CARPEDIEM® for continuous kidney replacement therapy in neonates and small infants: a French multicenter retrospective study

Pediatr Nephrol. 2023 Jan 10. doi: 10.1007/s00467-022-05871-0. Online ahead of print.

Jennifer Battista et al.

Reviewed by: Tom Forbes

BACKGROUND

CARPEDIEM (Cardio-Renal Pediatric Dialysis Emergency Machine) is one of a number of extracorporeal continuous kidney replacement therapy (CKRT) devices specially designed for neonates and small infants in critical care settings, where the adaptation of standard adult machines for small infants is limited by high priming volumes, slow flows, vascular access challenges and accuracy of ultrafiltration volumes. Whilst acute peritoneal dialysis (PD) can be performed in neonates and infants, there are distinct advantages to CKRT that make it attractive in the AKI setting or as a bridging therapy for CKD patients with PD complications or temporary contra-indications.

This represents the fourth report of outcomes for the CARPEDIEM machine, which retrospectively assessed the 131 sessions for 25 neonates/infants across 5 centres in France. Of note, this is the first report published by a group other than the original developers of the machine.

THE COHORT

Similar to previous reports, and not unexpected given relative infrequency of use, the presented cohort is a heterogenous mix of patients suffering from: AKI with fluid overload (60%); CKD5 with temporary PD problem (20%); hyperammonaemia due to inborn error of metabolism (IEM, 12%); and refractory dyselectrolytaemia (8%). The median (IQR) age was 4 days old (2-13) and weight was 3.3 kg (2.5-4.0).

RESULTS/MAIN LEARNING POINTS

CVVH was provided to most patients and CVVHD in three. Half of patients were treated through a catheter <6Fr size and the majority were treated via the IJV (72%) or left subclavian (20%). Individual blood flow rates are not provided, but the cohort median was 8 ml/kg/min (IQR 6-9, range 3-16). 88% were systemically anticoagulated with heparin. Monitoring of heparin was not discussed but there were no haemorrhagic complications. The most common complications were haemodynamic instability (23% of sessions), circuit clotting (19%) and catheter dysfunction (2%).

Fluid removal was the goal of therapy for at least 60% of infants, yet must have been difficulty to assess retrospectively as it was not presented as an outcome measure. Solute clearances were adequate in the case of potassium but impressive in the case of ammonia for patients with IEM.

Whilst all patients survived their time on CARPEDIEM, two thirds of the cohort died from their primary disease prior to discharge, which is similar to previous reports.(1-3)

SIGNIFICANCE

This article validates the published experience with this novel technique, informing decision making for its future application. Neonatal CKRT is now in regular use across many centres, and whilst it is reassuring to see efficacy in achieving clearance and UF, the accumulating data illustrates an ongoing high mortality from non-renal disease in spite of CKRT therapy. The data from these early studies will inform research questions pertaining to the utility of machines such as CARPEDIEM in more homogenous cohorts (eg. post-cardiac surgery) as well as in comparison to existing standards of care such as PD or non-neonatal CKRT machines. These studies are starting to enter the literature.(2)

  1. Garzotto F, Vidal E, Ricci Z, Paglialonga F, Giordano M, Laforgia N, et al. Continuous kidney replacement therapy in critically ill neonates and infants: a retrospective analysis of clinical results with a dedicated device. Pediatr Nephrol. 2020;35(9):1699-705.
  2. Goldstein SL, Vidal E, Ricci Z, Paglialonga F, Peruzzi L, Giordano M, et al. Survival of infants treated with CKRT: comparing adapted adult platforms with the Carpediem™. Pediatr Nephrol. 2022;37(3):667-75.
  3. Vidal E, Cocchi E, Paglialonga F, Ricci Z, Garzotto F, Peruzzi L, et al. Continuous Veno-Venous Hemodialysis Using the Cardio-Renal Pediatric Dialysis Emergency MachineTM: First Clinical Experiences. Blood Purif. 2019;47(1-3):149-55.