Skip to main content
SpringerLink
Log in

Current practices in pediatric continuous kidney replacement therapy: a systematic review-guided multinational modified Delphi consensus study

  • Original Article
  • Published:
Pediatric Nephrology Aims and scope Submit manuscript

Abstract 

Background

Continuous kidney replacement therapy (CKRT) has become an integral part of the care of critically ill children. However, uncertainty exists regarding the current state of how CKRT is prescribed and delivered in children. The main objective of this study was to identify the current practices for pediatric CKRT.

Methods

We conducted a systematic review of the literature from 2012 to 2022 to identify data regarding CKRT timing of initiation, dosing, anticoagulation, fluid removal, and quality monitoring. Using this data, we then performed a two-round modified Delphi process using a multinational internet-assisted survey of prescribers of CKRT.

Results

The survey was constructed using 172 articles that met inclusion criteria (12% of studies were pediatric focused). A total of 147 and 126 practitioners completed the survey in rounds 1 and 2, respectively. Participants represented Europe (9.5–11.6%) and North America including pediatric intensivists, nephrologists, and advance practice providers. Consensus (defined as a ≥ 75% participant response of “sometimes” or “always”) was achieved for 26 statements. There was consensus in the practices of CKRT initiation, dosing, method of anticoagulation, and fluid removal. In contrast, there appears to be greater variability in the methods used for monitoring anticoagulation and the quality of the delivered treatment.

Conclusions

Our study results suggest that the current state of pediatric CKRT practice is reflective of the literature over the last 10 years, which is largely based on the care of adult patients. This data provides a framework to study best practices to further improve outcomes for children receiving CKRT.

Graphical abstract

A higher resolution version of the Graphical abstract is available as Supplementary information

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

Data Availability

The datasets generated during and/or analyzed during the current study are presented in the main manuscript. Additional data is available from the corresponding author on reasonable request.

References

  1. Beltramo F, DiCarlo J, Gruber JB, Taylor T, Totapally BR (2019) Renal replacement therapy modalities in critically Ill children. Pediatr Crit Care Med 20:e1–e9

    Article  PubMed  Google Scholar 

  2. Sutherland SM, Zappitelli M, Alexander SR, Chua AN, Brophy PD, Bunchman TE, Hackbarth R, Somers MJ, Baum M, Symons JM, Flores FX, Benfield M, Askenazi D, Chand D, Fortenberry JD, Mahan JD, McBryde K, Blowey D, Goldstein SL (2010) Fluid overload and mortality in children receiving continuous renal replacement therapy: the prospective pediatric continuous renal replacement therapy registry. Am J Kidney Dis 55:316–325

    Article  PubMed  Google Scholar 

  3. Dalkey N, Helmer O (1963) An experimental application of the Delphi method to the use of experts. Manag Sci 9:458–467

    Article  Google Scholar 

  4. Murphy M, Black N, Lamping D, McKee D, Sanderson C, Askham J, Marteau T (1998) Consensus development methods, and their use in clinical guideline development. Health Technol Assess 2:1–88

    Article  Google Scholar 

  5. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, Chou R, Glanville J, Grimshaw JM, Hrobjartsson A, Lalu MM, Li T, Loder EW, Mayo-Wilson E, McDonald S, McGuinness LA, Stewart LA, Thomas J, Tricco AC, Welch VA, Whiting P, Moher D (2021) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 372:n71

    Article  PubMed  PubMed Central  Google Scholar 

  6. KDIGO AKI Working Group (2012) KDIGO clinical practice guideline for acute kidney injury. Kidney In Suppl 2:1–138

    Google Scholar 

  7. Foland JA, Fortenberry JD, Warshaw BL, Pettignano R, Merritt RK, Heard ML, Rogers K, Reid C, Tanner AJ, Easley KA (2004) Fluid overload before continuous hemofiltration and survival in critically ill children: a retrospective analysis. Crit Care Med 32:1771–1776

    Article  PubMed  Google Scholar 

  8. Hayes LW, Oster RA, Tofil NM, Tolwani AJ (2009) Outcomes of critically ill children requiring continuous renal replacement therapy. J Crit Care 24:394–400

    Article  PubMed  Google Scholar 

  9. Hall A, Crichton S, Dixon A, Skorniakov I, Kellum JA, Ostermann M (2020) Fluid removal associates with better outcomes in critically ill patients receiving continuous renal replacement therapy: a cohort study. Crit Care 24:279

