Kidney support for babies: building a comprehensive and integrated neonatal kidney support therapy program.

Kidney support therapy (KST), previously referred to as Renal Replacement Therapy, is utilized to treat children and adults with severe acute kidney injury (AKI), fluid overload, inborn errors of metabolism, and kidney failure. Several forms of KST are available including peritoneal dialysis (PD), intermittent hemodialysis (iHD), and continuous kidney support therapy (CKST). Traditionally, extracorporeal KST (CKST and iHD) in neonates has had unique challenges related to small patient size, lack of neonatal-specific devices, and risk of hemodynamic instability due to large extracorporeal circuit volume relative to patient total blood volume. Thus, PD has been the most commonly used modality in infants, followed by CKST and iHD. In recent years, CKST machines designed for small children and novel filters with smaller extracorporeal circuit volumes have emerged and are being used in many centers to provide neonatal KST for toxin removal and to achieve fluid and electrolyte homeostasis, increasing the options available for this unique and vulnerable group. These new treatment options create a dramatic paradigm shift with recalibration of the benefit: risk equation. Renewed focus on the infrastructure required to deliver neonatal KST safely and effectively is essential, especially in programs/units that do not traditionally provide KST to neonates. Building and implementing a neonatal KST program requires an expert multidisciplinary team with strong institutional support. In this review, we first describe the available neonatal KST modalities including newer neonatal and infant-specific platforms. Then, we describe the steps needed to develop and sustain a neonatal KST team, including recommendations for provider and nursing staff training. Finally, we describe how quality improvement initiatives can be integrated into programs.

Process based quality improvement using a continuous renal replacement therapy dashboard.

BACKGROUND: The prevalence of continuous renal replacement therapy (CRRT) utilization in critically ill patients with acute kidney is increasing. In comparison to published and on-going trials attempting to answer questions surrounding the optimal timing of CRRT initiation, anticoagulation, and modality, a paucity of literature describes the quality of the therapy delivered. METHODS: We conducted a single-center process improvement project to determine if a methodology to assess the quality of CRRT delivery could lead to improvement in CRRT delivery outcomes. We developed three broad categories of objective CRRT metrics to assess longitudinally, enabling creation of a CRRT Dashboard. Following the objective categories of "filter", "prescription", and "fluid balance" over time allowed us to perform quarterly analyses, target provider based CRRT education, and address variation from our standard of care. From 2012 to 2017, 184 critically ill patients received CRRT. RESULTS: We report a mean filter life of 56 + 28.4 h, a 60-h filter life of 62%, and unplanned filter changes of 15%. Compared to a minimum target prescription of 2000 ml/1.73 m2/hour, we report the mean prescribed dose (2300 ml/1.73 m2/hour) and the rate of patients receiving at least the minimum prescription (98%). Finally, using a 10% deviation in the acceptable range of desired daily patient fluid balance, we report 83% CRRT patient days achieving an acceptable stipulated fluid goal. CONCLUSION: We report the implementation of a quality dashboard and adopting quality improvement strategies provided a platform for measuring adherence to our institutional standards and the delivery of CRRT, specifically on the process of the care.

Therapeutic plasma exchange may improve hemodynamics and organ failure among children with sepsis-induced multiple organ dysfunction syndrome receiving extracorporeal life support.

