renal failure in pediatric cardiac surgery.ppt

Renal Replacement Therapy in Renal Replacement Therapy in Children after Surgery for Children after Surgery for Congenital Heart DiseaseCongenital Heart Disease

RiRi董奎廷董奎廷

ContentsContents

■ IntroductionIntroduction■ Risk factors for development of acute Risk factors for development of acute

renal failurerenal failure■ Renal replacement therapy optionsRenal replacement therapy options■ Outcome and survivalOutcome and survival■ DiscussionsDiscussions

IntroductionIntroduction

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

■ Incidence: 1.6-32.8% (~10% )Incidence: 1.6-32.8% (~10% )■ Mortality: 20-79% (~50% )Mortality: 20-79% (~50% )

■ Well studied cohorts availableWell studied cohorts available■ Timing of event (CPB) leading to ARF is Timing of event (CPB) leading to ARF is

precisely knownprecisely known■ Peritoneal dialysis (PD) predominant form Peritoneal dialysis (PD) predominant form

of renal replacement therapy (RRT)of renal replacement therapy (RRT)■ Continuous Hemofiltration Continuous Hemofiltration

(CVVH(CVVH、、 CAVH)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 FailureAcute Renal Failure

■ Definition: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)(Benfield MR, Pediatric Nephrology, 5th ed)

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

■ Clinical Definition:Clinical Definition:– Creatinine > 75 Creatinine > 75 µµmol/L (0.85 mg/dL)mol/L (0.85 mg/dL)– Oliguria (<1ml/kg/h) for more than 4 hours Oliguria (<1ml/kg/h) for more than 4 hours

despite aggressive diuretic/inotropic agentdespite aggressive diuretic/inotropic agent

Risk factors for development of Risk factors for development of acute renal failureacute renal failure■ Young ageYoung age■ High RACHS-1 ScoreHigh RACHS-1 Score■ Long cardio-pulmonary bypass timeLong cardio-pulmonary bypass time■ Need for circulatory arrestNeed for circulatory arrest■ Low cardiac output syndromeLow cardiac output syndrome

ManagmentManagment

■ Diuretic TherapyDiuretic Therapy■ Inotropic AgentsInotropic Agents■ Renal Replacement TherapyRenal Replacement Therapy

– Peritoneal DialysisPeritoneal Dialysis– HemofiltrationHemofiltration

■ CAVHCAVH■ CVVHCVVH

Indication of RRTIndication of RRTIn general:In general:■ 1. Anuria or oliguria (<1ml/kg/h) > 4 1. Anuria or oliguria (<1ml/kg/h) > 4

hours despite interventionhours despite intervention■ 2. Creatinine > 75 2. Creatinine > 75 µµmol/L (0.85 mg/dL)mol/L (0.85 mg/dL)■ 3. Increased Creatinine level with:3. Increased Creatinine level with:

– Clinical signs of fluid overloadClinical signs of fluid overload– Hyperkalemia: Serum K+ > 5.5 mmol/LHyperkalemia: Serum K+ > 5.5 mmol/L– Persistent acidosisPersistent acidosis– Low cardiac output syndromeLow cardiac output syndrome

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

-17.7-23-9.2Mean fluid deficit (mL/Hr)

CVVHCAVHPD

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

- Hemorrhage (2)- Limb ischemia (1)

CAVH

- SVC thrombosis (1)CVVH

-Failure of dialysate drainage (3)-Peritonitis (2)

PD

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

Discussion/SummaryDiscussion/Summary■ HemofiltrationHemofiltration superior to PD due to: superior to PD due to:

– Better fluid removalBetter fluid removal– Superior decrease of BUN/CreSuperior decrease of BUN/Cre

■ However:However:– Relatively high mortality in hemofiltration due to slower Relatively high mortality in hemofiltration due to slower

initiation of RRTinitiation of RRT– Hesitation due to:Hesitation due to:

■ new techniquenew technique■ vascular accessvascular access■ AnticoagulationAnticoagulation

■ Possibly lower mortality with early hemofiltration Possibly lower mortality with early hemofiltration therapy (~30%)therapy (~30%)– (Book et al 1982, Zobel et al 1991)(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)

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

Complications:

2. Hypothermia (32%)

3. Significant hemorrhage (28%)

4. Thrombocytopenia (92%)

Mortality: 76%

Peritoneal dialysisPeritoneal 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

ComparisonComparison

Fewer ReportsWell studied

1. Hemorrhage/thrombosis 2. e- imbalance

1. Peritonitis2. Catheter failure/leakage3. e- imbalance

Complications

Significant ReductionNon-significantBUN/Cre

More efficientEffectiveFluid Removal

HeparinNot neededAnticoagulation

Vascular accessPeritoneal catheterAccess

~50% (28-79%)~30% (20-79%)Mortality

Hemofiltration (CVVH/CAVH)

Peritoneal Dialysis

Timing of renal replacement Timing of renal replacement therapy rather than method?therapy rather than method?

Survival and early initiation of Survival and early initiation of RRTRRT

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 PDPost-operative Prophylactic PD

■ Method:Method:– Neonate and infants (n=756, age 0-1)Neonate and infants (n=756, age 0-1)– All underwent periopertaive ultrafiltrationAll underwent periopertaive ultrafiltration– 186/756 “high risk” patients received 186/756 “high risk” patients received

(24.6%) received (prophylactic) PD(24.6%) received (prophylactic) PD■ Results:Results:

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

– Mortality of ARF (17.3%)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

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

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

ComparisonComparison

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

Alkan et al. 3% 17.3% Favorable results

Discussions/SummaryDiscussions/Summary■ ARFARF is an important is an important complicationcomplication of pediatric cardiac of pediatric cardiac

surgerysurgery– High mortality rate (20-79%) ; Incidence (~1-10%)High mortality rate (20-79%) ; Incidence (~1-10%)– However, a definite diagnostic criteria does not existHowever, a definite diagnostic criteria does not exist

■ PD/HemofiltrationPD/Hemofiltration are are effectiveeffective RRT RRT– PD:PD:

■ Predominant, with more studies/evidencePredominant, with more studies/evidence■ better survival?better survival?

– Hemofiltration:Hemofiltration: ■ Fewer studies Fewer studies ■ Increasing use in critically ill patients with superior survivalIncreasing use in critically ill patients with superior survival

– Both methods Both methods lacklack large prospective or randomized large prospective or randomized control scales. Few head to head comparisonscontrol scales. Few head to head comparisons

– Timing and indications for RRT?Timing and indications for RRT?■ Early initiationEarly initiation RRT may be a more important RRT may be a more important predictor of predictor of

survivalsurvival than RRT modality than RRT modality

ComparisonComparison

Fewer ReportsWell studied

1. Hemorrhage/thrombosis 2. e- imbalance

1. Peritonitis2. Catheter failure/leakage3. e- imbalance

Complications

Significant ReductionNon-significantBUN/Cre

More efficientEffectiveFluid Removal

HeparinNot neededAnticoagulation

Vascular accessPeritoneal catheterAccess

~50% (28-79%)~30% (20-79%)Mortality

Hemofiltration (CVVH/CAVH)

Peritoneal Dialysis

Thank you for your attention!!Thank you for your attention!!

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

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

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

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

Independent Risk Factors:

2. Circulatory arrest

3. Duration of CPB

4. Low cardiac output syndrome