Time to Continuous Renal Replacement Therapy Initiation and 90-Day Major Adverse Kidney Events in Children and Young Adults
Authors: Gist Katja M. , Menon Shina , Anton-Martin Pilar , Bigelow Amee M. , Cortina Gerard , Deep Akash , De la Mata-Navazo Sara , Gelbart Ben , Gorga Stephen , Guzzo Isabella , Mah Kenneth E. , Ollberding Nicholas J. , Shin H. Stella , Thadani Sameer , Uber Amanda , Zang Huaiyu , Zappitelli Michael , Selewski David T. ,   WE-ROCK Investigators, Ahern Emily , Akcan Arikan Ayse , Alhamoud Issa , Alobaidi Rashid , Balani Shanthi S , Barhight Matthew , Basalely Abby , Bottari Gabriella , Cappoli Andrea , Ciccia Eileen A , Collins Michaela , Colosimo Denise , Damian Mihaela A , DeAbreu Gabrielle , Ding Kathy L , Dolan Kristin J , Fernandez LaFever Sarah N , Fuhrman Dana Y , Guzzi Francesco , Haga Taiki , Harvey Elizabeth , Hasson Denise C , Hill-Horowitza Taylor , Inthavong Haleigh , Joseph Catherine , Kaddourah Ahmad , Kakajiwala Aadil , Kessel Aaron D , Korn Sarah , Krallman Kelli A , Kwiatkowski David M , Lee Jasmine , Lequier Laurance , Madani Kia Tina , Marinari Eleonora , Martin Susan D , Mohamed Tahagod H , Morgan Catherine , Mottes Theresa , Muff-Luett Melissa A , Namachivayam Siva , Neumayr Tara M , Nhan Jennifer , O'Rourke Abigail , Pinto Matthew G , Qutob Dua , Raggi Valeria , Reynaud Stephanie , Ricci Zaccaria , Rumlow Zachary A , Santiago Lozano María J , See Emily , Serpe Carmela , Serratore Alyssa , Shah Ananya , Shih Weiwen V , Slagle Cara L , Solomon Sonia , Soranno Danielle E , Srivastava Rachana , Stanski Natalja L , Starr Michelle C , Stenson Erin K , Strong Amy E , Taylor Susan A , Van Wyk Brynna , Webb Tennille N , Zangla Emily E 
Published: January 2024

ImportanceIn clinical trials, the early or accelerated continuous renal replacement therapy (CRRT) initiation strategy among adults with acute kidney injury or volume overload has not demonstrated a survival benefit. Whether the timing of initiation of CRRT is associated with outcomes among children and young adults is unknown.ObjectiveTo determine whether timing of CRRT initiation, with and without consideration of volume overload (VO; &amp;lt;10% vs ≥10%), is associated with major adverse kidney events at 90 days (MAKE-90).Design, Setting, and ParticipantsThis multinational retrospective cohort study was conducted using data from the Worldwide Exploration of Renal Replacement Outcome Collaborative in Kidney Disease (WE-ROCK) registry from 2015 to 2021. Participants included children and young adults (birth to 25 years) receiving CRRT for acute kidney injury or VO at 32 centers across 7 countries. Statistical analysis was performed from February to July 2023.ExposureThe primary exposure was time to CRRT initiation from intensive care unit admission.Main Outcomes and measuresThe primary outcome was MAKE-90 (death, dialysis dependence, or persistent kidney dysfunction [&amp;gt;25% decline in estimated glomerular filtration rate from baseline]).ResultsData from 996 patients were entered into the registry. After exclusions (n = 27), 969 patients (440 [45.4%] female; 16 (1.9%) American Indian or Alaska Native, 40 (4.7%) Asian or Pacific Islander, 127 (14.9%) Black, 652 (76.4%) White, 18 (2.1%) more than 1 race; median [IQR] patient age, 8.8 [1.7-15.0] years) with data for the primary outcome (MAKE-90) were included. Median (IQR) time to CRRT initiation was 2 (1-6) days. MAKE-90 occurred in 630 patients (65.0%), of which 368 (58.4%) died. Among the 601 patients who survived, 262 (43.6%) had persistent kidney dysfunction. Of patients with persistent dysfunction, 91 (34.7%) were dependent on dialysis. Time to CRRT initiation was approximately 1 day longer among those with MAKE-90 (median [IQR], 3 [1-8] days vs 2 [1-4] days; P = .002). In the generalized propensity score–weighted regression, there were approximately 3% higher odds of MAKE-90 for each 1-day delay in CRRT initiation (odds ratio, 1.03 [95% CI, 1.02-1.04]).Conclusions and RelevanceIn this cohort study of children and young adults receiving CRRT, longer time to CRRT initiation was associated with greater risk of MAKE-90 outcomes, in particular, mortality. These findings suggest that prospective multicenter studies are needed to further delineate the appropriate time to initiate CRRT and the interaction between CRRT initiation timing and VO to continue to improve survival and reduce morbidity in this population.