OBJECTIVE: To determine the effect of therapeutic plasma exchange on hemodynamics, organ failure, and survival in children with multiple organ dysfunction syndrome due to sepsis requiring extracorporeal life support. DESIGN: A retrospective analysis. SETTING: A PICU in an academic children's hospital. PATIENTS: Fourteen consecutive children with sepsis and multiple organ dysfunction syndrome who received therapeutic plasma exchange while on extracorporeal life support from 2005 to 2013. INTERVENTIONS: Median of three cycles of therapeutic plasma exchange with median of 1.0 times the estimated plasma volume per exchange. MEASUREMENTS AND MAIN RESULTS: Organ Failure Index and Vasoactive-Inotropic Score were measured before and after therapeutic plasma exchange use. PICU survival in our cohort was 71.4%. Organ Failure Index decreased in patients following therapeutic plasma exchange (mean ± SD: pre, 4.1 ± 0.7 vs post, 2.9 ± 0.9; p = 0.0004). Patients showed improved Vasoactive-Inotropic Score following therapeutic plasma exchange (median [25th-75th]: pre, 24.5 [13.0-69.8] vs post, 5.0 [1.5-7.0]; p = 0.0002). Among all patients, the change in Organ Failure Index was greater for early therapeutic plasma exchange use than late use (early, -1.7 ± 1.2 vs late, -0.9 ± 0.6; p = 0.14), similar to the change in Vasoactive-Inotropic Score (early, -67.5 [28.0-171.2] vs late, -12.0 [7.2-18.5]; p = 0.02). Among survivors, the change in Organ Failure Index was greater among early therapeutic plasma exchange use than late use (early, -2.3 ± 1.0 vs late, -0.8 ± 0.8; p = 0.03), as was the change in Vasoactive-Inotropic Score (early, -42.0 [16.0-76.3] vs late, -12.0 [5.3-29.0]; p = 0.17). The mean duration of extracorporeal life support after therapeutic plasma exchange according to timing of therapeutic plasma exchange was not statistically different among all patients or among survivors. CONCLUSIONS: The use of therapeutic plasma exchange in children on extracorporeal life support with sepsis-induced multiple organ dysfunction syndrome is associated with organ failure recovery and improved hemodynamic status. Initiating therapeutic plasma exchange early in the hospital course was associated with greater improvement in organ dysfunction and decreased requirement for vasoactive and/or inotropic agents.

Use of the Selective Cytopheretic Device in Critically Ill Children.

INTRODUCTION: Critically ill children with acute kidney injury (AKI) requiring continuous kidney replacement therapy (CKRT) are at increased risk of death. The selective cytopheretic device (SCD) promotes an immunomodulatory effect when circuit ionized calcium (iCa2+) is maintained at <0.40 mmol/l with regional citrate anticoagulation (RCA). In a randomized trial of adult patients on CRRT, those treated with the SCD maintaining an iCa2+ <0.40 mmol/l had improved survival/dialysis independence. We conducted a US Food and Drug Administration (FDA)-sponsored study to evaluate safety and feasibility of the SCD in 16 critically ill children. METHODS: Four pediatric intensive care units (ICUs) enrolled children with AKI and multiorgan dysfunction receiving CKRT to receive the SCD integrated post-CKRT membrane. RCA was used to achieve a circuit iCa2+ level <0.40 mmol/l. Subjects received SCD treatment for 7 days or CKRT discontinuation, whichever came first. RESULTS: The FDA target enrollment of 16 subjects completed the study from December 2016 to February 2020. Mean age was 12.3 ± 5.1 years, weight was 53.8 ± 28.9 kg, and median Pediatric Risk of Mortality II was 7 (range 2-19). Circuit iCa2+ levels were maintained at <0.40 mmol/l for 90.2% of the SCD therapy time. Median SCD duration was 6 days. Fifteen subjects survived SCD therapy; 12 survived to ICU discharge. All ICU survivors were dialysis independent at 60 days. No SCD-related adverse events (AEs) were reported. CONCLUSION: Our data demonstrate that SCD therapy is feasible and safe in children who require CKRT. Although we cannot make efficacy claims, the 75% survival rate and 100% renal recovery rate observed suggest a possible favorable benefit-to-risk ratio.

Does Your Program Know Its AKI and CRRT Epidemiology? The Case for a Dashboard.

Current acute kidney injury (AKI) literature focuses on diagnosis, treatment, and outcomes. While little literature exists studying the quality of care delivered to patients with AKI. However, improving outcomes for patients is dependent on the specifics of the delivered care (i.e., the who, what, when, and how). Therefore, it is necessary to direct attention to process measures to assess the relationship between care and outcomes. The application of quality improvement science to the care of AKI, uses a series of metrics encompassing both processes and outcomes to better understand, evaluate, and ensure the delivery high quality care.

Survival and renal function in pediatric patients following extracorporeal life support with hemofiltration.

