For instances of acute kidney injury (AKI) where non-dialytic management is suboptimal, dialytic strategies, such as peritoneal dialysis (PD), hemodialysis (HD), continuous kidney replacement therapy (CKRT), and sustained low-efficiency dialysis (SLED) may be required. Advances in utilization of current KRT modalities, development of novel KRT machines for infants, and measures to protect pulmonary and cardiac organ systems have led to better outcomes.
Modifications to PD including biocompatible solutions and improved ultrafiltration methods have improved patient outcomes. The introduction of high-flow CKRT has shown increased clearance of metabolic waste products, leading to a survival benefit in hemodynamically unstable patients.
Increased awareness of the association between FO and adverse outcomes has led to earlier initiation of CKRT to alleviate the onset and severity of AKI. It has been shown that the earlier initiation of CKRT is associated with lower mortality, compared to late initiators.In addition, advancements in membrane adsorbers have shown clinical improvements in a number of studies. Single-use devices with adsorbent polystyrene divinylbenzene polymer beads specifically remove cytokines from the blood via hydrophobic interactions. Similarly, filter sets with an AN69 membrane coated with polyethyleneimine and unfractionated heparin adsorb endotoxins and cytokines.
Various advancements have also been made with hybrid modalities. The use of sustained low-efficiency daily dialysis-filtration (SLEDD-f) has recently been shown to optimize clearance of small solutes with higher blood and dialysate flow along with increased convective clearance and lesser requirements for anticoagulation.
The development of a new generation of dialyzers, that utilize both convection and diffusion and can produce ultrapure fluids during dialysis, has led to greater clearance rates. Currently, a number of new machines allow for both acute and chronic KRT in small infants. In addition, other devices utilized in combination with CKRT have been shown to improve outcomes in adult AKI patients and are currently being evaluated in pediatric cohorts.
These advancements in extracorporeal therapies have led to beneficial outcomes, though, additional studies are needed within the pediatric population. The ultimate choice of KRT modality should be based on the availability of resources, expertise and preference of the physician, and the relative cost of the modality.
This Research Topic addresses new advances in KRT in children and welcomes submissions that are focused on, but not limited to:
1) Advancement of renal replacement therapy in neonates: new devices
2) High Flow CRRT: role in IEM and role in outcome
3) The Prismaflex™ HF20 filter role of low extracorporeal blood volume and technological benefit for smaller children compared with current filter sets available in the USA
4) Renal replacement support in children using an ultrafiltration device
5) Extracorporeal life support and hepatic toxin filtration as life-saving interventions that provide cardiopulmonary support and hepatic dialysis to allow resolution of a child's illness
6) Advancement in peritoneal dialysis: long road to lasting development
7) Therapeutic plasma exchange in neonates and infants: successful use of a miniaturized machine
8) The future of pediatric nephrology critical care: advancement in kidney support
a. High-volume continuous renal replacement therapy (HV-CRRT) and role in cytokine modulation
b. Selective cytopheretic device (SCD, Seastar, Inc., San Diego, CA) role in improved outcomes in AKI in the pediatric cohort (NCT02820350, R01FD005092)
c. Sustained low-efficiency daily dialysis-filtration [SLEDD-f] and the clearance of small solutes with higher blood and dialysate flow, increased convective clearance and lesser requirements for anticoagulation
9) Role of advancements in membrane adsorbers, such as CytoSorb (CytoSorbents Corporation, NJ) and oXiris (Baxter, IL), and their potential role in sepsis-associated AKI.
For instances of acute kidney injury (AKI) where non-dialytic management is suboptimal, dialytic strategies, such as peritoneal dialysis (PD), hemodialysis (HD), continuous kidney replacement therapy (CKRT), and sustained low-efficiency dialysis (SLED) may be required. Advances in utilization of current KRT modalities, development of novel KRT machines for infants, and measures to protect pulmonary and cardiac organ systems have led to better outcomes.
Modifications to PD including biocompatible solutions and improved ultrafiltration methods have improved patient outcomes. The introduction of high-flow CKRT has shown increased clearance of metabolic waste products, leading to a survival benefit in hemodynamically unstable patients.
Increased awareness of the association between FO and adverse outcomes has led to earlier initiation of CKRT to alleviate the onset and severity of AKI. It has been shown that the earlier initiation of CKRT is associated with lower mortality, compared to late initiators.In addition, advancements in membrane adsorbers have shown clinical improvements in a number of studies. Single-use devices with adsorbent polystyrene divinylbenzene polymer beads specifically remove cytokines from the blood via hydrophobic interactions. Similarly, filter sets with an AN69 membrane coated with polyethyleneimine and unfractionated heparin adsorb endotoxins and cytokines.
Various advancements have also been made with hybrid modalities. The use of sustained low-efficiency daily dialysis-filtration (SLEDD-f) has recently been shown to optimize clearance of small solutes with higher blood and dialysate flow along with increased convective clearance and lesser requirements for anticoagulation.
The development of a new generation of dialyzers, that utilize both convection and diffusion and can produce ultrapure fluids during dialysis, has led to greater clearance rates. Currently, a number of new machines allow for both acute and chronic KRT in small infants. In addition, other devices utilized in combination with CKRT have been shown to improve outcomes in adult AKI patients and are currently being evaluated in pediatric cohorts.
These advancements in extracorporeal therapies have led to beneficial outcomes, though, additional studies are needed within the pediatric population. The ultimate choice of KRT modality should be based on the availability of resources, expertise and preference of the physician, and the relative cost of the modality.
This Research Topic addresses new advances in KRT in children and welcomes submissions that are focused on, but not limited to:
1) Advancement of renal replacement therapy in neonates: new devices
2) High Flow CRRT: role in IEM and role in outcome
3) The Prismaflex™ HF20 filter role of low extracorporeal blood volume and technological benefit for smaller children compared with current filter sets available in the USA
4) Renal replacement support in children using an ultrafiltration device
5) Extracorporeal life support and hepatic toxin filtration as life-saving interventions that provide cardiopulmonary support and hepatic dialysis to allow resolution of a child's illness
6) Advancement in peritoneal dialysis: long road to lasting development
7) Therapeutic plasma exchange in neonates and infants: successful use of a miniaturized machine
8) The future of pediatric nephrology critical care: advancement in kidney support
a. High-volume continuous renal replacement therapy (HV-CRRT) and role in cytokine modulation
b. Selective cytopheretic device (SCD, Seastar, Inc., San Diego, CA) role in improved outcomes in AKI in the pediatric cohort (NCT02820350, R01FD005092)
c. Sustained low-efficiency daily dialysis-filtration [SLEDD-f] and the clearance of small solutes with higher blood and dialysate flow, increased convective clearance and lesser requirements for anticoagulation
9) Role of advancements in membrane adsorbers, such as CytoSorb (CytoSorbents Corporation, NJ) and oXiris (Baxter, IL), and their potential role in sepsis-associated AKI.
