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CRRT in the Septic Patient

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Critical Care Nephrology and Renal Replacement Therapy in Children

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Abstract

Acute kidney injury (AKI) is very common and has been associated with mortality in septic patients. Severe acidosis, hemodynamic instability, and fluid overload due to resuscitation fluids are often also seen in this population of patients. In this setting, reduction of renal function is often seen and continuous renal replacement therapy (CRRT) is often used as a bridge to support the patient through their septic acute kidney injury. The ultimate goal of this therapy is to allow recovery of native function. If this is not possible, then to provide renal function until stability improves sufficiently to convert to a form of renal replacement that can be managed as an outpatient. Little medical evidence exists surrounding the optimal way to provide CRRT to septic patients, much less children with sepsis. In this chapter, we will discuss the potential benefits and issues surrounding the use of CRRT during sepsis, and review the outcomes that have been seen when using this approach. We will also review CRRT’s role in using multiple extracorporeal organ support therapies for sepsis.

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References

  1. Hartman ME, Linde-Zwirble WT, Angus DC, Watson RS. Trends in the epidemiology of pediatric severe sepsis. Pediatr Crit Care Med. 2013;14:686–93.

    Article  Google Scholar 

  2. Watson RS, Carcillo JA, Linde-Zwirble WT, Clermont G, Lidicker J, Angus DC. The epidemiology of severe sepsis in children in the United States. Am J Respir Crit Care Med. 2003;167:695–701.

    Article  Google Scholar 

  3. Weiss SL, Fitzgeral JC, Pappachan J, Wheeler D, et al. Global epidemiology of pediatric severe sepsis: the sepsis prevalence, outcomes, and therapies study. Am J Respir Crit Care Med. 2015;191(10):1147–57.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Kutko MC, Calarco MP, Flaherty MB, Helmrich RF, Ushay HM, Pon S, Greenwald BM. Mortality rates in pediatric septic shock with and without multiple organ system failure. Pediatr Crit Care Med. 2003;4:333–7.

    Article  Google Scholar 

  5. Singer M, Deutschman CS, Seymour CW, et al. The third international consensus defnitions for sepsis and septic shock (Sepsis-3). JAMA. 2016;315:801–10.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Goldstein B, Giroir B, Randolph A, et al. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med. 2005;6:2–8.

    Article  Google Scholar 

  7. Angus DC, Linde-Zwirble WT, Lidicker J, et al. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001;29:1303–10.

    Article  CAS  PubMed  Google Scholar 

  8. Poukkanen M, Vaara ST, Pettila V, et al. Acute kidney injury in patients with severe sepsis in finiish intensive care units. Acta Anaesthesiol Scand. 2013;57:863–72.

    Article  CAS  PubMed  Google Scholar 

  9. Fitzgerald JC, Basu R, Arkcan-Arikan A, et al. Acute kidney injury in pediatric severe sepsis, an independent risk factor for death and new disability. Crit Care Med. 2016;44(12):2241–50.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Cooper DS, Kwiatkowski DM, Goldstein SL, Krawczeski CD. Acute kidney injury and cardiorenal syndromes in pediatric cardiac intensive care. Pediatr Crit Care Med. 2016;17(8 Suppl 1):S250–6.

    Article  PubMed  Google Scholar 

  11. Fani F, Regolisti G, Delsante M, et al. Recent advances in the pathogenetic mechanisms of sepsis-associated acute kidney injury. J Nephrol. 2017. https://doi.org/10.1007/s40620-017-0452-4.

  12. Schrier RW, Wang W. Acute renal failure and sepsis. N Engl J Med. 2004;351(2):159–69.

    Article  CAS  PubMed  Google Scholar 

  13. Bellomo R, Kellum JA, Ronco C, Wald R, et al. Acute kidney injury in sepsis. Inten Care Med. 2017;43:816–28.

    Article  CAS  Google Scholar 

  14. Naveda-Romero OE, Naveda-Melendez AF. Fluid overload and kidney failure in children with severe sepsis and septic shock. Arch Argent Pediatr. 2017;115(2):118–24.

    PubMed  Google Scholar 

  15. Chen J, Li X, Bai Z, Fang F, et al. Association of fluid accumulation with clinical outcomes in critically ill children with severe sepsis. PLoS One. 2016;11(7):e0160093.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Maitland K, Kiguli S, Opoka RO, et al. Mortality after fluid bolus in African children with severe infection. NEJM. 2011;264:2483–95.

    Article  Google Scholar 

  17. Westrope CA, Fleming S, Kapetanstrataki M, et al. Renal replacement therapy in the critically ill child. Pediatr Crit Care Med. 2018;19(3):210–7.

