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      Acute Kidney Injury and Special Considerations during Renal Replacement Therapy in Children with Coronavirus Disease-19: Perspective from the Critical Care Nephrology Section of the European Society of Paediatric and Neonatal Intensive Care

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          Abstract

          Children seem to be less severely affected by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) as compared to adults. Little is known about the prevalence and pathogenesis of acute kidney injury (AKI) in children affected by SARS-CoV-2. Dehydration seems to be the most common trigger factor, and meticulous attention to fluid status is imperative. The principles of initiation, prescription, and complications related to renal replacement therapy are the same for coronavirus disease (COVID) patients as for non-COVID patients. Continuous renal replacement therapy (CRRT) remains the most common modality of treatment. When to initiate and what modality to use are dependent on the available resources. Though children are less often and less severely affected, diversion of all hospital resources to manage the adult surge might lead to limited CRRT resources. We describe how these shortages might be mitigated. Where machines are limited, one CRRT machine can be used for multiple patients, providing a limited number of hours of CRRT per day. In this case, increased exchange rates can be used to compensate for the decreased duration of CRRT. If consumables are limited, lower doses of CRRT (15–20 mL/kg/h) for 24 h may be feasible. Hypercoagulability leading to frequent filter clotting is an important issue in these children. Increased doses of unfractionated heparin, combination of heparin and regional citrate anticoagulation, or combination of prostacyclin and heparin might be used. If infusion pumps to deliver anticoagulants are limited, the administration of low-molecular-weight heparin might be considered. Alternatively in children, acute peritoneal dialysis can successfully control both fluid and metabolic disturbances. Intermittent hemodialysis can also be used in patients who are hemodynamically stable. The keys to successfully managing pediatric AKI in a pandemic are flexible use of resources, good understanding of dialysis techniques, and teamwork.

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          Most cited references 41

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          Detection of Covid-19 in Children in Early January 2020 in Wuhan, China

          To the Editor: A small number of cases of coronavirus disease 2019 (Covid-19) have been described in children, 1,2 and our understanding of the spectrum of illness is limited. 3 We conducted a retrospective analysis involving hospitalized children in Wuhan, China. From January 7 to January 15, 2020, a total of 366 hospitalized children (≤16 years of age) were enrolled in a retrospective study of respiratory infections at three branches of Tongji Hospital, which are located 14 km to 34 km from one another in central Wuhan (Fig. S1 in the Supplementary Appendix, available with the full text of this letter at NEJM.org). The study was approved by the ethics committee of Tongji Hospital. Among the 366 children, the most frequently detected pathogens were influenza A virus (in 23 patients [6.3%]) and influenza B virus (in 20 [5.5%]). SARS-CoV-2, the virus that causes Covid-19, was detected in 6 patients (1.6%). Informed consent was obtained from the parents or guardians of the patients with Covid-19 for the publication of their clinical data. The dates of illness onset in the six patients with Covid-19 were between January 2 and January 8, 2020, and the patients were hospitalized between January 7 and January 13 (Fig. S2). Details of the study methods are provided in the Supplementary Appendix. The median age of the six patients was 3 years (range, 1 to 7) (Table 1). All six children had previously been completely healthy. Common clinical characteristics included high fever (>39°C) (in all six patients), cough (in all six), and vomiting (in four). Laboratory investigations showed that the levels of lymphocytes, white cells, and neutrophils were below the normal range in six, four, and three patients, respectively. Four of the six patients had pneumonia, as assessed radiographically, with computed tomographic scans of the chest showing typical viral pneumonia patterns (Fig. S3). One child was admitted to the pediatric intensive care unit (ICU) and received pooled immune globulin from healthy donors. All the patients were treated empirically with antiviral agents, antibiotic agents, and supportive therapies. All the patients recovered after hospitalization for a median of 7.5 days (range, 5 to 13). This study showed that Covid-19 occurred in children, causing moderate-to-severe respiratory illness, in the early phase of the SARS-CoV-2 outbreak in Wuhan and was associated with ICU admission in one patient. None of the patients or their family members had had direct exposure to Huanan Seafood Wholesale Market (the initial location to which cases of Covid-19 were linked) or to one another. It is worth mentioning that we unexpectedly found a case of Covid-19 in one patient (Patient 3) who resided outside Wuhan; this patient had illness onset on January 2, 2020. The patient and her family were residents of the Yangxin area of Huangshi and had not traveled outside the city in the month before illness onset. We have not identified the source of infection for this patient. Our findings indicate that SARS-CoV-2 infections in children were occurring early in the epidemic. 4
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            Multi-centre evaluation of anticoagulation in patients receiving continuous renal replacement therapy (CRRT).