OBJECTIVE: To determine variables associated with survival in pediatric patients treated with hemofiltration while receiving extracorporeal life support and to determine the probability for recovery of renal function among survivors. DESIGN: Retrospective database analysis. SETTING: University of Michigan pediatric nephrology database. PATIENTS: All pediatric patients treated with continuous hemofiltration while on extracorporeal life support at the University of Michigan between January 1990 and May 1999. A pediatric patient was defined as any child between birth and 18 yrs of age, including children treated in both the pediatric intensive care unit and neonatal intensive care unit. Indications for extracorporeal life support included both cardiac and pulmonary failure. INTERVENTIONS: Data analysis of patients who were treated with hemofiltration while on extracorporeal life support. Hemofiltration includes both ultrafiltration and hemofiltration with countercurrent dialysis. MEASUREMENTS AND MAIN RESULTS: Thirty-five patients with a mean age of 39 +/- 65 months (median, 3 months) underwent hemofiltration while on extracorporeal life support. Forty-three percent survived to hospital discharge (95% CI, 26%-60%). All deaths occurred in the intensive care unit. Recovery of renal function occurred in 93% of survivors (95% CI, 79%-108%). Mean duration of hemofiltration in survivors, including time during and after extracorporeal life support, was 9 +/- 6 days. All nonsurvivors were on renal replacement therapy at the time of death. In this analysis, decreased survival was significantly associated with the use of vasopressor infusions (p =.01) and the presence of complications (p =.006). Vasopressor infusions were required in 89% of patients, and 37% of patients experienced complications. CONCLUSIONS: In patients receiving hemofiltration while on extracorporeal life support, survival is comparable to that reported in other extracorporeal life support or hemofiltration populations. Decreased survival in these patients may be associated with the use of vasopressor infusions and the occurrence of complications. Recovery of renal function occurs in most survivors.

Renal replacement therapy in the treatment of confirmed or suspected inborn errors of metabolism.

OBJECTIVE: Analysis of mortality and risk factors for mortality in the use of renal replacement therapy to correct metabolic disturbances associated with confirmed or suspected inborn errors of metabolism. STUDY DESIGN: A retrospective review of an institutional review board-approved pediatric acute renal failure data base at the University of Michigan. Eighteen patients underwent 21 renal replacement therapy treatments for metabolic disturbances caused by urea cycle defects (n = 14), organic acidemias (n = 5), idiopathic hyperammonemia (n = 1), and Reye syndrome (n = 1). RESULTS: There were 14 boys (74%) and 4 girls (26%), with a mean age and weight of 56.2 +/- 71.0 months and 18.5 +/- 19.2 kg, respectively, at the initiation of renal replacement therapy. Overall treatment mortality rate was 57.2% (12 of 21 treatments), with 11 of the 18 patients (61.1%) dying before hospital discharge. Two-year follow-up on those patients demonstrated that 5 patients (71.4%) remained alive. Initial therapy with hemodialysis was associated with improved survival. Ten treatments (47.6%) required transition to another form of renal replacement therapy to maintain ongoing metabolic control, with a mean duration of 6.1 +/- 9.8 days. Time to renal replacement therapy >24 hours was associated with an increased risk of mortality, whereas a blood pressure >5th percentile for age at the initiation of therapy and the use of anticoagulation were associated with a decreased risk of mortality. CONCLUSIONS: Renal replacement therapy can correct the metabolic disturbances that accompany suspected or confirmed inborn errors of metabolism. Our experience demonstrates an approximately 60% mortality rate associated with renal replacement treatment, with more than 70% of survivors living longer than 2 years.

Pre dialysis of blood prime in continuous hemodialysis normalizes pH and electrolytes.

In critically ill children weighing <10 kg, it is necessary to use blood as a priming solution for the extracorporeal continuous renal replacement therapy (CRRT) circuit before initiating CRRT to prevent hemodilution and maintain adequate oxygenation. However, blood bank blood usually contains supra-physiological electrolyte concentrations and a non-physiological acid-base balance that may exacerbate the patient's condition. The objective of this trial was to develop a simple protocol to pre-treat blood bank-derived blood to yield a more physiological blood priming solution. Expired human blood in a recirculating in vitro CRRT circuit was dialyzed prior to the initiation of CRRT using a physiological dialysate solution. Serial blood samples were assessed for electrolyte and pH content. Regimens using maximal blood flow rates (180-200 ml/min) and aggressive dialysate flow rates (33-42 ml/min) were able to correct severely hyperkalemic and acidemic blood within 7.5 min. Initially elevated blood potassium concentrations >20 mEq/l were normalized to below 5 mEq/l within 7.5 min of dialysis in all cases. Blood bank-derived blood can be "conditioned" quickly to physiological pH and electrolyte concentrations using these simple pre-dialysis regimens. Unlike some blood preparation regimens that have been published, the technique used in this trial requires no special equipment or added medications that are not already used in CRRT.