Continuous Renal Replacement Therapy with Dr. Stuart Goldstein Part 1

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Sep 2, 2024

Dr. Stuart Goldstein, a pediatric nephrologist and professor at the University of Cincinnati, joins the discussion alongside Dr. Katherine Melink, a future PICU fellow. They delve into the fundamentals of Continuous Renal Replacement Therapy (CRRT) and its critical role in treating acute kidney injury in children. The conversation covers the evolution of terminology from 'acute renal failure' to 'acute kidney injury,' the rationale for CRRT, and the significance of biomarkers like N-GAL for optimal patient care.

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INSIGHT

CRRT Defined

CRRT is gentler than intermittent dialysis like hemodialysis.
CRRT is continuous and allows for closer monitoring and management.

INSIGHT

Modalities of CRRT

Ultrafiltration removes plasma water, like using a coffee filter (convection) or tea bag (diffusion).
Convection (CVVH) and diffusion (CVVHD) clear small solutes equally well, but convection clears middle molecules better.

INSIGHT

Clinical Differences in CRRT Modalities

Diffusion and convection clear small solutes equally, but convection may clear middle molecules better.
Middle molecules include pro-inflammatory cytokines, and improved clearance could be beneficial.

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Stuart Goldstein, MD is a Professor of Pediatrics at the University of Cincinnati, where he serves as the Clark D. West Endowed Chair. He is a practicing pediatric nephrologist at Cincinnati Children’s where he also is the Director for the Center for Acute Care Nephrology and the Medical Director for the Pheresis Service. Dr Goldstein is the Founder and Principal Investigator for the Prospective Pediatric Acute Kidney Injury Research Group and has evaluated novel urinary AKI biomarkers in the pediatric critical care setting.

Dr. Katherine Melink (at time of recording) is currently finishing her residency at Cincinnati Children's Hospital where she was able to conduct research in biomarkers for the prediction of kidney injury in critically ill children (particularly in the CICU). Her exposure to CRRT under physicians like Dr. Goldstein at Cincinnati Children's has served as a motivating factor to participate in this episode! She is excited to start PICU fellowship at Boston Children's Hospital in July.

Learning Objectives:

By the end of this podcast, listeners should be able to discuss:

CRRT fundamentals, including how it differs from conventional hemodialysis and the rationale for its use in critically ill pediatric patients.
Key differences in ultrafiltration, diffusion, and convection and their clinical applications in CRRT.
Patient selection and indications for CRRT (AKI, fluid overload, toxic metabolite/ingestion among others)
Key evidence guiding use of CRRT in critically ill children.
Components of a CRRT prescription and guiding principles of how to titrate therapy.
Pitfalls and complications of CRRT
Common anticoagulation strategies in CRRT
General principles guiding liberation from CRRT.

Selected references:

Sutherland et al; ADQI 26 Workgroup. Epidemiology of acute kidney injury in children Pediatr Nephrol. 2024 Mar;39(3):919-928. doi: 10.1007/s00467-023-06164-w. Epub 2023 Oct 24.

Basu et al. Derivation and validation of the renal angina index to improve the prediction of acute kidney injury in critically ill children. Kidney Int. 2014 Mar;85(3):659-67. doi: 10.1038/ki.2013.349. Epub 2013 Sep 18. PMID: 24048379;

Fuhrman et al; ADQI 26 workgroup. A proposed framework for advancing acute kidney injury risk stratification and diagnosis in children. Pediatr Nephrol. 2024 Mar;39(3):929-939. doi: 10.1007/s00467-023-06133-3. Epub

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Thank you for listening to this episode of PedsCrit. Please remember that all content during this episode is intended for educational and entertainment purposes only. It should not be used as medical advice. The views expressed during this episode by hosts and our guests are their own and do not reflect the official position of their institutions. If you have any comments, suggestions, or feedback-you can email us at pedscritpodcast@gmail.com. Check out http://www.pedscrit.com for detailed show notes. And visit @critpeds on twitter and @pedscrit on instagram for real time show updates.