Workshop 2 - Session F
Abstract List
20 Sep 2026
14:00
15:30
Room 103
Pediatric Extracorporeal Therapies: From Basics to Advanced Clinical Challenges
I-Jung TsaiTaiwan
Moderator
Beyond Renal Replacement: Advanced Extracorporeal Blood Purification in Pediatric SepsisSepsis and hyperinflammatory syndromes remain leading causes of mortality in critically ill children, frequently complicated by multiorgan dysfunction syndrome and acute kidney injury. While continuous kidney replacement therapy (CKRT) is the cornerstone for managing fluid overload and solute clearance, standard modalities cannot adequately address the underlying dysregulated immune response driven by a profound cytokine storm. Recently, a significant paradigm shift has occurred in critical care nephrology, transitioning from conventional renal support toward advanced extracorporeal blood purification (EBP) techniques. Current literature emphasizes the clinical benefits of actively removing endotoxins and excessive cytokines to restore immune homeostasis. Modalities utilizing hemoadsorption membranes have demonstrated promising outcomes in adult studies, showing rapid hemodynamic stabilization and successful modulation of inflammatory markers in septic shock. However, literature regarding EBP in pediatric populations remains notably sparse. This knowledge gap is largely attributed to the physiological and technical challenges of pediatric care, particularly the high risks of hemodynamic instability associated with large extracorporeal circuit volumes in children weighing less than 10 kilograms. Standardized protocols for pediatric EBP are still lacking, necessitating cautious technical adaptations, such as targeted blood priming strategies. This presentation will review the current literature on EBP in sepsis, explore the physiological rationale behind targeted hemoadsorption, and discuss the practical challenges of applying these therapies in pediatrics. By moving beyond traditional renal replacement, we aim to highlight how integrating advanced blood purification into pediatric CKRT can safely modulate systemic inflammation, potentially improving clinical outcomes for vulnerable critically ill children.
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14:00
15:30
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Ting-Yuan ChangTaiwan
Speaker
The Critical Initiation: Circuit Priming & Hemodynamic ManagementThis workshop addresses the critical first steps of initiating continuous kidney replacement therapy (CKRT) in pediatric patients. Topics include selecting an appropriate CKRT machine, determining hemofilter size, and designing the extracorporeal circuit. Special emphasis is placed on preventing hemodynamic instability during blood priming and circuit initiation, including calculation of the patient's circulating blood volume relative to the extracorporeal volume to avoid hypovolemic shock from excessive extracorporeal blood sequestration. Participants will learn practical decision-making frameworks for safe circuit priming strategies tailored to children of different body sizes.
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Shotaro MatsumotoJapan
Speaker
The Ultimate Support: Heart-Lung-Kidney Crosstalk and ECMO-CRRT Integration in PediatricsExtracorporeal membrane oxygenation (ECMO) and continuous kidney replacement therapy (CKRT) support pediatric cardiopulmonary failure complicated by acute kidney injury (AKI) and fluid overload (FO). AKI and multiorgan dysfunction are increasingly viewed through bidirectional kidney-lung-heart crosstalk, extending in ECMO/CKRT patients to artificial organs: oxygenator, blood pump, and hemofilter.
Kidney-lung crosstalk shares pathways of vascular rigidity, neurohormonal activation, tissue hypoxia, and aberrant immune signaling. Ventilator-induced biotrauma impairs renal function, while AKI worsens lung injury via fluid, acid-base, and cytokine derangements; positive-pressure ventilation further raises right-ventricular afterload and central venous pressure, reducing renal perfusion. Kidney-heart crosstalk (cardiorenal syndrome type 3) involves analogous inflammatory and neuroendocrine mechanisms and carries a high mortality risk in children.
Beyond native organs, the oxygenator activates complement/inflammatory cascades via blood-biomaterial contact, and non-pulsatile pump flow causes shear-induced hemolysis, with free hemoglobin/iron contributing to AKI. CKRT-ECMO circuit connection requires attention to circuit pressures, embolism risk, and altered drug pharmacokinetics-challenges framed by the multiple organ support therapy (MOST) concept.
Key management priorities include early correction of FO, standardized CKRT-ECMO integration per PCRRT-ICONIC and ADQI/ELSO consensus recommendations, lung-protective ventilation and conservative fluid management, and long-term renal/blood-pressure surveillance after ECMO.
