PCRRT in HUS:

Role of peritoneal dialysis

Thomas J Neuhausand

GF Laube, JF Falger, EM Rüth, MJ Kemper, O Bänziger

University Children’s Hospital, Zurich

Zurich: Local History

1955: Gasser et al: Hemolytic-Uremic Syndromes: HUS

1964: Peritoneal dialysis for acute renal failure: HUS

1970: Hemodialysis and renal transplantation

1979: Continuous PD for chronic renal failure

1995: Continuous veno-venous hemofiltration for ARF

HUS = Hemolytic-Uremic Syndromes

Hemolytic microangiopathic anemia:

fragmentocytes, LDH , neg. Coombs

Thrombocytopenia

Uremia: acute renal failure

Further symptoms / complications: Central nervous system (seizures, hemorrhages) Hypertension and heart failure Liver / Pancreas (with diabetes mellitus) Eye: retinal bleedings

HUS: D+ and D-

D+ = Diarrhea-positive Verotoxin (or Shigatoxin)-producing E. Coli Other bacteria, e.g. Shigella …. („Big Mc disease“) Hemorrhagic colitis: mild – severe, intussusception

D- = Diarrhea-negative Pneumococcal infections (T-antigen positive) Inherited and/or recurrent forms: e.g. complement

(factor I/H) or vWF-cleavage protease deficiency Others: Pregnancy, drugs … „Many“ cases of unknown cause

Period

N

Per year

D+ /D -

1970 – 79

14

1.4

1 : 1

1970 – 94

63

2.5

1.8 : 1

1995 – 2005

68

6.2

3.2 : 1

Total

131

3.6

2.4 : 1

Zurich: Epidemiology of HUSHUS: most frequent cause of acute renal

failure in our hospital

HUS: Indications for dialysis

modality since 1995 (1)

Peritoneal dialysis: „in general“ first choice On ICU: CAPD On ward: mainly automated PD

Hemodialysis if „older“ patient in „good general condition“ not

requiring care in intensive care unit D-HUS and plasma-exchange (PEX) anticipated life-threatening hyperkalemia

Continuous veno-venous hemo(dia)filtration if „in bad general condition“ (+/- PEX) severe colitis

Plasma-exchange (PEX) or plasma infusion if D-HUS and inherited type / complement deficiency

suspected D- or D+ HUS with severe central nervous

system symptoms, e.g. impaired consciousness,

neurological deficit

HUS: Indications for dialysis

modality since 1995 (2)

Acute renal failure and

peritoneal dialyis among adults ?! Recent review on „Renal replacement therapy of

acute renal failure in ICU adult patients“

… Peritoneal dialysis is not further discussed … because of missing data no significant role 1 study showing a very high mortality ….

HUS: 1995 – 2005 (1)

N = 68: 30 males, 38 females

Age: median 2.3 years (2 months – 12 years)

D+: 52 = 76%: 5 months – 12 years

D- : 16 = 24%: 2 months – 10 years 6: pneumoccocal infection, 5 with septicemia 1: acute systemic lupus erythematodes 1: complement I deficiency (Dg: 9 yrs after onset !) 1: familial occurrence (mother / grandmother) 7: unknown cause

HUS: 1995 – 2005 (2)

„Extreme“ values median range

Creatinine 375 μmol/l (4.3 mg/dl) 50 – 995

Urea 32 mmol/l (192 mg/dl) 6 – 76

Hemoglobin 62 g/l 29 – 108

Platelets 36 G/l 7 – 271

Sodium 132 mmol/l 109 – 142

HUS and dialysis: 54 / 68 (79%)

5

11

43

9

D+ dialysis

D+ no dial

D- no dial

D- dialysis

52: D+HUS

16: D-HUS

HUS and PD: 44 / 54 dialysed (81%)

3

8

7

36

D+ PD

D+ no PD

D- no PD

D- PD

43: D+HUS

11: D-HUS

Acute PD

before 1995: „stiff“ Cook-catheter or „soft“(„peel away“) catheter, inserted with trocar or Tenckhoff

since 1995: only Tenckhoff catheter surgically placed by the surgeon (and the

nephrologist also in theatre) under general

anasthetic; at the same time insertion of

central venous line

Acute and chronic PD

Tenckhoff catheter: coil 2 sizes: < / > 1 year 1 cuff (glued by ourselves) upward facing

