Table 4.

Pediatric Continuous Renal Replacement Therapy (PCRRT) registry group suggestions for critically ill, pediatric COVID-19 patients.

•CVVHDF is recommended as the preferred modality as both convection and diffusion allows for removal of bigger molecules which may thus, help in removing inflammatory markers (The rate at which the solute crosses through a membrane is indicated by a number called the sieving. A larger size solute or one with greater affinity to protein binding will have better clearance in CVVHDF than any other CKRT modality). •Preemptive CKRT is suggested if there is progression of respiratory insufficiency, clinical indications of worsening pulmonary edema, and continuing systemic inflammation (high ferritin/CRP and ESR). •High flow CVVHDF is suggested to be performed at a rate of 50 ml/kg/h for the first 12 h followed by step down CVVHDF at a rate of 25–30 ml/kg/h. Alternatively, CVVH, CVVHD, SLEDD-f, or PD should be initiated if resources are not available. •The use of Normocarb bicarbonate-based solutions are recommended. •Circuit clotting in COVID-19 is high due to an increase in procoagulant state and thus, we recommend providing 1/3 of the total replacement fluid pre-filter, another 1/3 should be provided post filter and the remaining replacement fluid should be utilized as dialysate to dilute the circuit. •A higher blood flow rate of 4–5 mL/kg/min is advised to enhance clearance rates of cytokines and reduce the risk of clotting. •The monitoring of electrolyte levels and complete blood count is recommended to be performed every 2 h with high flow CVVHDF and then every 6 h in stepdown CVVHDF. •Nutritional supplementation through adjustment of the replacement fluids and infusion rates are recommended in these patients. •Earlier initiation of KRT is recommended to induce early cytokine clearance and improvement of hemodynamic stability for better outcomes and prevention of multiple organ failure.

CKRT, continuous kidney replacement therapy; CRP,C-reactive protein;CVVHDF, continuous venovenous hemodiafiltration; ESR, erythrocyte sedimentation rate; PD, peritoneal dialysis; SLEDD-f, sustained low-efficiency daily diafiltration.