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Implications of different fluid overload definitions in pediatric stem cell transplant patients requiring continuous renal replacement therapy

Rebecca M. Lombel| Mallika Kommareddi| Theresa Mottes| David T. Selewski| Yong Y. Han| Debbie S. Gipson| Katherine L. Collins| Michael Heung
Pediatric Original
Volume 38, Issue 4 / April , 2012

Pages 663 - 669

Abstract

Purpose

In critically ill pediatric patients, fluid overload (FO) >10% has been identified as a threshold for possible interventions, including initiation of continuous renal replacement therapy (CRRT). However, multiple definitions have been reported, and there remains no consensus method for FO calculation. The goal of this study was to compare different methods of FO determination and to assess their relative value in predicting outcomes.

Methods

This is a retrospective single-center review of 21 pediatric stem cell transplant patients (PSCT) that required CRRT from 2004 to 2009. We compared eight definitions (4 weight-based and 4 fluid-balance based) that varied by baseline weights. Outcome measures were pediatric intensive care unit (PICU) mortality and pediatric logistic organ dysfunction (PELOD) scores.

Results

The number of patients identified as having >10% FO varied significantly according to the definition used, from 14 to 48% (p = 0.002). Significant intra-subject variability was observed; the median difference between individual minimum and maximum %FO scores was 11.4% (IQR 6.8, 17.1%). %FO was not significantly associated with PICU mortality, but five of eight FO definitions were predictive of higher subsequent PELOD scores.

Conclusion

Our study is one of the first to compare different FO definitions and the impact on predicting outcomes. Our findings suggest that depending on the FO definition used, there is significant variability in the calculated %FO in PSCT patients, and this has important implications for clinical decision-making. Further studies are necessary to determine an optimal FO definition that is clinically relevant and predictive of important outcomes.

