9th International Conference on Pediatric ContinuousRenal Replacement Therapy

Orlando, USA, August 31–September 2, 2017

We would like to invite you to review and enjoy the abstracts and the science presented at the 9th International Conference onPediatric Renal Replacement Therapy, held in Orlando, FL, USA from August 31 to September 2, 2017. Attendees from morethan 25 countries exchanged science and experience in the areas of sepsis, AKI, liver failure, neonatal and ECMO. Like theprevious eight outstanding meetings, this meeting was the result of dedicated leaders in the field volunteering their time andenergy to ensure its success. Further information on this meeting as well as others can be found at our website: www.pcrrt.com.

Akash Deep MD, FRCPCHDirector, Paediatric Intensive Care UnitKing’s College Hospital, London, UK& Honorary Senior Lecturer, King’s College, London, UK

Timothy E Bunchman MDProfessor & Director, Pediatric Nephrology, Transplantation and RheumatologyChildren’s Hospital of Richmond at VCUOffice Room 5–4641000 East Broad StreetRichmond, VA 23298, USATel: 804–827-2264Fax: 804–628-5853Cell: 804–822-0659timothy.bunchman@vcuhealth.orgwww.pcrrt.com

Pediatr Nephrol (2017) 32:2173–2192DOI 10.1007/s00467-017-3790-5

ORAL 01 A NOVEL PRESCRIPTION CALCULATORFOR PEDIATRIC CRRT

M.A. Elbaba, 2017Hamad Medical Corporation, Weil Cornell Medical College-Qatar emai l : mos ta fae lbaba@hotmai l .com Tel :+97,433,919,891. Address: Hamad medical corporation,PO Box 3050, Doha, Qatar

Background: Continuous renal replacement therapy (CRRT)is an advanced treatment frequently required to support thecritically ill children. Because of the complexity of this kindof treatment, healthcare professionals frequently consume timeto implement the CRRT prescription from the local guidelinesto the machine. A novel pediatric CRRT calculator is intro-duced by the author to facilitate the pCRRT prescription.Aims & Objectives: The aim of this work is to assess thevalidity and reliability of the new pediatric CRRT calculatorcompared to the manual calculations used by the pediatricnephrologists for CRRT therapy.Methods: The pediatric CRRT prescription is assessed twicein each therapy, once by using the author’s calculator by aresearcher and again without the calculator (manual calcula-tion) by the pediatric nephrologist. The study was conductedon 7 patients in our PICU using the local pCRRT prescriptionguide. The time taken to copy the CRRT prescription in theorder sheet or the hospital computer (Cerner) and the totaltime taken to install the order to the CRRT machine are cal-culated. The accuracy of the calculator was revised manuallyafter each case. The difference in accuracy between the twomethods was analyzed. Student t-test was used to compare thetwo groups.Results: The data showed the mean time taken in calculatorgroup is 2.7 min ± 0.9 compared tomanual group (22.4 ± 4.7).There was a highly statistical difference in the time takenbetween the calculator group and the manual group (p-value0.00001). Also the same was found when we compare thepercent of error in the calculation between the two groups.The error was 2.5% ± 2.1 in the calculator group while itwas 18% ± 8.3 in the manual group. There was a poor corre-lation between the time and the percent of error between thetwo groups.Conclusions: The new pCRRT prescription calculator is sig-nificantly faster and more accurate compared to the manualprescription. Although the sample size is small but the reli-ability of the calculator was high. The physicians are expectedto be comfortable to use the calculator to save the time andreduce the error. Larger study is needed before disseminationto other centers.

References1. Banks DS. Prescribing continuous renal replacement

therapy using a JavaScript calculator improves delivered

dose. Journal of the Intensive Care Society. 2011Oct 1;12(4):289–92.

2. Ricci Z, Ronco C. Information technology for CRRT anddose delivery calculator. ln Acute Kidney Injury 2007Apr 25 (Vol. 156, pp. 197–202). Karger Publishers.

3. Goldstein SL. Overview of pediatric renal replacementtherapy in acute renal failure. Artificial organs. 2003 Sep1;27(9):781–5.

ORAL 02 INABILITY TO ACHIEVE NEGATIVEWATER BALANCE WITHIN 72 HOURS AFfERI N I T I AT ION OF CONT INUOUS RENALREPLACEMENT THERAPY IS ASSOCIATED WITHINCREASED MORTALITY IN CHILDREN WITHACUTE KIDNEY INJURY

M. Broman. R. Krmar. A. Andersson. U. FlaringDepartment of Pediatric perioperative medicine and intensivecare. Karolinska University Hospital. Stockholm. Sweden.Email: urban.flaring @ki.se. Tel: +46,708,763,900.

Introduction: Acute kidney injury is common in the PICUand is associated with fluid overload (FO). Increasing degreesof FO at the time of continuous renal replacement therapy(CRRT) initiation is associated with increased mortality.1

There is limited information of possible effect of the abilityto achieve negative water balance and its relation to outcomein children.Methods: A retrospective single centre registry trial wherecritically ill children (n = 60) subjected to acute kidney injuryand undergoing CRRT were characterized between 2009 and2016. Potential predictors of mortality were analysed by uni-variate logistic regression followed by step-wise backwardmultiple logistic regression. Only factors with p < 0.1 wereused in the multiple logistic regression analysis.Results: The multivariate analysis, preliminary showed astrong association between mortality and inability to achievenegative water balance within 72 h (p < O.OOOI) and withfluid overload (>20%) at the time of CRRT initiation(p = 0.02). Non-survivor s had more FO as compared to sur-vivors at the time of CRRT initiation (p < 0.05) and shortercircuit life span (p = 0.004).Conclusion: Fluid overload(>20%) at the time of CRRTinitiation and an inability to achieve a negative water

1 Melisa Gunsel Rosenthal,DVM;Small Animal Internal MedicineResident,Cummings School of Veterinary Medicine, Tufts University; 200Westboro Rd.,North Grafton, MA 01536; Phone:508–887-4681; Fax: 508–839- 7922; Email: melisa.rosenthal@tufts.edut Mary Anna Labato,DVM, DACVIM;Clinical Professor,Cummings School

of Veterinary Medicine,Tufts University; 200 Westboro Rd., North Grafton,MA 01536;Phone: 508–887-4681;Fax:508–839-7922; Email :mary.labato@tufts.edu

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balance within 72 h after CRRT initiation are associatedwith mortality. Short circuit life span may contribute tobad outcome.

References1. Modem V eta!. Timing of continuous renal replacement

therapy and mortality in critically ill children. Crit Caremed. (2014); 42: 1–11

ORAL 03 PREVALENCE ANDMORTALITY TRENDSIN HOSPITALIZED CHILDREN REQUIRINGHEMODIALYSIS: AN ANALYSIS KID INPATIENTDATABASE

M. Chegondi1, 2; O, Sendi3; B.R. Totapally3, 41Pediatric Critical Care Medicine, Nemours Children‘sHospital; 2Pediatrics, Univeristy of Central Florida Collegeof Medicine, Orlando, Florida, United States; 3PediatricCritical Care Medicine, Nickl au Children’s Hospital;4Pediatrics, Herbert Wertheim College of Medicine, FloridaJntemational Uni versity, Miami, Florida, United States.Corresponding Author: Madhuradhar Chegondi, MDEmail: madhuradhar.chegondi (a,nemours.org. Mchegondi(cv,yahoo.com; Phone: 4,076,507,828; Fax:4,076,507,48613,535 Nemours Parkway, Nemours Children ‘s Hospital,Orlando, FL, USA 32827

Introduction: Children requiring hemodialysi s (HD) ther-apy are at higher risk of morta lity compared to the age-adjusted children who doesn ‘t need HD. In the past de-cade advancement in technology-enabled application ofHD in a broad spectrum of age groups with various un-derlying etiologies.Objective: The aim of this study is to analyze the trends inprevalence and mortality rates in children requiring HD and tocompare prevalence and mortality.Design/Methods: A retrospective analysis of theHealthcare Cost and Utilization Project Kids’ InpatientDatabases for years 2003, 2006, 2009, and 2012 wasperformed. The databases were filtered using ICD-9 pro-cedure code 39.95 for hemodialysis. Sample weightingwas employed to produce national estimates. Trendanalysis using Chi-square test for linear trend analysiswas performed to evaluate the prevalence of HD amonghospitalized children and the mortality rate amonghemodial yzed children using CDC’s Epilnfo software.Results: Among a total of ll,810,223 admissions in the age-group of 1 month to 18 years during four years of the study,12,612 of them required hemodialysis. Among the patientswho required HD, 52.2% were males 32.6% were white, and31.8% with private insurance. The median age group was12 years (IQR: 5–15), the median length of stay was 7 days

(IQR: 3–17) and total charges of $55,440 (IQR: 21,748–164,488). The prevalence increased from 0.92/ 10,000 dis-charges in 2003 to 1.53/10,000 discharges in 2012(p < O.OOl, Chi-Square for linear trend) with an overall prev-alence of 1.07/10,000 discharges. The mortality rate in chil-dren who received HD decreased from 10.36% in 2003 to8.39% in 2012 (p = 0.01, Chi-Square for linear trend) withan overall mortality rate of 9.48%.

Table: Showing year specific and overall number of childrenwith HD, prevalence and mortality rates

Conclusion: The overall prevalence of children with HD in-creased significantly, and mortality rates significantly de-creased over the years.

ORAL 04 CHALLENGES OF IMPLEMENTING ACVVH PROGRAM IN A NEONATAL INTENSIVECARE UNIT

TL Jones. RN. BSN, M Vreeland, RN, BSN, ML Heard, RN,AJ Piazza, MD, SF Wagoner, MBA, RRTChildren‘s Healthcare of Atlanta, ECMO & AdvancedTechnologies Department, Atlanta, Georgia 30,322

Introduction: Continuous venovenous hemofiltration(CVVH) is the preferred method of continuous renalreplacement therapy (CRRT) at Children ‘s Heallhcareof Atlanta. We present the case of a three day old infantwith hemophagocytic lymphohistiocytosis (HLH).Nephrology was consulted for rising creatinine and ana-sarca. These infants usually are transferred to the PICUfor CVVH; however, the patient remained in the NICUfor continuing care, with CVVH beginning on day I Iof admission.Case Summary: The use of CVVH in the NICU waschallenging as the NICU nurses are not educated in thecare of CVVH patients. Also, vascath s are not used inthe NICU; so no nursing education was previou sly deliv-ered. Another challenge came from renal management.Nephrology is consulted for CVVH initiation but manage-ment is done by the critical care team. Neonat ology phy-sicians are not familiar with citrate/calcium protocols, cit-rate gap, and fluid management of a CVVH patient. Afinal challenge came from the NICU rarely caring for long

Year HD NoHD Prevalence Dead Survived MortalityRate(%)

2003 3127 3,413,621 0.92 324 2803 10.362006 3404 3,321,164 1.02 328 3076 9.642009 3150 3,162,934 0.99 297 2853 9.432012 2931 1,912,504 1.53 246 2685 8.392003–2012 12,612 11,810,233 1.07 1195 11.t17 9.-t8

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terrn HLH patient s. Staff was unaware of special precau-tions needed for patients receiving chemotherapy includingreverse isolation, proper waste disposal of diapers andsoiled items. A compromise in nursing care was reachedby having PICU nurses trained in CVVH floated to theNICU to care for this infant. While every nurse is expect-ed to float, this was difficult given the high acuity of thepatient. An additional drawback was the lack of knowl-edgeable resources to assist with the CVVH pump.Conclusion: The infant was successfully managed on CVVHin the NICU for ten days. Unfortunately, the infant developeda life threatening brain hemorrhage and the family decided towithdraw care.This case was a test for future neonates to be managed in theNICU on CVVH. While these cases remain rare, there werelessons learned for the future. A core group ofNICU nurseswill undergo training and will be mentored in the NICU, shiftto shift, by PICU nurses. Additionall y, Neonatologists will betrained in CVVH and Nephrology will increase involvementin the NICU.

