Hemodynamic instability during connection to continuous kidney replacement therapy in critically ill pediatric patients

Sameer Thadani; Thomas Fogarty; Theresa Mottes; Jack F Price; Poyyapakkam Srivaths; Cynthia Bell; Ayse Akcan-Arikan

doi:10.1007/s00467-022-05424-5

Hemodynamic instability during connection to continuous kidney replacement therapy in critically ill pediatric patients

Pediatr Nephrol. 2022 Sep;37(9):2167-2177. doi: 10.1007/s00467-022-05424-5. Epub 2022 Feb 3.

Authors

Sameer Thadani¹, Thomas Fogarty², Theresa Mottes³, Jack F Price⁴, Poyyapakkam Srivaths³, Cynthia Bell⁵, Ayse Akcan-Arikan^{2

3}

Affiliations

¹ Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA. sameer.thadani@bcm.edu.
² Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
³ Department of Pediatrics, Renal Section, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
⁴ Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
⁵ McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA.

PMID: 35118547
DOI: 10.1007/s00467-022-05424-5

Abstract

Background: Emerging data suggest evidence of organ hypoperfusion during continuous kidney replacement therapy (CKRT). To facilitate kidney and global recovery, we must understand the hemodynamic risks associated with CKRT. We aimed to investigate frequency of hemodynamic instability and association with patient outcomes in pediatric CKRT.

Methods: In a single-center study of CKRT patients between September 2016 and October 2018, we collected hemodynamic data using archived high-resolution physiologic data before and after connection. Primary outcome was hypotension defined as ≥ 20% decrease in baseline mean arterial pressure (MAP) for ≥ 2 consecutive minutes in the 60 min following connection. Secondary outcomes were tachycardia (≥ 20% increase in heart rate (HR)) and hemodynamic interventions.

Results: Seventy-one patients median age 54 months (IQR 7-144), weight 16.7 kg (IQR 8-41), on hemodiafiltration had 304 filter connections, 4 (IQR 1-7) filters per patient; the median duration of CKRT was 9 days (IQR 3-20). The most common CKRT indication was AKI with fluid overload (48/71, 69%). There were 78 (27%) hypotension and 42 (14%) tachycardia events; cumulative duration of hypotension was 14 min IQR (3-31.75). Teams provided intervention in 17/304 (6%) of connections. Pediatric Logistic Organ Dysfunction 2 was the only independent predictor of hypotension (aOR 2.12 (CI 1.02-4.41)).

Conclusions: One in four and one in six pediatric CKRT filter connections were complicated by hypotension and tachycardia, respectively. Higher illness severity at CKRT initiation was independently associated with hypotension. Impact of CKRT-associated hemodynamic instability on global patient outcomes requires further targeted study. A higher resolution version of the Graphical abstract is available as Supplementary information.

Keywords: Continuous kidney replacement therapy; Critical care; Dialysis; Hemodynamics; Hypotension; Outcomes.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Acute Kidney Injury* / etiology
Acute Kidney Injury* / therapy
Child
Child, Preschool
Continuous Renal Replacement Therapy* / adverse effects
Critical Illness / therapy
Hemodynamics / physiology
Humans
Hypotension* / epidemiology
Hypotension* / etiology