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The Other CRRT: Peritoneal Dialysis

The Other CRRT: Peritoneal Dialysis. Mignon McCulloch Associate Professor Paediatric Nephrology/Critical Care. Acknowledgements. Thanks to Stuart and Tim Including all forms of CRRT Disclosures Passionate about PD Access for children with AKI in poorly resourced areas.

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The Other CRRT: Peritoneal Dialysis

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  1. The Other CRRT:Peritoneal Dialysis Mignon McCulloch Associate Professor Paediatric Nephrology/Critical Care

  2. Acknowledgements • Thanks to Stuart and Tim • Including all forms of CRRT • Disclosures • Passionate about PD • Access for children with AKI in poorly resourced areas

  3. Evelina Children’s Hospital London UK London

  4. PICU 8818 Admissions 413 deaths Mortality 4.7% 20 Beds Staffing: 7 Consultants 20 Fellows 150 Nurses Training in nurses: CVVH 30% trained PD in 100% nurses Evelina Children’s HospitalAndrew DurwardPersonal Communication

  5. Evelina Children’s Hospital PICU2002 – 2009

  6. Red Cross Children’s HospitalCape Town SA

  7. Red Cross Children’s Hospital(RXH) University of Cape Town Experience • Increasing incidence in association with multi-organ failure in paediatric ICU’s • 1 200 – 1 400 admissions per year • Acute medical cases 600/yr • Cardiac cases 250/yr • Burns 50/yr • Head injuries 50/yr • Other Rest • Mortality 8% • Dialysis 3.5% • AKI ???

  8. Causes of Acute Renal Failure

  9. Causes of Acute Renal Failure

  10. Practicalities of PD • Quick – really quick – 20 mins K+ 9! • Bed-side insertion by Paeds Nephrologist/Intensivist/Surgeons • (Surgeons as backup) • Cook/Peel Away Tenckhoff/Formal Tenckhoff • Empty Bladder • Sedation + Local Anaesthetic

  11. Practicalities of PD • Prescription • 10-20ml/kg increase as tolerated • Dialysis fluid • Dianeal(Lactate buffered) or Bicarb based • Cycles • 10/30-90/20mins • Manual or Cycling Home choice > 3kg • Adapted to ventilatory requirements

  12. Manual Dialysis with Fluid Warmer

  13. Perit Dial Int 2001Flynn et al (Brophy & Bunchman)

  14. Acute Peritoneal DialysisJanuary 1999 to January 2004

  15. Acute PDLong term outcome

  16. Peritoneal Dialysis as a Form of CRRT for Infants in a Developing Country McCulloch M, Argent A. Red Cross Children’s Hospital University of Cape Town

  17. Specific Paeds Management IssuesVery Low Birth Weight InfantsKoralkar R et al. Ped Research 2011;69:4:354-8 • AKI reduces survival in infants <1500g • Independent risk factor • Very low glomerular filtration rate • Mild exposure – high degree of injury • High rates of infection • Nephrotoxic drugs • Premature infants <1000g • Increase SCr of 1.0mg/dL(88.5umol/l) • Doubles the odds of death

  18. Small infants < 5kg • 25 of these patients were < 5kg • 15/25 Infants (60%) survived • Age range from 2 - 138 days • Male:Female 2:1

  19. INFECTIVE CAUSES Septicaemia Diarrhoea Fungal sepsis SURGICAL CAUSES Necrotising Enterocolitis Cardiac Surgery - TGA’s Abdominal Surgery Diagnosis of Infants Surviving Dialysis

  20. DRUGS • 13/15 patients received large doses of Furosemide e.g. 5mg/kg/dose pre-dialysis • 10/13 patients were on Dopamine infusions at time of dialysis • 2 patients received Adrenaline infusions in addition • 7/14 patients were on an Aminoglycoside antibiotic (amikacin/gentamicin) pre - dialysis

  21. Weight of Infants surviving Dialysis

  22. Advantages of Acute PD Catheters • No bleeding complications • 2/15 catheters blocked - day 3 & 4 on dialysis • Replaced 1 catheter by “re-wiring”

  23. Duration Of Dialysis

  24. OUTCOME • 15/25(60%) Infants survived to come off dialysis • Nil required long term dialysis • 3 Subsequently demised - not related to dialysis: • 1 Accidental extubation • 1 Cerebral Palsy and developed septicaemia 1 year later • 1 Shock & Dehydration due to excessive colostomy losses 3 months later

