leading to need for CVVH </li></ul></ul><ul><ul><li>Co-morbid diseases </li></ul></ul><ul><ul><li>Reason for CVVH </li></ul></ul><ul><ul><li>Fluid intake (Fluid In) from PICU admission to CVVH initiation </li></ul></ul><ul><ul><li>Fluid output (Fluid Out) from PICU admission to CVVH initiation </li></ul></ul><ul><ul><li>GFR (Schwartz formula) at CVVH initiation </li></ul></ul>Goldstein SL et al: Pediatrics 2001 Jun;107(6):1309-12
  11. 11. Percent Fluid Overload Calculation % FO at CVVH initiation = [ Fluid In - Fluid Out ICU Admit Weight ] * 100% Goldstein SL et al: Pediatrics 2001 Jun;107(6):1309-12
  12. 12. Renal Replacement Therapy in the PICU Pediatric Literature <ul><li>PRISM scores at PICU admission and CVVH initiation calculated by same nurse </li></ul><ul><li>PICU Course Data: </li></ul><ul><ul><li>Maximum number of pressors used </li></ul></ul><ul><ul><li>Pressors completely weaned (y/n) </li></ul></ul><ul><ul><li>Mean Airway Pressure (Paw) at CVVH initiation and termination </li></ul></ul><ul><ul><li>ICU length of stay (days) </li></ul></ul><ul><ul><li>CVVH complications </li></ul></ul><ul><ul><li>Outcome (death or survival) </li></ul></ul>Goldstein SL et al: Pediatrics 2001 Jun;107(6):1309-12
  13. 13. Pediatric RISk of Mortality (PRISM) Score <ul><li>PRISM evaluates severity of illness by examining 14 clinical variables in 5 organ systems. </li></ul><ul><li>PRISM does not directly evaluate renal function--only BUN and potassium levels. </li></ul><ul><li>Higher PRISM scores (>10) on admission to the PICU have been associated with poorer prognosis. </li></ul><ul><li>The mean PRISM score at admission to the Texas Children’s Hospital PICU is 14. </li></ul>
  14. 14. RESULTS <ul><li>22 pt (12 male/10 female) received 23 courses (3028 hrs) of CVVH (n=10) or CVVHD (n=12) over study period. </li></ul><ul><li>Overall survival was 41% (9/22). </li></ul><ul><li>Survival in septic patients was 45% (5/11). </li></ul><ul><li>PRISM scores at ICU admission and CVVH initiation were 13.5 +/- 5.7 and 15.7 +/- 9.0, respectively (p=NS). </li></ul><ul><li>Conditions leading to CVVH (D) </li></ul><ul><ul><li>Sepsis (11) </li></ul></ul><ul><ul><li>Cardiogenic shock (4) </li></ul></ul><ul><ul><li>Hypovolemic ATN (2) </li></ul></ul><ul><ul><li>End Stage Heart Disease (2) </li></ul></ul><ul><ul><li>Hepatic necrosis, viral pneumonia, bowel obstruction and End-Stage Lung Disease (1 each) </li></ul></ul>Goldstein SL et al: Pediatrics 2001 Jun;107(6):1309-12
  15. 15. Renal Replacement Therapy in the PICU Pediatric Literature <ul><li>Survival curve demonstrates that nearly 75% of deaths occurred less than 25 days into the ICU course </li></ul>Goldstein SL et al: Pediatrics 2001 Jun;107(6):1309-12
  16. 16. Renal Replacement Therapy in the PICU Pediatric Literature <ul><li>Lesser % FO at CVVH (D) initiation was associated with improved outcome (p=0.03) </li></ul><ul><li>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) </li></ul>Goldstein SL et al: Pediatrics 2001 Jun;107(6):1309-12
  17. 17. Renal Replacement Therapy in the PICU Pediatric Outcome Literature Goldstein SL et al: Pediatrics 2001 Jun;107(6):1309-12
  18. 18. Neonatal CRRT <ul><li>36 critically ill neonates </li></ul><ul><ul><li>mean age 9.8 + 1.5 days </li></ul></ul><ul><ul><li>mean weight 3.0 + 0.1 kg </li></ul></ul><ul><li>CAVH (17) </li></ul><ul><li>CVVH (15) </li></ul><ul><li>SCUF/ECMO (4) </li></ul><ul><li>Therapeutic Intervention Scoring System (TISS) </li></ul><ul><li>Acute Physiologic Scoring System for Children (APSC) </li></ul>Zobel G et al: Kid Int 53:S169-S173, 1998
  19. 19. Neonatal CRRT <ul><li>Mean CRRT duration of 97 + 20 hours </li></ul><ul><li>Mean filter life-span 40.7 + 6.1 hours </li></ul><ul><li>Overall survival of 66% </li></ul><ul><li>No difference between survivors and non-survivors with respect to </li></ul><ul><ul><li>number of failed organs </li></ul></ul><ul><ul><li>TISS points </li></ul></ul><ul><li>Significant difference between S and NS with respect to </li></ul><ul><ul><li>MAP (49.2 mmHg versus 38.3 mmHg) </li></ul></ul><ul><ul><li>APSC 24 hours after starting CRRT </li></ul></ul>Zobel G et al: Kid Int 53:S169-S173, 1998
  20. 20. Neonatal/Infant CRRT Outcome <ul><li>Multicenter retrospective review of CRRT in neonates/infants (n=85) less than 10kg </li></ul><ul><li>655 patient-days (7.6+8.6 days/pt) </li></ul><ul><li>Mean weight 5.3 + 2.8kg (16 pt < 3 kg) </li></ul><ul><li>Mean Qb of 9.5 + 4.2ml/min/kg </li></ul>Symons JM et al: CRRT meeting 2002
  21. 21. Neonatal/Infant CRRT Outcome Symons JM et al: CRRT meeting 2002
  22. 22. Neonatal/Infant CRRT Outcome Symons JM et al: CRRT meeting 2002
  23. 23. Neonatal/Infant CRRT Outcome Symons JM et al: CRRT meeting 2002
  24. 24. Pediatric CRRT Outcome Literature: Summary <ul><li>Children with ARF requiring CRRT exhibit 40-50% survival </li></ul><ul><ul><li>PRISM score not predictive </li></ul></ul><ul><ul><li>Infants >3kg have similar survival rates as older children </li></ul></ul><ul><li>Most mortality occurs within 3 weeks of ICU admission </li></ul><ul><li>Children with increased degrees of fluid overload at CRRT initiation may have increased mortality </li></ul>
  25. 25. Pediatric CRRT Outcome Literature: Conclusions <ul><li>Earlier might be better </li></ul><ul><ul><li>Early mortality </li></ul></ul><ul><ul><li>Prevent fluid overload </li></ul></ul><ul><ul><li>Allow nutrition, blood product administration </li></ul></ul><ul><li>Single center data are limited </li></ul><ul><ul><li>No differences with respect to </li></ul></ul><ul><ul><ul><li>initiation protocols </li></ul></ul></ul><ul><ul><ul><li>anticoagulation </li></ul></ul></ul><ul><ul><ul><li>machines </li></ul></ul></ul><ul><ul><ul><li>nutrition </li></ul></ul></ul><ul><ul><ul><li>data assessed </li></ul></ul></ul>

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