"What Is Measured Gets Improved" (or If You Cannot Measure It, You Cannot Improve It).

Pediatric Critical Care Medicine www.pccmjournal. org 267 the prospective pediatric CRRT registry data (4) and is not surprising given the comorbidities stemming from liver disease. The results in the study by Westrope et al (3) were limited by the lack of data granularity in the PICANet database, making it difficult to glean information that could inform RRT practice. As mentioned above, it is likely that RRT and general PICU care evolved over the 8-year study period as the interest in “early” versus “late” RRT, and the attention to fluid overload have become more prevalent despite the paucity of prospective pediatric studies and conflicting adult data addressing these clinical practices (5, 9, 10). Furthermore, the question of whether fluid overload or AKI staging (or both) should guide initiation of RRT remains unanswered. It would be informative to add the following data elements to the PICANet database and prospectively study their variation over the next decade: KDIGO AKI staging and percent fluid overload at time of RRT initiation, timing between PICU admission and RRT initiation, CRRT type and dosage, venous access site and catheter size, circuit priming and anticoagulation strategy, and complications. Although the effort to generate prospective data on an entire western country’s pediatric RRT use is laudable if not herculean, the critical care community is still awaiting multicenter prospective studies evaluating best CRRT and PD practice. Only after digging into the details of the patient and RRT practice, complications, and outcomes, we will be better informed to define optimal pediatric RRT and create more standardized work. REFERENCES 1. Kaddourah A, Basu RK, Bagshaw SM, et al; AWARE Investigators: Epidemiology of acute kidney injury in critically ill children and young adults. N Engl J Med 2017; 376:11–20 2. Khwaja A: KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl 2012; 2:1–138 3. Westrope CA, Fleming S, Kapetanstrataki M, et al: Renal Replacement Therapy in the Critically Ill Child. Pediatr Crit Care Med 2018; 19:210–217 4. Symons JM, Chua AN, Somers MJ, et al: Demographic characteristics of pediatric continuous renal replacement therapy: A report of the prospective pediatric continuous renal replacement therapy registry. Clin J Am Soc Nephrol 2007; 2:732–738 5. Modem V, Thompson M, Gollhofer D, et al: Timing of continuous renal replacement therapy and mortality in critically ill children*. Crit Care Med 2014; 42:943–953 6. de Galasso L, Emma F, Picca S, et al: Continuous renal replacement therapy in children: Fluid overload does not always predict mortality. Pediatr Nephrol 2016; 31:651–659 7. Hayes LW, Oster RA, Tofil NM, et al: Outcomes of critically ill children requiring continuous renal replacement therapy. J Crit Care 2009; 24:394–400 8. Boschee ED, Cave DA, Garros D, et al: Indications and outcomes in children receiving renal replacement therapy in pediatric intensive care. J Crit Care 2014; 29:37–42 9. Leite TT, Macedo E, Pereira SM, et al: Timing of renal replacement therapy initiation by AKIN classification system. Crit Care 2013; 17:R62 10. Gaudry S, Hajage D, Schortgen F, et al; AKIKI Study Group: Initiation strategies for renal-replacement therapy in the intensive care unit. N Engl J Med 2016; 375:122–133