Incidence and Risk Factors of Neurological Complications in Pediatric Continuous Kidney Replacement Therapy

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Incidence and Risk Factors of Neurological Complications in Pediatric Continuous Kidney Replacement Therapy

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Co-author 1

Kentaro Nishi nishi-k@ncchd.go.jp National Center for Child Health and Development Division of Nephrology and Rheumatology Tokyo Japan *

Co-author 2

Kentaro Ide ide-k@ncchd.go.jp National Center for Child Health and Development Division of Critical Care Medicine Tokyo Japan -

Co-author 3

Itaru Hayakawa hayakawa-i@ncchd.go.jp National Center for Child Health and Development Division of Neurology Tokyo Japan -

Co-author 4

Yusuke Tokuda tokuda-y@ncchd.go.jp National Center for Child Health and Development Division of Critical Care Medicine Tokyo Japan -

Co-author 5

Junichiro Morota j-morota@gunma-u.ac.jp National Center for Child Health and Development Division of Critical Care Medicine Tokyo Japan -

Co-author 6

Eisaku Nashiki nashiki-e@ncchd.go.jp National Center for Child Health and Development Division of Critical Care Medicine Tokyo Japan -

Co-author 7

Mai Miyaji mai.miyaji@gmail.com St. Marianna University School of Medicine Pediatric Intensive Care Unit Kanagawa Japan -

Co-author 8

Koichi Kamei kamei-k@ncchd.go.jp National Center for Child Health and Development Division of Nephrology and Rheumatology Tokyo Japan -

Co-author 9

Shotaro Matsumoto matsumoto-s@ncchd.go.jp National Center for Child Health and Development Division of Critical Care Medicine Tokyo Japan -

Co-author 10

Co-author 11

Co-author 12

Co-author 13

Co-author 14

Co-author 15

Introduction

Continuous kidney replacement therapy (CKRT) is increasingly utilized in pediatric patients; however, its application is often complicated by small body size, complex comorbidities, and physiological immaturity. Among these challenges, neurological complications are particularly severe. This study aimed to investigate the incidence and risk factors of neurological complications in children undergoing CKRT.

Methods

We retrospectively reviewed patients under 18 years of age who underwent CKRT at our institution between July 2014 and June 2023. Patients treated with extracorporeal membrane oxygenation were excluded. The primary outcome was the occurrence of cerebral infarction or intracranial hemorrhage diagnosed by head CT or MRI within 3 months after CKRT initiation. Risk factors were analyzed using logistic regression.

Results

Among 239 patients (135 males; 92 with renal indications), 18 (7.5%) developed neurological complications at a median of 14 days after CKRT initiation (intracranial hemorrhage, n=9; cerebral infarction, n=6; both, n=3). Initial anticoagulation regimens included heparin (n=46), nafamostat (n=178), and combination therapy (n=15). Compared with the non-complication group, patients with complications had lower age at initiation (median 17 vs. 465 days, P<0.001), lower body weight (median 3 vs. 9 kg, P<0.001), lower systolic blood pressure (85 vs. 94 mmHg, P=0.03), more frequent vasopressor use (44% vs. 19%, P=0.02), higher serum creatinine (1.1 vs. 0.4 mg/dL, P=0.03), higher lactate (5.3 vs. 2.0 mmol/L, P<0.001), longer APTT (76 vs. 51 sec, P=0.02), and longer CKRT duration (11 vs. 5 days, P<0.001). ICU mortality was 28% in the complication group vs. 16% in the non-complication group (P=0.19). Multivariate analysis showed that lower body weight (OR 0.93, 95% CI 0.86–0.99, P=0.04), higher lactate (OR 1.15, 95% CI 1.04–1.28, P=0.005), and longer CKRT duration (OR 1.04, 95% CI 1.01–1.07, P=0.005) were independent risk factors.

Conclusion

Neurological complications are not uncommon in pediatric CKRT. Careful monitoring and preventive strategies are warranted, particularly in children with low body weight, elevated lactate at initiation, and prolonged CKRT duration.

Kewords