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Nikkiso Educational Framework: Continuous Renal Replacement Therapy (CRRT) for Paediatrics
PM /2015-1
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Renal Development
Foetal development of the kidney begins at week one gestation.
Nephron development commences at 8 weeks and is complete by weeks, the number of nephrons is the same as the mature kidney, one million per kidney.
The kidneys develop at the same time as the ears and the lungs.
‘Skin tags’ at the ears may denote kidney disease at birth.
Loop of Henle is shorter when the child is born resulting in the production of dilute urine, this has matured by 2 years of age.
The kidney reaches adult size by adolescence and because of maturation of the tubular system increases in weight by 10 fold from birth.
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Loop of Henle
A shorter loop of Henle in paediatric patients reduces the functional ability compared to adults which has a number of effects:
Reduction in ability to concentrate urine
Inability to secrete sodium
Alteration of water reabsorption
Altered secretion of hydrogen ions
Reduced reabsorption of bicarbonate ions
Maturity of tubular transport system does not happen until the child is 2 years of age.
When a child becomes unwell, their ability to maintain homeostasis is compromised.
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4. Average Daily Urine Output in Children1
Output ml/kg/hr
Neonate
2-3
Infant 2
Child
1-2
Adolescent
0.5-1
The newborn may not void for 12 – 24 hours
1Great Ormond Street Hospital – Normal Urine Output Appendix 8 adapted from Hazinski (2013) file:///C:/Users/Administrator/Downloads/Appendix%208%20Normal%20Urine%20Output.pdf accessed November 2nd 2015
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5. Indications for CRRT in Paediatrics
Indications are often different than in adult therapy although pre, intra and post renal indications can still apply.
CRRT in paediatrics and specifically indications and choices of modality are under-researched and evidence is often anecdotal.
Acute Kidney Injury (AKI) is still prevalent in the paediatric population but more common indications for CRRT include2;
Acidosis
Sepsis
Fluid Overload
Hyperammonemia
Metabolic disturbances often from birth
Liver Failure
Individual patient presentations
Understandably it is unethical to experiment or carry out research on children. A lot of what is done is based on experience, education and trial and error with the child’s best interests at the forefront of care at all times.
2Khilnani P Section 6 Fluids, Electrolytes and Renal Issues in Practical Approach to Pediatric Intensive Care 3rd Edition (2015) Jaypee:
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6. Aqualine Set & Aquamax Filters
Extracorporeal volume in paediatric patients on CRRT is significant.
Consider your patient’s circulating volume and adjust therapy accordingly. Some examples; colloids, blood priming, Aquarius – Aquarius connection.
Volumes:
Tubing Set and Filter
Total Extracorporeal Volume
HF03 Filter & Aqualine S
32mls + 61mls
= 93mls
HF07+
& Aqualine S
49mls + 61mls
= 110mls
HF12 Filter & Aqualine
73mls + 100mls
= 173mls
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7. Inadequacies in vascular access may limit delivered therapy
Access Is KING
Vascular Access is continuously tested during ABP treatment.
Catheter site, size, type and patient preparation should be considered.
Practical understanding about vascular access is necessary for optimal treatment.
Inadequacies in vascular access may limit delivered therapy
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8. Adjuctive therapies associated with CRRT in paediatrics - SPAD
SPAD – Single Pass Albumin Dialysis is a simple method of albumin dialysis using standard renal replacement therapy machines without an additional perfusion pump system.
Successful clinical application of SPAD has been reported in isolated cases of Acute on Chronic Liver Failure associated with hyperbilirubinemia, Wilson’s disease and hepatorenal syndrome. Kreymann et al successfully bridged a patient with multi-organ failure secondary to ALF and Wilson’s disease to transplantation following 59 days of supportive therapy using SPAD3. Ringe et al described the successful application of SPAD for eight days as a bridge-to-re-transplantation in a 19 month old anhepatic child following primary liver-graft dysfunction.
Ed’s White Paper on SPAD
3 Kreymann B et al. Albumin dialysis: effective removal of copper in a patient with fulminant Wilson disease and successful bridging to liver transplantation: a new possibility for the elimination of protein-bound toxins. J Hepatol 1999, 31:
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9. Adjuctive therapies associated with CRRT in paediatrics -ECMO
The Extra Corporeal Membrane Oxygenation (ECMO) system is very similar those used during open-heart surgery.  It is a supportive measure that uses an artificial lung membrane to oxygenate blood via an extracorporeal circuit.
CRRT is often required as the patient’s renal function can also deteriorate as a result of multi-organ failure or can also be used to control fluid balance.  
There are four paediatric ECMO centers in the UK: 
- Glenfield Hospital: Leicester  - The Freeman Hospital: Newcastle - The Royal Hospital for Sick Children: Glasgow  - Great Ormond Street Hospital: London
These paediatric centers have all been performing ECMO for more than 15 years and through regular collaboration and review maintain the highest standards of paediatric ECMO.
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10. Adjuctive therapies associated with CRRT in paediatrics - TPE
Total Plasma Exchange (TPE) - Plasma exchange separates and removes the patient’s plasma.
Plasma refers to the “liquid” portion of the blood which contains proteins, electrolytes, vitamins, hormones, etc.
The plasma that is removed from the patient must be replaced with another protein solution such as 5% human albumin.
Conditions that are commonly treated with plasma exchange include diseases that affect the nervous system like Guillain-Barré Syndrome, CIDP (chronic inflammatory demyelinating polyneuropathy), and myasthenia gravis. It is also used to treat some diseases in which the blood is too thick, and a blood disorder called TTP (thrombotic thrombocytopenic purpura) where small blood clots can cause damage to organs.
TPE - accessed 2nd November
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11. AQUALINE and AQUARIUS are trademarks of Nikkiso Co Ltd.
AQUARIUS system
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Germany
AQUAMAX hemofilter
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AQUALINE tubing
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CITRASETRCA
Assembled by Haemotronic
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AQUALINE and AQUARIUS are trademarks of Nikkiso Co Ltd.
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