    Article  PubMed  Google Scholar 

  18. Fleming GM, Askenazi DJ, Bridges BC, et al. A multicenter international survey of renal supportive therapy during ECMO: the kidney intervention during extracorporeal membrane oxygenation (KIDMO) group. ASAIO J. 2012;58(4):407–14.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. John S, Griesbach D, Baumgartel M, et al. Effects of continuous haemofiltration vs. intermittent haemodialysis on systemic haemodynamics and splanchnic regional perfusion in septic shock patients: a prospective, randomized trial. Nephrol Dial Transplant. 2001;16(2):320–7.

    Article  CAS  PubMed  Google Scholar 

  20. Ronco C, Bonello M, Bordoni V, et al. Extracorporeal therapies in non-renal disease: treatment of sepsis and the peak concentration hypothesis. Blood Purif. 2004;22(1):164–74.

    Article  PubMed  Google Scholar 

  21. Honore PM, Jacobs R, Joannes-Boyau O, et al. Newly designed CRRT membranes for sepsis and SIRS—a pragmatic approach for bedside intensivists summarizing the more recent advances: a systematic structured review. ASAIO J. 2013;59(2):99–106.

    Article  CAS  PubMed  Google Scholar 

  22. Shimizu T, Miyake T, Kitamura N, et al. Endotoxin adsorption: direct hemoperfusion with the polymixin B immobilized fiber column (PMX). Tranfus Apher Sci. 2017;56(5):682–8.

    Article  Google Scholar 

  23. Zheng S, Weng Q, Wu W, Ding G. Blood purification treatment initiated at the time of sepsis diagnosis effectively attenuates serum HMGB1 upregulation and improves patient prognosis. Exp Ther Med. 2017;14(4):3029–35.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Ronco C, Bellomo R, Homel P, et al. Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial. Lancet. 2000;356:26–30.

    Article  CAS  PubMed  Google Scholar 

  25. Palevsky PM, Zhang JH, O’Conner TZ, et al. Intensity of renal support in critically ill patients with acute kidney injury. NEJM. 2008;359:7–20.

    Article  CAS  PubMed  Google Scholar 

  26. Bellomo R, Cass A, Cole L, et al. Intensity of continuous renal replacement therapy in critically ill patients. NEJM. 2009;361:1627–38.

    Article  PubMed  Google Scholar 

  27. Joannes-Boyau O, Honore PM, Perez P, et al. High-volume versus standard volume haemofiltration for septic shock patients with acute kidney injury (IVOIRE study): a multicenter randomized controlled trial. Intensive Care Med. 2013;39:1535–46.

    Article  PubMed  Google Scholar 

  28. Park JT, Lee H, Kee YK, et al. High-dose versus conventional dose continuous venovenous hemodiafiltration and patient and kidney survival and cytokine removal in sepsis-associated acute kidney injury: a randomized controlled trial. Am J Kidney Dis. 2016;68:599–608.

    Article  PubMed  Google Scholar 

  29. Wong WT, Choi G, Gomersall CD, Lipman J. To increase or decrease dosage of antimicrobials in septic patients during continuous renal replacement therapy: the eternal doubt. Curr Opin Pharmacol. 2015;24:68–78.

    Article  CAS  PubMed  Google Scholar 

  30. Sethi SK, Maxvold N, Bunchman T, et al. Nutritional management in the critically ill child with acute kidney injury: a review. Pediatr Nephrol. 2017;32(4):589–601.

    Article  PubMed  Google Scholar 

  31. Deep A, Zoha M, Dutta Kukreja P. Prostacyclin as an anticoagulant for continuous renal replacement therapy in children. Blood Purif. 2017;43(4):279–89.

    Article  CAS  PubMed  Google Scholar 

  32. Jones CH, Goutcher E, Newstead CG, et al. Hemodynamics and survival of patients with acute renal failure treated by continuous dialysis with two synthetic membranes. Artif Organs. 1998;22(8):638–43.

    Article  CAS  PubMed  Google Scholar 

  33. Stoves J, Goode NP, Visvanathan R, et al. The bradykinin response and early hypotension at the introduction of continuous renal replacement therapy in the intensive care unit. Artif Organs. 2001;25(1):1009–13.

    Article  CAS  PubMed  Google Scholar 

  34. Friedrich JO, Wald R, Bagshaw SW, Burns KE, Adhikari NK. Hemofiltration compared to hemodialysis for acute kidney injury: systematic review and meta-analysis. Crit Care. 2012;16(4):R146.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Kovacs B, Sullivan KJ, Hiremath S, et al. Effect of sustained low efficiency dialysis versus continuous renal replacement therapy on renal recovery after acute kidney injury in the intensive care unit: a systematic review and meta-analysis. Neprhology. 2017;22(5):343–53.

