Advertisement
American Journal of Kidney Diseases

Fluid Overload and Mortality in Children Receiving Continuous Renal Replacement Therapy: The Prospective Pediatric Continuous Renal Replacement Therapy Registry

Published:December 31, 2009DOI:https://doi.org/10.1053/j.ajkd.2009.10.048

      Background

      Critically ill children with hemodynamic instability and acute kidney injury often develop fluid overload. Continuous renal replacement therapy (CRRT) has emerged as a favored modality in the management of such children. This study investigated the association between fluid overload and mortality in children receiving CRRT.

      Study Design

      Prospective observational study.

      Setting & Participants

      297 children from 13 centers across the United States participating in the Prospective Pediatric CRRT Registry.

      Predictor

      Fluid overload from intensive care unit (ICU) admission to CRRT initiation, defined as a percentage equal to (fluid in [L] − fluid out [L])/(ICU admit weight [kg]) × 100%.

      Outcome & Measurements

      The primary outcome was survival to pediatric ICU discharge. Data were collected regarding demographics, CRRT parameters, underlying disease process, and severity of illness.

      Results

      153 patients (51.5%) developed < 10% fluid overload, 51 patients (17.2%) developed 10%-20% fluid overload, and 93 patients (31.3%) developed ≥ 20% fluid overload. Patients who developed ≥ 20% fluid overload at CRRT initiation had significantly higher mortality (61/93; 65.6%) than those who had 10%-20% fluid overload (22/51; 43.1%) and those with < 10% fluid overload (45/153; 29.4%). The association between degree of fluid overload and mortality remained after adjusting for intergroup differences and severity of illness. The adjusted mortality OR was 1.03 (95% CI, 1.01-1.05), suggesting a 3% increase in mortality for each 1% increase in severity of fluid overload. When fluid overload was dichotomized to ≥ 20% and < 20%, patients with ≥ 20% fluid overload had an adjusted mortality OR of 8.5 (95% CI, 2.8-25.7).

      Limitations

      This was an observational study; interventions were not standardized. The relationship between fluid overload and mortality remains an association without definitive evidence of causality.

      Conclusions

      Critically ill children who develop greater fluid overload before initiation of CRRT experience higher mortality than those with less fluid overload. Further goal-directed research is required to accurately define optimal fluid overload thresholds for initiation of CRRT.

