Factors associated with successful liberation from continuous renal replacement therapy in children and young adults: analysis of the worldwide exploration of renal replacement outcomes collaborative in Kidney Disease Registry

Abstract

Purpose: Continuous renal replacement therapy (CRRT) is used for supportive management of acute kidney injury (AKI) and disorders of fluid balance (FB). Little is known about the predictors of successful liberation in children and young adults. We aimed to identify the factors associated with successful CRRT liberation.

Methods: The Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease study is an international multicenter retrospective study (32 centers, 7 nations) conducted from 2015 to 2021 in children and young adults (aged 0-25 years) treated with CRRT for AKI or FB disorders. Patients with previous dialysis dependence, tandem extracorporeal membrane oxygenation use, died within the first 72 h of CRRT initiation, and those who never had liberation attempted were excluded. Patients were categorized based on first liberation attempt: reinstituted (resumption of any dialysis within 72 h) vs. success (no receipt of dialysis for ≥ 72 h). Multivariable logistic regression was used to identify factors associated with successful CRRT liberation.

Results: A total of 622 patients were included: 287 (46%) had CRRT reinstituted and 335 (54%) were successfully liberated. After adjusting for sepsis at admission and illness severity parameters, several factors were associated with successful liberation, including higher VIS (vasoactive-inotropic score) at CRRT initiation (odds ratio [OR] 1.35 [1.12-1.63]), higher PELOD-2 (pediatric logistic organ dysfunction-2) score at CRRT initiation (OR 1.71 [1.24-2.35]), higher urine output prior to CRRT initiation (OR 1.15 [1.001-1.32]), and shorter CRRT duration (OR 0.19 [0.12-0.28]).

Conclusions: Inability to liberate from CRRT was common in this multinational retrospective study. Modifiable and non-modifiable factors were associated with successful liberation. These results may inform the design of future clinical trials to optimize likelihood of CRRT liberation success.

Keywords: CRRT; Dialysis; Pediatrics.

Figure 1:

Consort Diagram of the Included Patients. There were 996 patients in the initial registry, of which 17 were removed as CRRT (Continuous renal replacement therapy) was performed prior to 2015 or the patients had a diagnosis of CKD (chronic kidney disease with dialysis dependence). In 357 patients there was no attempt at CRRT liberation or patients died within 72 hours after CRRT initiation and were not included in the analysis. This resulted in a final cohort of 622 patients. There was missing covariate data for 21 patients, and thus 601 patients were included in overall multivariable regression models. Subanalyses were performed based on patient characteristics.

Figure 2.

Predicted probability of successful CRRT (Continuous renal replacement therapy) liberation as a function of duration of CRRT days from multivariate logistic regression, adjusted for a priori relevant covariates (Supplemental Table 3) at the most frequent or median level. CRRT duration was modeled with restricted cubic splines (4 knots) to allow for potential non-linear association with successful liberation. CRRT duration (days) is significantly associated with decreased probabilities of successful liberation (p< 0.001). Shaded area denotes 95% confidence intervals.