THE INCIDENCE OF HYPOTENSION IMMEDIATELY AFTER INITIATING CONTINUOUS RENAL REPLACEMENT THERAPY IN CHILDREN AND THE ASSOCIATED FACTORS: A JAPANESE NATIONWIDE COHORT STUDY

Introduction:

Continuous renal replacement therapy (CRRT) for critically ill pediatric patients is increasingly used worldwide. In Japan, we have established a multicenter prospective registry of pediatric CRRT (the jpCRRT registry) to identify factors contributing to an optimal CRRT protocol. Hypotension shortly after the CRRT initiation is a serious complication in children that potentially affects prognosis. Therefore, the present study explored its incidence and associated factors.

Methods:

This observational study utilized data that was prospectively collected through the jpCRRT registry which includes 17 pediatric intensive care units (PICUs) across Japan. The study population comprised patients under 16 years old who underwent CRRT for acute illnesses in these PICUs between January 2023 and June 2024. The primary outcome was hypotension within one hour of starting CRRT. Hypotension was defined as requiring a fluid bolus, or the initiation or increase of vasopressors. Secondary outcomes were length of stay in the PICU and mortality within the PICU. Candidate predictors included demographic details, clinical status before and at the initiation of CRRT, and first dialysis circuit data. Categorical data were expressed as n (%), and continuous data as median (Interquartile Range, IQR). Fisher's exact test and Mann-Whitney's U test were used to compare between groups for the presence or absence of the development of hypotension. A logistic regression was used to examine predictors associated with hypotension and estimate odds ratios, adjusted for age (months).

Results:

The study included 112 patients. Of these, 28 (25%) experienced hypotension. The group with hypotension was characterized as younger, with lower weight and height, and a higher prevalence of neurological disorders as the reason for PICU admission, compared to those without hypotension. Among the indications for CRRT, metabolic disturbances were more common, while cases of fluid overload were less frequent. Regarding parameters of the CRRT protocol, the hypotensive group was more likely to use a cellulose triacetate-type filter membrane, higher initial treatment dose (dialysate flow plus replacement flow rate), higher dialysis circuit priming volume per circulating blood volume, and blood priming, than the non-hypotensive group. Moreover, the hypotensive group used higher blood volume for circuit priming and more pre-dialysis in the circuit before connecting the patient compared with the non-hypotensive group. Although the group with hypotension showed a higher PICU mortality rate than those without (21.4% vs 10.7%), this difference was not statistically significant (p = 0.34). Factors significantly associated with hypotension are presented in a separate table.

Conclusions:

Choice of hemofilter, blood priming, and pre-dialysis in the circuit prior to patient connection may be potential modifiable factors associated with hypotension shortly after the CRRT initiation among critically ill pediatric patients. A further large observational study, including our registry, is warranted to validate the impact of these factors on hypotension and prognosis.

I have no potential conflict of interest to disclose.

I did not use generative AI and AI-assisted technologies in the writing process.