Continuous Renal Replacement Therapy with Dr. Stuart Goldstein Part 2

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Sep 9, 2024

Dr. Stuart Goldstein, a pediatric nephrologist and director at Cincinnati Children's, joins the conversation along with Dr. Katherine Melink, a resident engaged in kidney injury research. They delve into the fundamentals of Continuous Renal Replacement Therapy (CRRT) and its advantages over conventional dialysis for critically ill children. Highlighted are innovative anticoagulation strategies, advancements in filter technology, and the vital role of biomarkers in patient assessment. Collaboration in pediatric care emerges as a key theme in effectively managing acute kidney injury.

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ADVICE

Personalizing CRRT

Personalize CRRT prescriptions, especially for pediatric patients, considering extracorporeal volume and blood priming.
Match pump flow to the patient's cardiac output based on weight.

INSIGHT

Key CRRT Prescription Components

Key prescription components include clearance (effluent volume) and anticoagulation.
In children, clearance is often calculated on a per-meter-squared basis.

ADVICE

Anticoagulation in CRRT

Anticoagulate the CRRT circuit, often with heparin or regional citrate anticoagulation.
Monitor citrate levels closely, especially in patients with reduced muscle mass or liver issues, to prevent complications.

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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.