    Article  PubMed  PubMed Central  Google Scholar 

  10. Goldstein SL, Somers MJ, Baum MA, Symons JM, Brophy PD, Blowey D, Bunchman TE, Baker C, Mottes T, McAfee N, Barnett J, Morrison G, Rogers K, Fortenberry JD (2005) Pediatric patients with multi-organ dysfunction syndrome receiving continuous renal replacement therapy. Kidney Int 67:653–658

    Article  PubMed  Google Scholar 

  11. Wald R, Bagshaw SM; STARRT-AKI Investigators (2020) Timing of initiation of renal-replacement therapy in acute kidney injury. Reply. N Engl J Med 383:1797–1798

  12. Zampieri FG, da Costa BR, Vaara ST, Lamontagne F, Rochwerg B, Nichol AD, McGuinness S, McAuley DF, Ostermann M, Wald R, Bagshaw SM; STARRT-AKI Investigators (2022) A Bayesian reanalysis of the standard versus accelerated initiation of renal-replacement therapy in acute kidney injury (STARRT-AKI) trial. Crit Care 26:255

    Article  PubMed  PubMed Central  Google Scholar 

  13. Bunchman TE, Donckerwolcke RA (1994) Continuous arterial-venous diahemofiltration and continuous veno-venous diahemofiltration in infants and children. Pediatr Nephrol 8:96–102

    Article  CAS  PubMed  Google Scholar 

  14. Maxvold NJ, Smoyer WE, Custer JR, Bunchman TE (2000) Amino acid loss and nitrogen balance in critically ill children with acute renal failure: a prospective comparison between classic hemofiltration and hemofiltration with dialysis. Crit Care Med 28:1161–1165

    Article  CAS  PubMed  Google Scholar 

  15. Romagnoli S, Clark WR, Ricci Z, Ronco C (2017) Renal replacement therapy for AKI: when? how much? when to stop? Best Pract Res Clin Anaesthesiol 31:371–385

    Article  PubMed  Google Scholar 

  16. Tsujimoto Y, Miki S, Shimada H, Tsujimoto H, Yasuda H, Kataoka Y, Fujii T (2021) Non-pharmacological interventions for preventing clotting of extracorporeal circuits during continuous renal replacement therapy. Cochrane Database Syst Rev 9:CD013330

    PubMed  Google Scholar 

  17. Bunchman TE, Brophy PD, Goldstein SL (2008) Technical considerations for renal replacement therapy in children. Semin Nephrol 28:488–492

    Article  CAS  PubMed  Google Scholar 

  18. Zaoral T, Hladik M, Zapletalova J, Travnicek B, Gelnarova E (2016) Circuit lifetime with citrate versus heparin in pediatric continuous venovenous hemodialysis. Pediatr Crit Care Med 17:e399-405

    Article  PubMed  Google Scholar 

  19. Rico MP, Fernandez Sarmiento J, Rojas Velasquez AM, Gonzalez Chaparro LS, Gastelbondo Amaya R, MulettHoyos H, Tibaduiza D, Quintero Gomez AM (2017) Regional citrate anticoagulation for continuous renal replacement therapy in children. Pediatr Nephrol 32:703–711

    Article  PubMed  Google Scholar 

  20. Rodriguez K, Srivaths PR, Tal L, Watson MN, Riley AA, Himes RW, Desai MS, Braun MC, Akcan Arikan A (2017) Regional citrate anticoagulation for continuous renal replacement therapy in pediatric patients with liver failure. PLoS One 12:e0182134

    Article  PubMed  PubMed Central  Google Scholar 

  21. Goldstein SL, Vidal E, Ricci Z, Paglialonga F, Peruzzi L, Giordano M, Laforgia N, Ronco C (2022) Survival of infants treated with CKRT: comparing adapted adult platforms with the Carpediem. Pediatr Nephrol 37:667–675

    Article  PubMed  Google Scholar 

  22. Menon S, Broderick J, Munshi R, Dill L, DePaoli B, Fathallah-Shaykh S, Claes D, Goldstein SL, Askenazi DJ (2019) Kidney support in children using an ultrafiltration device: a multicenter, retrospective study. Clin J Am Soc Nephrol 14:1432–1440

    Article  PubMed  PubMed Central  Google Scholar 

  23. Murugan R, Ostermann M, Peng Z, Kitamura K, Fujitani S, Romagnoli S, Di Lullo L, Srisawat N, Todi S, Ramakrishnan N, Hoste E, Puttarajappa CM, Bagshaw SM, Weisbord S, Palevsky PM, Kellum JA, Bellomo R, Ronco C (2020) Net ultrafiltration prescription and practice among critically Ill patients receiving renal replacement therapy: a multinational survey of critical care practitioners. Crit Care Med 48:e87–e97

