Renal replacement (supportive) therapy in infants

1. Renal replacement (supportive) therapy in infants Patrick D. Brophy MD, Associate Professor Director Pediatric Nephrology University of Iowa Children’s Hospital PCRRT Rome 2010 Brophy University of Iowa

2. Outline: • Renal Replacement/Supportive Therapy: Options & Technical challenges & Costs • Neonatal AKI/CKD/ESRD- Outcomes • Neonatal ESRD- summary Brophy University of Iowa

3. Case • 36 wk infant born to 36 yr old mother G1 P1 • Parents told they could not conceive had adopted children and found out they were pregnant • Pregnancy went well until emergent C-sec required for placental abruption Brophy University of Iowa

4. Case • Infant volume resuscitated (apgars 1, 3 & 6) & intubated • Multiple transfusions- stabilized the infant, transferred to NICU • Birth weight 2831 gm • Patient entered in cooling (brain/body cooling study) for presumed hypoxia Brophy University of Iowa

5. Case • Patient remained anuric for duration of brain/body cooling- Pediatric Nephrology consulted day 4 of life • Pediatric Surgery not interested in placing lines or PD cath for dialysis at this time: Patient managed conservatively with limited nutrition • Family consulted- wished maximal therapy Brophy University of Iowa

6. Case • Issues: • Does this infant have Acute Kidney injury? (or Cortical necrosis) • What extent of CNS injury? • Technical issues surrounding renal replacement therapy • Timing becoming critical- patient anuric with limited nutrition • What are the outcomes from RRT in such patients? Should we proceed Brophy University of Iowa

7. RRT Options • Hemodialysis, Peritoneal Dialysis, CRRT • Each has advantages & disadvantages • Choice is guided by • Patient Characteristics • Disease/Symptoms • Hemodynamic stability • Goals of therapy • Fluid removal • Electrolyte correction • Both • Availability, expertise and cost Walters et. al. Peds Neph 2008 Brophy University of Iowa

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9. Technical Issues: • Resources: what techniques are you able to provide • Catheter placement, expertise • What would be the best for the patient • What co-morbidities does the patient have • What are the goals for the therapy • Metabolic control, fluid, both Brophy University of Iowa

10. Resources- very expensive • Facility fee daily (for neonates) • CRRT- $2200 USD + Profee • PD- $1200 USD + Profee • HD- $3200 USD + Profee • Team: specialized Nursing • Dietary, Social work, Physician • Therapy is an intense endeavor- not much patient volume but very time consuming Brophy University of Iowa

11. Not present Diabetes Older age Atherosclerotic disease Hypertension Volume of patients Present Size/Access variation Less frequent than adults/less experience Machinery is adapted (not made) for pediatrics Blood priming UF, thermic controls Neonatal/Pediatric Co-Morbidities: ConsiderationsApproaching Renal Replacement Therapy Brophy University of Iowa

12. Peritoneal Dialysis • Catheter placement may be acute or permanent • Dictated by the abdomen of the patient- can be difficult in Prune Belly, patients requiring nephrectomy (ARPKD, CNS) • Those with respiratory issues • May be ideal for those with pure renal issues (congenital) and some urine output • Usually well tolerated and gentle: can transition from acute care to chronic quite easily Brophy University of Iowa

13. Hemodialysis in Infants Brophy University of Iowa

14. Smaller patients require smaller catheters Difficulty achieving access Difficulty maintaining access Limited access sites Femoral veins Jugular veins Subclavian veins Umbilical vessels Vascular Access for Infant HD/CRRT Brophy University of Iowa

15. Catheter Type Manufacturer Potential Pts. Single-lumen 5Fr Cook Small Neonates Double-lumen 7Fr Cook Medcomp 3 – 6 Kg Triple-lumen 7Fr Medcomp 3 – 6 Kg Double-lumen 8Fr Kendall Arrow 6 – 30 Kg Choices for Infant Vascular Access Brophy University of Iowa