Keywords

References

  1. 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
    • View reference on PubMed
    • View reference on publisher's website
  2. 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
    • View reference on PubMed
    • View reference on publisher's website
  3. Gillespie RS, Seidel K, Symons JM (2004) Effect of fluid overload and dose of replacement fluid on survival in hemofiltration. Pediatr Nephrol 19:1394–1399
    • View reference on PubMed
    • View reference on publisher's website
  4. Goldstein SL, Currier H, Graf C, Cosio CC, Brewer ED, Sachdeva R (2001) Outcome in children receiving continuous venovenous hemofiltration. Pediatrics 107:1309–1312
    • View reference on PubMed
    • View reference on publisher's website
  5. 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
    • View reference on PubMed
    • View reference on publisher's website
  6. Bouchard J, Soroko SB, Chertow GM, Himmelfarb J, Ikizler TA, Paganini EP, Mehta RL (2009) Fluid accumulation, survival and recovery of kidney function in critically ill patients with acute kidney injury. Kidney Int 76:422–427
    • View reference on PubMed
    • View reference on publisher's website
  7. 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
    • View reference on PubMed
    • View reference on publisher's website
  8. Antonelli M, Azoulay E, Bonten M, Chastre J, Citerio G, Conti G, De Backer D, Lemaire F, Gerlach H, Groeneveld J, Hedenstierna G, Macrae D, Mancebo J, Maggiore SM, Mebazaa A, Metnitz P, Pugin J, Wernerman J, Zhang H (2009) Year in review in Intensive Care Medicine, 2008: I. Brain injury and neurology, renal failure and endocrinology, metabolism and nutrition, sepsis, infections and pneumonia. Intensive Care Med 35:30–44
  9. Flores FX, Brophy PD, Symons JM, Fortenberry JD, Chua AN, Alexander SR, Mahan JD, Bunchman TE, Blowey D, Somers MJ, Baum M, Hackbarth R, Chand D, McBryde K, Benfield M, Goldstein SL (2008) Continuous renal replacement therapy (CRRT) after stem cell transplantation. A report from the prospective pediatric CRRT Registry Group. Pediatr Nephrol 23:625–630
    • View reference on PubMed
    • View reference on publisher's website
  10. Selewski DT, Cornell TT, Lombel RM, Blatt NB, Han YY, Mottes T, Kommareddi M, Kershaw DB, Shanley TP, Heung M (2011) Weight-based determination of fluid overload status and mortality in pediatric intensive care unit patients requiring continuous renal replacement therapy. Intensive Care Med 37:1166–1173
  11. Brierley J, Carcillo JA, Choong K, Cornell T, Decaen A, Deymann A, Doctor A, Davis A, Duff J, Dugas MA, Duncan A, Evans B, Feldman J, Felmet K, Fisher G, Frankel L, Jeffries H, Greenwald B, Gutierrez J, Hall M, Han YY, Hanson J, Hazelzet J, Hernan L, Kiff J, Kissoon N, Kon A, Irazuzta J, Lin J, Lorts A, Mariscalco M, Mehta R, Nadel S, Nguyen T, Nicholson C, Peters M, Okhuysen-Cawley R, Poulton T, Relves M, Rodriguez A, Rozenfeld R, Schnitzler E, Shanley T, Kache S, Skippen P, Torres A, von Dessauer B, Weingarten J, Yeh T, Zaritsky A, Stojadinovic B, Zimmerman J, Zuckerberg A (2009) Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med 37:666–688
    • View reference on PubMed
    • View reference on publisher's website
  12. Lane PH, Mauer SM, Blazar BR, Ramsay NK, Kashtan CE (1994) Outcome of dialysis for acute renal failure in pediatric bone marrow transplant patients. Bone Marrow Transplant 13:613–617
    • View reference on PubMed
  13. Patzer L, Kentouche K, Ringelmann F, Misselwitz J (2003) Renal function following hematological stem cell transplantation in childhood. Pediatr Nephrol 18:623–635
    • View reference on PubMed
  14. Van Why SK, Friedman AL, Wei LJ, Hong R (1991) Renal insufficiency after bone marrow transplantation in children. Bone Marrow Transplant 7:383–388
    • View reference on PubMed
  15. Balduzzi A, Valsecchi MG, Silvestri D, Locatelli F, Manfredini L, Busca A, Iori AP, Messina C, Prete A, Andolina M, Porta F, Favre C, Ceppi S, Giorgiani G, Lanino E, Rovelli A, Fagioli F, De Fusco C, Rondelli R, Uderzo C (2002) Transplant-related toxicity and mortality: an AIEOP prospective study in 636 pediatric patients transplanted for acute leukemia. Bone Marrow Transplant 29:93–100
    • View reference on PubMed
    • View reference on publisher's website
  16. Kist-van Holthe JE, van Zwet JM, Brand R, van Weel MH, Vossen JM, van der Heijden AJ (1998) Bone marrow transplantation in children: consequences for renal function shortly after and 1 year post-BMT. Bone Marrow Transplant 22:559–564
    • View reference on PubMed
    • View reference on publisher's website
  17. Bunchman TE, McBryde KD, Mottes TE, Gardner JJ, Maxvold NJ, Brophy PD (2001) Pediatric acute renal failure: outcome by modality and disease. Pediatr Nephrol 16:1067–1071
    • View reference on PubMed
    • View reference on publisher's website
  18. Michael M, Kuehnle I, Goldstein SL (2004) Fluid overload and acute renal failure in pediatric stem cell transplant patients. Pediatr Nephrol 19:91–95
    • View reference on PubMed
    • View reference on publisher's website
  19. Rajasekaran S, Jones DP, Avent Y, Shaffer ML, Elbahlawan L, Henderson N, Barfield RC, Morrison RR, Tamburro RF (2010) Outcomes of hematopoietic stem cell transplant patients who received continuous renal replacement therapy in a pediatric oncology intensive care unit. Pediatr Crit Care Med 11:699–706
    • View reference on PubMed
    • View reference on publisher's website
  20. Bunchman TE, Maxvold NJ, Barnett J, Hutchings A, Benfield MR (2002) Pediatric hemofiltration: Normocarb dialysate solution with citrate anticoagulation. Pediatr Nephrol 17:150–154
    • View reference on PubMed
    • View reference on publisher's website
  21. Pollack MM, Patel KM, Ruttimann UE (1996) PRISM III: an updated pediatric risk of mortality score. Crit Care Med 24:743–752
    • View reference on PubMed
    • View reference on publisher's website
  22. Leteurtre S, Martinot A, Duhamel A, Proulx F, Grandbastien B, Cotting J, Gottesman R, Joffe A, Pfenninger J, Hubert P, Lacroix J, Leclerc F (2003) Validation of the paediatric logistic organ dysfunction (PELOD) score: prospective, observational, multicentre study. Lancet 362:192–197
    • View reference on PubMed
    • View reference on publisher's website
  23. Garcia PC, Eulmesekian P, Branco RG, Perez A, Sffogia A, Olivero L, Piva JP, Tasker RC (2010) External validation of the paediatric logistic organ dysfunction score. Intensive Care Med 36:116–122
  24. Leteurtre S, Martinot A, Duhamel A, Gauvin F, Grandbastien B, Nam TV, Proulx F, Lacroix J, Leclerc F (1999) Development of a pediatric multiple organ dysfunction score: use of two strategies. Med Decis Making 19:399–410
    • View reference on PubMed
    • View reference on publisher's website
  25. Leteurtre S, Duhamel A, Grandbastien B, Lacroix J, Leclerc F (2006) Paediatric logistic organ dysfunction (PELOD) score. Lancet 367:897; author reply 900–892

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