Pediatric Continuous Renal Replacement Therapy Principles and Practice
- London Springer International Publishing Switzerland 2016
- 171 Pages
Includes Appendix and Index
Acute kidney injury (AKI) is a common cause of morbidity and mortality rates in critically ill patients requiring intensive care therapies (40–50 %). The incidence of AKI varies from 5 % of all hospitalized patients to 30–40 % of patients admitted to the pediatric intensive care unit. The critically ill children with AKI often have multiple organ dysfunctions and are frequently treated with several drugs including antibiotics, anticonvulsants, vasopressors, and antihypertensive and cardiovascular agents or which require appropriate dosing and interval. Despite significant improvements in the care of critically ill patients, the mortality and morbidity associated with AKI remains high (>50 %) and can lead to end-stage renal disease. Approach to the treatment of AKI patients requiring dialysis has gone under evolution with the advent of continuous renal replacement therapy (CRRT) techniques over the last two decades. Critically ill and hemodynamic instable children better tolerate CRRT than the intermittent hemodialysis. CRRT technology attempts to replace the excretory function of the kidney. CRRT provides a slow and gentle fluid removal from body much like the native kidneys and removes inflammatory mediators of sepsis such as interleukin, TNF-alpha, and complement. CRRT also provides adequate nutritional support for the catabolic AKI patients, a controlled desired fluid balance. Many AKI patients receiving CRRT suffer from multiple organ dysfunctions and have various types of medications including antibiotics, anticonvulsants, anticoagulants, and cardiovascular agents. Drugs predominantly eliminated by the normal kidneys often undergo substantial changes by CRRT. Therefore, a dose adjustment is required to prevent under dosing of the medication or drug toxicity. Unfortunately, few clinical studies have been published, and few drugs have been studied pharmacoclinically in intensive care patients. Many guidelines for drug dosing during CRRT are extrapolated from experiences with adult chronic hemodialysis, and there has been a relative paucity of published data about drug dosing during CRRT in critically ill children. Doses used in adults CRRT cannot be directly applied to these children, as the CRRT dialysate prescription and pharmacokinetics are different in adults compared with children. Failure to correctly dose may result in either drug toxicity or treatment failure. In order to understand the optimal drug dosing for children receiving CRRT, one must understand the pattern of water and solutes transport through a semipermeable membrane by all forms of CRRT. In this book, we review the current understanding of CRRT techniques, with a focus on drug dosing in critically ill children receiving CRRT. The effect of CRRT on drug pharmacokinetics, which provides guidelines whether or not dose adjustment is required, is provided in an accompanying reference table. Variations in the drug properties regarding their molecular weights, dialysis and blood flow rates, and dialysis membranes are discussed. The book also provides a simple and easy method for estimating drug clearance as a function of total creatinine clearance when the information on the pharmacokinetics of a particular drug is not available. In this book, we provide a series of challenging, clinically oriented case studies. The selected case reports focus on the essential aspects of the patient’s presentation and laboratory data and management to accelerate recovery. A series of logical questioning from the presentation is followed by a detailed explanation that reviews recent publications and translates emerging areas of science into data that is useful at the bedside. We hope that the book will expand the clinical knowledge of nephrology and critical care trainees and other practicing physicians from different specialties who are frequently involved in the care of critically ill children suffering from severe AKI to improve and sustain their quality of life. We are grateful to the staff at Springer Publishers, Inc., for their outstanding editorial contributions to this endeavor and all those who have dedicated their skills to make this effort entirely possible.