KDIGO Clinical Practice Guideline for Acute Kidney Injury
Pediatric considerations

Pediatric considerations

RRTmodality choice for children with AKI is guided by many of the same principles used for adult patients. However, since severe AKI is relatively rare in children compared to adults, occurring in less than 1% of hospitalized children⁷⁴⁰ and only 4.5% of children admitted to an intensive care unit,⁷⁴¹ the impact of local expertise and resource restrictions may be greater for pediatric acute RRT modality decisions. As noted below, each modality of acute RRT can be successfully provided to pediatric patients of all sizes. Thus, with rare exception driven by medical indication or contraindication, no form of acute RRT can be recommended above another at the present time. Each program should evaluate which modality is provided most optimally and feasibly in its particular setting.

Provision of RRT as IHD, PD, or CRRT is now a mainstay of treatment for the child with severe AKI. The widely varying size range of pediatric patients imparts technical considerations in selection of a modality. Given their small size and associated low blood volume, PD may provide the least technically challenging option for infants and small children. However, technological advances aimed at providing accurate ultrafiltration with volumetric control incorporated into IHD and CRRT equipment, and disposable lines, circuits, and dialyzers sized for the entire pediatric weight spectrum have made IHD and CRRT safer and feasible for children of all ages and sizes.^{570,742–744} Transition from the use of adaptive CRRT equipment to production of high-flow machines with volumetric control allowing for accurate ultrafiltration flows has likewise lead to a change in pediatric RRT modality prevalence patterns in the USA. Accurate ultrafiltration and blood flow rates are crucial for pediatric RRT, since the extracorporeal circuit volume can comprise more than 15% of a small pediatric patient’s total blood volume, and small ultrafiltration inaccuracies may represent a large percentage of a small pediatric patient’s total body water. Polls of USA pediatric nephrologists demonstrate increased CRRT use over PD as the preferred modality for treating pediatric ARF. In 1995, 45% of pediatric centers ranked PD and 18% ranked CRRT as the most common modality used for initial ARF treatment. In 1999, 31% of centers chose PD vs. 36% of centers reported CRRT as their primary initial modality for ARF treatment.⁷⁴⁵

In the 1990 s, survival rates stratified by RRT modality were better for children receiving IHD (73–89%) than those receiving PD (49–64%) or CRRT (34–42%).^545,746 However, this analysis did not correct for illness severity. More recent data demonstrate much improved survival in children receiving CRRT,^{543,544,546,570} with survival rates ranging from 50–70% for children with multiple-organ dysfunction who receive CRRT. While no RCT exists to assess the impact of CRRT modality on survival, convective modalities were associated with increased survival in children with stem-cell transplants in a prospective cohort study (59% vs. 27%, P < 0.05).⁷⁴⁷