Question

• In children with sepsis, can early CRRT prior to the onset of ARF and volume overload improve survival?

Clinical Bottom Lines

1. Continuous Renal Replacement Therapy (CRRT) has become a main form of treatment in critically ill patients with ARF or fluid overload.¹
2. Retrospective studies in children with acute respiratory distress syndrome (ARDS) show benefit of CRRT via blood purification and fluid control prior to onset of ARF.²
3. There are currently no randomized controlled studies examining the benefit of CRRT prior to onset of ARF in children with sepsis.
4. A randomized controlled trial in adults with sepsis shows no difference in clearance of inflammatory mediators or clinical outcomes when CRRT is started prior to onset of ARF.¹

Summary of Key Evidence

1. Cole et al analyzed inflammatory mediators involved in SIRS/MODS (TNF-α, IL-6, IL-10, IL-8, C3a, C5a) at baseline, 2, 24, 36, 48 and 72 hours after initiation of CRRT.
2. Clinical outcomes based on severity of illness scales (Acute Physiology and Chronic Health Evaluation (APACHE) II and SAPS II scores) collected after first 24 hours of admission.
3. Organ dysfunction based on MODS scores at time of recruitment and daily until discharge or death.
4. Conclusions:
• No reduction in the plasma concentration of inflammatory mediators after 48 hours of CRRT at 2L/hr compared to controls
• No effect on clinical outcomes including need for vasopressors, mechanical ventilation, length of ICU stay and organ dysfunction

Additional Comments

• Limitations of this study include patient population (adults only), timing of measurements, low ultrafiltration rate (2L/hr)
• Despite these results, CRRT continues to show promise in the treatment of sepsis in adults and children.^2,3,4 More research involving multi-center, prospective trials need to be performed to examine its role in immunomodulation via blood purification irregardless of renal function in both children and adults.

Citation

1. Cole L, Bellomo R, Hart G, Journois D, Davenport P, Tipping P, Ronco C. A phase II randomized, controlled trial of continuous hemofiltration in sepsis. Crit Care Med 2002; 30 (1): 100—106.
2. DiCarlo JV et al. Continuous veno-venous hemofiltration may improve survival from acute respiratory distress syndrome after bone marrow transplantation or chemotherapy. J Pediatr Hematol Oncol 2003; 25(10): 801—805.
3. Ronco C. Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial. Lancet 2000; 355: 26—30.
4. Ronco C. Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial. Lancet 2000; 355: 26—30.

CAT Author: Anne Maliszewski, MD

CAT Appraisers: Cynthia Chi, MD

Date appraised: May 9, 2007