ORAL 05 IS CITRATE 4% A SAFER ALTERNATIVETO HEPARIN IN MAINTAINING CATHETERPATENCY FOR CHILDREN VULNERABLE TOSYSTEMIC BLEEDING?

J.R. Morgan RN1 A.N. Snyder RN1; S.L. Goldstein MD1;D. Lazear PharrnD2

Center for Acute Care Nephrology, Cincinnati Children‘sHospital Medical Center1; Division of Pharmacy, CincinnatiChildren‘s Hospital Medical Cente

Introduction: Central venous catheters (CVCs) are the pri-mary vascular access used to provide hemodialysis (HD) forchildren. CVC thrombosis is a leading complication resultingin occlusion, decreased delivered HD dose and CVC survival.High-dose heparin (HH) (1000–5000 ul mL) is the lockingagent (LA) of choice for HD CVCs, but is associated withadverse effects. An alternative, sodium citrate 4% (SC) pre-vents clotting by lowering ionized calcium. The potential forsystemic hypocalcemia from accidental SC infusion led toinquiries regarding its safety. If SC is as effective as HH atmaintaining CVC patency and associated with lower bleedingrisks, SC may be a preferable LA.Methods: Cincinnati Children ‘s Hospital Medical Center(CCHMC) uses caffeine citrate (CC) (1.33%, 13.3 mg/ mL)to treat patients (pts) with apnea of prematurity (AOP). Thestandard dose ofCC for AOP is 40 mg/ kg (2 mLI kg). Wecompared CC to SC to assess the total and weight based citrate

dose each formulation would deliver to a 5 kg pt. A standarddose of heparin is 25–50 ul kg. For HD, we assumed eachlumen of the CVC would have a 1.2 mL volume.Results: The comparison shown in the table.

Medication Dose Exposure

Caffeine citrate (1.33%) 2 mL/kg 133 mg citrate

Sodium citrate (4%) 2.4 mL 96 mg citrate

Heparin 1000 units/ mL 2.4 mL 480 ul kg

Review of the table shows a lower citrate exposure forSC compared to CC, even if both lumens were flushed.Inadvertent flushing of HH would lead to severe sys-temic anticoagulation and may be detrimental. To date,no known bleeding or hypocalcemic events were report-ed involving the administration of CC.Conclusion: Further research needed to assess SC safety andefficacy as a LA. We will conduct a prospective randomizedcontrolled study at CCHMC for pts. with temporary or per-manent HD eves.

References1. Passero BA, Zappone P, Lee HE, Nova k C, Maceira EL, Naber M. Citrate versu s heparin for apheresis catheter locks:An efficacy analysis. Journal of clinical apheresis. 20 15Feb 1;30(I): 22–7.

ORAL 06 SINGLE-PASS ALBUMIN DIALYSISDURING CONTINUOUS RENAL REPLACEMENTTHERAPY FOR MANAGEMENT OF LIVERFAlLURE

N. Beinsl, B. English2, R. Greene2, M. Thompson2, U. Garg3,D. Weidemann1 V. Chadha1

Section of Nephrology1, Critical Care Medicine2, Pathologyand Laboratory Medicine3, Children’s Mercy, Kansas City,MO, United States

Introduction: While Acute Kidney Injury (AKI) requiringrenal replacement therapy (CRRT) is common in critically illchildren, liver failure necessitating liver suppot1 therapy isuncommon in pediatric critical care setting. In patients withliver failure, several metabolites, such as bile acids, bilirubin,aromatic amino acids, and endogenous benzodiazepines accu-mulate and most of these are strongly protein bound whichprevents their clearance during conventional CRRT.Molecular Adsorbent Recycling System (MARS) has beensuccessfully used for the management of liver failure, but is

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not available in most centers. Several case reports have shownsuccess of modification of CRRT with Single-Pass AlbuminDialysis (SPAD) in cases with acute liver failure.

Case Summaries IMethod:We report our experience in fourchildren who were treated with SPAD-CRRT.The cases are briefly summarized in the Table.

While severe hyperbilirubinemia was the main reason forusing SPAD in patients 1, 2, and 4, it was used as a bridgeto liver transplant in patient #3.All patients received CRRT (CVVHDF) with a clear-ance of 2 L/h/ 1.73m2. For SPAD, 400 mL of 25%albumin was added to the 5 L dialysate (PrismaSol®)bag to give final albumin concentration of 1.85%.Serum bilirubin was used as a surrogate marker ofefficacy of SPAD. Serum and dialysate bilirubin con-centrations were monitored to calculate the mass bili-rubin removal. Results of patient # I are shown inFigure.

Conclusions: Our experience shows > 10-fold increasein bilirubin clearance with SPAD-CRRT with recoveryin three out four patients. While SPAD-CRRT is effec-tive in decreasing serum bilirubin and possibly otherprotein-bound toxins, its impact on removal of nutrientsand medications is unknown and needs to be carefully

explored. Large scale studies are needed to see if SPAD-CRRT can improve patient outcomes.

POSTER 01 EFFECTOF PERITONEALDIALYSISONBLOOD CARBON DIOXIDE LEVELS IN PICUPATIENTS

Chaitra K R1, Virendra KumarCorresponding Author: Dr. Chaitra K RSenior Resident Dept of Pediatrics, KGMU, LucknowEmail Id: Chetu.kims@gmail.com, Ph.No: 8,375,856,693

Introduction: Despite maximal ventilator support, many pa-tients die from hypercarbia in the setting of potentially revers-ible respiratory failure. There remains a pressing need foradditional pulmonary supportive measures, which are feasibleand cost effective.Objective: The objective was to determine whether peritonealdialysis had any effect on blood levels of carbon dioxide.Materials and Methods: It was a prospective observa-tional study in which 30 children in whom peritoneal di-alysis was indicated were enrolled in the study inPediatric intensive care unit of Kalawati Saran ChildrenHospital, New Delhi. Serial measurement of venous bloodand dialysate fluid at Ohrs, 30 min, 1 h, 4 h, 12 h and 24 hwere done using the ABG 800 basic analyzer and pH,pC02 and p02 ofboth the fluids were subsequently mea-sured and interpreted.Results:Venous levels of blood pC02 measured at the start ofperitoneal dialysis was 46.18 ± 10.61, followed by whichvenous pC02 measured at 1 h showed a mean decrease in

Patient Age (yrs) Sex Diagnosis Max. bilirubin(mg/dL)

Length ofSPAD (hrs)

% decrease in bilirubinduring SPAD

Outcome

I 0.6 M Hemophago cytic histiolymphocytosis with severe hyperbilirubinemia

51.5 35 56% Expired

2 7 M Cystic fibrosis, sepsi s, acuteon chronic liver failure

32.6 96 42% Recovered, expired 3weeks. Later

3 5 M Fulminant acute liver failurewith encephalopathy

23.9 26 2 1% Received livertransplant

4 3 M Neuroblastoma, post-HCT,VOD, and severehyperbilirubinemia

32 240 73% Recovered, expired1.5 years later

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60

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pC02 levels to 43.07 ± 8 .89 with a continuous in pC02 levelsobserved over a period of 24 h. The dialysis fluid pC02 ana-lyzed at baseline was 17.67 ± 1.82 and that measured at 1 hshowed amean increase to 33.94 ± 11.6, showing there was anincrease in dialysate fluid pC02 in comparison to baseline,showing the exchange of C02 through peritoneum, and alsoa rapid equilibration of dialysate fluid pC02 to blood pC02levels subsequently.Conclusion: Our study demonstrated that peritoneal di-alysis effectively decreases the blood levels of C02,supported by the observation that carbon dioxide levelsof returning dialysate fluid increased with respect to thebaseline and subsequently attained equilibrium withblood levels. This study opens up new avenues in themanagement of respiratory failure and use of peritonealdialysis as an alternative mode of therapy in respiratoryfailure to decrease pC02 levels.

POSTER 02 OUTCOMES OF REGIONAL CITRATEANTICOAGULATION (RCA) IN PEDIATRICCONTINUOUS RENAL REPLACEMENT THERAPY(pCRRT) IN A SINGLE CENTER.

I Alhamoud1, 2, D Gollhofer2, R Quigley1, 2

Division of Pediatric Nephrology; University of TexasSouthwestern Medical Center,1; Children’s Medical Center2;Dallas, Texas, United States

Introduction: The efficacy of Continuous Renal ReplacementTherapy (CRRT) in critically sick children is dependentlargely on the anticoagulation of circuit. Different anti-coagulants have been utilized with heparin as the mostcommon anticoagulant. But systemic heparin carries ahigh risk of bleeding and thrombocytopenia which arevery often present in critically ill children. Since clinicalintroduction in 1990, regional citrate anticoagulation(RCA) has become a more suitable alternative for circuitanticoagulation. The aim of this retrospective study wasto evaluate the efficacy and safety profile of RCA asanticoagulation in a pediatric CRRT cohort compared tothe outcomes of systemic heparin-CRRT.Methods: We conducted a retrospective study of all childrenaged from neonatal period till 21 years who required CRRTand either RCA or systemic heparin as anticoagulation thera-py between January 2012 and December 2016. 48 h was de-termined as the primary end point for filter lifespan.Results: Seventy patients underwent CWH longer than48 h with a median age of 11 years (range:one week to20 years) .237 filters were used in citrate group (35

patients) during a period of 12,856 h, and 193 filterswere utilized in heparin group (35 patients) during9209 h. Median lifespan of hemofilters was significantlylonger in citrate group compared to heparin group (55.1versus 42.2 h for citrate and heparin group respectively;p = 0.018, Mann–Whitney rank sum test). Failedhemofilters were noted in 108/236 (46%) in the RCA groupwhile the number of failed hemofilters was 107/193 (56%)in the heparin group (p = 0.037, Kaplan-Meier survivalanalysis for the whole timeframe of filters) .Conclusion: We demonstrated in this large pediatric cohortthat RCA is more effective than systemic heparin in terms ofthe duration of filter ‘s patency.