Research has evolved from single-center FO-mortality studies to consensus statements, the extracorporeal organ support concept, and the multicenter WE-ROCK registry, with recent work clarifying molecular mechanisms of sepsis-associated lung-kidney crosstalk. Future work should pursue biomarker-driven endotyping and integrated MOST platforms.Core Decisions: Modality Selection (CVVH / CVVHD / CVVHDF) & PrescriptionModality selection and dose prescription remain unresolved in pediatric continuous kidney replacement therapy (CKRT). Pediatric trials are scarce, so practice extrapolates from adult evidence, while 2026 KDIGO and Surviving Sepsis Campaign updates have reopened debate.
Ronco's 2000 trial established an "at least 35 mL/kg/h" paradigm after showing improved survival with higher ultrafiltration, later refuted by the large ATN and RENAL trials, which found no survival benefit from higher intensity and more complications. KDIGO 2012 therefore recommended a delivered dose of 20-25 mL/kg/h, unchanged in the 2026 draft, which additionally now recommends against high-volume hemofiltration (HVHF) in adult septic AKI, reflecting negative IVOIRE trial and Cochrane review findings.
For modality, CVVHDF has become dominant in the WE-ROCK pediatric registry, rising from 30% to 76% of prescriptions, though some favor CVVH for convective clearance; no modality shows a survival advantage. For dose, the 2026 KDIGO draft newly defines pediatric practice points: weight- rather than surface-area-based prescription to avoid inadvertent infant overdosing, initial effluent of 25-30 mL/kg/h, augmented dosing to 200 mL/kg/h for hyperammonemia, and an ultrafiltration-rate of maximal 2.5ml/kg/h. WE-ROCK data show prescribed doses far exceeding these targets without an observed dose-outcome association.
Adding to this uncertainty, the 2026 pediatric Surviving Sepsis Campaign guideline newly recommends HVHF (>35 mL/kg/h) in septic shock, conditionally and with low certainty, reversing its 2020 position on a fragile three-trial meta-analysis (Fragility Index=1)-contrasting with adult evidence and the concurrent adult KDIGO recommendation against HVHF. Given risks such as dialytrauma and drug underdosing, this fragile signal warrants cautious application.
This session invites participants to weigh this evidence and build a practical framework for individualizing modality and dose decisions at the bedside.
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Hou-Xuan HuangTaiwan
Speaker
The Perfect Balance: Regional Citrate Anticoagulation (RCA) in PracticeRegional Citrate Anticoagulation (RCA) is widely used, effective and safe for pediatric continuous kidney replacement therapy(CKRT). There are many well-established RCA protocols around the world depending on the citrate products and the CKRT machines available. During this session, we will walk through the principles of RCA and I will present a simple and practical protocol using Prismaflex machine and Regiocit product. We will also closely examine and possible electrolyte and acid-base derangement when RCA is used and introduce the monitoring strategy to ensure a smooth and safe CKRT treatment.
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Jhao-Jhuang DingTaiwan
Speaker
Advanced Purification: Therapeutic Plasma Exchange (TPE) Concepts & ChallengesTherapeutic plasma exchange (TPE) is the most widely used therapeutic apheresis modality in critically ill children, yet it remains technically demanding and conceptually distinct from diffusion- and convection-based renal replacement. This hands-on station reviews the core principles of TPE—one-compartment kinetics, the rationale for a 1.0–1.5 plasma-volume exchange, and how molecular size and protein binding determine what TPE can and cannot remove—and links them to evidence-based indications from the ASFA guidelines relevant to pediatric practice (e.g., thrombotic microangiopathies, ANCA-associated and anti-GBM disease, autoimmune neurologic disease, and liver failure). Emphasis is placed on the practical challenges unique to children: vascular access and circuit sizing, blood priming for small patients, choice of replacement fluid (albumin vs. fresh frozen plasma), anticoagulation with citrate versus heparin, and the recognition and management of complications such as hypocalcemia, coagulopathy, and hemodynamic instability. Through short clinical cases, participants will practice prescribing and troubleshooting TPE at the bedside.
By the end of this station, participants will be able to: 1. Explain the pharmacokinetic basis of TPE and justify the prescribed exchange volume and frequency. 2. Select appropriate ASFA-supported indications for TPE in pediatric AKI/critical-care settings and distinguish TPE from CRRT modalities. 3. Prescribe TPE for a child—vascular access, replacement fluid, anticoagulation—and adjust for body size. 4. Recognize and manage common complications (hypocalcemia, coagulopathy, hypotension, reactions).
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