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The Prospective Pediatric CRRT Registry: Enhancing Pediatric Patient Care

Learn about the ppCRRT Registry's origin, design, data collection, and outcomes, aiming to improve CRRT practices in pediatric patients. Explore findings on treatments, machine functioning, patient outcomes, and more.

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The Prospective Pediatric CRRT Registry: Enhancing Pediatric Patient Care

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  1. The Prospective Pediatric CRRT (ppCRRT) Registry Stuart L. Goldstein, MD Principal Investigator and Founder Timothy E Bunchman Helen DeVos Children’s Hospital Grand Rapids MI USA

  2. How did the ppCRRT registry come to exist? • Stu Goldstein MD originated the concept and identified a group who work well together to • Initially look at “what is being done as standard of practice ” • Perform studies on • New devices • Drug clearance • What can be done in the future

  3. The Founding Five Bunchman Brophy Goldstein Symons Somers

  4. Co-Investigators/Data Coordinators • Michael Somers • Michelle Baum • Cheryl Baker • Pat Brophy • Theresa Mottes • Jordan Symons • Nancy McAfee • Tim Bunchman • Rick Hackbarth • Dawn Eding • Mark Benfield • David Askenazi • James Fortenberry • Kristine Rogers • Renee Robinson • John Mahan • Deepa Chand • Francisco Flores • Kevin McBryde • Steven Alexander • Annabelle Chua • Douglas Blowey • Stuart Goldstein

  5. ppCRRT Sponsors The ppCRRT Registry receives grant funding from Gambro Renal Products Dialysis Solutions, Incorporated Baxter Healthcare B Braun, Inc

  6. ppCRRT Registry: Phase 1 Observational Data • Assess for potential associations between various practices and pediatric patient outcomes in 300 patients • Assess for potential associations between varying practices and CRRT machine functioning

  7. ppCRRT Registry Design • Prospective, observational format • Informed consent required • All centers practice according to their local protocol with respect to • initiation and termination criteria • modality • prescription • clearance • fluids • anticoagulation

  8. ppCRRT Data Collected • Divided into three electronic or paper forms • Pre-Initiation/Demographic Data • ICU data • Filter data • Each patient has unique identifier to describe center site and patient number (e.g., the third Texas Children’s patient is #1003) • Some sites’ IRB’s prevent listing date of birth, so investigator calculates age

  9. Pre-CRRT Registry Data • Demographics • primary disease leading to CRRT • co-morbid illness • MODS (yes/no) • gender • days in PICU prior to CRRT • ICU admit weight and height/length • CRRT specifics • Modality • CRRT reason(s) • Treatment or prevention of fluid overload and/or • Treatment or prevention of electrolyte imbalance • Access size, configuration and site • Pediatric Risk of Mortality 2 (PRISM 2) score

  10. PRISM 2 score • 14 variables, 5 organ domains • Cardiovascular (SBP, DBP, pulse) • Respiratory (Resp rate, pO2, pCO2) • Neurological (Glasgow Coma score, pupillary reaction) • Hepatic (bilirubin) • Metabolic (potassium, calcium, total CO2, glucose) • Direct assessment of renal function not included • Easy to calculate • Data remains with ppCRRT and not sent elsewhere for analysis Pollack M: Crit Care Med. 1988 16:1110-6

  11. Pre-CRRT Registry Data: CRRT Initiation • Renal failure indices at CRRT initiation • GFR (Schwartz) • Urine output in previous 24 hours • Percent fluid overload (%FO) • PRISM 2 score • CVP • Mean airway pressure • Number of inotropic agents used • Diuretics? (yes/no)

  12. Percent Fluid Overload Calculation [ ] Fluid In - Fluid Out ICU Admit Weight * 100% % FO at CVVH initiation = Fluid In = Total Input from ICU admit to CRRT initiation Fluid Out = Total Output from ICU admit to CRRT initiation

  13. Registry PICU Data • Cardiopulmonary • Maximum inotrope doses • Pressors weaned? (yes/no) • MAP change • ICU length of stay

  14. ppCRRT Registry Circuit Data • Separate dataset for each circuit • Machine brand • Extracorporeal circuit volume • Priming fluid • Dialysis or replacement fluid composition • Anticoagulation • Citrate • Heparin rate • ACT measured per hour • Mean ACT • # ACT < 180 seconds

  15. ppCRRT Registry Circuit Data • Clearance prescription • CVVH versus CVVHD versus CVVHDF • ml/1.73m2/hour • Nutrition prescription at each circuit initiation • Kcal/kg/day • Grams protein/kg/day • Total fluid intake • Total fluid output • Total and net ultrafiltration • Percent blood volume UF’d per hour

  16. ppCRRT Registry Patient Data: Outcome • Survival versus death (discharge from PICU) • Attainment of target dry weight • Reason to discontinue CRRT • Death • Regained renal function • Underlying illness resolved • Tolerates intermittent hemodialysis

  17. ppCRRT Registry Circuit Data: Outcome • Filter life-span (hours) • Reason for circuit change • clotting • access malfunction • machine malfunction • unrelated patient indication (e.g., needs CT scan) • CRRT discontinued

