Renal Replacement Therapy in Children after Surgery for Congenital Heart Disease - PowerPoint PPT Presentation

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Renal Replacement Therapy in Children after Surgery for Congenital Heart Disease

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  1. Renal Replacement Therapy in Children after Surgery for Congenital Heart Disease Ri董奎廷

  2. Contents • Introduction • Risk factors for development of acute renal failure • Renal replacement therapy options • Outcome and survival • Discussions

  3. 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% )

  4. 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)

  5. 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

  6. 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

  7. 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

  8. Managment • Diuretic Therapy • Inotropic Agents • Renal Replacement Therapy • Peritoneal Dialysis • Hemofiltration • CAVH • CVVH

  9. 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

  10. 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.

  11. 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.

  12. 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.

  13. 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.

  14. 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

  15. 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

  16. Comparison

  17. Timing of renal replacement therapy rather than method?

  18. 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

  19. 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

  20. 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

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

  22. 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

  23. 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

  24. Comparison

  25. Thank you for your attention!!

  26. 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.

  27. 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

  28. 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

  29. 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