Fluid overload manifests as pulmonary edema. Hence, the patient experiences dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea. Additionally, another frequent complaint in pulmonary edema secondary to CHF is a cough that produces pink, frothy sputum.

In cases with chronic fluid overload, the patients present with dyspnea and peripheral edema.

Physical exam

Remarkable findings on the lung exam include crackles or rales. The cardiovascular exam is notable for tachycardia, tachypnea, hypertension, jugular venous distension, peripheral edema, and ascites. Moreover, cardiac auscultation may reveal the S3 heart sound.

Further observations include an altered mental status and anxiety.

• Congestive Heart Failure

  Accordingly, we propose the development of a simple, safe miniature portable device that can slowly remove sufficient excess fluid, on a continuous basis, from patients with congestive heart failure (CHF). [sbir.gov]

  HIPERVOLEMIA PADA PASIEN CONGESTIVE HEART FAILURE (CHF) Sari Background : Congestive Heart Failure (CHF) is a condition in which the heart is unable to pump blood normally, causing disturbed venous return pressure to cause edema. [jurnal.poltekkes-solo.ac.id]

  […] are independent risk factors for morbidity and mortality in patients with congestive heart failure. [ajconline.org]

  Congestive heart failure Congestive heart failure is a condition in which the heart cannot pump enough blood to meet the body’s needs. [medicalnewstoday.com]

  The mechanism usually stems from compromised regulatory mechanisms for sodium handling as seen in congestive heart failure (CHF), kidney failure, and liver failure. [en.wikipedia.org]

• Weight Gain

  The rate of this weight gain does not correlate with obesity-related weight gain due to increased body fat, which is usually slower and gradual. Coughing and Difficulty Breathing Shortness of breath is another sign of fluid overload. [healthhype.com]

  Symptoms Symptoms include weight gain, swelling, and shortness of breath. Treatments Treatments include medications, such as diuretics, and a low-salt diet. Any underlying conditions need treatment. [tmcaz.com]

  Share on Pinterest One symptom of hypervolemia is unexplained and rapid weight gain. Hypervolemia symptoms may vary depending on where the fluid is collecting and what other health problems are present. [medicalnewstoday.com]

  Track your weight to help identify excess fluid weight gain. Alert your doctor or nurse if you notice any large shifts in weight, along with swelling or other symptoms. [freseniuskidneycare.com]

  Sudden Weight Gain: A case of hypervolemia can cause sudden weight gain as the extra fluid you are retaining will pack on more weight. [doctorshealthpress.com]

• Anemia

  Strict/severe risk thresholds were set for congestion (TBV excess >+22%) and anemia (nHct < 30% F/ < 33% M). [onlinejcf.com]

  Fluid overload ( hypervolemia ) causes decreased hemoglobin concentration and apparent anemia: As with any intravenously administered fluid, excessive amounts of FFP may result in hypervolemia and cardiac failure. [diki.pl]

  Eventually, the fluid enters the air spaces in the lungs (pulmonary edema) reduces the amount of oxygen that can enter the blood, leading to anemia and causes shortness of breath (dyspnea) or enters pleural space by transudation (pleural effusion which [en.wikipedia.org]

• Inflammation

  The link between inflammation and hypervolemia has not been extensively studied. The aim of this study was to determine if an association exists between hypervolemia and markers of inflammation in PD patients. [bodystat.com]

  Fluid Overload and Inflammation Axis. Blood Purif. 2018, 45, 159–165. [mdpi.com]

  Additionally, the existence of malnutrition, inflammation and atherosclerosis (MIA) syndrome is now established. [revportcardiol.org]

  SLIDESHOW Sex-Drive Killers: The Causes of Low Libido See Slideshow From Healthy Resources 11 Ways to Treat Your Psoriasis Naturally Food Dos and Don’ts to Tame Inflammation Understanding COVID-19 Testing and Treatment Featured Centers What Are the Best [rxlist.com]

• Asymptomatic

  Patients may be asymptomatic or have a slight fever. Rarely, severe symptoms occur. [merck.com]

  Clinical Signs and Symptoms Most patients with hyponatremia are asymptomatic. [aafp.org]

  For euvolemic, asymptomatic hyponatremic patients, free water restriction (< 1 L/day) is generally the treatment of choice. There is no role for hypertonic saline in these patients. [emedicine.medscape.com]