  25. Acute PD in PICU 1999-2009 Presented IPNA Aug 2010 New York Red Cross Children’s Hospital, Cape Town SA • Total 406 cases/10years • Wt range 900g – 70kg • Age 1 day – 16yrs • Diphtheria – Liver Transplant

  26. PD IN PICU • Total Nos 406 • Neonates(<1mth) 85(21%) • Infants(<1yr) 221(54%) • Cardiac 95(23%)

  27. Overall Mortality Rate Rate %

  28. Specific Mortality Rate

  29. Peritoneal Dialysis in neonates with inborn errors of metabolism: Is it really out of date?

  30. Neonatal Inborn Error of Metabolism • If response to dietary and pharmacologic treatment poor or severe hyperammonemic coma • Require rapid removal of neurotoxic metabolites • Risk: • Ammonia > 1355ug/dl(800umol/l) – 34% survival rate • Enns et al NEJM 2007 256:2282-92 • Coma > 2 - 3days • Msall et al. N Eng J Med 310:1500-5 • Extra-corporeal dialysis more effective >> PD • Outcome primarily related to duration of neonatal hyperammonemic coma

  31. PD in IOM Ped Nephrol(2008) 23:163-8 • 7 Neonates ammonia > 1000ug/dL(588umol/l) • Bed-side surgically inserted PD catheter • No difficulties – mild leakage in 2 patients • Baxter closed system • 1.36% lactate buffered • Added K+ and Antibiotics • Fill volumes – 10-15ml/kg incr to 30ml/kg • Dwell times 30-45mins

  32. PD in IOM Ped Nephrol(2008) 23:163-8 4 organic aciduria pts ammonia < 200umol/l • Average after 20hrs of PD + medical rx • 1 propionic aciduria ammonia < 362umol/l • Catheter out day 5 – sepsis day 19 - death • Mean time coma 14.5hrs • 4/7 Survivors – 3 normal outcome + 1 delay • Death 3/7 • 1 OTC – death after few hrs on dialysis • 1 Sepsis after recovery of acute metabolic decompensation • 1 survived acute neonatal hyperammonia

  33. PD in IOM Ped Nephrol(2008) 23:163-8 • CVVH/D • Vascular access – difficult in neonates • Anti-coagulation • PD maintains some effectiveness • Applied in ALL neonatal units • Less efficacious than extra-corporeal dialysis • But can improve prognosis • Rapid access – bridging procedure • Small patient size • Less severe hyperammonemia

  34. Quick and Easy

  35. Continuous Flow Peritoneal Dialysis Clin J Am Soc Nephrol. 2011 Feb;6(2):311-8 • PD useful in hypotension, disturbed coagulation or difficult venous access • Disadvantage – limited efficacy • CFPD – 2 bed-side catheters + adapted CVVHF machine • CFPD vs Conventional PD for 8-16 hours • First report of CFPD in Paeds practice • Clearances and UF significantly higher than PD

  36. Continuous Flow Peritoneal Dialysis Clin J Am Soc Nephrol. 2011 Feb;6(2):311-8 • Mean UF • PD 0.20ml/min/1.73m2 vs • CFPD 1.8ml/min/1.73m2 • Creatinine clearance • PD 7.6ml/1.73m2 vs 28.8ml/1.73m2 • 2 Catheters vs Double lumen catheters • Urea clearances 44-58ml/min(2xC) vs 14-20(DL) • DL not available in paeds

  37. Continuous Flow Peritoneal Dialysis Clin J Am Soc Nephrol. 2011 Feb;6(2):311-8 • Complications • Catheter related – major complication rate <2% Pederson KR KI Supp 108:S81-86, 2008 • Infection – closed system • Intra-abdominal pressure – carefully monitored • Clearances + UF Lower values than predicted adults: • Low flow rate 100ml/1.73m2/min • Re-circulation due to small patient

  38. Continuous Flow Peritoneal Dialysis Clin J Am Soc Nephrol. 2011 Feb;6(2):311-8 • CFPD useful for ARF Ronco C Perit Dial Int 27:251-3, 2007 • Especially in children • Especially if small haemodynamically infant • Developing and Developed countries • Future • Larger studies in Paeds • Higher flow volumes • Improved catheter technology

  39. Acute Kidney Injury:The Future is now The past of acute kidney injury was observation, and the present is intervention with renal replacement therapy, but perhaps the future is the use of biomarkers to identify AKI sooner and intervene early. Bunchman TE. Oct 2009. Nephrology Times 15-16. 

  40. Thank you for your attention !

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