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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


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contents
Contents
  • Introduction
  • Risk factors for development of acute renal failure
  • Renal replacement therapy options
  • Outcome and survival
  • Discussions
introduction
Introduction
  • Acute renal failure is an important complication following surgery for congenital heart disease (CHD)
  • Incidence: 1.6-32.8% (~10% )
  • Mortality: 20-79% (~50% )
slide4
Well studied cohorts available
  • 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
Incidence and Mortality (PD)

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
Acute Renal Failure
  • 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
risk factors for development of acute renal failure
Risk factors for development of acute renal failure
  • Young age
  • High RACHS-1 Score
  • Long cardio-pulmonary bypass time
  • Need for circulatory arrest
  • Low cardiac output syndrome
managment
Managment
  • Diuretic Therapy
  • Inotropic Agents
  • Renal Replacement Therapy
    • Peritoneal Dialysis
    • Hemofiltration
      • CAVH
      • CVVH
indication of rrt
Indication of RRT

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
slide10

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.

slide11

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.

slide12

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.

discussion summary
Discussion/Summary
  • 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.

hemofiltration 1
Hemofiltration (1)
  • 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
Peritoneal dialysis

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

survival and early initiation of rrt
Survival and early initiation of RRT

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

post operative prophylactic pd
Post-operative Prophylactic PD
  • 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

slide21

Indications of PD

  • 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
slide22

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

comparison23
Comparison

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
Discussions/Summary
  • 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
risk adjustment for congenital heart surgery 1 rachs 1
Risk Adjustment for Congenital Heart 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.

slide28

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

slide29

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

slide30

Independent Risk Factors:

  • Circulatory arrest
  • Duration of CPB
  • Low cardiac output syndrome

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