Standardizing care in pediatric continuous kidney replacement therapy: can we reach consensus without adequate evidence?

Continuous kidney replacement therapy (CKRT) is the predominant extracorporeal support for management of acute kidney injury, fluid overload, and metabolic derangements. Daverio and colleagues surveyed professionals from pediatric intensive care units (PICU’s) from 20 countries in Europe covering various domains of center and respondent characteristics, organizational aspects for education and training, CKRT duration, vascular access, approach to termination, anticoagulation, and fluid removal strategies.¹ Only a single response from each center was captured, with an impressive 76% response rate. Not surprisingly, there was significant heterogeneity in practice across all domains of assessment. Perhaps the true testament of success for the high response rate should be attributed to how this survey was disseminated, leveraging an official organization – the European Society of Neonatal and Pediatric Intensive Care (ESPNIC). Indeed, members might be more likely to complete a survey when disseminated by an official organization as it potentially aids in amplifying importance.

There are several issues with this survey that should be underscored. This report encompasses only European centers¹, and cannot glean practice global variation. Moreover, of the 161 responses from 211 centers, 52% of them came from the United Kingdom, Germany, Turkey, and Italy, so there may be substantial intra and inter country hetero-, or even homogeneity that has not been identified by this survey. Elucidating patient characteristics was not the goal of the survey due to survey design, which will limit translation to developing consensus recommendations, as the authors correctly identify. Interestingly, practice patterns that differ from what has been reported from other organizations, including a recent report from the Worldwide Exploration of Renal Outcomes Collaborative in Kidney Disease (WE-ROCK) describing the clinical characteristics of 1000 children from 32 centers supported by CKRT in North America and Europe.² The most common reported form of anticoagulation used, differing from the Kidney Disease Improving Global Outcomes (KDIGO) guidelines, underlining regional practice differences. Only about a third of centers use citrate and we cannot determine if this is related to regional availability, cost, or other factors such as resource constraints. Unanimous preference was for lines to be placed in the right internal jugular vein, consistent with KDIGO recommendations. The caliber of lines used are much smaller than traditionally available in the United States, emphasizing differences in access to right size equipment and disposables that challenge pediatric clinicians. Ideally, a balancing metric exploring line-associated thrombi would shed more light into best practices, given the recent reports of increased hypotensive episodes with IJ lines.

This report may not capture actual practice patterns as only one person per center was surveyed, potentially introducing confirmation bias and availability heuristic. Indeed, this might explain the surprisingly short time reported between the decision to initiate, and the time to initiate CKRT (2 hours) as it is not quite clear how this data point was collected and may be biased by recall or optimism. The authors report a notable lack of continuing education and yearly refreshers, but this could be influenced by the majority of providers completing the survey being physicians (90% of respondents) and not necessarily being familiar with ongoing nursing education efforts in their centers. This survey lacked detailed information across several domains of CKRT practice. Some of the most important areas to consider in future evaluation include practice differences in prescribed and delivered dose in order to determine the most optimal dose for children, as well as nutritional practices. It is known that there are nutritional losses during CKRT. Identifying how and what changes are being made to nutrition during CKRT would be essential to identify areas for improving protein and calorie delivery optimizing short – and long-term outcomes related to growth and development.

In order to move forward, it is essential to identify gaps in education, training, and practice. The necessity of this approach was recently emphasized by the first pediatric acute disease quality initiative (ADQI). This group of experts provided consensus recommendations and suggestions for children receiving kidney support therapy to ensure high-quality programs and provide a general guide for prioritizing areas of focus for future research.³ The 22^nd ADQI consensus meeting had outlined minimum programmatic standards and quality metrics for delivering high-quality CKRT across the age spectrum.⁴ Before we can establish consensus, we need to understand the current practice. Daverio and colleagues have provided an important first step, there is insufficient granularity to truly get a scope of practice patterns across all European centers. Most pediatric CKRT knowledge originates from adult studies, single center pediatric reports and an old multicenter registry with selective enrollment of children from the United States⁵ making it especially challenging to identify which practice approach is likely to result in the best patient outcome. A recent single center report comparing outcomes across 2 different eras demonstrated significant practice change over the 10 years of study that did not translate to a discernable survival benefit across eras.⁶ Goldstein and colleagues compared survival among infants treated with CKRT using adapted adult platforms vs. the Carpediem^™ and demonstrated improved survival to CKRT discontinuation in those treated with Carpediem^™.⁷ It should be noted however, that there was nearly 20 years difference between the study period of the 2 populations. It is likely that there have been substantial improvements in medical care in the past 20 years, independent of provision of CKRT. Consensus, while helpful, needs to be based on contemporary practice and recent supporting pediatric data.

In summary, data around CKRT practice and outcomes for generation of best practice recommendations are sparse, limited to dated multicenter studies, and small single center reports. This ESPNIC report is a well -timed opportunity to better understand how to improve pediatric CKRT outcomes in Europe. Global efforts with stakeholder participation from relevant geographic areas would be needed to extrapolate the methodology to children everywhere with adequate understanding of local resources to make tangible implementation of lessons learned a pragmatic reality.