      Index Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Kidney Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Belsha C.W.
        • Kohaut E.C.
        • Warady B.A.
        Dialytic management of childhood acute renal failure: a survey of North American pediatric nephrologists.
        Pediatr Nephrol. 1995; 9: 361-363
        • Ricci Z.
        • Ronco C.
        • D'Amico G.
        • et al.
        Practice patterns in the management of acute renal failure in the critically ill patient: an international survey.
        Nephrol Dial Transplant. 2006; 21: 690-696
        • Warady B.A.
        • Bunchman T.
        Dialysis therapy for children with acute renal failure: survey results.
        Pediatr Nephrol. 2000; 15: 11-13
        • Palevsky P.
        Indications and timing of renal replacement therapy in acute kidney injury.
        Crit Care Med. 2008; 36: S224-S228
        • Seabra V.
        • Balk E.
        • Liangos O.
        • Sosa M.
        • Cendoroglo M.
        • Jaber B.
        Timing of renal replacement therapy initiation in acute renal failure: a meta-analysis.
        Am J Kidney Dis. 2008; 52: 272-284
        • Goldstein S.L.
        • Somers M.J.
        • Baum M.A.
        • et al.
        Pediatric patients with multi-organ dysfunction syndrome receiving continuous renal replacement therapy.
        Kidney Int. 2005; 67: 653-658
        • Goldstein S.L.
        • Currier H.
        • Graf C.
        • Cosio C.C.
        • Brewer E.D.
        • Sachdeva R.
        Outcome in children receiving continuous venovenous hemofiltration.
        Pediatrics. 2001; 107: 1309-1312
        • Foland J.A.
        • Fortenberry J.D.
        • Warshaw B.L.
        • et al.
        Fluid overload before continuous hemofiltration and survival in critically ill children: a retrospective analysis.
        Crit Care Med. 2004; 32: 1771-1776
        • Gillespie R.S.
        • Seidel K.
        • Symons J.M.
        Effect of fluid overload and dose of replacement fluid on survival in hemofiltration.
        Pediatr Nephrol. 2004; 19: 1394-1399
        • Hayes L.W.
        • Oster R.A.
        • Tofil N.M.
        • Tolwani A.J.
        Outcomes of critically ill children requiring continuous renal replacement therapy.
        J Crit Care. 2009; 24: 394-400
        • Payen D.de Pont A. Cl
        • Sakr Y.
        • Spies C.
        • Reinhart K.
        • Vincent J.L.
        A positive fluid balance is associated with a worse outcome in patients with acute renal failure.
        Crit Care. 2008; 12: R74
        • Schetz M.
        Non-renal indications for continuous renal replacement therapy.
        Kidney Int Suppl. 1999; 72: S88-S94
        • Goldstein S.L.
        • Somers M.J.
        • Brophy P.D.
        • et al.
        The Prospective Pediatric Continuous Renal Replacement Therapy (ppCRRT) Registry: design, development and data assessed.
        Int J Artific Organs. 2004; 27: 9-14
        • Schwartz G.J.
        • Brion L.P.
        • Spitzer A.
        The use of plasma creatinine concentration for estimating glomerular filtration rate in infants, children, and adolescents.
        Pediatr Clin North Am. 1987; 34: 571-590
        • Pollack M.M.
        • Ruttimann U.E.
        • Getson P.R.
        Pediatric Risk of Mortality (PRISM) score.
        Crit Care Med. 1988; 16: 1110-1116
        • Brierley J.
        • Carcillo J.
        • Choong K.
        • et al.
        Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine.
        Crit Care Med. 2009; 37: 666-688
        • Hayes L.
        • Oster R.
        • Tofil N.
        • Tolwani A.
        Outcomes of critically ill children requiring continuous renal replacement therapy.
        J Crit Care. 2009; 24: 394-400
        • Uchino S.
        • Doig G.
        • Bellomo R.
        • et al.
        Diuretics and mortality in acute renal failure.
        Crit Care Med. 2004; 32: 1669-1677
        • Mehta R.
        • Pascual M.
        • Soroko S.
        • Chertow G.
        Diuretics, mortality, and nonrecovery of renal function in acute renal failure.
        JAMA. 2002; 288: 2547-2553
        • Bagshaw S.
        • Bellomo R.
        • Kellum J.
        Oliguria, volume overload, and loop diuretics.
        Crit Care Med. 2008; 36: S172-S178
        • Van Biesen W.
        • Yegenaga I.
        • Vanholder R.
        • et al.
        Relationship between fluid status and its management on acute renal failure (ARF) in intensive care unit (ICU) patients with sepsis: a prospective analysis.
        J Nephrol. 2005; 18: 54-60
        • Bagshaw S.
        • Delaney A.
        • Haase M.
        • Ghali W.
        • Bellomo R.
        Loop diuretics in the management of acute renal failure: a systematic review and meta-analysis.
        Crit Care Resuscitation. 2007; 9: 60-68
        • Ho K.
        • Sheridan D.
        Meta-analysis of frusemide to prevent or treat acute renal failure.
        BMJ. 2006; 333: 420
        • Carcillo J.A.
        • Fields A.I.
        Clinical practice parameters for hemodynamic support of pediatric and neonatal patients in septic shock.
        Crit Care Med. 2002; 30: 1365-1378
        • Dellinger R.P.
        • Levy M.M.
        • Carlet J.M.
        • et al.
        Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008.
        Crit Care Med. 2008; 36: 296-327
        • Brandstrup B.
        • Tnnesen H.
        • Beier-Holgersen R.
        • et al.
        Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial.
        Ann Surg. 2003; 238: 641-648
        • Nisanevich V.
        • Felsenstein I.
        • Almogy G.
        • Weissman C.
        • Einav S.
        • Matot I.
        Effect of intraoperative fluid management on outcome after intraabdominal surgery.
        Anesthesiology. 2005; 103: 25-32
        • Wiedemann H.
        • Wheeler A.
        • Bernard G.
        • et al.
        Comparison of two fluid-management strategies in acute lung injury.
        N Engl J Med. 2006; 354: 2564-2575
        • Rabindranath K.
        • Adams J.
        • Macleod A.M.
        • Muirhead N.
        Intermittent versus continuous renal replacement therapy for acute renal failure in adults.
        Cochrane Database Syst Rev. 2007; 3 (CD003773)
        • Rabindranath K.S.
        • Strippoli G.F.
        • Daly C.
        • Roderick P.J.
        • Wallace S.
        • MacLeod A.M.
        Haemodiafiltration, haemofiltration and haemodialysis for end-stage kidney disease.
        Cochrane Database Syst Rev. 2006; 4 (CD006258)
        • Pannu N.
        • Klarenbach S.
        • Wiebe N.
        • Manns B.
        • Tonelli M.
        Renal replacement therapy in patients with acute renal failure: a systematic review.
        JAMA. 2008; 299: 793-805
        • Tonelli M.
        • Manns B.
        • Feller-Kopman D.
        Acute renal failure in the intensive care unit: a systematic review of the impact of dialytic modality on mortality and renal recovery.
        Am J Kidney Dis. 2002; 40: 875-885
        • Overberger P.
        • Pesacreta M.
        • Palevsky P.
        Management of renal replacement therapy in acute kidney injury: a survey of practitioner prescribing practices.
        Clin J Am Soc Nephrol. 2007; 2: 623-630
        • RENAL Study Investigators. Renal replacement therapy for acute kidney injury in Australian and New Zealand intensive care units
        a practice survey.
        Crit Care Resuscitation. 2008; 10: 225-230
        • Strazdins V.
        • Watson A.R.
        • Harvey B.
        Renal replacement therapy for acute renal failure in children: European guidelines.
        Pediatr Nephrol. 2004; 19: 199-207