    Google Scholar 

  36. Saudan P, Niederberger M, De Seigneux S, et al. Adding a dialysis dose to continous hemofiltration increases survival in patients with acute renal failure. Kidney Int. 2006;70(7):1312–7.

    Article  CAS  PubMed  Google Scholar 

  37. Al Enezi F, Al Hazzani W, Ma J, et al. Continuous venovenous hemofiltration versus continuous venovenous hemodiafiltration in critically ill patients: a retrospective cohort study from a Canadian tertiary Centre. Can Respir J. 2014;21(3):176–80.

    Article  Google Scholar 

  38. Premuzic V, Basic-Jukic N, Jelakovic B, Kes P. Differences in CVVH vs. CVVHDF in the management of sepsis-induced acute kidney injury in critically ill patients. J Artif Organs. 2017;20:326–34.

    Article  PubMed  Google Scholar 

  39. Gaudry S, Hajage D, Schortgen F, et al. Initiation strategies for renal replacement therapy in the intensive care unit. NEJM. 2016;375(2):122–33.

    Article  PubMed  Google Scholar 

  40. Zarbock A, Kellum JA, Schmidt C, et al. Effect of early vs. delayed initation of renal replacement therapy on mortality in critically ill patients with acute kidney injury: the ELAIN randomized clinical trial. JAMA. 2016;315(20):2190–9.

    Article  CAS  PubMed  Google Scholar 

  41. Brandenburger T, Dimski T, Slowinski T, Kindgen-Milles D. Renal replacement therapy and anticoagulation. Best Pract Res Clin Anaesthesiol. 2017;31(3):387–401.

    Article  PubMed  Google Scholar 

  42. Pschowski R, Briegel S, Von Haehling S, et al. Effects of dialysis modality on blood loss, bleeding complications and transfusion requirements in critically ill patients with dialysis-dependent acute renal failure. Anaesth Intensive Care. 2015;43(6):764–70.

    PubMed  CAS  Google Scholar 

  43. Iba T, Fowler L. Is polymyxin B immobilized fiber column ineffective for septic shock? A discussion on the press release for EUPHRATES trial. J Intensive Care. 2017;5:40.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Skinner SC, Iocono JA, Ballard HO, Turner MD, Ward AN, Davenport DL, Paden ML, Zwischenberger JB. Improved survival in venovenous vs. venoarterial extracorporeal membrane oxygenation for pediatric noncardiac sepsis patients: a study of the extracorporeal life support organization registry. J Pediatr Surg. 2012;47(1):63–7.

    Article  PubMed  Google Scholar 

  45. Hoover NG, Heard M, Reid C, Wagoner S, Rogers K, Foland J, Paden ML, Fortenberry JD. Enhanced fluid management with continuous venovenous hemofiltration in pediatric respiratory failure patients receiving extracorporeal membrane oxygenation support. Intensive Care Med. 2008;34(12):2241–7.

    Article  PubMed  Google Scholar 

  46. Lawson DS, Holt D. Insensible water loss from the Jostra Quadrox D oxygenator: an in vitro study. Perfusion. 2007;22(6):407–10.

    Article  CAS  PubMed  Google Scholar 

  47. Li L, Oi Yan T, Ming Chit Arthur K, Hoi Ping S, et al. Insensible water loss through adult extracorporeal membrane oxygenation circuit: an in vitro study. ASAIO J. 2014;60(4):508–12.

    Article  CAS  Google Scholar 

  48. Paden ML, Warshaw BL, Heard ML, Fortenberry JD. Recovery of renal function and survival after continuous renal replacement therapy during extracorporeal membrane oxygenation. Pediatr Crit Care Med. 2011;12(2):153–8.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Carcillo JA, Halstead ES, Hall MW, Nguyen TC, et al. Three hypothetical inflammation pathobiology phenotypes and pediatric sepsis induced multiple organ failure outcome. Pediatr Crit Care Med. 2017;18(6):513–23.

    Article  PubMed  PubMed Central  Google Scholar 

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Author information

Authors and Affiliations

  1. Division of Pediatric Critical Care, Emory University, Atlanta, GA, USA

    Matthew L. Paden

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  1. Matthew L. Paden
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Correspondence to Matthew L. Paden .

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Editors and Affiliations

  1. Paediatric Intensive Care Unit, King’s College Hospital, London, United Kingdom

    Akash Deep

  2. Center for Acute Care Nephrology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA

    Stuart L. Goldstein

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Paden, M.L. (2018). CRRT in the Septic Patient. In: Deep, A., Goldstein, S. (eds) Critical Care Nephrology and Renal Replacement Therapy in Children. Springer, Cham. https://doi.org/10.1007/978-3-319-90281-4_26

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  • DOI: https://doi.org/10.1007/978-3-319-90281-4_26

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-90280-7

  • Online ISBN: 978-3-319-90281-4

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