POSTER 03 THE USE OF HIGH HEMOFILTRATIONVENOUS VINE CONTINUES IN A 5 YEAROLDGIRLWITH STREPTOCOCO PNEUMONIA PNEUMONIA

Gaston E CastilloEmail: gastonemd@hotmail.es; gastonedgardo74@gmail.com

Case of a patient of 5 years old 4 months, femenina is report-ed, which presents table of 4 days of fever and generalmalestar, consults to hospital of the periphery and gives am-bulatory management with ketotifeno metoclopramida andacetaminofen.Has torped evolution and in the new consultation, presentssigns of respiratory difficulty , lumbar pain, oliguria.Hydrical and vasopresines (norepinefrine) and vasopresin,mechanical ventilation are placed, vancomycin, cefepimaclindamycin, and linezolid are diagnosed, diagnosis ofpneumonia and bilateral pleural spillage, it is taken tosurgery, with decortication , debriding , bilateral toraxtube.Patient septical shock and acute renal failure, IGM and IGGdeficiency inmates inmunoglobulins-human plasma proteinvial 100mL (PENTAGLOBIN) , INTRAVENOUS, 400.00milliliters, for 4 days.No improvement after, the immunoglobulin step was notimproved.The patient stops the clinical picture from the view ofenfernedad and decides to start veno-venous continuoushemofiltra tion therapy where:Pump flow: 100 ml i min ultrafiltration:30 CC I H dializer veolosity: 60 CC I KG I H for 6hours and after low 30 CC I KG I H ASI: POSFILTRO440 CC I H PREFILTER 190 CC I H withoutantocoagulant with this, the patient has notable improve-ment after two months.

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This form of renal replacement therapy , where combined highfiltration pulses, with standard doses make the pdiatric pa-tients improve a more acute manner and we also have resultsvery satisfactory

POSTER 04 CONTINUOUS RENAL REPLACEMENTTHERAPY IN A PEDIATRIC AND ONCOLOGICALHOSPITAL OF BOGOTA, COLOMBIA

CA Jimenez-Triana1,2, J Chamorro-Rojas% R Perez-Morales21Ped ia t r i c Nephro logy Depar tment , Fundac iónHospitalPediatrico de Ia Misericordia; 2Pediatric IntensiveCare; Unit, Fundación Hospital Pediatrico de IaMisericordia. Bogota D.C., Colombia

Introduction: Continuous renal replacement therapy (CRRT)has been shown to be useful in critically ill patients byhelping to improve problems arising from volume over-load states or those caused by metabolic disturbancessuch as uremia or electrolyte imbalance, etc. In mostthird-level hospital in Bogota, these techniques are avail-able and have become an indispensable tool in intensivecare units.Methods: We performed a retrospective observationalstudy describing the clinical characteristics of pediatricpatients receiving CRRT in the PICU of the FundaciónHospital Pediatrico de Ia Misericordia in Bogota, Colombiafor a period of 7 months (September 2016–March 2017).We used the Aquarius™ System technology (NikkisoAmerica Inc.).Results: We report 11 children with a mean age of11.8 years,64% (7/11) had a diagnosis of any kidney diseaseand 36% (4/11) an oncological disease. The indication forinitiating CRRT was uremia (4/11), hypervolemia (3/11) orboth (4/11); the glomerular filtration rate (GFR) at the begin-ning of therapy in uremic patients was 16.5 mllmin/1.73 m2and in hypervolemic patients 71.7 ml/min/1.73 m2. The meaneffluent dose was 42 ml!Kg/h (1249 mllm2/h), 38 ml!Kg/h inHF and 46 mllkg/h in HOF. The mean fluid overload was8.7%, the time between ICU admission and the beginning ofCRRTwas 59.4 h (range 5–216, SO 71.5) and the duration oftherapy on average was 86.8 Hours (range 16–163, SO 58).All patients received citrate anticoagulation (ACO-A, BaxterHealthcare Corporation), maintaining mean serum calciumvalues of 1,16 mmoi/L and extracorporeal calcium of 0.39mmoi/L. The ICU stay was 12 days (range 12–31, SO 9.6)and mortality was 45% (5/11), all of whom had septic shockincluding all cancer patients. Finally, patients who died had ahigher percentage of hypervolemia (13.7 vs. 4.4%, p

value = 0.02), a later onset of therapy vs. 24.3 h,p value = 0.07)and a slightly lower effluent dose (38,6 vs. 44.8 mllkg/h, pvalue = 0.49) .Conclusion. Based on this series of patients we concludedthat CRRT are a useful therapeutic option in the pediatricpopulation, however, in cancer patients and those with septicshock should be initiated early avoiding high percentages ofwater overload.

POSTER 05 CYCLIC HIGH-FREQUENCY TIDALPERITONEAL DIALYSIS WITH THE CYCLERDRAINES BY HIGHT DIFFRRENCES IN A 3 KGCKD INFANT

Mariko Sawada, Michisato Hirata, Kazutoshi Ueda, NorikoKimura, Keiji Tsuchimoto, Masamichi Kubota, AkihitoTakahashi, Shinichi Watabe, Kenji Waki, Yoshio ArakakiDepartment of Pediatrics, Kurashiki Central HospitalAddress: 1·1·1 Miwa, Kurashiki, Okayama, 7108602, JapanTEL: +81·86·422·0210 FAX: +81·86·421·3424 Email:mariko·sawada@hotmail.co.jp

Introduction: The modality of pediatric renal replaceme nttherapy has shifted from peritoneal dialysis (PD) to continu-ous renal replacement therapy. But PD is also useful in chil-dren with unstable circulatory status and chronic kidney dis-ease. Additiona lly, automated PD (APD) has been consideredas the better modality for pediatric patients. APD improvesultrafiltration and decreases intraabdomin al pressure. Wehave a 3 · kg infant who suffered from congenital heart dis-eases and chronic kidney disease treated with APDsuccessfully.Case Summary: An 18 month · old girl weighing 3 kg hadcardiac surgery for hypoplastic left heart syndrome. She wasalso suffered from prolonged post · operative kidney failure.She was started continuous ambulatory PD (CAPD). After shewas changed from CAPD to APD with drainage pumps, APDdidn’t work because of hypotension during dialysate retentionand drainage problems. Just after intraabdominal massivehemorrhage because of damages of abdominal wall vesselsthat caused by the negative pressure of roller pumps, shewas changed to cyclic high frequency tidal PD with othercycler; PD · Mini NeoTM (JMS, Japan), not using dialysatedrainage pumps. The fluid cycles ware 23 cycles a day. Theinitial fill volume was started 60 mL and gradually increasedto 120 mL. The tidal volume was 50% of the initial one, andthe dialysate was completely drained every 4 cycles. Thedialysate was drained by the 1 · m height difference. Threemonths later, she presented no intraabdominal bleeding, and

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her blood pressure become stable. She had no PD · relatedproblems and fluid imbalance.Conclusion: The profit of cyclic high frequency tidal PDwiththe cycler; PD · Mini Neo™ was to minimize adverse effectson her cardiorespiratory status and to be able to perform PDwith enough dialysate amounts and ultrafiltration. The APDsystem could improve the outcome of renal failure in criticallyill infants.

POSTER 06 ACTIVATED PHOPHOINSOSITIDE3 - K I N A S E S Y N D R O M E W I T HMESANGIOPROLIFERA TIVE AND MEMBRANOUSGLOMERULONEPHRITIS TREATMENT WITHTR350 FILTER IMMUNOADSORPTION

0. Beringer, F. Kropp, A Schulz, K.M. Debatin, C. SchuetzOrtraud Beringer, MD, Pediatric NephrologyUniversity Medical Center Ulm, Department of Pediatricsand Adolescent Medicine; Eythstr. 24, 89,075 Ulm Germany.Ortraud.Berinqer@uniklinik -ulm.de; Phone: 0049 73150,057,065; Fax: 0049 731 50,057,334Prefered poster; Session AKI and physiology

Introduction: Activated phophoinositide 3 -kinase 8 syn-drome is a combined immunodeficiency syndromeresulting from a gain of function mutation in the geneencoding the catalytic subunit of phophoinositide 3 kinase8. (1).Case summary: This 16 year old turkish patient sufferedfrom recurrent bronchitis, tonsilitis, otitis, parotitis sincebirth. She also had persistent massively enlarged lymph-adenopathy and hepatosplenomegaly. A diagnosticlymphnode extirpation resulted in a toxic shock syn-drome .Investigations: Persistent tricytopenia. In lymphocyte differ-entiation low T-, B-cells; low naive T-cells. Elevated lgM.pANCA and dsDNA moderately elevated. No complementalterations. Serologies inconclusive. No evidence of autoim-mune lymphoproliferative syndrome .Thoracic CT: signs of chronic inflammation, bronchiolyticinfiltrates, wall thickening, obliteration of bronchis.Kidney biopsies: at age 13 incomplete membranous glomeru-lonephritis, at age 15 global and focal segmental sclerosingmesangioproliferative and membraneous GN with 20% tubu-lar atrophy .Genetics: heterozygeous mutations in Exon 24 of the PKI3CDgene (c.30611G > A p.1Lys).Medical course and treatment:At age 13 the patient developed severe colitis and glo-meru la r nephro t i c p ro te inur i a wi th pe r s i s t en tmicrohematuria, progressive kidney insuffiiciency.Following 1st kidney biopsy start of treatment with

MMF, ACE inhibitor. Decline of GFR (40 ml/m2&min), increasing proteinuria. Following a 2”d biop-sy, start with 5 sessions of immunadsorption (sigmaauto plus, TR350 filter) and rituximab (2 cycles total),regular IVIG, cotrimoxazole prophylaxis. After geneticdiagnosis a treatment with sirolimus was initiated.The patient is stable under sirolimus, MMF and lgG substitu-tion. No further severe infections have occured. There is nolymphadenopathy anymore! GFR has increased to 51 ml/m2&min with decrease in proteinuria.Conclusion: Kidney function in this patient with a com-bined immunodeficiency could be preserved withimmunoadsorpt ion. Early aggressive therapy removinglgM was followed by stabilisation and led to postpone-ment of BMT.

Reference1. Coulter Tl, Chandra A, Bacon CM, Babar J, Curtis J,Screaton Net al. Clinical spectrum and features of APDS. JAllergy Clin lmmunol. 2017

POSTER 07 MANAGEMENT OF ACUTE KIDNEYINJURY USING CONTINUOUS VENOVENOUSHEMOFILTRATION IN DOGS

M.G. Rosenthal; M.A. LabatotCummings School of Veterinary Medicine, Tufts University

Introduction: Continuous renal replacement therapy(CRRT) is an emerging therapy in the veterinary field. Ithas been used for patients with a variety of causes ofacute kidney injury (AKI) including leptospirosis, tumorlysis syndrome, heatstroke, ureteral obstructions, and avariety of toxicities [1). This report describes two patientstreated with Continuous Venovenous Hemofiltration(CVVH). These two cases help illustrate some of the chal-lenges and complexities of utilizing CRRT in veterinarypatients.Case Summary: The first patient was a 6.9 kg, 2 yearold, female spayed, Border Terrier presenting with icterusand progressive, oliguric AKI in the face of aggressivemedical management who was started on CVVH. After28 h of treatment, she experienced cardiopulmonary ar-rest. Cardiopulmonary resuscitation was successful, andshe was able to re-start CVVH two hours after return ofspontaneous circulation. By the end of her 48 h of CVVHtherapy, her kidney values had normalized, and her liverparameters had significantly improved. Leptospirosis titersconfirmed that her AKI and acute liver injury were causedby leptospirosis infection.The second patient was a 9.4 kg,1 year old, male castrated,American Cocker Spaniel who presented for progressive,

2180 Pediatr Nephrol (2017) 32:2173–2192

anuric AKI despite medical management. Five days prior topresentation, he had ingested up to 1000mg of enalapril. Afterpresentation to our facility, he received CVVH for 84 h. Hebegan producing urine 48 h after the start of CVVH, and waspolyuric by the end of his session. Kidney values normalizedprior to the time of discharge, and remained normal at followup appointments.Conclusion: These cases demonstrate that CVVH is avalid and effective treatment modality for small patients,although careful monitoring is essential for avoiding po-tentially serious consequences.

