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Renal Replacement Therapy in Children after Surgery for Congenital Heart Disease Ri 董奎廷 Contents Introduction Risk factors for development of acute renal failure Renal replacement therapy options Outcome and survival Discussions Introduction

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Renal replacement therapy in children after surgery for congenital heart disease l.jpg

Renal Replacement Therapy in Children after Surgery for Congenital Heart Disease

Ri董奎廷


Contents l.jpg
Contents Congenital Heart Disease

  • Introduction

  • Risk factors for development of acute renal failure

  • Renal replacement therapy options

  • Outcome and survival

  • Discussions


Introduction l.jpg
Introduction Congenital Heart Disease

  • Acute renal failure is an important complication following surgery for congenital heart disease (CHD)

  • Incidence: 1.6-32.8% (~10% )

  • Mortality: 20-79% (~50% )


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  • Well studied cohorts available Congenital Heart Disease

  • Timing of event (CPB) leading to ARF is precisely known

  • Peritoneal dialysis (PD) predominant form of renal replacement therapy (RRT)

  • Continuous Hemofiltration (CVVH、CAVH)


Incidence and mortality pd l.jpg
Incidence and Mortality (PD) Congenital Heart Disease

Kwok-lap Chan, et al. Peritoneal Dialysis After Surgery for Congenital

Heart Disease in Infants and Young Children.Ann Thorac Surg 2003;76:1443–9


Acute renal failure l.jpg
Acute Renal Failure Congenital Heart Disease

  • Definition:

    • decline in GFR and an inability of the kidneys to appropriately regulate fluid, electrolytes, and acid-base homeostasis (Benfield MR, Pediatric Nephrology, 5th ed)

    • Sudden decline in renal function with increasing BUN/Cr ratio; with or without changes in urine output (Johns Hopkins: The Harriet Lane Handbook, 17th ed. - 2005 )

  • Clinical Definition:

    • Creatinine > 75 mol/L (0.85 mg/dL)

    • Oliguria (<1ml/kg/h) for more than 4 hours despite aggressive diuretic/inotropic agent


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Risk factors for development of acute renal failure Congenital Heart Disease

  • Young age

  • High RACHS-1 Score

  • Long cardio-pulmonary bypass time

  • Need for circulatory arrest

  • Low cardiac output syndrome


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Managment Congenital Heart Disease

  • Diuretic Therapy

  • Inotropic Agents

  • Renal Replacement Therapy

    • Peritoneal Dialysis

    • Hemofiltration

      • CAVH

      • CVVH


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Indication of RRT Congenital Heart Disease

In general:

  • 1. Anuria or oliguria (<1ml/kg/h) > 4 hours despite intervention

  • 2. Creatinine > 75 mol/L (0.85 mg/dL)

  • 3. Increased Creatinine level with:

    • Clinical signs of fluid overload

    • Hyperkalemia: Serum K+ > 5.5 mmol/L

    • Persistent acidosis

    • Low cardiac output syndrome


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Fleming F,, Congenital Heart Diseaseet al: Renal replacement therapy after repair of congenital heart disease in children:A comparison of hemofiltration and peritoneal dialysis J Thorac Cardiovasc Surg 109: 322–331, 1995.


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Fleming F,, Congenital Heart Diseaseet al: Renal replacement therapy after repair of congenital heart disease in children: A comparison of hemofiltration and peritoneal dialysis. J Thorac Cardiovasc Surg 109: 322–331, 1995.


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Fleming F,, Congenital Heart Diseaseet al: Renal replacement therapy after repair of congenital heart disease in children: A comparison of hemofiltration and peritoneal dialysis. J Thorac Cardiovasc Surg 109: 322–331, 1995.


Discussion summary l.jpg
Discussion/Summary Congenital Heart Disease

  • Hemofiltration superior to PD due to:

    • Better fluid removal

    • Superior decrease of BUN/Cre

  • However:

    • Relatively high mortality in hemofiltration due to slower initiation of RRT

    • Hesitation due to:

      • new technique

      • vascular access

      • Anticoagulation

  • Possibly lower mortality with early hemofiltration therapy (~30%)

    • (Book et al 1982, Zobel et al 1991)

Fleming F,, et al: Renal replacement therapy after repair of congenital heart disease in children: A comparison of hemofiltration and peritoneal dialysis. J Thorac Cardiovasc Surg 109: 322–331, 1995.