            Heparin (hepACG) and regional citrate anticoagulation (citACG) remain the most commonly reported continuous renal replacement therapy (CRRT) ACG methods employed. No prospective multi-centre published data exist that compare different ACG methods with respect to CRRT filter life span or patient complications. A total of 138 patients from seven US centres receiving 18 208 h of CRRT comprising a total of 442 CRRT circuits were utilized to assess filter life span and ACG-related complications in patients receiving CRRT with hepACG, citACG or no ACG (noACG). Mean circuit life was 41.2+/-30.8 h. Mean circuit survival was no different for circuits receiving hepACG (42.1+/-27.1 h) and citACG (44.7+/-35.9 h), but was significantly lower for circuits with noACG (27.2+/-21.5 h, P<0.005). Kaplan-Meier analyses revealed no survival difference between hepACG and citACG circuits, but significantly lower survival for noACG circuits (P<0.001). Log-rank analysis showed that 69% of hepACG and citACG circuits whereas only 28% of noACG were functional at 60 h. Clotting rates were similar for hepACG circuits (58 out of 230, 25%) and citACG circuits (43 out of 158, 27%), but were significantly higher for noACG circuits (27 out of 54, 50%, P < 0.001). Life-threatening bleeding complications attributable to ACG were noted in the hepACG group but were absent in the citACG group. The current analysis represents the largest evaluation of CRRT ACG methods to date. While the standard hepACG and citACG methods studied in the prospective paediatric CRRT registry led to similar filter life spans and were superior to noACG, our data suggest that citACG may result in less life-threatening complications.
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              Use of peritoneal dialysis in AKI: a systematic review.

              The role of peritoneal dialysis in the management of AKI is not well defined, although it remains frequently used, especially in low-resource settings. A systematic review was performed to describe outcomes in AKI treated with peritoneal dialysis and compare peritoneal dialysis with extracorporeal blood purification, such as continuous or intermittent hemodialysis.
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                Author and article information

                Journal
                Blood Purif
                Blood Purif
                BPU
                Blood Purification
                S. Karger AG (Allschwilerstrasse 10, P.O. Box · Postfach · Case postale, CH–4009, Basel, Switzerland · Schweiz · Suisse, Phone: +41 61 306 11 11, Fax: +41 61 306 12 34, karger@karger.com )
                0253-5068
                1421-9735
                14 July 2020
                : 1-11
                Affiliations
                aPaediatric Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, United Kingdom
                bPediatric Intensive Care Unit, SPS Hospitals, Ludhiana, India
                cPediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
                Author notes
                *Akash Deep, Consultant Intensivist, Paediatric Intensive Care Unit, 3rd Floor, Cheyne Wing, King's College Hospital, Denmark Hill, London SE5 9RS (UK), akash.deep@ 123456nhs.net
                Article
                bpu-0001
                10.1159/000509677
                7445370
                32663827
                Copyright © 2020 by S. Karger AG, Basel

                This article is made available via the PMC Open Access Subset for unrestricted re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the COVID-19 pandemic or until permissions are revoked in writing. Upon expiration of these permissions, PMC is granted a perpetual license to make this article available via PMC and Europe PMC, consistent with existing copyright protections.

                Page count
                Tables: 2, References: 56, Pages: 11
                Categories
                Review

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