  The magnitude of lower body suction was mild compared with that in previous studies, which determined dynamic cerebral autoregulation during orthostatic stress using LBNP ( 20,30 ), and only one of our 12 subjects developed slight asymptomatic hypotension [journals.lww.com]

• Dyspnea

  […] also causes dyspnea), which is the best indicator of estimating central venous pressure is increased. [en.wikipedia.org]

  Hence, the patient experiences dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea. Additionally, another frequent complaint in pulmonary edema secondary to CHF is a cough that produces pink, frothy sputum. [symptoma.com]

• Rales

  Most common symptoms include: O Edema esp lower extremities as well as anywhereas there is tissue O Tiredness O High BP O Bounding pulse, Tachycardia O SOB, Rales or rhonchi O Heart problems eg; palpitation O Abdomen distension O Pitting edema 9. [slideshare.net]

  * Defining Characteristics: Weight gain * Edema * Bounding pulses * Shortness of breath; orthopnea * Pulmonary congestion on x-ray * Abnormal breath sounds: crackles (rales) * Change in respiratory pattern * Third heart sound (S3) * Intake greater than [nursingcareplan.blogspot.com]

  Physical exam Remarkable findings on the lung exam include crackles or rales. The cardiovascular exam is notable for tachycardia, tachypnea, hypertension, jugular venous distension, peripheral edema, and ascites. [symptoma.com]

  Respiratory problems Respiratory pattern changes Presence of crackles or rales upon auscultation Dyspnea (difficulty of breathing) Orthopnea (difficulty of breathing when lying down) Paroxysmal nocturnal dyspnea Cough X-ray results show pulmonary edema [howshealth.com]

• Overeating

  Serial angiograms filmed over the next 8 h demonstrated reperfusion of the hemisphere, through collateral flow. The patient's symptoms resolved. [ncbi.nlm.nih.gov]

  These are early signs of pulmonary congestion. * Assess for presence of edema by palpating over tibia, ankles, feet, and sacrum. [nursingcareplan.blogspot.com]

  Flaccid paralysis, dysarthria, and dysphagia can evolve over a few days or weeks after a hyponatremic episode. [merck.com]

• Loss of Appetite

  Stomach Pain Loss of appetite Muscle weakness Rash Sore throat with fever Unusual bleeding Conivaptan (Vaprisol) [7] V1A and V2 vasopressin receptor antagonist Raise serum sodium in patients with euvolemic and hypervolemic hyponatremia Induces both sodium [physio-pedia.com]

  A loss of appetite and insufficient nutrition in patients with hypervolemia might be related to increased TNF-α and proinflammatory cytokines [33,34]. [hoajonline.com]

• Polydipsia

  Patients affected include those with psychosis or more modest degrees of polydipsia plus renal insufficiency. [merck.com]

  Mechanisms of altered water metabolism in psychotic patients with polydipsia and hyponatremia. N Engl J Med. 1988 Feb 18. 318(7):397-403. [Medline]. Danz M, Pöttgen K, Tönjes PM, Hinkelbein J, Braunecker S. [emedicine.medscape.com]

• Heart Failure

  Am Heart J. 1998; 136: 10-18 Drazner M.H Rame J.E Stevenson L.W Dries D.L Prognostic importance of elevated jugular venous pressure and a third heart sound in patients with heart failure. [ajconline.org]

  Congestive heart failure Congestive heart failure is a condition in which the heart cannot pump enough blood to meet the body’s needs. [medicalnewstoday.com]

  Evaluation of changes in the natriuretic response to hypervolemia and diuretic injection in patients with chronic heart failure. Materials and methods. 25 men with chronic heart failure were examined; the average age was 68 y. o. (67; 73). [journals.eco-vector.com]

  Accordingly, we propose the development of a simple, safe miniature portable device that can slowly remove sufficient excess fluid, on a continuous basis, from patients with congestive heart failure (CHF). [sbir.gov]

  HIPERVOLEMIA PADA PASIEN CONGESTIVE HEART FAILURE (CHF) Sari Background : Congestive Heart Failure (CHF) is a condition in which the heart is unable to pump blood normally, causing disturbed venous return pressure to cause edema. [jurnal.poltekkes-solo.ac.id]

• Hypertension

  KEYWORDS: aerobic training; hypertension; older men; supplement; thermoregulation [Indexed for MEDLINE] Free full text [ncbi.nlm.nih.gov]