    Article  PubMed  Google Scholar 

  24. Murugan R, Hoste E, Mehta RL, Samoni S, Ding X, Rosner MH, Kellum JA, Ronco C, Acute Disease Quality Initiative (ADQI) Consensus Group (2016) Precision fluid management in continuous renal replacement therapy. Blood Purif 42:266–278

    Article  CAS  PubMed  Google Scholar 

  25. Mottes TA, Goldstein SL, Basu RK (2019) Process based quality improvement using a continuous renal replacement therapy dashboard. BMC Nephrol 20:17

    Article  PubMed  PubMed Central  Google Scholar 

  26. Selewski DT, Askenazi DJ, Kashani K, Basu RK, Gist KM, Harer MW, Jetton JG, Sutherland SM, Zappitelli M, Ronco C, Goldstein SL, Mottes TA (2021) Quality improvement goals for pediatric acute kidney injury: pediatric applications of the 22nd Acute Disease Quality Initiative (ADQI) conference. Pediatr Nephrol 36:733–746

    Article  PubMed  Google Scholar 

  27. Harer MW, Selewski DT, Kashani K, Basu RK, Gist KM, Jetton JG, Sutherland SM, Zappitelli M, Goldstein SL, Mottes TA, Askenazi DJ (2021) Improving the quality of neonatal acute kidney injury care: neonatal-specific response to the 22nd Acute Disease Quality Initiative (ADQI) conference. J Perinatol 41:185–195

    Article  PubMed  Google Scholar 

  28. Goldstein SL, Akcan-Arikan A, Alobaidi R, Askenazi DJ, Bagshaw SM, Barhight M, Barreto E, Bayrakci B, Bignall ONR, Bjornstad E, Brophy PD, Chanchlani R, Charlton JR, Conroy AL, Deep A, Devarajan P, Dolan K, Fuhrman DY, Gist KM, Gorga SM, Greenberg JH, Hasson D, Ulrich EH, Iyengar A, Jetton JG, Krawczeski C, Meigs L, Menon S, Morgan J, Morgan CJ, Mottes T, Neumayr TM, Ricci Z, Selewski D, Soranno DE, Starr M, Stanski NL, Sutherland SM, Symons J, Tavares MS, Vega MW, Zappitelli M, Ronco C, Mehta RL, Kellum J, Ostermann M, Basu RK; Pediatric ADQI Collaborative (2022) Consensus-based recommendations on priority activities to address acute kidney injury in children: a modified Delphi consensus statement. JAMA Netw Open 5:e2229442

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

The authors would like to thank the Worldwide Exploration of Renal Replacement Outcomes Collaboration in Kidney Disease (WE-ROCK) Collaborative for helping with recruitment for the study. Importantly, we thank the survey participants for their time in completing the survey.

Funding

NIH K23DK116973 (DYF); Gerber Foundation (KMG), NIH 1RL1HD107780-01 (AAA).

Author information

Authors and Affiliations

  1. Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA

    Dana Y. Fuhrman

  2. Department of Pediatrics, Division of Nephrology, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA

    Dana Y. Fuhrman

  3. University of Pittsburgh Children’s Hospital of Pittsburgh, 4401 Penn Avenue, Suite 2000, Pittsburgh, PA, 15224, USA

    Dana Y. Fuhrman

  4. Department of Pediatrics, Division of Cardiology, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA

    Katja M. Gist

  5. Department of Pediatrics, Division of Critical Care Medicine, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA

    Ayse Akcan-Arikan

  6. Department of Pediatrics, Division of Nephrology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA

    Ayse Akcan-Arikan

Authors
  1. Dana Y. Fuhrman
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Katja M. Gist
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ayse Akcan-Arikan
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Dana Y. Fuhrman, Katja M. Gist, and Ayse Akcan-Arikan. The first draft of the manuscript was written by Dana Y. Fuhrman, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Dana Y. Fuhrman.

Ethics declarations

Conflict of interest

The authors declare no competing interests.

Additional information

Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Graphical Abstract (PPTX 234 KB)

Supplementary file2 (PDF 80 KB)

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Fuhrman, D.Y., Gist, K.M. & Akcan-Arikan, A. Current practices in pediatric continuous kidney replacement therapy: a systematic review-guided multinational modified Delphi consensus study. Pediatr Nephrol 38, 2817–2826 (2023). https://doi.org/10.1007/s00467-022-05864-z

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00467-022-05864-z

Keywords

Search

Navigation