1. Acierno MJ. Continuous Renal Replacement Therapyin Dogs and Cats. Vet Clin N Am-Small. 2011;41(1):135–46.

POSTER 08 HEMODIALYSIS CATHETER BACK-BLEEDING: A UNIQUE COMPLICATION OFVASCULAR ACCESS IN AYOUNG PATIENT

MF. Ali, M. J. Defreitas, C. P. Katsoufis, C. L. Abitbol, J. C.Chandar, M. Freundlich, G. Zilleruelo, W. SeeherunvongUniversity of Miami, Department of Pediatric Nephrology

Introduction:& The 2016 report of the United States Renal Data

Systems (USRDS) indicates that children with EndStage Renal Disease (ESRD) are initiated onHemodialysis (HD) (50.4%) more frequently thanPeritoneal Dialysis (PD).

& The 2006 NKF KDOQI Guidelines for Vascular access inpediatric patients recommend permanent access in theform of fistula or graft as the preferred form of vascularaccess for most pediatric patients on maintenance HDtherapy.

& However, since 2006, 81% of incident pediatricESRD patients have started hemodialysis with a cen-tral venous catheter (CVC) without a maturing fistu-la or graft.

Case Summary: We present DW who is a 7-year-oldAA boy with ESRD. He was born full term withmultiple congenital anomalies including bilateral en-larged cystic echogenic kidneys, with a presumptivediagnosis of Bardet-Biedl Syndrome. At age of10 months he underwent a left nephrectomy and was startedon PD. He developed multiple complications includingintraabdominal bleeding, fungal peritonitis and small bow-el obstruction requiring colostomy and termination of hisPD with initiation of HD by CVCAt 5 years of age, he received a deceased donor kidneytransplant that was complicated by T and B cell mediated

rejection and Klebsiella sepsis, He lost his graft and wasreinitiated on HD.One year ago and after multiple CVC exchanges, hewas noted to have recurrent episodes of back bleedingfrom the catheter exit site while being dialyzed.Interestingly the bleeding would stop with the discon-tinuation of the HD. Venogram demonstrated high-gradestenosis/fibrin sheath involving the superior venacava.The tip of the dialysis catheter retracted into the severe-ly stenotic portion of the SVC obstructing venous out-flow causing back bleeding through the exit site duringdialysis.Conclusion:& This case demonstrates a unique and challenging compli-

cation of prolonged vascular access resulting in fibrinsheath and vena caval occlusion.

& Back bleeding occurs when the catheter is pulled abovethe occlusion and hemodialysis is instituted resulting inreverse flow ofblood at the exit site.

& Management requires use of a longer catheter beyond thestenosis.

POSTER 09 IONIZED CALCIUM MONITORING INCITRATE REGIONAL ANTICOAGULATION

D. Ranch, MD, University of Texas Health Science Cente r,San Anton io, Texas; S. Collins, RN, University HospitalECMO and Advanced Technologies, San Antonio, Texas; C.Assanasen, MD, University of Texas Health Science Center,San Antonio, Texas; T. Wu, MD, University of Texas HealthScience Center, San Antonio, Texas

Citrate is an effective option for regional anticoagulationduring continuous renal replacement therapy (CRRT).This may help to avoid potential complications with sys-temic heparin, such as bleeding or heparin-inducedthrombocytopenia. Patients are monitored for complica-tions, such as hypocalcem ia and citrate toxicity, requir-ing frequent monitoring of ionized calcium (iCa) levelsin the patient and the circuit. This could result in excesstesting, blood loss, lost staff time and increased costs.Also, certain blood gas machines are unable to accuratelydetermine iCa levels in the lower range, with the vari-ability of some machines being greater than the parame-ters used to determine treatment changes. This could leadto complications such as circuit clotting or citrate toxic-ity. It has been suggested that monitoring of the CRRTcircuit iCa levels is misleading and unnecessary. Ourhypothesis for this study was that eliminating routineiCa evaluation of the CRRT circuit would not affect circuitlife compared to those patients who had routine circuitiCa monitoring.

Pediatr Nephrol (2017) 32:2173–2192 2181

Methods: Retrospective review of CRRT treatmentsusing only citrate regional anticoagulation at our cen-ter from April 2014 to April 2017. Primary Outcome:Mean circuit life per treatment. Secondary Outcomes:number of iCa tests, number of infusion rate changes,citrate rate per treatment, proportion of clottedcircuits.Results: There was no statistically significant differencein mean circuit life between the group without circuitiCa monitoring (−iCa) and that with circuit iCa moni-toring (+iCa) (48.2 vs 37.5 h, P = 0.396). The -iCagroup had a significantly lower number of iCa testsper treatment compared to the + iCa group (mean 23vs 50, P = 0.001). There was no difference in the num-ber of infusion rate changes per treatment between thegroups (mean 1.1vs 2.6, P = 0.129). The -iCa grouphad a slightly lower citrate infusion rate per treatmentcompared to the + iCa group (mean 4.58 vs 6.66 ml/kg/h, P = 0.04). There was no difference in the proportionof clotted circuits per group (P = 0.664).Conclusions: CRRT using citrate anticoagulation with onlypatient iCa monitoring did not negatively affect circuit life.The elimination of routine circuit iCa evaluation decreasedthe number of blood tests, and was 111ot associated withincreased circuit clotting.

POSTER 10 CRRT IN ECMO

J. John, MD, C.D.W. Kaspar, MD and R. Bholah, MDDepar tmen t o f Ped ia t r i c Nephro logy, Vi rg in iaCommonwealth University 1000 East Broad Street,P.O. Box 980,498, Richmond VA 23298; Tel.: 804–827-2264

The use of continuous renal replacement therapy(CRRT) in tandem with ECMO is perceived to be chal-lenging secondary to the technical aspects of initiatingCRRT. We report on our center’s 3 year experience (2015–2017) of 45 patients (neonates to 18 years of age)maintained on VA ECMO. Of those, 69% were neonatesand 27% of patients were both on ECMO and CRRT.Indications for CRRT were solute clearance, improve-ment in volume status and consolidation of medicationand nutrition requirements. Heparin was used as system-ic anticoagulation for ECMO with no additional heparinrequired upon CRRT initiation. Due to use of ECMOaccess, the normally negative access pressures werechanged to positive to offset alarms. Blood priming oc-curred in 82% of our patients using the bypass maneu-ver as described by Brophy et. a!. [I], the AN69 mem-brane hemofilter was used with no issues of membranereaction. The median time to initiation of CRRT was2 days (IQR 0, 5) . Fluid overload is often a

complication with ECMO and the concurrent ongoinggrowth in the neonatal population makes assessment ofdry weight difficult. Therefore, z-scores were used as anestimate of fluid changes between init iat ion anddecannulation, with a mean z-score change of 0.78 (95% CI:0.37, 1.20) in all ECMO patient s. A two-tailed t-test wasperformed demonstrating a statistically significant differencebetween z scores, suggesting that the change of z-score couldcorrelate with a degree of fluid overload post ECMO.Evaluations ofz-score changes for ECMO in conjunctionwith CRRT were not able to achieve statistical signifi-cance due to low numbers. Our experience has shown usthat initiation of commercially available CRRT in ECMOis feasible, and that early initiation should be consideredin this patient population to prevent significant comorbid-ity with regards to fluid overload.

References1. Brophy PO, Mottes TA, Kudelka TL, McBryde KD,Gardner JJ, Maxvold NJ, eta!. AN-69 membrane reactionsare pH-dependent and preventable. American Journal ofKidney Diseases 2001 7;38(1):173–178.

POSTER 11 INVESTIGATE VARIATION INPROINFLAMATORY CYTOKINE LEVEL ANDE F F I C A C Y O F C O N T I N U O U S R E N A LREPLACEMENT THERAPY ON TREATMENT OFBEE STING COMPLICATED WITH MULTIPLEORGAN DYSFUNCT ION SYNDROME INCHILDREN 2007- 2016

Nguyen Minh Tien MD*, LeVu Phuong Thy MD**Pediatric Intensive Care Unit, City Children ‘s Hospital, HoChi Minh City, Vietnam Corresponding Author: Nguyen MinhTien, Mobile: +84,903,391,798, Email: tiennd 1@yahoo.comConsultant of PICU & Toxicology Vice Director; CityChildren’s Hospital, HCM city, VN; 15 Vo Tran Chi, BinhChanh District, VN; +84 90 3,391,798; +84 8 22,536,688

Introduction: Bee sting is a common accident in theworld, especially in Asia and Africa. Vespa affmisvenoms include amines such as acetylcholine, hista-mine, serotonin and catecolamine and proteins with av-erage molecular weights such as kinin, phospholipaseA2, protease, hyaluronidase, causing directly or indi-rectly by inflammatory cytokines multiple organs dam-age such as haemolysis, rhabdomyolysis, liver failure,renal failure, acute respiratory distress syndrome. In thelast two decades, continuous renal replacement therapyhas been introduced and applied to patients with mul-tiple organ dysfunction syndrome, giving encouragingoutcomes. Objective of the study is to investigate

2182 Pediatr Nephrol (2017) 32:2173–2192

variation in prointlammatory cytokine level and effica-cy of continuous renal replacement therapy on treat-ment of bee sting complicated with multiple organ dys-function syndrome in children.Methods:Study design: Retrospective descriptive study of cases series.Patients: children with age of 1–15 years old suffering beesting complicated with multiple organ dysfunction syndromeby Goldstein’s criteria, admitted at PICU, Children’s hospital,Ho Chi Minh City, Vietnam from 2007 till 2016.Steps to act- Sampling for the first episode of CRRT: TNFa, ILl J3, IL6 inblood at time of 0, 12, 24 h in effluent fluid at time of 12, 24 h.- Others: electrolytes, ABGs, Lactate, coagulation test,Bilirubin T, D, I, AST/ALT, BUN, CPK,NH 3 every 6 h. CRRT action:– Set up of CRRT machines: BM25 or Aquarius or

PRISMAFLEX.– Replacement fluid: Hemosol.