  Haraguchi S, & Ebina K: [Evaluation of the dopamine induced hypertension therapy for vasospasm.] No Shinkei Geka 10:279–289, 1982 Haraguchi S, Ebina K: [Evaluation of the dopamine induced hypertension therapy for vasospasm.] [thejns.org]

  Discussion Hypertension is a public health problem. [hindawi.com]

• Tachycardia

  Thoracic hypovolemia and splanchnic hypervolemia characterize certain patients with postural tachycardia syndrome (POTS) during orthostatic stress. These patients also experience abnormal phase II hypotension and phase IV hypertension during VM. [ncbi.nlm.nih.gov]

  Most common symptoms include: O Edema esp lower extremities as well as anywhereas there is tissue O Tiredness O High BP O Bounding pulse, Tachycardia O SOB, Rales or rhonchi O Heart problems eg; palpitation O Abdomen distension O Pitting edema 9. [slideshare.net]

  If ME/CFS caused you to have the following symptoms (as it did with me): A generally lowered heart rate than you had before the disease with only some periods of tachycardia Higher blood pressure than you had before the disease A bounding pulse, you feel [forums.phoenixrising.me]

  Tachycardia; bounding pulse; Increased blood pressure; Decreased temperature; Edema; pitting edema; Distended neck veins; SOB; crackles; Increased weight; Increased urine output; HA; visual disturbances What happens to the BUN level when a patient is [studystack.com]

  Sinus tachycardia and increased blood pressure are seen in early stages. [nursingcareplan.blogspot.com]

• Withdrawn

  In the event of subsequent bleeding, there is a loss of diluted, hemoglobin-reduced blood, which can be replaced with the previously withdrawn hemoglobin-rich blood when the individual transfusion cutoff value is reached. [ccforum.biomedcentral.com]

• Kidney Failure

  These conditions may include: Kidney failure. Your kidneys are responsible for removing excess fluid from your body. When your kidneys aren’t working well, fluid can build up. Congestive heart failure. [freseniuskidneycare.com]

  Examples of diseases are: Congestive heart failure Kidney failure Liver failure Liver diseases such as cirrhosis Corticosteroid use Hyperaldosteronism Kidney diseases such as glomerulonephritis Excessive fluid in the diet Excessive sodium in the diet [symptoma.com]

  The mechanism usually stems from compromised regulatory mechanisms for sodium handling as seen in congestive heart failure (CHF), kidney failure, and liver failure. [operativeneurosurgery.com]

  ECF volume expansion typically occurs in heart failure, kidney failure, nephrotic syndrome, and cirrhosis. Renal sodium retention leads to increased total body sodium content. This increase results in varying degrees of volume overload. [openmd.com]

  Cushing's syndrome Glomerulonephritis Acute Focal or embolic Membranoproliferati Postinfectious Post-streptococcal Heart problems Hyperaldosteronism Kidney failure Liver failure Lung problems Nephritis (kidney inflammation) Familial interstitial Hereditary [hypervolemia.com]

• Oliguria

  Perform assessment of postoperative oliguria cases at bedside. In spite of no complications, there are chances that oliguria may occur post-operatively, as a normal response of the body to surgery. [howshealth.com]

  Bedside assessment of postoperative patients with oliguria[1]: In the absence of complications, oliguria occurring soon after operation is usually a normal physiological response to surgery. [patient.info]

  The results of this study were the assessment of both patients complaining of dyspnea, the presence of peripheral edema, oliguria, neck venous distention, decreased Hb, decreased Ht, and positive fluid balance. Nursing diagnoses are hypervolemia. [repository.poltekkes-denpasar.ac.id]

  Decreased BP; increased RR; Postural hypotension; Weak, rapid heart rate;Increased temperature; Dry mouth; thirst; Oliguria; concentrated urine; Decreased bowel sounds; Constipation; Decreased skin turgor; Flattened neck veins; Acute weight loss What [studystack.com]

  […] diastole Ascites and fluid in the abdomen from buildups of excessive fluid in the different regions of the body Paroxysmal nocturnal dyspnea and orthopnea, both from fluid collection in the lungs Abnormalities in renal function leading to azotemia, oliguria [ihealthblogger.com]

