Sekhar Jerin C, Nallasamy Karthi, Jayashree Muralidharan, Randhawa Manjinder Singh, Ravikumar Namita, C Sudeep K, Angurana Suresh Kumar, Bansal Arun
Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
Department of Pediatrics, Ramaiah Medical College, Bengaluru, Karnataka, India.
BMC Nephrol. 2025 Jul 14;26(1):386. doi: 10.1186/s12882-025-04255-4.
Continuous Renal Replacement Therapy (CRRT) is emerging as an essential component of organ support in critically ill children. In low- and middle- income countries (LMIC), limited resources, lack of technical support, cost, and administrative issues are major barriers in initiating and sustaining a CRRT program.
A core team, comprising a consultant and two pediatric intensive care fellows, was assigned additional responsibility of initiating and sustaining a CRRT program in the PICU of a tertiary care teaching and referral hospital. We retrospectively reviewed the data from initiation in February 2019 till May 2023 to understand the indications, prescription details, challenges, and their relation to outcomes.
During this period, 52 children with mean (SD) age of 7.6 (3.2) years and median (IQR) weight of 20 (17, 30) kg underwent CRRT in 71 sessions. The mean PRISM-III score was 18 (5.2), with 98.1% having multiorgan dysfunction at CRRT initiation. Acute kidney injury (53.8%), hyperammonemia (21.2%), and a combination of both (17.3%) were common indications. Continuous venovenous hemodiafiltration was the most used modality (61.5%). Median CRRT duration was 36 (20.3, 58) hours. Filter usage averaged 1.4 per patient with a median life of 35 (17, 48) hours, improving from 24 to 36 h over time. Filter clotting (33.8%), access flow issues (7%), and hemodynamic instability (4.2%) were complications encountered. Survival to discharge was 25%, with serum lactate [Formula: see text]3 mmol/L at CRRT initiation being an independent predictor of mortality (adjusted OR 6.1, 95% CI: 1.1-34.9; P = 0.04). Major challenges faced in our program included the SARS-CoV-2 pandemic, non-availability of technical support, and out-of-pocket expenses. These were circumvented by involvement of fellows and nurses, training them with internal and external experts, and mobilizing resources from governmental and non-governmental organizations.
Initiating a CRRT program in LMICs is feasible despite challenges. Creating a team with members willing to shoulder additional responsibility and training them gave impetus to our program. Tapping governmental and non-governmental support helped us circumvent financial challenges. However, in a resource limited setting, sustainability requires in-house technical and financial support. Survival to discharge was 25%, with hyperlactatemia at CRRT initiation predicting mortality.
连续性肾脏替代疗法（CRRT）正逐渐成为危重症儿童器官支持的重要组成部分。在低收入和中等收入国家（LMIC），资源有限、缺乏技术支持、成本以及管理问题是启动和维持CRRT项目的主要障碍。
一个由一名顾问和两名儿科重症监护住院医师组成的核心团队，被赋予了在一家三级医疗教学和转诊医院的儿科重症监护病房（PICU）启动和维持CRRT项目的额外职责。我们回顾性分析了2019年2月启动至2023年5月的数据，以了解适应证、处方细节、挑战及其与预后的关系。
在此期间，52名儿童接受了71次CRRT治疗，平均（标准差）年龄为7.6（3.2）岁，中位数（四分位间距）体重为20（17，30）kg。PRISM-III评分平均为18（5.2），98.1%的患儿在开始CRRT时存在多器官功能障碍。急性肾损伤（53.8%）、高氨血症（21.2%）以及两者并存（17.3%）是常见的适应证。连续性静脉-静脉血液透析滤过是最常用的模式（61.5%）。CRRT的中位持续时间为36（20.3，58）小时。每位患者平均使用滤器1.4个，中位使用寿命为35（17，48）小时，随着时间的推移从24小时提高到了36小时。遇到的并发症包括滤器凝血（33.8%）、血管通路血流量问题（7%）和血流动力学不稳定（4.2%）。出院生存率为25%，开始CRRT时血清乳酸[公式：见正文]3 mmol/L是死亡的独立预测因素（校正比值比6.1，95%置信区间：1.1 - 34.9；P = 0.04）。我们项目面临的主要挑战包括新冠疫情、缺乏技术支持以及自付费用。通过住院医师和护士的参与、与内部和外部专家对他们进行培训以及从政府和非政府组织筹集资源，这些问题得到了解决。
尽管存在挑战，但在低收入和中等收入国家启动CRRT项目是可行的。组建一个愿意承担额外责任的团队并对其进行培训推动了我们的项目。利用政府和非政府支持帮助我们克服了财务挑战。然而，在资源有限的环境中，可持续性需要内部的技术和财务支持。出院生存率为25%，开始CRRT时高乳酸血症可预测死亡率。
