Extracorporeal therapy for the smallest children.

www.thelancet.com Vol 383 May 24, 2014 1785 Acute kidney injury is increasingly common in children admitted to hospital, with an incidence of almost 20% in children who require intensive care. Although the long-term eff ects of acute kidney injury continue to be debated, in the short-term it increases resource use, length of stay in hospital, and risk of death—all eff ects that become more pronounced in children who require renal replacement therapy. In The Lancet, Claudio Ronco and colleagues report the development of a new machine specifi cally designed to treat the smallest children in need of extracorporeal therapy, including children with acute kidney injury. Peritoneal dialysis is generally preferred to extracorporeal methods such as intermittent haemodialysis or continuous renal replacement therapy (CRRT) in neonates and young children who develop acute kidney injury or end-stage kidney disease that requires renal replacement therapy. The reasons for this preference are that peritoneal dialysis does not require large-diameter vascular access, can be haemodynamically less taxing than extracorporeal therapy, and is technically easier to do. However, some children are poor candidates for peritoneal dialysis, such as those with a history of abdominal surgery, severe anasarca, or who present with toxic ingestions or inborn errors of metabolism that require rapid solute removal. In the past few years, dialysis manufacturers have developed smaller fi lters for use in children receiving intermittent haemodialysis or CRRT. However, because the dialysis machines were designed for adult use, smaller children often need blood priming, which increases the risks of hypotension from bradykinin release and cardiac dysfunction secondary to chelation of calcium by the citrate anticoagulant used in banked blood. The high blood-fl ow requirements of adult machines also necessitate large-bore vascular access, which can be challenging to insert surgically and can permanently damage central vessels. There is a clear unmet technical need for paediatric-specifi c dialysis treatment. Ronco and colleagues describe their design, develop ment, and testing of a new CRRT machine, named CARPEDIEM (Cardio-Renal Pediatric Dialysis Emergency Machine), specifi cally for use in neonates and infants. This work expands on the group’s previous experience doing continuous arteriovenous haemofi ltration with a minifi lter that they designed and used to treat four very young infants (younger than 12 days) with acute kidney injury. The investigators should be commended for their eff orts in this important area and for their use of several collaborators, including non-profi t funding support. Importantly, they report the fi rst ever patient treated with their new machine, a neonate who developed oligoanuric acute kidney injury and several metabolic derangements secondary to severe haemorrhagic shock. The child survived the neonatal period, an outcome that would have been less likely just several years ago, without the new machine or improvements in overall neonatal care. In addition to having the capability to provide several forms of extracorporeal therapy (CRRT, plasmapheresis, and albumin dialysis), the small volume of the CARPEDIEM circuit does not require blood priming. The importance of limiting exposure to blood products, which decreases the risk of developing sensitising antibodies, should not be underestimated in children Extracorporeal therapy for the smallest children 6 Rubin HR, Fink NE, Plantinga LC, Sadler JH, Kliger AS, Powe NR. Patient ratings of dialysis care with peritoneal dialysis vs hemodialysis. JAMA 2004; 291: 697–703. 7 Jassal SV, Krishna G, Mallick NP, Mendelssohn DC. Attitudes of British Isles nephrologists towards dialysis modality selection: a questionnaire study. Nephrol Dial Transplant 2002; 17: 474–77. 8 Kleophas W, Reichel H. International study of health care organization and fi nancing: development of renal replacement therapy in Germany. Int J Health Care Finance Econ 2007; 7: 185–200. 9 Murtagh FE, Marsh JE, Donohoe P, Ekbal NJ, Sheerin NS, Harris FE. Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5. Nephrol Dial Transplant 2007; 22: 1955–62. 10 Robinson BM, Zhang J, Morgenstern H, et al. Worldwide, mortality risk is high soon after initiation of hemodialysis. Kidney Int 2014; 85: 158–65. 11 Couchoud C, Labeeuw M, Moranne O, et al. A clinical score to predict 6-month prognosis in elderly patients starting dialysis for end-stage renal disease. Nephrol Dial Transplant 2009; 24: 1553–61. 12 Ponce P, Marcelli D, GuerreiroA, et al. Converting to a capitation system for dialysis payment—the Portuguese experience. Blood Purif 2012; 34: 313–24. 13 Desai AA, Bolus R, Nissenson A, et al. Is there “cherry picking” in the ESRD Program? Perceptions from a dialysis provider survey. Clin J Am Soc Nephrol 2009; 4: 772–77.