• Renal Insufficiency

  However, its diagnostic value is unclear in hemodialysis (HD) patients owing to renal insufficiency. [ncbi.nlm.nih.gov]

  Permanent renal insufficiency is unusual. Prolonged oliguria and shock are poor prognostic signs. If AHTR is suspected, the transfusion should be stopped and supportive treatment begun. [merck.com]

  insufficiency or failure * Steroid therapy * Low protein intake or malnutrition * Decreased cardiac output; chronic or acute heart disease * Head injury * Liver disease * Severe stress * Hormonal disturbances * Expected Outcomes Patient maintains adequate [nursingcareplan.blogspot.com]

  Q J Med. 1969; 39: 377-394 Google Scholar de Planque BA Mulder E Dorhout Mees EJ The behaviour of blood and extracellular volume in hypertensive patients with renal insufficiency. [ajkd.org]

The clinician should assess the overall clinical picture and patient's history. Other key components of the workup include a physical exam, and laboratory and imaging studies.

Laboratory tests

Measurement of the serum electrolytes will reveal any imbalances such as with sodium and potassium levels. Also important are the serum creatinine and glomerular filtration rate (GFR) levels since these will provide details about the renal function. Furthermore, liver function tests (LFTs) may show hypoalbuminemia.

A useful test, the complete blood count (CBC), will demonstrate manifestations such as anemia, low hematocrit, and infection.
Further studies include the B-type natriuretic peptide (BNP), which can be helpful in diagnosing cardiac failure. Additionally, an arterial blood gas (ABG) is indicated in respiratory failure.

Electrocardiogram

An electrocardiogram (ECG) will identify the heart rate and rhythm, and display existing arrhythmias, hypertrophy, and/or ischemia.

Imaging

A chest X-ray will depict edema and underlying diseases such as pneumonia.

Echocardiography, an important investigation, will provide critical information about the heart performance, the wall measurements, the integrity of the valves, and the presence of heart diseases.

The mainstay treatment for hypervolemia in the hospital setting is the restriction of fluid intake or reduction in IVF. Medical therapy and dietary modifications may be considered as well.

Medications

Diuretic therapy eliminates excess fluid. The various types of diuretics are classified according to which part of the nephron they influence. Additionally, some drug preparations combine a diuretic with an antihypertensive in the same pill. The clinician will choose the appropriate regimen for the patient. Note that certain diuretics may produce hypokalemia and other side effects. Hence, potassium replacement may be required.

Dietary modifications

For outpatients, the fluid intake has to be limited to 2L or less. Also, the sodium consumption should be restricted per the normal daily allowance, which is 2,000mg. Patients must avoid food such as bacon, potato chips, and others products with salt. Alternatives to salt may be used, and these include spices, pepper, and herbs.

Other

Edematous feet should be elevated to prevent fluid pooling in the lower extremities. Sometimes, compression stockings and certain physical activities will help as well.

Profound acute kidney injury (AKI) is complicated by fluid overload, which was initially demonstrated in children who underwent bone marrow transplantation [4]. In fact, 70% of patients of the study warranted dialysis as they did not exhibit renal improvement. Similarly, hypervolemia was prevalent in pediatric populations who needed continuous renal replacement therapy (CRRT) [5] [6] [7] [8] [9] [10].

According to these studies, the severity of overload in itself is indicative of poor outcomes and fatality. The survivors' treatment course was associated with a delay in renal recovery and a prolonged duration of hospitalization and mechanical ventilation [11].

Collectively, these investigations concluded that the presence of hypervolemia is significant in kidney failure. Hence, the excessive fluid volume should be corrected to prevent morbidity and mortality.

There are numerous causes of hypervolemia as described below.

Iatrogenic

Fluid overload may occur when patients receive large amounts of intravenous fluids (IVF), blood transfusions, medications, or contrast dyes. This occurrence is especially observed in the elderly population, postoperative patients, and individuals with heart or kidney dysfunction. Moreover, in perioperative patients, electrolyte monitoring and avoidance of hypertonic fluids are warranted. With regards to blood transfusion, the clinician must not administer it rapidly or in high volumes.

Water or sodium retention

Increased fluid in the intravascular compartment is a consequence of elevated sodium levels and the subsequent increase in water. The following conditions or factors are associated with water or sodium retention.

Cardiac diseases such as CHF promote the production of hypervolemia. In CHF, contractility is impaired, which results in the buildup of blood in the vasculature.

