Impact of Early Versus Late CRRT Initiation in Children and Young Adults, with Katja Gist, DO

A secondary analysis of data from the Worldwide Exploration of Renal Replacement Outcome Collaborative in Kidney Disease (WE-ROCK) registry is calling attention to the risk of death, dialysis dependence, and persistent kidney dysfunction due to delayed continuous renal replacement therapy (CRRT) initiation.

Encompassing 969 patients at 32 centers across 7 countries, the retrospective study examined time to initiation from intensive care unit admission for children and young adults with acute kidney injury or volume overload. For the purpose of analysis, investigators defined initiation ≤ 2 days from admission as early and > 2 days as late.

The primary outcome of interest was major adverse kidney events at 90 days (MAKE-90), including death, dialysis dependence, or persistent kidney dysfunction. Secondary outcomes included ventilator-free days and ICU-free days assessed during the first 28 ICU days.

Among the cohort, the median time to CRRT initiation was 2 (Interquartile range [IQR], 1-6) days and the median therapy duration was 6 (IQR, 3-14) days. There were 514 (52.5%) patients who initiated therapy within ≤ 2 days of ICU admission, 314 (61.1%) of whom had MAKE-90 compared to 315 of 465 patients with late initiation (67.7%; P = .054).

Of the 630 patients in the total cohort affected by MAKE-90, 368 (58.4%) died. Persistent kidney function was prevalent among 262 (43.6%) of the 601 patients who survived and 91 (34.7%) were dependent on dialysis.

Investigators noted there were approximately 3% greater odds of MAKE-90 for each 1-day delay in CRRT initiation (odds ratio [OR], 1.03; 95% Confidence interval [CI], 1.02-1.04). Those with late initiation experienced greater rates of mortality at 90 days than those who initiated CRRT early (42.5% vs 33.7%; P = .01), with further analysis revealing mortality was significantly increased among the CRRT > 2 days and volume overload < 10% subphenotype (44.0%) (P < .001).

Of note, median ventilator-free days (19 days vs 0 days; P < .001) and ICU-free days (2 days vs 0 days; P < .001) were also reduced among those with late initiation compared to early initiation, further highlighting the negative impact of delayed CRRT. Additionally, investigators noted the median volume overload at CRRT initiation was greater for patients who started CRRT > 2 days (12.5%; IQR, 5.3%-28.7%) than patients who started CRRT ≤ 2 days (4.8%; IQR, 1.1%-10.4%) (P < .001).

The editorial team of HCPLive Nephrology reached out to Katja Gist, DO, codirector of the Center for Acute Care Nephrology at Cincinnati Children's Hospital Medical Center, for additional insight into the use of CRRT in children and young adults, what is currently known about the best timing of therapy initiation, and what the present study adds to clinicians’ arsenal of knowledge about utilizing CRRT in this patient population.

Brooks, A. Study Details Consequences of Delayed CRRT Initiation in Children, Young Adults. HCPLive. January 2, 2024. Accessed January 8, 2024. https://www.hcplive.com/view/study-details-consequences-of-delayed-crrt-initiation-in-children-young-adults