title: What is this chocolate milk in my circuit? A cause of acute clotting of a continuous renal replacement circuit: Questions.
abstract: One of the greatest problems associated with continuous renal replacement therapy (CRRT) is the early clotting of filters. A literature search revealed three case reports of lipemic blood causing recurrent clotting and reduced CRRT circuit survival time in adult patients, but no reports of cases in children.
  
  
  
  A 23-month-old male infant with Martinez-Frias syndrome and multivisceral transplant was admitted to the hospital with severe sepsis and hemolytic anemia. He developed acute kidney injury, fluid overload and electrolyte imbalances requiring CRRT and was also administered total parenteral nutrition (TPN) and fat emulsion. The first circuit lasted 60 h before routine change was required. The second circuit showed acute clotting after only 18 h, and brownish-milky fluid was found in the circuit tubing layered between the clotted blood. The patient's serum triglyceride levels were elevated at 988 mg/dL. The lipid infusion was stopped and CRRT restarted. Serum triglyceride levels improved to 363 mg/dL. The new circuit lasted 63 h before routine change was required.
  
  
  
  Clotting of CRRT circuits due to elevated triglyceride levels is rare and has not been reported in the pediatric population. Physicians should be mindful of this risk in patients receiving TPN who have unexpected clotting of CRRT circuits.
authors.affiliation: Division of Nephrology, The Department of Pediatrics, The Children's Hospital of Philadelphia, 34th Street and Civic Center Blvd, Philadelphia, PA, 19147, USA. kakajiwalaa@email.chop.edu.
authors.forename: Aadil
authors.initials: A
authors.lastname: Kakajiwala
authors.affiliation: Division of Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
authors.forename: Kathleen
authors.initials: K
authors.lastname: Chiotos
authors.affiliation: Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
authors.forename: Julie
authors.initials: J
authors.lastname: Brothers
authors.affiliation: Division of Nephrology, The Department of Pediatrics, The Children's Hospital of Philadelphia, 34th Street and Civic Center Blvd, Philadelphia, PA, 19147, USA.
authors.forename: April
authors.initials: A
authors.lastname: Lederman
authors.affiliation: Division of Nephrology, The Department of Pediatrics, The Children's Hospital of Philadelphia, 34th Street and Civic Center Blvd, Philadelphia, PA, 19147, USA.
authors.forename: Sandra
authors.initials: S
authors.lastname: Amaral
mesh_terms: D001777:Blood Coagulation; D003920:Diabetes Mellitus / Q000601:surgery / Q000628:therapy*; D004868:Equipment Failure; D005374:Filtration; D005705:Gallbladder Diseases / Q000601:surgery / Q000628:therapy*; D006801:Humans; D007223:Infant; D007409:Intestinal Atresia / Q000601:surgery / Q000628:therapy*; D008055:Lipids / Q000097:blood; D008297:Male; D016377:Organ Transplantation; D017582:Renal Replacement Therapy / Q000295:instrumentation*; D014138:Tracheoesophageal Fistula / Q000601:surgery / Q000628:therapy*
chemical_list: D008055:Lipids
keywords: Acute clotting; Child; Continuous renal replacement therapy; Martinez–Frias syndrome