KDIGO Clinical Practice Guideline for Acute Kidney Injury
Pediatric considerations

Pediatric considerations

Provision of acute RRT to children requires special considerations. Pediatric and adolescent patients range in age from the premature neonate to 25 years of age, with a size range of 1.5–200 kg. In addition, the epidemiology of the pediatric AKI has changed from primary kidney disease in the 1980 s to injury resulting from another systemic illness or its treatment (e.g., sepsis and nephrotoxic medications).^552,553 Newborns with inborn errors of metabolism who do not respond to dietary and pharmacologic management require expeditious dialytic removal of ammonia to decrease the risk of death and long-term neurologic dysfunction,⁵⁵⁴ and infants who receive surgical correction of congenital heart disease, often receive PD early after cardiopulmonary bypass to prevent fluid overload and/or minimize the proinflammatory response. Finally, children develop multiorgan dysfunction very rapidly in their ICU course, with the maximal organ dysfunction

Table 17 | Potential applications for RRT

AKI, acute kidney injury; BUN, blood urea nitrogen; CHF, congestive heart failure; SCr, serum creatinine; RRT, renal replacement therapy.

Table 18 | Fluid overload and outcome in critically ill children with AKI

AKI, acute kidney injury; FO, fluid overload; MODS, multiple-organ dysfunction syndrome; OR, odds ratio. Reprinted from Goldstein SL. Advances in pediatric renal replacement therapy for acute kidney injury. Semin Dial 2011; 24: 187–191 with permission from John Wiley and Sons⁵⁶⁰; accessed http://onlinelibrary.wiley.com/doi/10.1111/j.1525-139X.2011.00834.x/full

occurring with 72 hours and mortality occurring within 7 days of ICU admission, respectively.^555,556 Thus, the issue of timing of dialysis initiation is critically important in children.

Both recommendations in this section of the guideline are applicable to pediatric patients. A detailed discussion of the specific pediatric clinical situations is beyond the scope of this guideline, and the reader is referred to in-depth reviews.^557,558

Importantly, fluid overload has emerged as a significant factor associated with mortality in children with AKI requiring CRRT (Table 18), although the physiological link between increasing percent volume overload and mortality is not completely clear.^{543–548,559} The largest trial to assess this relationship in children is a multicenter prospective study showing that the percentage fluid accumulation at CRRT initiation is significantly lower in survivors vs. non-survivors (14.2 ± 15.9% vs. 25.4 ± 32.9%; P < 0.03) even after adjustment for severity of illness. This study also found a significantly higher mortality in patient with > 20% fluid overload (58%) vs. < 20% fluid overload (40%) at CRRT initiation.⁵⁴⁶ One retrospective study, in pediatric patients who received stem-cell transplantation and developed AKI, suggested that survival may be improved by an aggressive use of diuretics and early initiation of RRT. All survivors (n = 11) maintained or remained with percentage fluid accumulation < 10%, with diuretics and RRT. Among the 15 nonsurvivors, only 6 (40%) had percentage fluid accumulation < 10% at the time of death.⁵⁵⁹ The latest analysis on this issue confirmed increased mortality with increasing fluid overload in 297 children treated with RRT: 29.6% mortality with less than 10% fluid overload, 43.1% with 10–20% fluid overload, and 65.6% with > 20% fluid overload.⁵⁴⁸ However, strong evidence to suggest that preventing this fluid overload with earlier RRT will improve outcome remains absent.