-Double lumen catheter: 6.5- SF, 11–12 F by patient age.– Filter: AquamaxHF 03/ HF 07 for BM25, Aquarius, M60

I M100 for PRISMA PRISMAFLEX– Turnover rate: 40 ml/kglhr, BPR 4-6 ml/kg/min.– Anticoagulation: Heparin or Fraxiparin

Data collection: patient features, clinical signs, lab. Test bythe time.Data analysis: using statistical software of SPSS 18.0 formeans, SO, paired-sample t test Wilcoxon Signed RanksTest, significant threshold P < 0.05.Result: From 2007 till 2016, 36 patients of bee sting complicat-edwithMODS have been investigated level of proinflammatorycytokines and given CRRT, average age of 6.4 years old, youn-gest of 18 months old. Reasons for bee sting were due to beehives destruction (83.3%), bee species of Vespa affinis (97.2%),Vespa nigrithorax 1/36 (2.8%), average number of 66.5 stings,maximum of 120 stings, mean stings to bodyweight ratio of 3.8.Clinical manifestations consisted of shock (61.1%), acute re-spiratory failure (91.7%) where ARDS (47.2%), hepatic fail-ure (77.8%), acute renal failure (72.2%), disorder of con-sciousness (47.2%), convulsion (13.9%), DIC (38.9%),haemolysis, rhabdomyolysis (100%).Interventional therapy besides CRRT included respiratorysupport such as CPAP, CMV (75%), resuscitation of anaphy-lactic shock with epinephrine 1 M or IVP (61.1%) IV fluidunder CVPmonitor (61.1%) and IBP (100%), hydrocortisone,pipolphen (antihistamine), ranitidin, metabolic acidosis cor-rection (66.7%), hypoglycemia control (38.9%).Investigation of blood level of proinflammatory cytokines in31 patients of bee sting complicated with MODS showed thatlevel of TNFa, ILl f3, IL6 elevated up to 26, 1 ± 3.5 (normalrange of TNFa < 11 pg/ml), 22,4 ± 1,2 (ILl f3 < 14,5 pg/ml),109,8 ± 26,5 (IL6 < 1,23 pg/ml) declined at 12 h (21,4 ± 3,6),

(7,6 ± 1,1), (101,7 ± 28,3), 24 h (20,6 ± 3,4), (6,2 ± 1,3),(84,4 ± 23,5) respectively.All patients received CRRT at average time of 12.4 h, whereCVVH account ing for 88.9%, CVVHDF 11.1%,anticoagulation with Fraxiparin (80.6%) due to hepatic failureand thrombocytopenia. The effectiveness of CRRT was evi-denced by the clinical improvement, paraclinical - CPK, liverenzymes, especially the improvement of respiratory failure,renal function. Improvement was also demonstrated by thereduction of inflammatory cytokines level in the blood beforeand after dialysis as well as the presence of these cytokines inthe filtrate.There were 9 patients (25%) with body weight under 15 kgneeded blood transfusion instead of normal saline for CRRTcircuit priming.CRRT associated complications were noted filter clotted(16.7%), air in CRRT circuit (19.4%), catheter-related blood-stream infection (13.9%).Outcome of treatment showed survival rate 91.6%, three pa-tients died due to catheter related bloodstream infection andprolonged and refractory. It were noted that average number ofCRRT episodes of2.5 and subsequent hemodialysis of 1.3,length of stay in PICU of 11.4 days.Conclus ion: The s t udy r evea l ed t h e ro l e o fproinflamrnatory cytokines as a basis for CRRT ontreatment of bee sting with complications of MODS,reducing mortality and saving many patients with beesting with severe complications.Keywords: bee sting, vespa affinis, MODS: multiple organdysfunction syndrome, CRRT: continuous renal replacementtherapy.

1. Ling Zhang, Yingying Yang Recovery from AKIFollowing Multiple Wasp Stings: A Case Series. C/inJAm Soc Nephrol. 2013; 8(11): 1850–1856.

2. Rathi Sharmila R,Multiple Organ Dysfunction SyndromeFollowing Single Wasp Sting. Indian Journal ofPediatrics, 2007; 74: 1111–1112.

3. Xie C, Xu S, Ding F, Xie M, Lv J, Yao J, et a!. Clinica lFeatures of Severe Wasp Sting Patients with DominantlyTox i c R eaction: Analysis of I09 1 Cases. PLoS ONE. 201 3; 8(1 2): e83 164. doi: I0. 1371/journal.pone.0083164.Available from: http://journals.plos .org/plosone/article?id = l 0.1371/joumal.pone.0083164

POSTER 12 FEASIBILITY OF PERFORMING CRRTIN CHILDREN LESS THAN 10 KG USINGSTANDARD CRRT MACHINES

A. Deep1, S. Glace21King’s College Hospital NHS Foundation Trust, London,UK; 2King’s College London, London, UK

Pediatr Nephrol (2017) 32:2173–2192 2183

Introduction: Continuous renal replacement therapy(CRRT) is an established supportive treatment for acutekidney injury in the PICU with machines designed foradults. However, its use is considered off-label in childrenweighing <10 kg. The aim of this study is to assess thesafety and efficacy of CRRT in children weighing: s;1Okg using standard CRRT machines.Methods: Six-year retrospective analysis of data from allpatients weighing: 510 kg undergoing CRRT. Survivalto PICU discharge, duration of mechanical ventilationand ICU stay, primary diagnosis, illness severity at ad-mission, CRRT indication, machine, vascular access andCRRT characteristics were collected. Descriptive analy-sis compared survivors and non-survivors. Serial pro-gression in markers of safety and efficacy were collect-ed (changes in creatinine, fluid overload and electro-lytes, bleeding episodes, vascular complications and hy-potension following CRRT initiation). Multivariate lo-gistic analysis with stepwise regression identified riskfactors for non survival. We also compared data in chil-dren:s; 5 kg with 5–10 kg.Results: Forty-one patients: 510 kg received 8655 h ofCRRT for various indications including 60% for liverfailure. Median weight was 4.4 kg. 58.5% survived tohospital discharge. Survivors had a lower PIM2 score atICU admission (p = 0.0019) and lower Fi02 require-ment at CRRT initiation (p = 0.339). Analysis of effi-cacy showed reductions in fluid overload at 48 h(p = 0.0002), creatinine at 24 and 48 h (p = 0.0023,p = 0.0110) and potassium at 4 h (p = 0.0139). There wereno complications related to blood priming, anticoagulation,bleeding or hypotension. Filter life was longer inchildren:55 kg (p < 0.0001), maximum blood flow washigher (p = 0.0194) and survival was not significantlydifferent (p = 0.1672) between less than and more than5 kg.Conclusion: This study demonstrates that CRRT can besafely and effectively delivered on children: 5 1Okgusing adult-sized CRRT machines and literature-matched survival.

POSTER 13 LIBERALIZED POST-FILTER IONIZEDCALCIUM GOALS IN A PATIENTWITH FULMINANTLIVER FAILURE AT RISK FOR CITRATE TOXICITYDURING CRRT

1J. Lusk, 1, 2K. Ward, 1, 2M. Cadnapaphornchai, 1, 2T. Stidham1Children’s Hospital Colorado; 2University of Colorado

Introduction: In liver failure patients, anticoagulationduring Continuous Renal Replacement Therapy (CRRT)is complicated by risk for citrate toxicity from impaired

hepatic metabolism. This contributes to shortened circuitlife and high mortality rates in this CRRT population.We present a unique approach, utilizing a liberalizedcircuit ionized calcium (iCa) goal to minimize citrateexposure without compromising circuit life.Case Summary: A 3-year-old male with a presumedmetabolic disorder developed C. difficile associated sep-tic shock with fulminant liver failure, MODS, and acutekidney injury with subsequent fluid overload and elec-trolyte derangements necessitating CRRT. Despite pre-emptive efforts to decrease citrate load and optimizeclearance, toxicity occurred within 24 h. The post-filteriCa goal was broadened to 0.3–0.8 mmoi/L to reducecitrate delivery. The patient exhibited no evidence ofcitrate toxicity or premature filter clotting for the re-maining CRRT course.Conclusion: In this case, a liberalized post-filter iCa ap-proach mitigated citrate toxicity. This strategy has beenapplied in 2 additional patients with similar success.While this approach is feasible, circuit viability relativeto standard anticoagulation practices warrants furtherstudy.

References1. Link A, Klingele M, Speer T, et al. Total-to-ionized cal-

cium ratio predicts mortality in .continuous renal replace-ment therapy with citrate anticoagulation in critically illpatients. Crit Care. 2012;16{3):R97. doi:10.1186/cm311363

2. Symons J , Golds te in S, e t a l . DemographicCharacteristics of Pediatric Continuous RenalReplacement Therapy: A Report of the ProspectiveContinuous Renal Replacement Therapy Registry. ClinJAm Soc Nephrol. 2007;2:732–738.

POSTER 14 LONG TERM RENAL OUTCOMES INCRRT SURVIVORS OF PEDIATRIC LIVER FAILURE

Naile Tufan Pekkucuksen, Ad nan Safdar, PoyyapakkamSrivaths, Michael Braun, Sa rah Swartz, Ayse AkcanArikan, Joseph Angelo

Background: Children with liver failure (LF) frequentlydevelop multi organ fa ilure and need continuous renalreplacement therapy (CRRT). Long term renal outcomesof pediatric LF patients requiring CRRT are not welldescribed.Objective: We aimed to describe the long term renal out-comes in LF patients requiring CRRT.Materials and Methods: Retrospective review of institu-tional database from 2011 to 2016 to identify LF patientstreated with CRRT and surviving to discharge. Demographic

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and clinical data were collected and estimated glomerularfiltration (eGFR) was calculated using the updatedSchwartz formula. Outcome data were extracted from themedical record.Results: 72 LF patients received CRRT during the studyperiod, 31 Patients survived to discharge and were in-cluded in the study. Mean CRRT duration was28.2 ± 22.0 days. Mean pediatric intensive care unitstay was 75.6 ± 139.5 days. The most common indica-tion for CRRT was acute kidney injury {61%). 19 pa-tients received median 7.5{1QR3–16) hemodialysistreatments after liberation from CRRT. Two patients{6%) developed end stage renal disease (ESRD), onesubsequently died from complications of elective sur-gery. 31 patients had a median of 2 {IQR2–4) yearsfollow up. Follow up median eGFR was 124 {IQR97–133) ml/m2/min. Six patients had eGFR > 150 ml/m2/min consistent with hyperfiltration. 55% {16/29) hadproteinuria and 41%{12/29) had hypertension at fol-low-up.Conclusion: Although pediatric LF patients receivingCRRT have excellent renal recovery, they remain athigh risk for CKD given high frequency of proteinuria,hypertension, and hyperfiltration and require close renalsurveillance.

POSTER 15 TREATMENT OF AN INTENTIONALMETFORMIN OVERDOSE IN AN ADOLESCENTWITH RENAL REPLACEMENT THERAPY

W.R. Glaberson,1 A. Arenas-Morales1, M.F. Ali1,L. Thomas2, M.J. Defreitas2, J.C. Chandar1, B. Gelman2,C.K. Abitbol1

1Universi ty of Miami Department of PediatricNephrology, 2University of Miami Department ofPediatric Critical Care

Introduction:& Metformin overdose can cause life-threatening lactic aci-

dosis with a mortality of 30–80%.& Hemodialysis and continuous renal replacement therapy

(CRRT) can be effective and life-saving modalities in themanagement of overdose.