Also, renal causes including kidney failure and glomerulonephritis lead to poor excretion of fluids. Furthermore, albumin deficiency in nephrotic syndrome favors the flux of intravascular fluid into the tissues, which is followed by the physiologic response of water and salt retention.

In the cardiorenal and renocardiac syndromes, there is a complicated interplay between the two organs with respect to regulation of sodium and water [1] [2].

Liver pathologies such as cirrhosis play a role by elevating plasma levels.

Additionally, endocrine diseases such as hyperaldosteronism lead to fluid overload due to the effects of aldosterone.

As for medications, drugs such as corticosteroids and chemotherapy agents may result in fluid and salt retention.

Stress response mechanisms also contribute to the development of hypervolemia. For example, post-operative patients experience an increase in antidiuretic hormone (ADH) secretion, which is a hormone involved in sodium and water reabsorption. The same applies to individuals suffering from a head injury. Additionally, these patients experiencing stress have trouble excreting the excess water and sodium.

Finally, individuals who consume low protein diets are predisposed to hypervolemia.

Fluid shift into the intravascular space

There are conditions in which there is fluid displacement. For example, burn patients treated with albumin, mannitol or hypertonic fluids may undergo fluid remobilization. Moreover, these medications may cause hypervolemia in non-burn patients as well.

Altered physiology

Note that pregnant patients develop significant hemodynamic changes that cause fluid overload. Additionally, a severe disease known as preeclampsia results in critical fluid status changes.

One investigation studied the fluid status of 43 patients with CHF through measurements of the blood volume by utilizing radioisotope [3]. It reported that 65% of the participants demonstrated an increase in volume despite therapy with loop diuretics. Furthermore, the hypervolemic group was linked to a one-year mortality rate of 39% and a two-year rate of 55%. In contrast, there were no deaths in the normal or low volume groups.

Note that there are more than 4.5 million individuals in the United States who have heart failure. Each year, there are more than half a million new cases. Hence, measurement of the blood volume may impact the treatment and prognosis of these patients.

Normal physiology

The total blood volume is the sum of plasma and red blood cells, which is around 5L. The extracellular compartment takes up 15L while the intracellular volume is 25L. Note that administration of saline may affect all spaces. While fluid overload involves the plasma space, other compartments may play a role as well.

Pathophysiology

The fluid shift between the compartments operates under the influence of Starling's Law. For example, fluid outflux occurs when there is both a positive capillary hydrostatic pressure and negative interstitial hydrostatic pressure. In contrast, fluid shift into the blood occurs when the oncotic pressure gradient is greater than the hydrostatic pressure.

Iatrogenic causes can be prevented when clinicians are cautious with IVF resuscitation and blood transfusions especially in high-risk populations such as the elderly, postoperative patients, burn victims, or those affected with underlying conditions such as cardiac or renal failure. Additionally, the NICE guidelines provide algorithms with details regarding the assessment of fluid.

There also specific guidelines provided by the Surviving Sepsis Campaign for critically ill patients with sepsis or shock.

Additionally, special consideration should be applied to oliguric individuals as these patients may or may not have intravascular depletion. The clinician must perform a thorough clinical evaluation of their vitals, capillary refill times, and jugular venous pressure.

Furthermore, clinical correlation should be used in post- surgery oliguria cases so that these patients' fluids can be appropriately managed.

Hypervolemia is a condition in which there is an excess of fluid volume in the intravascular compartment. It is either caused by increased fluid intake, diseases that lead to sodium and water retention, or phenomena that promote the influx of fluid into the plasma. For example, congestive heart failure (CHF), renal failure, and liver failure may lead to impairment of sodium handling. Furthermore, treatment with albumin or hypertonic solutions results in the intravascular shift of fluids.

The clinical picture and physical examination will reflect the abnormal fluid status. Furthermore, the patients will likely exhibit signs and symptoms of pulmonary edema and CHF in addition to features of underlying pathologies.

The clinician should obtain a detailed history and perform a full evaluation of the patient's presentation and physical assessment. Moreover, key laboratory tests and imaging techniques are pertinent components of the workup. The latter will help identify the etiology of the hypervolemia. Prompt diagnosis and treatment are paramount for the prevention of overload progression.

