Pediatric patients with multi-organ dysfunction syndrome receiving continuous renal replacement therapy

Stuart L Goldstein, Michael J G Somers, Michelle A Baum, Jordan M Symons, Patrick D Brophy, Douglas Blowey, Timothy E Bunchman, Cheryl Baker, Theresa Mottes, Nancy McAfee, Joni Barnett, Gloria Morrison, Kristine Rogers, James D Fortenberry
Kidney International 2005, 67 (2): 653-8

BACKGROUND: Critical illness leading to multi-organ dysfunction syndrome (MODS) and associated acute renal failure (ARF) is less common in children compared to adult patients. As a result, many issues plague the pediatric ARF outcome literature, including a relative lack of prospective study, a lack of modality stratification in subject populations and inconsistent controls for patient illness severity in outcome analysis.

METHODS: We now report data from the first multicenter study to assess the outcome of pediatric patients with MODS receiving continuous renal replacement therapy (CRRT). One hundred twenty of 157 Registry patients (63 male/57 female) experienced MODS during their course.

RESULTS: One hundred sixteen patients had complete data available for analysis. The most common causes leading to CRRT were sepsis (N= 47; 39.2%) and cardiogenic shock (N= 24; 20%). Overall survival was 51.7%. Pediatric Risk of Mortality (PRISM 2) score, central venous pressure (CVP), and% fluid overload (%FO) at CRRT initiation were significantly lower for survivors versus nonsurvivors. Multivariate analysis controlling for severity of illness using PRISM 2 at CRRT initiation revealed that%FO was still significantly lower for survivors versus nonsurvivors (P < 0.05) even for patients receiving both mechanical ventilation and vasoactive pressors. We speculate that increased fluid administration from PICU admission to CRRT initiation is an independent risk factor for mortality in pediatric patients with MODS receiving CRRT.

CONCLUSION: We suggest that after initial resuscitative efforts, an increased emphasis should be placed on early initiation of CRRT and inotropic agent use over fluid administration to maintain acceptable blood pressure.

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