  18. ppCRRT Experience • First patient enrolled on 1/1/01 • 376 patients entered into database as of 07/31/05 (study end) • 342 with complete data • >60,000 hours of CRRT • Texas Children’s • Boston Children’s • Seattle Children’s • UAB • University of Michigan • Mercy Children’s, KC • Egleston Children’s, Atlanta • All Children’s, Tampa • DC Children’s • Columbus Children’s • Packard Children’s, Palo Alto • DeVos Children’s, Grand Rapids

  19. Fluid Overload and CRRT

  20. 22 pt (12 male/10 female) received 23 courses (3028 hrs) of CVVH (n=10) or CVVHD (n=12) over study period. • Overall survival was 41% (9/22). • Survival in septic patients was 45% (5/11). • PRISM scores at ICU admission and CVVH initiation were 13.5 +/- 5.7 and 15.7 +/- 9.0, respectively (p=NS). • Conditions leading to CVVH (D) • Sepsis (11) • Cardiogenic shock (4) • Hypovolemic ATN (2) • End Stage Heart Disease (2) • Hepatic necrosis, viral pneumonia, bowel obstruction and End-Stage Lung Disease (1 each)

  21. Percent Fluid Overload Calculation [ ] Fluid In - Fluid Out ICU Admit Weight * 100% % FO at CVVH initiation = Fluid In = Total Input from ICU admit to CRRT initiation Fluid Out = Total Output from ICU admit to CRRT initiation Goldstein SL et al: Pediatrics 2001 Jun;107(6):1309-12

  22. Lesser % FO at CVVH (D) initiation was associated with improved outcome (p=0.03) • Lesser % FO at CVVH (D) initiation was also associated with improved outcome when sample was adjusted for severity of illness (p=0.03; multiple regression analysis)

  23. N=113 *p=0.02; **p=0.01

  24. Kaplan-Meier survival estimates, by percentage fluid overload category

  25. Seven center study from the ppCRRT Registry • 116 patients with MODS • PRISM 2 score used to assess patient severity of illness • Survival defined at PICU discharge

  26. Anticoagulation and CRRT • Heparin and citrate anticoagulation most commonly used methods • Heparin: bleeding risk • Citrate: alkalosis, citrate lock

  27. (Ca = 0.4 x citrate rate 60 mls/hr) (Citrate = 1.5 x BFR 150 mls/hr) Pediatr Neph 2002, 17:150-154 (BFR = 100 mls/min) Normal Saline Replacement Fluid Calcium can be infused in 3rd lumen of triple lumen access if available. Normocarb Dialysate • ACD-A/Normocarb Wt range 2.8 kg – 115 kg • Average life of circuit on citrate 72 hrs (range 24-143 hrs)

  28. Seven ppCRRT centers • 138 patients/442 circuits • 3 centers: hepACG only • 2 centers: citACG only • 2 centers: switched from hepACG to citACG • HepACG = 230 circuits • CitACG= 158 circuits • NoACG = 54 circuits • Circuit survival censored for • Scheduled change • Unrelated patient issue • Death/witdrawal of support • Regain renal function/switch to intermittent HD

  29. Access • If you don’t have a functional access, you may as well go home • Small studies show • Short femoral catheters have greater recirculation • Femoral catheters have shorter functional survival

  30. ppCRRT Access • Data from entire ppCRRT • Assessed for association between functional survival and • Catheter size • Catheter site • Modality (convection vs. diffusion) • Femoral (69%) • IJ (16%) • SCV (8%) • Not specified (7%) Hackbarth R et al: IJAIO Dec 2007, 30: 1116-1121

  31. Hackbarth R et al: IJAIO Dec 2007, 30: 1116-1121

  32. Hackbarth R et al: IJAIO Dec 2007, 30: 1116-1121

  33. p<0.03 in favor of IJ • 5 Fr removed from analysis • All ACG • No difference in citACG Hackbarth R et al: IJAIO Dec 2007, 30: 1116-1121

  34. p<0.02 • All ACG • 8 Fr > 9Fr survival • 9 Fr > 8 Fr femoral Hackbarth R et al: IJAIO Dec 2007, 30: 1116-1121

  35. p<0.001 • No difference in cath size or ACG • used between three modalities • Modality strongest predictor in Cox • Proportional hazards model Hackbarth R et al: IJAIO Dec 2007, 30: 1116-1121

  36. At high risk for death with AKI needing CRRT • Fluid overload >12% associated with mortality in BMT patients with AKI

  37. Stem Cell Transplant: ppCRRT • 51 patients in ppCRRT with SCT • Mean %FO = 12.41 + 3.7%. • 45% survival • Convection: 17/29 survived (59%) • Diffusion: 6/22 (27%), p<0.05 • Survival lower in MODS and ventilated patients Flores FX et al: Pediatric Nephrology 2008, 23: 625-630

  38. ppCRRT & SCT • Patients kept dry prior to CRRT initiation • No difference in any parameter at CRRT initiation • Paw worse for non-survivors at CRRT end Flores FX et al: Pediatric Nephrology 2008, 23: 625-630

  39. ppCRRT • Under the guidance of Stu this group has been very productive producing to data 11 papers in CRRT • Under the guidance of Stu we are now looking prospectively • Impact of cytokine clearance by modality • Drug clearance by modality

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