16. Ultrafiltration Rate for Infant CRRT • As tolerated by the patient • Potentially limited by dialyzer/hemofilter, blood flow rates • Small errors have a larger effect in a tiny patient ***** Brophy University of Iowa

17. Other Special Considerations for HD/CRRT in Infants • Large extracorporeal volume compared to small patient • Blood prime (1:1 PRBC:Albumin 5%) at initiation frequently required • Risk of thermic loss often requires heating system Brophy University of Iowa

18. Potential Complications of Infant HD/CRRT • Volume related problems • Biochemical and nutritional problems • Hemorrhage • Infection • Technical problems • Logistical problems • Bradykinin release syndrome Brophy University of Iowa

19. Logistical Issues for Infant HD/CRRT • Infrequently performed procedure in neonatal units • Vascular access can be difficult to organize and obtain • Neonatology staff may be unfamiliar with equipment, procedure, risks • Written procedures may improve coordination and results of therapy Brophy University of Iowa

20. OUTCOMES • How successful are we? • Some Neonates will start with AKI and progress to ESRD • Others will seemingly have ESRD but eventually come off of dialysis • “the dumbest kidneys are always smarter than the smartest Nephrologist” Brophy University of Iowa

21. Outcomes for Neonatal CRRT • Data are scant • Most studies are single-center, retrospective • No randomized controlled trials • Small numbers limit power • Extension from adult studies may not be appropriate Brophy University of Iowa

22. CRRT in Pediatric Patients <10Kg • Multi-center, retrospective study • 5 pediatric centers • 85 patients • Demographic data • Technique description • Outcome Am J Kid Dis, 18:833-837, 2003 Brophy University of Iowa

23. Congenital heart disease Metabolic disorder Multiorgan dysfunction Sepsis syndrome Liver failure Malignancy Congenital nephrotic syndrome Congenital diaphragmatic hernia Congenital renal/urological disease Hemolytic uremic syndrome Heart failure Other 16.5% 16.5% 15.3% 14.1% 10.6% 5.9% 4.7% 3.5% 2.4% 2.3% 2.3% 5.9% Which Babies Require CRRT? N=85 Am J Kid Dis, 18:833-837, 2003 Brophy University of Iowa

24. Combined volume overload and biochemical abnormalities of renal failure 54% Volume overload 18% Metabolic imbalance unrelated to renal failure (e.g., hyperammonemia) 14% Biochemical abnormalities of renal failure 9% Other (e.g., medication overdose) 4% Volume overload and hyperammonemia 1% Why do Babies Need CRRT? N=85 Brophy University of Iowa Am J Kid Dis, 18:833-837, 2003

25. CRRT in Infants <10Kg: Outcome 38% Survival 41% Survival 25% Survival Patients <10kg Patients 3-10kg Patients <3kg Brophy University of Iowa Am J Kid Dis, 18:833-837, 2003

26. 36% 71% 15% 42% 22% 0 50% 0 50% 50% 100% 0 60% Survival by Diagnosis Am J Kid Dis, 18:833-837, 2003 Totals: N=85; Survivors=32 Brophy University of Iowa

27. Retrospective Study of InfantCRRT: Summary • Overall outcome acceptable • 3 – 10kg: outcome similar to that for older patients • Metabolic disorders: good outcome • <3kg, selected diagnoses: poor outcome Am J Kid Dis, 18:833-837, 2003 Brophy University of Iowa

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29. 78% 68% 63% CRF 62% 60% ARF 53% Deaths due to co-morbid conditions Brophy University of Iowa

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36. Co-Morbidity Mortality Risk 1.8X greater <1 vs 1-5 yrs Mortality Risk 2.7X greater <1 vs >5 yrs This increases to 7.5X when co-morbid factors present Co-Mobidity: Lung hypoplasia Liver cirrhosis Cong Heart DZ Brophy University of Iowa

37. Data Summary • Infants with Stand alone renal disease can be effectively dialyzed to transplant • The mortality increases significantly after adding in co-morbid conditions Brophy University of Iowa

38. Thank You • NICU colleagues • Nursing staff • Dietitians Brophy University of Iowa