Case Summary: We report the case of a 17 year oldAfrican American male, who presented with abdominalpain, emesis, hypertension, tachycardia, and alteredmental status. He had ingested 20 Metformin tablets ofunknown strength belonging to a family member. Thepatient reported experiencing auditory hallucinations pri-or to the intentional ingestion.His initial electrolytes were remarkable for a non-oliguricacute kidney injury and a positive anion gap metabolic acido-sis (MA), with elevated lactic acid. Drug screens were nega-tive. He received boluses of saline and sodium bicarbonate.Five hours later, repeat laboratories revealed worsening MAwith pH 7.05 mmHg, pC02 30.6 mmHg, bicarbonate of8 mmol/L, and base deficit of −21 .3 mmol/L. He becamehypoglycemic (17 mg/dl) and received glucagon anddextrose.Repeat laboratories showed persistent MA and acute re-nal failure. Emergent hemodialysis was begun with ahigh flux filter and standard bicarbonate solution.Hemodialysis was followed by high dose CRRT.CRRT was discontinued 24 h later when the MA re-solved. No rebound was noted. Relevant laboratorychanges are shown in Table 1. Patient was dischargedto inpatient psychiatry with normal creatinine on day 4.

Table 1: Laboratory trends throughout treatment

Conclusion:& High flux hemodialysis followed by CRRT proved an ef-

fective way to clear both Metformin and lactic acid in an

acute overdose and early initiation of treatment could re-verse the morbidity and mortality associated withoverdose.

Normal (or Therapeutic) Values Prior toHemodialysis

After 3 Hours ofHemodialysis

6 Hours of CRRT 24 Hours of CRRT

Blood pH (7.39–7.45 mmHg) 7.16 7.33 7.32 7.35

Blood pC02 (37–45 mmHg) 15 30 35 40

Serum Bicarbonate (22–30 mmol/L) 10 - - 21

Serum Creatinine (0.5–1 mg/d1) 2.18 - - 1.63

Anion gap (12–18) 43 - - 13

Lactic acid (0.7–2.1 mmol/L) >24 9.4 5.5 2.5

Metformin level (1–2 mcg/ml) - 18 6.1 2.2

Pediatr Nephrol (2017) 32:2173–2192 2185

POSTER 16 NUTRITIONAL RESILIENCE FACTORSFOR SURVIVAL IN CHILDREN ON CRRT: ANEXPLORATORYANALYSIS

K.R. Reichmann, M.S. Tavares, A.F. Delgado, A. WatanabeInstitute da Crianc;a, HC School of Medicine- University ofSao Paulo, Brazil

Introduction: Analysis of nutritional approach in pedi-atric patients on hemodiafiltration (HDF) is still scaroe.The aim of the present study was to analyze the corre-lation between nutritional parameters, calorie and pro-tein prescriptions and estimate requirements, and sur-vival of patients on HDF.Methods: Single-center retrospective cohort of patientsadmitted to a PICU who received HDF. Period: 01/01/2015 to 12/31/2015. Exclusion criteria: <24 h on HDFand newborns. Parameters analyzed: nutritional statuson admission (WHO); mid-upper arm circumference(MUAC); modality of diet (parenteral, enteral, mixed);mean and maximum protein and caloric prescription;calor ie (Schof ie ld , RDI, Hol l iday) and prote in(ASPEN, RDI) requirements; biomarkers. SPSS ®was used for statistica l analysis, significance levelof 5%. Analyzed outcome was survival.Results: Thirty patients were included (83.3%), 66.7%males, median age 3.75y (28d-14y), 93.3% on mechan-ical ventilation, 40% submitted to surgery, PRISM IImedian 3.75 (0.7–48), survival rate 40%. Nutritionalstatus: 63.3% eutrophic, 33.3% at risk of overweightor above. MUAC was < p10 in 23.1%. Biomarkers:median albumin 2.7 g/dL, hemoglob in 10.1 g/dL, lym-phocytes 2005/mm3. Diet modality: enteral10%, paren-teral20%, mixed 70%. Estimated nutritional needs weresignificantly differente among the equations: for calorie:Shofield 757.3 kcal/d, Hollyday 1252,2 and RDI 1075.5(p < 0.001); for protein: ASPEN 25.65 g/d, RDI15.72 g/d {p < 0.001). Adequate protein prescriptionwas observed in 47.75% of time and it was higher thancalloric prescription (28.9%), p < 0.001. Observed meancalorie prescription was 39.7 kcal/kg/day and protein1.3 g/kg/day. No find ing was associated with theoutcome.Conclusion: Differences between protein and caloric re-quirements were observed depending on which formulawas chosen. Protein and calorie prescription differedfrom a previous pediatric multicenter study. No ana-lyzed parameter was associated with survival.

Reference: − Zappitelli M, Goldstein SL, Symons JMet al. Protein and calorie prescription for children andyoung adults receiving continuous renal replacement ther-apy: a report from the Prospective Pediatric Continuous

Renal Replacement Therapy Registry Group. Crit CareMed. 2008 Dec;36(12):3239–45.

POSTER 17 OUTCOMES OF PROLONGED CRRT INA PEDIATRIC POPULATION- A SINGLE CENTEREXPERIENCE

Naile Tufan Pekkucuksen, Poyyapakkam Srivaths, MaryWatson, Ayse Akcan Arikan, Joseph Angelo

Background: Continuous Renal Replacement Therapy(CRRT) is the preferred modality to optimize fluid andelectrolyte management as well as nutritional support forchildren who develop acute kidney injury (AKI) in thePediatric Intensive Care Unit {PICU). Paralleling im-proved outcomes in critically ill patients, survival forpediatric A KI has improved. However, some patientsremain too fragile for transition to intermittent renal re-placement therapies and require CRRT for a prolongedperiod of time. Factors impacting outcome in this cohortare not well known.Objective:We aimed to evaluate the factors impactingoutcome in pediatric patients on prolonged CRRT.Methods: This was a retrospective chart review, withdata extracted from patient medical records from 2013to 2016. Prolonged CRRT was defined as continuousCRRT dependence 28 days. Primary outcome was mor-tality. Patients who had wh ite blood cell count (WBC)less than 1500/mm3, diagnosed with any type of canceror received bone marrow transplantation (BMT) wereclassified as immunosuppressed.Results: 36 patients were included, mean age was7.2 ± 6.9 years, 41% were female. Survival rate at hos-pital discharge was 50%. Mean CRRT duration was59.8 ± 34.1 days. Most common PICU admission rea-son was respiratory failure 28%, most common CRRTindication was AKI 67% (24/36). Mean days in PICUbefore CRRT initiation was 3.7 ± 4.9 days. 47% {17/36) met the criteria of immunosuppression by studydefinit ion. PELOD at CRRT initiation (OR 1.07 95%Cl 1.01–1.15;p = 0.026), CRRT indication (OR0.25,95% Cl 0.07–0.82;p = 0.024) and immunosuppres-sion (OR 17.50 95% 3.31–92.47;p = 0.001) were allassociated with mortality. Fluid overload at CRRT initi-ation, age, cause of AKI, time to CRRT initiation werenot associated with mortality. In multivariate analyses,immunosuppression was the only independent prexdictorof mortality (OR 9.34 (95% Cl1.43–60.85; p = 0.019)when controlled for age, CRRT indication, and PELOD.Conclusion: Immunosuppression status at CRRT initiationwas associated with an increased risk for mortality amongpatients who received prolonged CRRT.

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POSTER 18 THE CRRT DASHBOARD: UTILIZINGSOFTWARE ENGINEERING TO PROVIDE ACCESSTO MULTIMODAL DATA

1BH Keith, 2 J Lusk,2KM Gist,2 T Stidham, 1, 2DE Soranno1University of Colorado, Dept of Bioengineering; 2Universityof Colorado, Dept of Pediatrics

Introduction: Continuous Renal Replacement Therapy(CRRT) is a complex life-saving therapy involving multiplevariables that affect circuit life and patient outcomes.Combining manually extracted data from the electronic healthrecord (EHR) with stored data from the machine has not beenfeasible, thus inherent difficulty exists in identifying both pa-tient and circuit related factors that impact overall outcomes.The purpose of this pilot study was to demonstrate the feasi-bility of an automated EHR extraction and integrate it with thePrismaflex™machine data.Methods: As a proof of concept, patient data from patientsundergoing CRRT from 2012 to 2016 was combined withpump functional data from the Baxter Prismaflex™.APython™script was then used to scrub data and place it in alocally housed PostgreSQL™database. This data was con-nected to a TableauTM dashboard allowing for dynamic view-ing and analysis of correlated patient-machine data.Results: A combination database was successfully created in-corporating a total of 7,977,878 variables, 205,910 from ourEHR ’s CRRT f l ow s h e e t a n d 7 , 7 7 1 , 9 68 f r omPrismaflex™machines. The data dashboard incorporated hu-man and machine data to assess multiple functional parametersand outcomes, and could also be used across multiple institu-tions. Metrics such as circuit life and error summaries can beviewed, sorted, and analyzedwithin the views of the dashboard.Conclusion: We have shown feasibility in combining EHRand Prismaflex™data in order to evaluate a variety of metricsfor individual patients and for comparison amongst patients.This has the potential to enhance both clinical research andquality improvement.The versatility of the database andPythonTM script make it easy for use across centers to com-bine data and create a more robust database to assess CRRTmetrics and outcomes.13,123 E 16th Ave, Aurora, CO 80045Danielle.Soranno@childrenscolorado.org

POSTER 19 COMPARISON OF PRESCRIBEDVERSUS DELIVERED DOSE IN CONTINUOUSRENAL REPLACEMENT THERAPY

N.Celebi1, R. Lion2, P. Srivaths1, J. Angelo1, S. Swartz1,M. Braun1, A. Akcan-Arikan1, 21Section of Nephrology, Department of Pediatrics, BaylorCollege of Medicine, Houston, Texas; 2Section of Critical

Care Medicine, Department of Pediatrics, Baylor College ofMedicine, Houston, Texas

Introduction: Recommended continuous renal replacementtherapy (CRRT) dose in pediatric patients is 2000 ml/1.73 m2/h. Delivered dose may differ from prescribed dose due tounintended interruptions in treatment. In addition, use ofprefilter hemodilution, standard of care in our institution, de-creases solute clearance, and thus actual dose delivered. Dataon delivered dose in pediatric CRRT patients are scarce. Wehypothesized that actual delivered dose and urea clearance(UCL) will be less than prescribed in prefilter dilution contin-uous venovenous hemodiafiltration (CVVHDF).Methods:We performed a single center prospective observa-tional study of patients requiring CVVHDF. All patients weretreated with scale based machines using polyarylethersulfonefilters, prefilter hemodilution, and regional citrateanticoagulation. Clearance was prescribed as 50% convectiveand 50% diffusive. Data was collected from 16 patients, 35filters over 5 days. Effluent urea nitrogen (FUN) and bloodurea nitrogen {BUN) were measured at the start oftreatmentand every 24 h. Prescribed UCL was derived from effluentvolume; actual UCL was calculated as {FUN/BUN) x UCL.Prescribed and delivered dose were calculated similarly (pre-scribed dose = effluent rate (ml/kg/h), delivereddose = [{(FUN/BUN) × 24 h effluent volume)/24/weight]).Results: Mean filter life was 51 ± 28 h, mean average FUN/BUN ratio was 0.81 ± 0.1. Mean daily CRRT time was19 ± 6 h. Mean prescribed and actual doses were 96 ± 69 ml/kg/h, and 89 ± 70 ml/kg/h, respectively (p < 0.004).Prescribeddose overestimated actual dose by 19%. Prescribed UCL washigher than actual UCL (prescribed UCL = 25 ± 10 ml/min vsactual UCL = 21 ± 8 ml/min]; p < 0.0001).Conclusion: In predilutionCVVHDF, prescribed dose andUCLoverestimate the actual delivered dose and UCL. FUN needs tobe monitored regularly for accurate calculation of dialysis dose.

