1. Neonatal and Infant CRRT
Jordan M. Symons, MD
University of Washington School of Medicine
Children’s Hospital & Regional Medical Center
Seattle, WA

2. Pediatric CRRT: Vicenza, 1984

3. This is a schematic of one of our old CRRT set-ups
This is a schematic of one of our old CRRT set-ups. Here is a simple blood pump with an attached hemofilter. There are separate IV pumps for replacement fluids, for dialysate, and to generate the negative pressure to remove the ultrafiltrate. Because this system has dialysate and replacement fluids, it would most accurately be called CVVHDF.
These glued-together systems were not terribly user friendly and could be inaccurate as well.

4. CRRT Machines: Current Generation
Now, we have fancy new machines, dedicated to CRRT, able to perform numerous modalities accurately on a single platform.
This one over here on the right, the Baxter BM-25, happens to be the machine we use here at Children’s.
These new machines, and the other new technologies and techniques that have become available in only the last few years, have made CRRT a tremendously effective tool in the care of critically ill patients.
I would add that despite all of this advancing technology, what really makes CRRT work for our patients is the incredible care and commitment of our nursing staff. Without our remarkable dialysis and ICU nurses, all of this would be useless.

5. Vascular Access for Pediatric CRRT
Smaller patients require smaller catheters
Difficulty achieving access
Difficulty maintaining access
Limited access sites

6. Choices for Vascular Access
Catheter Type
Manufacturers
Potential Pts.
Single-lumen 5Fr
Cook
Small Neonates
Double-lumen 7Fr
Medcomp
3 – 6 Kg
Triple-lumen 7Fr
Double-lumen 8Fr
Kendall
Arrow
6 – 30 Kg

7. Access Sites for CRRT Femoral veins Jugular veins Subclavian veins
Umbilical vessels
ECMO circuit

8. Prescribing CRRT for Small Kids
Modality
Blood flow rate
Hemofilter
Solution(s)
Ultrafiltration rate
Anticoagulation
Special considerations

9. CRRT Modality for Small Kids
Am J Kid Dis, 18: , 2003

10. Hemofilters for Pediatric CRRTN
Material
Surface area (m2)
Prime vol (ml)
Renaflo® II HF-400
41 (48%)
Polysulfone
0.3 28
Multiflow 60
20 (24%)
AN-69
0.6 48
Fresenius F3
19 (22%)
0.4 30
Amicon® Minifilter®
5 (6%)
0.08 15
Am J Kid Dis, 18: , 2003

11. Ultrafiltration Rate for Infant CRRT
As tolerated by the patient
Potentially limited by hemofilter, blood flow rates
Small errors have a larger effect in a tiny patient

12. Anticoagulation for Infant CRRT
Heparin
Citrate
Nothing
? Other things ?

13. Other Special Considerations for CRRT in Infants
Large extracorporeal volume compared to small patient
Blood prime (1:1 PRBC:Albumin 5%) at initiation frequently required
Risk of thermic loss often requires heating system

14. Potential Complications of Infant CRRT
Volume related problems
Biochemical and nutritional problems
Hemorrhage
Infection
Technical problems
Logistical problems
Bradykinin release syndrome

15. Logistical Issues for Infant CRRT
Infrequently performed procedure in neonatal units
Vascular access can be difficult to organize and obtain
Neonatology staff may be unfamiliar with equipment, procedure, risks
Written procedures may improve coordination and results of therapy

16. Bradykinin Release Syndrome
Mucosal congestion, bronchospasm, hypotension at start of CRRT
Resolves with discontinuation of CRRT
Thought to be related to bradykinin release when patient’s blood contacts hemofilter
Exquisitely pH sensitive

17. Technique Modifications to Prevent Bradykinin Release Syndrome
Buffered system: add THAM, CaCl, NaBicarb to PRBCs
Bypass system: prime circuit with saline, run PRBCs into patient on venous return line
Recirculation system: recirculate blood prime against dialysate

18. Bypass System to Prevent Bradykinin Release Syndrome
PRBC
Waste
Modified from Brophy, et al. AJKD, 2001.

19. Recirculation System to Prevent Bradykinin Release Syndrome
Normalize pH
Normalize K+
Recirculation Plan:
Qb 200ml/min
Qd ~40ml/min
Time 7.5 min
Waste
Based on Pasko, et al. Ped Neph 18: , 2003

20. Outcomes for Pediatric CRRT
Data are scant
Most studies are single-center, retrospective
No randomized controlled trials
Small numbers limit power
Extension from adult studies may not be appropriate

21. CRRT in Pediatric Patients <10Kg
Multi-center, retrospective study
5 pediatric centers
85 patients
Demographic data
Technique description
Outcome
Am J Kid Dis, 18: , 2003

22. Which Babies Require CRRT?
Congenital heart disease
Metabolic disorder
Multiorgan dysfunction
Sepsis syndrome
Liver failure
Malignancy
Congenital nephrotic syndrome
Congenital diaphragmatic hernia
Congenital renal/urological disease
Hemolytic uremic syndrome
Heart failure
Other
16.5%
15.3%
14.1%
10.6%
5.9%
4.7%
3.5%
2.4%
2.3%
N=85
Am J Kid Dis, 18: , 2003

23. Why do Babies Need CRRT?
Combined volume overload and biochemical abnormalities of renal failure
54%
Volume overload
18%
Metabolic imbalance unrelated to renal failure (e.g., hyperammonemia)
14%
Biochemical abnormalities of renal failure 9%
Other (e.g., medication overdose) 4%
Volume overload and hyperammonemia 1%
N=85
Am J Kid Dis, 18: , 2003

24. CRRT in Infants <10Kg: Outcome
38% Survival
41% Survival
25% Survival
Patients <10kg
Patients 3-10kg
Patients <3kg
Am J Kid Dis, 18: , 2003

25. Survival by Diagnosis Totals: N=85; Survivors=32
Am J Kid Dis, 18: , 2003
36%
71%
15%
42%
22%
50%
100%
60%
Percentages instead of numbers
Totals: N=85; Survivors=32

26. Survival by Modality Modality N Survivors CVVH 27 11 (41%) CVVHD 12
3 (25%)
CVVHDF
4 (33%)
CVVHD or CVVHDF 24
7 (29%)
Am J Kid Dis, 18: , 2003
p=NS

27. Retrospective Study of Infant CRRT: Summary
Overall outcome acceptable
3 – 10kg: outcome similar to that for older patients
Metabolic disorders: good outcome
<3kg, selected diagnoses: poor outcome
No clear advantage between modalities
Am J Kid Dis, 18: , 2003

28. Prospective Pediatric CRRT Registry (ppCRRT)
Multi-center registry of pediatric CRRT
Currently eleven US centers participating
Collecting demographic, technical and outcome data on all pediatric patients receiving CRRT
Sub-analysis of infants <10kg presented at ASN and PAS/ASPN

29. ppCRRT Data of Infants <10kg: Demographic Information
28 children <10 kg
14 boys, 14 girls
Median age 40 days old
Range 3 days to 2.9 years
Median weight 4.1 kg
Range 1.3 to 9.5 kg

30. ppCRRT Data of Infants <10kg: Indications for CRRT

31. ppCRRT Data of Infants <10kg: Vascular Access Location

32. ppCRRT Infant Survival Data

33. Infant CRRT: Continuing Questions
How does CRRT compare to other modalities for small patients?
What is optimal nutrition for infants on CRRT?
What further equipment refinements are necessary?
What is the long-term effect of CRRT?

34. Thanks!