Treatment involves fluid restriction, possible use of diuretic therapy, and dietary modifications. Furthermore, iatrogenic causes such as excessive fluid resuscitation may be avoided with careful treatment especially in the elderly and those with cardiac and renal dysfunction.

What is hypervolemia?

Hypervolemia is the medical condition in which there is too much fluid in the blood. One way this occurs is through blood transfusions or increased intravenous fluids. It also results from mechanisms that lead to increased sodium and water in the blood. Finally, it may be caused by situations that pull water out from the tissues into the blood.

What are the causes of hypervolemia?

When the mechanisms that regulate the water and salt levels in the fluid are impaired, the consequences are fluid overload. Examples of diseases are:

• Congestive heart failure
• Kidney failure
• Liver failure
• Liver diseases such as cirrhosis
• Corticosteroid use
• Hyperaldosteronism
• Kidney diseases such as glomerulonephritis
• Excessive fluid in the diet
• Excessive sodium in the diet
• Rapid blood transfusion
• Excessive intravenous fluids

Fluid shift into the intravascular space as caused by:

• Burns
• Albumin therapy
• Mannitol treatment
• Hypertonic fluid therapy

What are the symptoms?

The signs and symptom manifest as pulmonary edema which is a condition where there is fluid buildup in the lungs. These patients will have shortness of breath while lying down and performing physical activity. They may wake up from sleep due to shortness of breath as well. If they develop a cough, it often produces a pink, frothy sputum. Also, there may be fluid and, therefore, swelling in the legs, feet and arms. Sometimes, there is fluid accumulation in the abdomen, which is a sign known as ascites.

On the physical exam, the clinician will find a fast heart rate, high blood pressure, abnormal heart sounds and maybe murmurs. On the lung exam, the clinician will hear sounds that suggest there is fluid.

Also, these patients may experience confusion and lethargy as well as anxiety.

How is this diagnosed?

The doctor will assess the symptoms, the medical history of the patient, and the physical signs.

The tests will include chest X-ray which shows the fluid in the lungs. Also, an echocardiogram will show the heart function and identify if there are any problems. The electrocardiogram (EKG) will reveal the heart rate and rhythm of the heart and if there are ischemia and enlargement of the heart.

Blood tests will assess the electrolytes, the kidney function, protein levels, and other measurements as well.

How is this treated?

One of the ways this condition is treated is by fluid restriction. Patients have to limit the quantity of fluid they drink. Also, they are highly advised to limit the quantity of salt they eat. They should avoid potato chips, bacon, canned foods, etc. The doctor may also prescribe a diuretic to help them urinate more fluids out.

1. Ronco C, Di Lullo L. Cardiorenal syndrome. Heart Failure Clinics. 2014;10(2):251-80.
2. Bouchard J, Mehta RL. Fluid accumulation and acute kidney injury: consequence or cause. Current Opinion in Critical Care. 2009;15(6):509-13.
3. Androne AS, Hryniewicz K, Hudaihed A, Mancini D, Lamanca J, Katz SD. Relation of unrecognized hypervolemia in chronic heart failure to clinical status, hemodynamics, and patient outcomes. American Journal of Cardiology. 2004;93(10):1254-9.
4. Lane PH, Mauer SM, Blazar BR, et al. Outcome of dialysis for acute renal failure in pediatric bone marrow transplant patients. Bone Marrow Transplant. 1994;13(5):613–617.
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6. Goldstein SL, Currier H, Graf CdCC, et al. Outcome in children receiving continuous venovenous hemofiltration. Pediatrics. 2001;107(6):1309–1312.
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8. Foland J, Fortenberry J, Warshaw B, et al. Fluid overload before continuous hemofiltration and survival in critically ill children: a retrospective analysis. Critical Care Medicine. 2004;32(8):1771–1776.
9. Goldstein S, Somers MJG, Baum M, et al. Pediatric patients with multi-organ dysfunction syndrome receiving continuous renal replacement therapy. Kidney International. 2005;67(2):653–658.
10. Selewski DT, Cornell TT, Lombel RM, et al. Weight-based determination of fluid overload status and mortality in pediatric intensive care unit patients requiring continuous renal replacement therapy. Intensive Care Medicine. 2011;37(7):1166–1173.
11. Hayes L, Oster R, Tofil N, et al. Outcomes of critically ill children requiring continuous renal replacement therapy. Journal of Critical Care. 2009;24(3):394–400.