POSTER 20 CREATING HIGH LEVEL RNCOMPETENCE IN DELIVERING CONTINUOUSRENAL REPLACEMENT THERAPY

C.A. Peck BSN, RN, CCRNHasbro Children’s Hospital, Providence, Rhode Island

Introduction:A parent’s apprehension of having a critically illchild in the pediatric intensive care unit (PICU) is far reaching.Two cases of continuous renal replacement therapy (CRRT)will be described to capture the contrast between a failed at-tempt to implement and maintain CRRTand a subsequent suc-cessful run. Opportunities for improvement were identifiedresulting in enhancement of the current competency programwithin the framework of patient and family centered care.

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Case Summaries: With case one, CRRT with citrateanticoagulation was initiated on a 4 year old with acute kidneyinjury with a small femoral catheter. After multiple attempts,CRRT was abandoned without harm to the patient; howeverthere was a troubling parental perception of staff incompe-tence and lack of trust. A team consisting of representativesfrom medicine, nursing, pharmacy, quality and risk was as-sembled to address concerns within the existing program.Problematic areas included policy and procedure, equipment,documentation, education and resources.Case two was a 19 month old patient with nephrotic syndrome.Feedback and recommendations from the analysis of case onealong with consultation from national experts were integratedinto the patient’s plan of care. Noted differences between caseone and case two included heparin anticoagulation, a largerinternal jugular catheter, and a deliberate mindfulness of paren-tal presence fostering communication and partnering. After atwo week CRRT run, the patient was successfully decannulatedand discharged home soon after.Conclusion: Within an eighteen month time frame, the nurseCRRT competency in the pediatric intensive care unit in-creased from 23% to 90%. Proficient CRRT nurses workeddirectly with novice nurses to foster development and easeanxiety. A pediatric specific order set, heparin and citrate pro-tocols were implemented. The second case reengaged,reenergized and recommitted the staff. This ultimately led toan optimal patient outcome and a highly satisfied family.

POSTER 21 RISK OF CKD AFTER CRRTAND ECMO

R. Bholah, MD, C.D.W. Kaspar, MD and J.C. John, MDDepar tmen t o f Ped ia t r i c Nephro logy, Vi rg in iaCommonwealth University 1000 East Broad Street,P.O. Box 980,498, Richmond VA 23298;Tel.: 804–827-2264

AKI associated with VA ECMO has been recognized in theliterature and is thought to be multifactorial in relation to lackof pulsatile flow, hemolysis, and activation of inflammatorystates. Traditionally, these insults have been thought to be tran-sient but recent literature shows that a proportion of these chil-dren progress to CKD [1]. We report on our center’s experiencewith pediatric ECMOwith regards to factors pertaining to CKD.Over the course of 3 years (2015–2017), we have had a total of45 patients who required VA ECMOwith 27% of these patientsrequiring CRRT. At time of discharge, all patients were normo-tensive with 19% on anti-hypertensive medications. Proteinuriawas assessed at time of discharge on 26% (7 patients), and allbut one had significant microalbuminuria (196–2755 mg/g).None of the patients were placed on ACE inhibitors. Given thatthese patients have risk factors for progression to CKD, wepropose that all patients on ECMO should be evaluated at thetime of discharge with a baseline serum creatinine, urine micro-

albumin and appropriate blood pressure assessment. Long-termfollow up is warranted to assess progression ofCKD.

References1. Zwiers AJM, IJsselstinjn H, van Rosmalen J, Gischler SJ,de Wildt SN, Tibboel D, et al. CKD and Hypertension duringLong-Term Follow-Up in Children and AdolescentsPreviously Treated with Extracorporeal MembraneOxygenation. Clin J Am Soc Nephrol 9(12):2070–2078.

POSTER 2 2 COMPL ICAT IONS DUR INGEXTRACORPOREAL BLOOD PURIFICATIONTHERAPY FOR NEONATES

S. Nishimi, K. Ishikawa, H. Sugawara, T. Yamamoto, M.Sasaki, H. Furukawa, K. OyamaDepartment of Pediatrics, School of Medicine, lwate MedicalUniversity; 19–1 Uchimaru, Morioka, lwate 020–8505, Japan;Corresponding author: Ken Ishikawa, Department of Pediatrics,School of Medicine, lwate Medical University; 19–1 Uchimaru,Morioka,]wale 020–8505, Japan; Tel: +8 1–19–651-5111; Fax:+81–19–651-0515; E-mail: kenishi@iwate-med.ac.jp

Introduction: Neonates often undergo extracorporealblood purification therapy (eBPT) thanks to advancesin practical skills and technical innovations in devicesfor eBPT. However, complications sometimes arise.Therefore, we aimed to determine complications thatarise during eBPT in neonates to establish safety stan-dards. Met/rods: This retrospective study reviewed theclinical courses of neonates who received eBPT in ourneonatal intensive care unit (NICU) between 2009 and2017 to identify complications. All data are presented asmedians (range).Results: Eight neonates with a median body weight of 2333(1.462–3288) g and a gestational age of 37 (33–41) weeksunderwent 70 eBPT sessions due to volume overload(n = 3), metabolic acidosis (n = 2), hyperammonemia(n = 2), and hyperkalemia (n = 1). Hypotension comprising7 (3–25) mmHg was evident at the start of 40 (57%) eBPTsessions. Hypothermia occurred during nine sessions, whenbody temperature fell by 0.9 °C (0.5 °C - 1.8 °C).Thrombocytopenia occurred in all neonates after eBPT. Theinitial platelet count of 239,000 (76,000–430,000)/ L de-creased by 138,500 (29,000–332,000)/ L to 78,000 (20,000–122,000)f!,tL.Conclusion: Frequent complications that developed dur-ing eBPT in neonates comprised initial hypotension, hy-pothermia, and thrombocytopenia. These complicationsneed to be recognized so that appropriate preparationscan be established to improve and standardize the safetyof eBPT for neonates.

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POSTER 23 PEDIATRIC INTRADIALYTICHYPOTENSION: A SYSTEMATIC REVIEW

Vinod Krisbnappa1, Prashanth Vijayaraghaven1, NishaNangethu1, Michael J. Ensley2, Sidarth Kumar Sethi3,Rupesh Raina41Cleveland Clinic Akron General/Akron NephrologyAssociates, Akron, Ohio, USA; 1Department of PoliticalScience, Kent State University, Kent, OH, USA;3KidneyInstitute, Medanta, The Medicity Hospital, Gurgaon.Haryana, India;4Department of Nephrology, ClevelandClinic Akron General and Akron Children’s Hospital, Akron,Ohio, USA

Background: Intradialytic hypotension (IDH) is commonlyencountered in pediatric patients that receive hemodialysis(HD) sessions lasting 4 h. Unfortunately, our etiological un-derstanding of pediatric IDH is largely derived from studiesconducted in adult patients.Moreover, performing HD in pediatric patients poses uniquechallenges directly related to patient size, difficult in attainingvascular access and hemodynamic instability. Inunediately ad-dressing episodes of IDH is important to curtail symptomseverity as well as prevent increased risk of mortality. Thepurpose of this study was to systematically review publica-tions discussing IDH in pediatric patients, and preventativemeasure taken in the particular patient population.Methods: PubMediMEDLINEwas searched for the tenns “he-modialysis” and “hypotension”, with the word “peritoneal”excluded. The Medical Subject Heading (MeSH) tenns in-cluded hypotension, infant, child, or adolescent, again withthe word “peritoneum” excluded. 183 potential matches werereturned, of which I0 met inclusion and exclusion criteria.Results: The total number of subjects across the ten selectedstudies was 148 with ages ranging from 2 days- 18 years old,patient weight ranged from 3.2 kg to 61.4 kg. Non-invasiveblood monitoring (NIVM) was implemented with HD in 65%of patients. Ultrafiltration (UF) strategies were not unifonnacross all studies. UF either remained constant throughoutstudy duration or UF profiles were implemented based onchanges observed in dry weight. Similar to UF, sodium levelswere not synonymous across studies and either remained con-stant or sodiwn ramping in linear and/or stepwise fashion wasobserved. Although not reported in all studies, percent fre-quency of hypotensive events ranged from 19.6%–75%, withlower percentages observed in patients who received NNMduring HD.Conclusion: Among studies reviewed, use of NIVM washelpful in achieving appropriate dry weight as well aspredicting and preventing intradialytic adverse events suchas hypotension.Although such findings appear significant, studies reviewedhere had small patient populations and relatively short

study durations. Therefore, future studies involving larg-er study populations and more in depth examination ofNIVM utilization with the goal of reducing episodes ofintradialytic hypotension will be necessary in detenniningthe effectiveness of this approach in HD therapy in pe-diatric patients.

POSTER 24 GOING FROM THE DEVIL YOU KNOWTO THE DEVIL YOU DON’T: TRANSITIONINGACTIVATED CLOTIING TIME MONITORS INHEPARINIZED PEDIATRIC CONTINUOUS RENALREPLACEMENT THERAPY. A COMPARISON OFSIDE BY SIDE MONITORING IN A CRRT PATIENT

M. R. Meyers MD & L. Copelovitch MDDivision of Pediatric Nephrology, Children’s Hospital ofPhiladelphia

Introduction:Maintaining valid and specific measurementsof anticoagulation is paramount to sustaining a heparinizedcontinuous renal replacement therapy (CRRT) circuit.Given the need for close monitoring, bedside point-of-careinstruments are often used to measure activated clottingtime (ACT). As newer models with improved accuracycome on the market, it is important to compare the differ-ences between older (reference) models to ensure adequateanticoagulation during transition. Recently our centertransitioned to a new point-of-care ACT monitoring system.Quality control measures conducted internally and by themanufacturer found a negative bias of 23–28 s between theolder Hemochron ® Response model (reference) and thenew Hemochron® Signature Elite on a combined sampleof hemodialysis and CRRT patients. These values felllargely within the standard norms our center’s publishedACT guidelines. Benefits of the new system include lowerrisk for user error and a 50% reduction in required bloodvolumes for testing.Recent quality improvement efforts highlight that despitenearly twenty years of work, care of CRRT for acute kidneyinjury remains poor with increased risk for morbidity andmortality due to iatrogenic complications and suboptimalquality of care during critical illness. Given the risk of bothbleeding and clotting, anticoagulation during CRRT must becarefully monitored to find the “Goldilocks zone.” Well-monitored transitions in point-of-care ACTs systems can helpreduce morbidities and potential mortality. Previous studieshave compared activated partial thromboplastin time (aPTI)and anti-Xa levels in other populations to assess the accuracyand validity of bedside point-of-care ACT testing. To ourknowledge, this is the first report to discuss monitoringmethods-based variability in ACT point-of-care systems dur-ing transition in a pediatric CRRT patient.