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Hemofiltration (1) Congenital Heart Disease

  • Complications:

  • Hypothermia (32%)

  • Significant hemorrhage (28%)

  • Thrombocytopenia (92%)

Mortality: 76%

A. Jander et al. Continuous veno-venous hemodiafiltration in children after cardiac surgery European Journal of Cardio-thoracic Surgery 31 (2007) 1022—1028


Peritoneal dialysis l.jpg
Peritoneal dialysis Congenital Heart Disease

Kwok-lap Chan, et al. Peritoneal Dialysis After Surgery for Congenital

Heart Disease in Infants and Young Children.Ann Thorac Surg 2003;76:1443–9


Comparison l.jpg
Comparison Congenital Heart Disease



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Survival and early initiation of RRT Congenital Heart Disease

Elahi MM, et al. Early hemofiltration improves survival in post-cardiotomy patients with acute renal failure. Eur J Cardiothorac Surg 2004;26:1027—31


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Post-operative Prophylactic PD Congenital Heart Disease

  • Method:

    • Neonate and infants (n=756, age 0-1)

    • All underwent periopertaive ultrafiltration

    • 186/756 “high risk” patients received (24.6%) received (prophylactic) PD

  • Results:

    • 23/186 (12.3%) of pPD, 23/756 (3%) of all developed ARF

    • Mortality of ARF (17.3%)

Alkan et al. Postoperative Prophylactic Peritoneal Dialysis in Neonates and Infants After Complex Congenital Cardiac Surgery ASAIO Journal 2006; 52: 693–697


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Indications of PD Congenital Heart Disease

  • 1. Anuria or oliguria despite intervention

  • 2. Increased Creatinine level with:

    • Clinical signs of fluid overload

    • Hyperkalemia: Serum K+ > 5.5 mmol/L

    • Persistent acidosis

    • Low cardiac output syndrome


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Alkan et al. Congenital Heart DiseasePostoperative Prophylactic Peritoneal Dialysis in Neonates and Infants After Complex Congenital Cardiac Surgery ASAIO Journal 2006; 52: 693–697


Comparison23 l.jpg
Comparison Congenital Heart Disease

Alkan et al. 3% 17.3%  Favorable results

Kwok-lap Chan, et al. Peritoneal Dialysis After Surgery for Congenital

Heart Disease in Infants and Young Children.Ann Thorac Surg 2003;76:1443–9


Discussions summary l.jpg
Discussions/Summary Congenital Heart Disease

  • ARF is an important complication of pediatric cardiac surgery

    • High mortality rate (20-79%) ; Incidence (~1-10%)

    • However, a definite diagnostic criteria does not exist

  • PD/Hemofiltration are effective RRT

    • PD:

      • Predominant, with more studies/evidence

      • better survival?

    • Hemofiltration:

      • Fewer studies

      • Increasing use in critically ill patients with superior survival

    • Both methods lack large prospective or randomized control scales. Few head to head comparisons

    • Timing and indications for RRT?

  • Early initiation RRT may be a more important predictor of survival than RRT modality


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Comparison Congenital Heart Disease


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Thank you for your attention!! Congenital Heart Disease


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Risk Adjustment for Congenital Congenital Heart DiseaseHeart Surgery 1 (RACHS-1)

Jenkins KJ, et al. Consensus-based method for risk adjustment for surgery for congenital heart disease. J Thorac Cardiovasc Surg 2002; 123 (1): 110–8.


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K. R. Pedersen et al, Congenital Heart DiseaseRisk factors for acute renal failure requiring dialysis after surgery for congenital heart disease in children, Acta Anaesthesiol Scand 2007; 51: 1344–1349


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K. R. Pedersen et al, Congenital Heart DiseaseRisk factors for acute renal failure requiring dialysis after surgery for congenital heart disease in children, Acta Anaesthesiol Scand 2007; 51: 1344–1349


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Kwok-lap Chan, et al. Peritoneal Dialysis After Surgery for Congenital

Heart Disease in Infants and Young Children.Ann Thorac Surg 2003;76:1443–9


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