Introduction:
For the treatment of acute kidney injury (AKI) and fluid overload in critically sick patients, including children, continuous renal replacement therapy (CRRT) has emerged as a crucial modality. Due to their distinct physiological and clinical requirements, children benefit greatly from continuous renal replacement therapy (CRRT) over intermittent hemodialysis because it provides a gentle and persistent approach to renal replacement.
Peritoneal dialysis (PD) can be a valuable option for managing acute kidney injury (AKI) in paediatric patients, but it also comes with several disadvantages and challenges like the risk of peritonitis, catheter related complications, limited clearance of solutes, fluid management challenges, and abdominal complications, making CRRT an invaluable modality in the treatment of AKI.
Methods:
Despite its advantages, the application of CRRT in children involves intricate considerations regarding dosing, anticoagulation, and access strategies. Furthermore, there is a need for a comprehensive understanding of the efficacy, safety, and outcomes associated with CRRT in this specific population.
This case series aims to provide an in-depth exploration of CRRT in paediatric patients, focusing on its clinical application, patient outcomes, and the challenges encountered. By examining a series of cases, this study seeks to contribute valuable insights into optimizing CRRT protocols, enhancing patient care, and improving overall outcomes in the paediatric intensive care setting.
The first case in our series involves an extremely preterm infant, born at 25 weeks of gestation with a birth weight of 675 grams, following preterm premature rupture of membranes (PPROM). The infant required immediate resuscitation due to a low APGAR score and was subsequently admitted to the ICU for mechanical ventilation. Laboratory findings revealed multiorgan dysfunction and anuria, necessitating the initiation of Continuous Renal Replacement Therapy (CRRT).
Due to the infant's extremely low birth weight, technical challenges were significant. Umbilical artery and vein access was employed, with tubing lengths cut short and blood priming utilized to accommodate the small size. Given the limitations of using the Prisma flex system due to the infant's weight, the 4008 machine was adapted to function for CRRT. The treatment proceeded successfully for 24 hours with a blood flow rate adjusted to the infant’s needs and no ultrafiltration. The case highlights the complexities and adaptations required for effective CRRT in extremely low birth weight infants, and the challenges involved in the setting up of 4008 Fresenius machine to function like a CRRT machine.
The second case is that of a 8 year old girl, who was a known case of Wilms tumour s/p right radical nephrectomy when the patient was 1 year of age. She was subsequently lost to follow up, and currently presented to our department in fluid overload with a creatinine of 5, and was initiated on haemodialysis with access being right IJ HD catheter. Ultrafiltration was done at a rate of 10 ml /kg, and blood flow was kept as per body weight. She underwent a renal biopsyafter back to back sessions of hemodialysis, and was labelled as end stage renal disease, and is currently worked up for renal transplant.
Third case is that of 2 year old boy who was admitted with Dengue shock syndrome with multi organ dysfunction, affecting hepatic, renal and haematology systems. In view of severe renal failure associated with severe metabolic acidosis and uraemia, he was initiated on hemodialysis, with right femoral HD catheter as access. The underlying coagulopathy and the presence of third spacing along with fluid overload, and the challenges associated with capillary leak syndrome were the major highlights of the case.
Fourth case is of a 14 year old girl, who is a known case of Systemic Lupus erythematosus, admitted with pneumonia and sepsis, with multi organ dysfunction, and was subsequently started on haemodialysis via right IJ HD catheter as access. The presence of serositis, and volume overload, and the increased recurrence of fluid overload warranting appropraiate fluid removal was the maor challenge of this case.
The final case is of a 1 month old baby, who was detected to have hyperammonaemia secondary to inherited errors of metabolism, and was initiated on CRRT, with umbilical artery and vein as the chosen access. The technical aspects of the CRRT prescription and the low birth weight were the major challenges faced in this case. Frequent monitoring of serum ammonia levels and titrating the timing of CRRT based on the ammonia values, and assessing their clearance and otimisng the CRRT prescription were the maor challenges highlighting this case.
Results:
Continuous Renal Replacement Therapy (CRRT) plays a critical role in managing acute kidney injury (AKI) in the pediatric population, offering several advantages over traditional intermittent hemodialysis. CRRT provides a continuous, gentle approach to renal replacement, which is particularly beneficial for children due to their smaller size, varying physiological states, and unique clinical needs. This continuous modality helps in maintaining stable fluid and electrolyte balance, which is essential in the dynamic conditions often seen in critically ill pediatric patients.
The adaptability of CRRT allows for precise control over fluid removal and solute clearance, making it suitable for managing severe cases of AKI where intermittent dialysis might be less effective. It is especially advantageous in cases of multiorgan dysfunction or those requiring intensive hemodynamic support. CRRT's slower, steady process reduces the risk of hemodynamic instability and can be tailored to the specific needs of each child, including adjustments for size and weight.
Conclusions:
The importance of Continuous Renal Replacement Therapy (CRRT) in treating juvenile patients with acute kidney injury (AKI) is highlighted by this case series. By carefully analyzing five different instances, we have brought to light the therapeutic advantages, difficulties, and complexities of CRRT in a pediatric context.
Our results show that, although CRRT is a useful strategy for handling complicated AKI cases in pediatric patients, it is crucial to carefully evaluate aspects including fluid balance, catheter management, and customized treatment plans. Every case study highlights the necessity of a customized strategy and stresses the significance of ongoing evaluation and modification to maximize patient results.
In conclusion, this series highlights topics for continued study and development in addition to reaffirming the effectiveness of CRRT in pediatric AKI. Improved comprehension and improvement of CRRT procedures will eventually lead to better results and a higher standard of living for pediatric renal replacement therapy patients.
I have no potential conflict of interest to disclose.
I did not use generative AI and AI-assisted technologies in the writing process.