A Retrospective Study of Outcomes in Pediatric Hematology/Oncology Patients Receiving Continuous Ven...
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A Retrospective Study of Outcomes in Pediatric Hematology/Oncology Patients Receiving Continuous Venovenous Hemodialysis Y Avent 1 , N Henderson 1 , T Collie 1 , RF Tamburro 2 , L Elbahlawan 1 , RR Morrison 1 , S Rajasekaran 1 1 St. Jude Children’s Research Hospital, Memphis, TN

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Study Design

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Study design

A Retrospective Study of Outcomes in Pediatric Hematology/Oncology Patients Receiving Continuous Venovenous Hemodialysis

Y Avent1, N Henderson1, T Collie1, RF Tamburro2, L Elbahlawan1, RR Morrison1, S Rajasekaran1

1 St. Jude Children’s Research Hospital, Memphis, TN

2 Pennsylvania State University College of Medicine, Hershey, Pennsylvania


Study design

Study Design

  • Single Center Retrospective Review from January 2003-December 2007

  • 8 bed ICU

  • Total CRRT days 689 averaging 172 treatment days/year

  • 41 patients received a total of 48 treatments

  • Median age of this cohort was 12 years. Range (7.8 months -24 years)

  • 23 males and 18 females

    • 30 Hematopoietic Stem Cell Transplant (HSCT) patients (73%)

      • Allogenic n=29

      • Autologous n=1

    • 11 non-HSCT patients (26%)

      • Acute Lymphoblastic Leukemia n=5

      • Acute Myeloid Leukemia n=4

      • Ewing’s Sarcoma n=1

      • Glioblastoma Multiforme n=1


Crrt modality

CRRT Modality

  • Modality

    • CVVHD

  • Anti-coagulant

    • Citrate

  • Dialysate

    • Normocarb HFTM

  • Dialysate rates

    • (2000ml/hr x BSA)/1.73m2=ml/hr

  • Blood Flow Rates

    • Average 2-4 ml/kg/min.

  • Filters

    • Renaflo II – polysulfone membrane

    • PAN – polyacrylonitrile membrane

  • Circuit Change

    • Every 3 days if patient’s clinical condition permits

  • Machine

    • B Braun Diapact


Indications for crrt

Indications for CRRT

41 patients with 48 episodes of CRRT

  • Fluid overload

    • n=12

  • Renal Failure

    • acute: n=29

    • transition from Intermittent Hemodialysis (IHD) to CRRT n=5

  • Improving Fluid homeostasis in Congestive Heart Failure

    • n=1

  • Tumor Cell Lysis

    • n=1


Crrt variables

CRRT Variables

  • HSCT patients 15.9±2.02 days therapy

  • Non HSCT 9.6±2.9 days therapy

  • 2 different filters used ( PAN and Renaflo)

  • Of all variables statistically compared BUN > 75 at CVVHD initiation and C-Reactive Protein (CRP) at end of therapy were predictive of ICU death (p-value < 0.05).

  • Hyperglycemia, high creatinine, oliguria and fluid balance not predictive of ICU mortality.

  • A BUN > 29 mg/dL at day +7 was said to be predictive of mortality in HSCT patients in previous study. (Bacigalupo et al 1999)


Crrt survivors

CRRT Survivors

  • HSCT patients (n=30)

    • ICU survival – HSCT pts 36%

    • Reasons for CVVHD D/C

      • IHD Transition

        n=7

      • Improved renal function

        n=4

      • Support withdrawn

        n=2

  • Non-HSCT patients (n=11)

    • ICU survival – non-HSCT pts 42%

    • Reasons for CVVHD D/C

      • IHD Transition

        n=2

      • Improved Renal Function

        n=3


Icu non survivors

ICU Non-Survivors

  • HSCT ICU patients - 70% (21 of 30)

    • MSOD n=7

    • Veno-occlusive disease of liver n=3

    • Pulmonary failure n=3

    • Sepsis n=2

    • Cardiopulmonary failure n=2

    • Relapse n=1

    • Other n=3

    • Median PRISM score at CRRT initiation n=17

  • Non-HSCT patients – 55% (6 of 11)

    • MSOD n=3

    • Primary malignancy n=2

    • Secondary malignancy n=1

    • Median PRISM score at CRRT initiation n=21.5


Survivors vs non survivors

Survivors Vs Non Survivors

*

Non survivors had higher BUN at -24 * than survivors P<0.05.


Hsct patients

HSCT patients

*

Difference in CRP value reaches statistical significance* only at CVVHD end


Icu issues

ICU Issues

  • HSCT patients - BUN > 75mg/dL and CRP are predictive of ICU mortality.

  • Mechanical ventilation, use of pressors, hyperglycemia at CVVHD onset not predictive of ICU mortality.

  • Oxygenation index and PF ratio in allogenic HSCT patients improved after 24 hours of CVVHD.

    • 13.2±1.5 Vs 9.2±1.5 and 176.7±17.2 Vs 236±20.3 (Both indices P<0.05)

  • Mean PRISM scores for CVVHD episodes among HSCT patients were 16.4±0.7 compared to non-HSCT 19.9±1.1 (not statistically significant)


6 month survival

6 month Survival

  • HSCT patients - 3% (1of 30 patients)

  • Only 3/30 HSCTs had recurrence of primary oncologic disease.

  • Non HSCT patients – 36% (4 of 11 patients) survived to 6 months

  • Overall 6 mo. Survival – 12% (5 of 41)

  • Benoit et al reported 6 month survival in adult patients with hematologic malignancies at 14%.


Limitations of study

Limitations of Study

  • Small sample size makes it difficult to draw conclusions

  • Findings may not be relevant to other centers

  • Retrospective analysis

  • No data regarding patients not referred to the ICU for CRRT

  • Heterogeneity in primary oncologic disease and variation in oncologic therapy makes analysis difficult.


Conclusion

Conclusion

  • Effective, safe renal replacement modality

  • Resource intensive

  • Non-HSCT patient ICU survival compares favorably with general ICU populations (Goldstein et al Pediatrics 107(6); June 2001)

  • 6 month survival rates for HSCT patients is not encouraging


Ethical considerations

Ethical Considerations

  • Poor 6 month survival outcomes for HSCT patients

  • More selective in offering therapy if we can identify patients who are likely to survive to ICU discharge

  • Managing expectations of families


Future research

Future Research

  • Attempt to delineate factors which can translate short term success into 6 month survival for HSCT patients

  • Parent/patient perceptions

  • CVVHD vs. other modalities in HSCT patients

  • Immune modulation with CVVHD

  • PRISM scores for HSCT vs. Non HSCT patients


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