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Case Summary: An 11 year old female with history of cerebralpalsy, mitral valve insufficiency, Asperger’s syndrome, attentiondeficit disorder, and cyclic vomiting presented in shock andmultiorgan failure secondary to presumed sepsis. Early in hercourse she developed acute kidney injury attributed to hypoten-sion and nephrotoxic agent exposures (Toradol and vancomycin)and sustained significant volume overload during early resuscita-tion efforts. Given her underlying cardiac dysfunction, she wasinitiated on ECMO treatment on hospital day #3. Continuousvenovenous hemodiafiltration (CVVHDF) was subsequently ini-tiated in response to volume overload, hyperkalemia and meta-bolic acidosis. CVVHDF was performed on a Prismaflex withM100 dialyzer, blood pump speed 330 milliter (ml)/minute, dial-ysate 800 ml/h(hr), pre blood pump replacement fluid rate of550ml/h and replacement rate of 250ml/h. Initial anticoagulationgoals were determined by ECMO protocol until removal fromECMO circuit after 5 days. At that time ECMO cannulas wereexchanged for a 12 French triple lumen right internal jugulardialysis catheter. She was initially transitioned to citrateanticoagulation due to significant bleeding. The following day,the decision to switch back to heparin was made to treat an oc-clusive thrombus of the right common femoral and external iliacveins. Goals for systemic anticoagulation (PTI 60–85, anti-Xa0.3–0.7) were established in conjunction with hematology in or-der to both treat the thrombus and maintain circuitanticoagulation.Paired ACTs were assessed on the new Hemochron®Signature Elite and reference Hemochron® Response instru-ments hourly while on the heparinized circuit. A total of 22simultaneous comparisons were performed over two hospitaldays. One time point was excluded as the reference value wasnot available for comparison; this left 21 samples for analysis.The mean ACT of Hemochron® Response (reference) was205.3 ± 14.3 s whereas the mean Hemochron® SignatureElite (new instrument) was 165.8 ± 16.6 s. A mean differenceof 38.7 ± 21.8 was noted between paired samples.Conclusion: These data represent values obtained from pairedsamples over two hospital days on a single patient undergoingCRRT through a heparinized circuit. These results are consis-tent with prior hemodialysis data and suggest a systematicnegative bias when comparing ACT levels on theHemochron ® Response model and the Hemochron®Signature Elite instrument. In our center standard ACT goalsare set as 180–220 s or tight control as 180–200 s. A meandifference of 38.7 s occupies nearly the full range of standardanticoagulation guidelines and is almost twice the range oftight ACT goals. More cases are needed to assess whetherinter-individual results have similar variability and to assesswhether our traditional ACT target ranges should berecalibrated to accommodate the new monitoring system.This case highlights the importance of careful observationwhen transitioning from one bedside point-of-care model toanother.

References1. Rewa 0, Mottes T, Bagshaw SM. Quality measures foracute kidney injury and continuous renal replacement therapy.Curr Opin Crit Care. 2015; 21(6):490–9.2. Racioppi L, Quinart A, Biais M, Nouette-Gaulain K, RevelP, Sztark F. Validation of a bedside activated clotting time test(Hemochron Jr. II Signature) with low dose heparin therapy.Anaesthesia .2009; 64(4):430–4.

POSTER 25 CIRCUIT TO PATIENT, PATIENT TOCIRCUIT INFLUENCES ON CRRT QUALITY DATA

T. Fulkerson, P. Yorgin, S. Miller-HooverTracy Fulkerson, BSN RN CCRN Rady Children’s HospitalSan Diego 3020 Children’s way MC 5067; San Diego, CA92123 Nursing Supervisor; Pediatric Intensive Care UnitPh: (858) 966–4070; Fax: (858) 966–8055; Pgr: (858)494–6453; tfulkerson@rchsd.org

Introduction: Pediatric patients requiring CRRT are tenuousdue to hemodynamically instability inherent in the diseaseprocesses. Hemodynamic instability can be aggravated by flu-id shifts caused by the initiation of CRRT and filter changes.One method used to reduce instability in pediatric CRRT pa-tients are blood primes, however, the use of stored bloodproducts preserved with citrate often alters the patient’s calci-um and pH levels. Increased therapy time is essential toreaching treatment goals.Methods:Our center began using a procedure called circuit topatient, patient to circuit for scheduled filter changes. FromJanuary 1, 2016 to date 23 patient cases with a total of 235 rundays were reviewed for trends in hemodynamic stability, ther-apy downtime, and blood product exposure.Results: Patients were exposed to less blood bank products.Scheduled filter changes could completed within 5 min andhave no downtime. Therapy time increased. Hemodynamicstability during filter changes increased. Center averages forfilter life is above Baxter benchmark.Conclusions: There is limited data-driven evidence in pediat-rics regarding best practice for scheduled filter changes. Ourobserved trends warrant further research to evaluate potentialoutcomes associated with circuit to patient, patient to circuitchange method.

ReferencesThere is very limited research on the evaluated criteria forpatient stability with circuit changes.1. Eding D, Jelsma L, Metz C, Steen V, Wincek J.

Innovative Techniques to Decrease Blood Exposure andMinimize Interruptions in Pediatric Continuous RenalRep lacement Therapy. Cr i t i ca l Care Nurse .2011;31(1):64–71.

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2. Mottes T, Patel U, Gardner J, Kudelka T, Brophy P.Dualing Prismas: Blood Priming in Pediatric CRRT.Blood Purification. 2003;21: 183–207.

POSTER 26 RISK FACTORS AND OUTCOME FORACUTE KIDNEY INJURY {AKI} IN PAEDIATRICACUTE LIVER FAILURE{PALF)

Romit Saxena, Akash DeepPaediatric Intensive Care Unit, King’s College Hospital,London, UK

Background: Patients with acute liver failure (ALF) areknown to have acute kidney injury(AKI)l, but there ismarked paucity of paediatric data on aetiopathogenesis.In light of recent advances in understanding of paediat-ric AKI in non-liver failure patients, we used the currentliterature and renal indices to find the risk factors andaetiology of AKI in ALF in a large tertiary paediatricliver ICU.Aim: A retrospective case review to analyse the incidence,aetiology, ICU course and outcome of acute kidney injury inPALF patients.Material and methods: All patients with PALF as defined bythe US paediatric acute liver failure group admitted to thePICU from 2012 to 2016 were studied. Data was collectedin a prospective paediatric Acute liver failure registry main-tained at King’s College Hospital, london. We analysed theirdemographic, clinical, biochemical details and followed theirICU course for the first 7 days of stay • We looked at theirprogression to AKI (as classified by KDIGO classification)during this period, and analysed the risk factors leading tothe causation, including final outcome.Results: 30% of children with PALF (n = 52) had AKIat admission .80% of these were pre-renal, with 60%having received fluid resuscitation before arrival intoPICU. Mean vasoactive infusion score(VIS) at arrivalwas 10 and mean fluid overload % on day 1 was45%. Majority of patients (average age:4.2 years) hadhepatic encephalopathy stage 3−/4 at arrival with mostcommon aetiology being interdeterminate. The meanPIM 2 score at admission to the PICU was 29 and theirrenal angina index2 at arrival was 10.The incidence of AKIwas highest in liver disease ofmetaboliccause(S/10 patients) and infective aetiology(4/8 patients), re-spectively, as compared to those with indeterminatecause(S/23 patients).Majority of the ICU admissions receivednephrotoxic drugs(69%, 36/52 patients), which were predom-inantly antibiotics.AKI (at arrival:16/52 patients), had resolved in most pa-tients by day 4 of ICU stay (81%)(13/16). 13/52 patientsdeveloped new onset AKI in the first week of admission,

which also subsequently resolved. Majority of patientshad significant renal angina index at arrival (46/52), butof these only 43.5%(20/46), had AKI on day 3 • Onethird of the patients admitted (32.9%), underwent livertransplant.Patients with AKI had an average PICU stay of17 days(with 10 days of mechanical ventilation), whichwas not very different from non AKI patients(15 daysPICU stay, and 10 days ventilation). Maximum creatinineduring course of stay was observed on day 4, but themaximum change in serum creatinine was observed inthe first 24 h, associated with high VIS scores, degreeof fluid resuscitation and net fluid overload. Most patientswere discharged alive (67%) with none of them requiringdialysis or being listed for renal transplantation at dis-charge. Mortality rate was comparable in the AKI group(6/16;37.5%) and non AKI groups (ll/36;30.6%).Conclusion: Children with ALF, develop transient AKI,which does not usually progress to chronic kidney dis-ease. Children with underlying metabolic liver diseaseand infective aetiologies, were more predisposed to de-velop AKI, than those with indeterminate aetiologies.The aetiology of AKI in ALF is multifactorial, andmaybe due to pre-renal and renal causes (drugs, inotropes).Existing scores need to be adapted to Aki to ALF, to makethem more predictive.

References1. Tujios S.K., Hyman S.L. et al., Risk Factors and

Outcomes of Acute Kidney Injury in Patients WithAcute Liver Failure. Clinical gastroenterology andhepatology.(Feb,2015) 13(2): 352–359.

2. Basu RK, Zappitelli M. Derivation and validation of therenal angina index to improve the prediction of acute kid-ney injury in critically ill children. Kidney International(2014) 85: 659–667

POSTER 27 CASE REPORT: PATIENT WITH ATIPICUREMICHEMOLITIC SYNDROMEANDNEFROTICS Y N D R O M E , E F F E C T I V E N E S S O FHAEMOPHILTRATION AND ECULIZUMAB

Gaston Castillo CanoEmail: gastonemd@hotmail.es; gastonedgardo74@gmail.com

Patient who has 1 years and 8 months, has dx of nefroticsyndrome, had no renal biopsy, but has had several reasons,the patient was in such a general status in april, of 2016, thepatient entered by respiratory failure and also by failure acuterenal renal, also presents:edemarenal failuretrombocytopeniaand anemia

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The patient is considered to have a trombotic microangiopathyand makes a hypolic uremic atipic syndrome:has hb of 8plots of 50,000 and today are at 80000has ldh of 880direct negative coombs and this anurityPeritoneal dialysis is decided to be started, for two days, but,the patient present dysfunction of the catheter and after presentperitonitis.

After venous venous haemophiltration is placed and continuesto improve plasmaferesis placed, but in the third section, thepatient was in shock and almost dies.After the diagnosis of uremic hemolitic syn rome, hewas placed eculizumab, after hemorragic cystitis pres-ent, but this was by a candidury, the patient, improvedof all this and in these moments, recovered the renalfunction.

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