title: Fluid overload and fluid removal in pediatric patients on extracorporeal membrane oxygenation requiring continuous renal replacement therapy.
abstract: OBJECTIVE
  In pediatric patients, fluid overload at continuous renal replacement therapy initiation is associated with increased mortality. The aim of this study was to characterize the association between fluid overload at continuous renal replacement therapy initiation, fluid removal during continuous renal replacement therapy, the kinetics of fluid removal and mortality in a large pediatric population receiving continuous renal replacement therapy while on extracorporeal membrane oxygenation.
  
  
  METHODS
  Retrospective chart review.
  
  
  METHODS
  Tertiary children's hospital.
  
  
  METHODS
  Extracorporeal membrane oxygenation patients requiring continuous renal replacement therapy from July 2006 to September 2010.
  
  
  METHODS
  None.
  
  
  RESULTS
  Overall intensive care unit survival was 34% for 53 patients that were initiated on continuous renal replacement therapy while on extracorporeal membrane oxygenation during the study period. Median fluid overload at continuous renal replacement therapy initiation was significantly lower in survivors compared to nonsurvivors (24.5% vs. 38%, p = .006). Median fluid overload at continuous renal replacement therapy discontinuation was significantly lower in survivors compared to nonsurvivors (7.1% vs. 17.5%, p = .035). After adjusting for percent fluid overload at continuous renal replacement therapy initiation, age, and severity of illness, the change in fluid overload at continuous renal replacement therapy discontinuation was not significantly associated with mortality (p = .212). Models investigating the rates of fluid removal in different periods, age, severity of illness, and fluid overload at continuous renal replacement therapy initiation found that fluid overload at continuous renal replacement therapy initiation was the most consistent predictor of survival.
  
  
  CONCLUSIONS
  Our data demonstrate an association between fluid overload at continuous renal replacement therapy initiation and mortality in pediatric patients receiving extracorporeal membrane oxygenation. The degree of fluid overload at continuous renal replacement therapy discontinuation is also associated with mortality, but appears to reflect the effect of fluid overload at initiation. Furthermore, correction of fluid overload to ≤ 10% was not associated with improved survival. These results suggest that intervening prior to the development of significant fluid overload may be more clinically effective than attempting fluid removal after significant fluid overload has developed. Our findings suggest a role for earlier initiation of continuous renal replacement therapy in this population, and warrant further clinical studies.
authors: Division of Nephrology, Department of Pediatrics & Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA. dselewsk@med.umich.edu
authors: David T
authors: DT
authors: Selewski
authors: Timothy T
authors: TT
authors: Cornell
authors: Neal B
authors: NB
authors: Blatt
authors: Yong Y
authors: YY
authors: Han
authors: Theresa
authors: T
authors: Mottes
authors: Mallika
authors: M
authors: Kommareddi
authors: Michael G
authors: MG
authors: Gaies
authors: Gail M
authors: GM
authors: Annich
authors: David B
authors: DB
authors: Kershaw
authors: Thomas P
authors: TP
authors: Shanley
authors: Michael
authors: M
authors: Heung
mesh_terms: D058186:Acute Kidney Injury / Q000401:mortality / Q000628:therapy*; D015331:Cohort Studies; D003131:Combined Modality Therapy; D016638:Critical Illness / Q000401:mortality / Q000628:therapy; D015199:Extracorporeal Membrane Oxygenation / Q000379:methods / Q000401:mortality*; D005260:Female; D017052:Hospital Mortality / Q000639:trends*; D006776:Hospitals, Pediatric; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D015278:Intensive Care Units, Pediatric; D008297:Male; D011379:Prognosis; D017582:Renal Replacement Therapy / Q000379:methods / Q000401:mortality*; D012189:Retrospective Studies; D018570:Risk Assessment; D015996:Survival Rate; D016896:Treatment Outcome; D014883:Water-Electrolyte Imbalance / Q000401:mortality / Q000628:therapy*