Kidney Support in Children using an Ultrafiltration Device: A Multicenter, Retrospective Study.

BACKGROUND AND OBJECTIVES: Provision of kidney replacement therapy (KRT) to manage kidney injury and volume overload in critically ill neonates and small children is technically challenging. The use of machines designed for adult-sized patients, necessitates large catheters, a high extracorporeal volume relative to patient size, and need for blood priming. The Aquadex FlexFlow System (CHF Solutions Inc., Eden Prairie, MN) is an ultrafiltration device designed for fluid removal in adults with diuretic resistant heart failure. It has an extracorporeal volume of 33 ml, which can potentially mitigate some complications seen at onset of KRT in smaller infants. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In this multicenter, retrospective case series of children who received KRT with an ultrafiltration device (n=119 admissions, 884 circuits), we report demographics, circuit characteristics, complications, and short- and long-term outcomes. Patients were grouped according to weight (<10, 10-20, and >20 kg), and received one of three modalities: slow continuous ultrafiltration, continuous venovenous hemofiltration (CVVH), or prolonged intermittent KRT. Our primary outcome was survival to end of KRT. RESULTS: Treatment patterns and outcomes varied between the groups. In patients who weighed <10 kg, the primary indication was AKI in 40%, volume overload in 46%, and ESKD in 14%. These patients primarily received CVVH (66%, n=48) and prolonged intermittent KRT (21%, n=15). In the group weighing >20 kg, volume overload was the primary indication in 91% and slow continuous ultrafiltration was the most common modality. Patients <10 kg had lower KRT survival than those >20 kg (60% versus 97%), more volume overload at onset, and received KRT for a longer duration. Cardiovascular complications at initiation were seen in 3% of treatments and none were severe. Complications during therapy were seen in 15% treatments and most were vascular access-related. CONCLUSIONS: We report the first pediatric experience using an ultrafiltration device to provide a range of therapies, including CVVH, prolonged intermittent KRT, and slow continuous ultrafiltration. We were able to initiate KRT with minimal complications, particularly in critically ill neonates. There is an unmet need for devices specifically designed for younger patients. Having size-appropriate machines will improve the care of smaller children who require kidney support.

Validation of the British Thoracic Society Severity Criteria for Pediatric Community-acquired Pneumonia.

BACKGROUND: The British Thoracic Society (BTS) guideline for pediatric community-acquired pneumonia (CAP) outlines severity criteria to guide clinical decision-making. Our objective was to examine the predictive performance of the criteria on the need for hospitalization (NFH) and disposition. METHODS: This was a retrospective cohort study of children 3 months-18 years of age diagnosed with CAP in an urban, pediatric emergency department (ED) in the United States from September 2014 to August 2015. Children with chronic medical conditions, recent ED visits, and ED transfers were excluded. The main outcomes were interventions or diagnoses that necessitate hospitalization (ie, NFH) and disposition (eg, admit vs. discharge). Test characteristics, stratified by age, were calculated for each outcome. RESULTS: Of 518 eligible children, 56.6% (n = 293) were discharged from the ED with 372 children meeting at least 1 BTS criterion. Overall BTS criteria were specific but not sensitive for NFH nor for disposition. For children <1 year of age sensitive criteria included not feeding and temperature for NFH and tachycardia, cyanosis and not feeding for disposition. For children ≥1 year of age, tachycardia had a sensitivity of >0.60 for both outcomes. The areas under the receiver operator characteristic curves for predicting any BTS criteria was 0.57 for NFH and 0.84 for disposition. CONCLUSIONS: The BTS CAP severity criteria had fair to excellent ability to predict NFH and disposition, respectively. Although specific, the low sensitivity and poor discriminatory ability for NFH of these criteria suggest a need for improved prognostic tools for children with CAP.

Validation of the Pediatric Infectious Diseases Society-Infectious Diseases Society of America Severity Criteria in Children With Community-Acquired Pneumonia.

Background: The Pediatric Infectious Diseases Society (PIDS)-Infectious Diseases Society of America (IDSA) guideline for community-acquired pneumonia (CAP) recommends intensive care unit (ICU) admission or continuous monitoring for children meeting severity criteria. Our objective was to validate these criteria. Methods: This was a retrospective cohort study of children aged 3 months-18 years diagnosed with CAP in a pediatric emergency department (ED) from September 2014 through August 2015. Children with chronic conditions and recent ED visits were excluded. The primary predictor was the PIDS-IDSA severity criteria. Outcomes included disposition, and interventions and diagnoses that necessitated hospitalization (ie, need for hospitalization [NFH]). Results: Of 518 children, 56.6% were discharged; 54.3% of discharged patients and 80.8% of those hospitalized for less than 24 hours were classified as severe. Of those admitted, 10.7% did not meet severity criteria; 69.5% met PIDS-IDSA severity criteria. Of those children, 73.1% did not demonstrate NFH. The areas under the receiver operator characteristic curves (AUC) for PIDS-IDSA major criteria were 0.63 and 0.51 for predicting disposition and NFH, respectively. For PIDS-IDSA minor criteria, the AUC was 0.81 and 0.56 for predicting disposition and NFH, respectively. The sensitivity, specificity, and likelihood ratios (LR)+ and LR- of the PIDS-IDSA criteria were 89%, 46%, 1.65, and 0.23 for disposition and 95%, 16%, 1.13, and 0.31 for NFH. Conclusions: More than half of children classified as severe by PIDS-IDSA criteria were not hospitalized. The PIDS-IDSA CAP severity criteria have only fair ability to predict the need for hospitalization. New predictive tools specifically for children are required to improve clinical decision making.