54 Timing the initiation of renal replacement therapy (RRT) in critically ill children

Clinical Question

In infants and children admitted to the paediatric intensive care unit requiring RRT, does early initiation of RRT (within 48 hours of stage III Acute Kidney Injury (AKI)) vs late initiation of RRT (over 48 hours from stage III AKI) lead to a decrease in mortality from ICU?

Purpose

Severe AKI increases mortality in critically ill children and infants, with variations in treatment strategies from conservatively managing volume status and biochemical abnormalities, to the escalated and invasive nature of RRT. There are few studies exploring the optimal timing of RRT.

Methods

The following databases were searched: PubMed, Cochrane Library and Emboss, using specific search terms. 7 articles met the inclusion criteria and were reviewed.

Results and Conclusions

When the timing of RRT initiation is defined as from ICU admission, early initiation is associated with lower mortality but this should be treated with caution, as there is an assumption all patients require RRT from the time of ICU admission (figure 1). When the time to initiation of RRT is defined as from when RRT was indicated (for example severe AKI refractory to medical management), observational data shows the longer time is associated with higher mortality. However there is conflicting data in randomised controlled trials in adults.

Limitations

The current, mainly retrospective data, in a heterogenous paediatric population, is prone to bias and confounding given that the decision to start RRT is complex and multifactorial.

Implications

Determining the optimal strategy and timing of initiation of RRT is vital in improving clinical outcomes. Future prospective studies differentiating which children require RRT from those that can be managed supportively would allow fairer comparison of outcomes between 'early' versus 'late' initiation, as the need for RRT may be averted in a 'delayed' strategy.