Pediatric nephrology : journal of the International Pediatric Nephrology Association
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Over the past several decades, the epidemiology of acute kidney injury (AKI) in children has changed significantly. Pediatric patients with AKI frequently have co-morbid conditions, substantial fluid overload, and marked disease severity. At the same time, continuous renal replacement therapy (CRRT) has become the preferred modality for the management of these patients. This manuscript provides a state-of-the-art review of the technical aspects of pediatric CRRT and examines the most recent data regarding CRRT indications, timing of initiation, dosing, and outcomes in critically ill children.
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Despite advances in biomaterials and dialyzer design, thrombin generation occurs in the dialysis circuit because of platelet and leukocyte activation. As such, anticoagulation is required by the majority of children for successful dialysis to prevent clotting in the venous air detector and the capillary dialyzer, particularly for small children with slower blood flow rates. ⋯ These nonheparin alternatives are significantly more expensive than heparins, and may add a degree of complexity, such as citrate, which is a regional anticoagulant, although citrate-containing dialysate may permit short anticoagulant-free dialysis sessions. Systemic anticoagulants required for immune-mediated, heparin-induced thrombocytopenia are expensive and either have short half-lives, and therefore require continuous infusions, or prolonged half-lives, which, although allowing simple bolus administration, increases the risk of drug accumulation, over-dosage and hemorrhage.
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We evaluated serum (s) cystatin C (CysC) and neutrophil gelatinase-associated lipocalin (NGAL) and urine (u) CysC, NGAL and kidney injury molecule-1 (KIM-1) as markers of acute kidney injury (AKI) in asphyxiated neonates. ⋯ sNGAL, uCysC, and uNGAL are sensitive, early AKI biomarkers, increasing significantly in asphyxiated neonates even in those not fulfilling AKI criteria. Their measurement on DOL 1 is predictive of post-asphyxia-AKI.
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Acute kidney injury (AKI) is a common event in several neonatal populations, and those neonates with AKI have poor outcomes. Serum creatinine (SCr)-based definitions of AKI are not ideal and are additionally limited in neonates whose SCr reflects the maternal creatinine level at birth and normally drops over the first weeks of life dependent on gestational age. Recent studies show that urine and serum biomarkers may provide a better basis than SCr on which to diagnose AKI. ⋯ While these findings strengthen the argument for the clinical use of these AKI biomarkers, further work is needed before they can be implemented in clinical practice. Large-scale observational multi-center studies are needed to test these biomarkers against hard clinical endpoints. In addition, randomized intervention trials which use biomarkers to define AKI need to be performed.
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Pedriatric acute kidney injury (AKI) is a well-described clinical syndrome that is characterized by a reduction of both the urine output and glomerular filtration rate. AKI in critically ill children is typically associated with multiple organ dysfunction. A dramatic increase in the incidence of AKI in pediatric intensive care units has been observed in the last 10 years. ⋯ Consequently, dialysis/hemofiltration in critically ill children is currently performed by adapting adult systems to the much smaller pediatric patients. In particular, research in this field should focus on children weighing less than 10 kg for whom the delivery of RRT is a clinical and technological challenge. We describe here the evolution of pediatric RRT during the last 30 years and report in detail on the CARPEDIEM project, which has recently been established to finally provide neonates and infants with a reliable dialysis machine that is specifically designed for this age group.