Acute PD on ICU:• Fresenius system

• Lactate (march 2006:

bicarbonate)

• Initial prescription:

• >10 - 15 ml / kg

• exchange: every hour

• 1000 IU Heparin/l

• 1.36% Glucose

• no antibiotics

• run by ICU-nurses

Acute PD on ward:• Baxter system

• mainly automated PD

• Bicarbonate (Physioneal)

• Prescription:

• up to 40 ml / kg

• exchange: 2 – 4 hours

• 1000 IU Heparin/l

• 1.36% Glucose

• no antibiotics

• Run by ward / renal nurses

HUS and PD: 44 / 54 with dialysis

Start with PD: 41/54 (76%)

D+ 35/43 (81%) D- 6/11 (55%)

Only PD: 35/54 (65%)

D+ 30/43 (70%) D- 5/11 (45%)

HUS and PD:

3 patients: switch to PD from

HD: 1 D+, transfer ICU ward and

end-stage renal failure

CVVH: 1 D-, transfer ICU ward

HD/PEX: 1 D-, transfer ICU ward and

ESRF

6 patients: switch from PD to

CVVH : 2 1: D+, general deterioration: †1: D+, rectumperf. 2° peritonitis

HD: 2 1: D+, insufficient ultrafiltration despite 3.86% glucose1: D-, ESRF

plus PEX: 2 D+, cerebral involvement: 1 †

HUS and PD:

HUS and PD: technical aspects

Time span between emergency room entry and

onset of PD in ICU: median 4 hours (2 – 20)

Duration of PD: median 10 days (1 – 35)

HUS and PD: technical complications

Peritonitis: n = 9 (all in ICU)

Exit-site infection n = 3

Insufficient ultrafiltration: n = 1 switch: HD

Catheter obstruction: n = 0

Insufficient dialysis: n = 0

No catheter had to be replaced.

HUS and hemofiltration

Hemofiltration: 7

Only CVVH: 2 1 D+: presentation with epileptic state 1 D-: pneumoccocal septicemia

CVVH and PD: 3

CVVH and HD: 2

HUS and hemodialysis / PEX

Only HD: 5, all D+ HUS 3: older patients – 12 years – in „good condition“ 1: recurrent intussusception and bowel resection

before onset of ARF 1: severe hemorrhagic colitis

Plus PEX: 4 2 D-, 2 D+

HUS: clinical complications (1) Hypertension: requiring medication

40 / 68 (59%), 28 / 44 with PD

16 patients with PD: „no medication, only PD“

Cardiomyopathy: 6: impaired ventricular function

Pancreatitis: Amylase ↑ 24: but no diabetes mellitus

Hepatopathy: Transaminases ↑ 43: but no liver failure

HUS: clinical complications (2) Gastrointestinal tract: n = 4 (all D+)

2 intussusception 1 rectum perforation 1 severe colitis

Severe central nervous system: n = 7

4 D+: 3: remission, 1: † 3 D-: 2: sequelae (pneumococcal meningitis,

massive hemorrhage), 1: † (SLE)

Retinal bleeding: n = 2 (all D+)

HUS: stay in ICU / hospital

ICU: median: 5 days (0 – 30)

Hospital: median: 17 days (1 – 93)

HUS: daily running costs: Pat 20 kg

CHF US$ Ratio to PD PD:

2 x 5 l bag: 44 34 1.0

HD: 60 46 1.5 set: 40 concentrate: 20

CVVH: 1 set / 3 days 175 – 210 135 – 160 4.5

set: 225 – 325 4 x 5 l filtrate: 100

HD and CVVH: plus costs of hardware…

Outcome: D+ HUS: n = 52

4

44 = 85%

4Recovery =no dialysis

ESRF

Exitus

Outcome: D- HUS: n = 16

3

9 = 56%4

Recovery =no dialysis

ESRF

Exitus

Conclusions (1): HUS

Incidence: D+ >>> D- (over the last 35 years)

80% require dialysis

Outcome: D+ >> D- Patient survival Recovery of renal function

Conclusions (2): HUS – PD

Surgically placed Tenckhoff-catheter: Simple technique High efficacy Low frequency of side effects / complications

PD in HUS is safe efficient convenient economic