renal replacement therapy for acute renal failure timothy e. bunchman professor pediatrics
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Renal Replacement Therapy for Acute Renal Failure
Timothy E. Bunchman Professor Pediatrics
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Infant ARF Single RRT Modality • Ronco et al; Intens Care Med, 1995 45% survival-CRRT• Sadowski et al; KI 1995 primary renal disease 71%-HD secondary renal disease 33%-
HD
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Pediatric ARF Single RRT Modality• Niaudet et al; KI, 1985 80% survival-primary ARF all RRT• Zobel et al; Ped Neph, 1989 65% survival-CRRT• Zobel et al; Contrib Neph, 1991 60% survival-CAVH, 35%-survival- CVVH
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Pediatric ARF Single RRT Modality • Paret et al; J Thor Cardiovas Surg ,
1992 33% survival-CAVH• Gallego et al; Nephron, 1993 52% survival with PD/HD features of poorer prognosis
–less then 1 mos of age–hypotension
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Pediatric ARF Single RRT Modality • Bradbury et al; Arch Dis Child,
1994 33% survival-CVVH• Latta et al; Ped Neph, 1994 37% survival-CAVH• Smoyer et al; JASN, 1995 43% survival-CRRT
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Pediatric ARF Comparison of RRT modalities• Fleming et al; J Thor Cardiovas Surg,
1995 38% survival-PD 33% survival-CAVH 42% survival-CVVH• Maxvold et al; Am J Kid Dis, 1997
43% survival-CVVH 83% survival-HD
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Pediatric ARF Comparison of RRT modalities• Lowrie et al; Ped Neph, 2000
– evaluation of PD vs CVVHF in children with MOSF
– survival equal but related to disease state and the number of organs non functioning
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Adult ARF Comparison of RRT modalities• Kruczynski et al; ASAIO, 1993 75% Survival-CAVH; 18% survival-HD• Bellomo et al; ASAIO, 1993 40% Survival-CRRT; 30% survival-HD• van Brommel et al: Am J Neph, 1995 43% Survival-CRRT; 59% survival-HD
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New Dialysis Patients 1992-1998 (total 354)
72
282
ESRDARF
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Demographics
Total (354) ARF (282)Age 79 mos 74 mosWeight 27. 5 kg 25 kgSex 54% male 51% maleHypotension atonset
27% 32%
Pressor use duringtherapy
53% 65%
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Modality of Choice at onsetRRT modality Total (354) ARF (282)
Hemofiltration (HF) 106 106
Peritoneal Dial (PD) 107 59
Hemodialysis (HD) 107 83
HF on ECMO 34 34
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Diagnosis
2614
22
12
22
16
487
18
14
40
392
BMTTLS/MalHLHSHt TxCyanotic HtHUSARF/ATNARDSLiver TxInborn Error MetSepsisCRFOther
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ARF-282 patients
• Time on therapy– HF-8.7 days– HD-9.5 days– PD-9.6 days NS
• Heparin Free Therapies– HF-51%– HD-28% < 0.01
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Survivors: Analysis by weight
27.9
23.7
0
5
10
15
20
25
30
Survivors Non Survivors
Weight (kg)
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Survivors: Analysis byBP at onset
33%
61%
100%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Low BP Nl BP High BP
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Survivors: Analysis by use of Pressors
35%
89%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
+ Pressors - Pressors
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Survivors: Analysis by RRT modality
40%
49%41%
81%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
HF PD HF/ECMO HD
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Survivors: Analysis by RRT modality and weight
0
5
10
15
20
25
30
35
40
HF PD HF/ECMO HD
Survivor wtNon Survivor wt
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21% 19%
33%
50%
78%
50%42%
33%
0%
10%
20%
30%
40%
50%
60%
70%
80%
HF PD HD Overall
BMTSepsis
Survivors: Analysis by Diagnosis and RRT Modality
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79%
95%
100%90%
60%50%
0%
10%
20%30%
40%
50%
60%
70%80%
90%
100%
HF PD HD
BMTSepsis
Analysis by Diagnosis RRT Modality and Pressors
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50%
22%
82%
0%
82%
0%
67%
17%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
HF PD HD Overall
ARFLiver Tx
Survivors: Analysis by Diagnosis and RRT Modality
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75% 79%
64%
100%
31%
50%
0%
10%
20%30%
40%
50%
60%
70%
80%90%
100%
HF PD HD
ARFLiver Tx
Analysis by Diagnosis RRT Modality and Pressors
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67%
33%
0%
33%
0%
100%
41%36%
0%
10%
20%
30%40%
50%
60%
70%
80%
90%100%
HF PD HD Overall
HLHSCyan Ht Dis
Survivors: Analysis by Diagnosis and RRT Modality
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100%100% 100%
83%100%
0%
10%20%
30%
40%
50%60%
70%
80%90%
100%
HF PD HD
HLHSCyan Ht Dis
Analysis by Diagnosis RRT Modality and Pressors
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RRT for ARF
• Best RRT is one that’s continuous, done with ease, and minimizes risk of hypotension, access complications, infectious risk, or coagulation risk
• Best local standard is the best modality
• Nutritional needs of the child need to be factored in and adjusted for RRT modality
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• Survival is related to diagnosis, hypotension, use of pressor agents and PRISM scores and may be influenced by RRT choice
• ARF management needs to be a cooperative effort between Nephrologists and Intensivists for the optimal care of children
RRT for ARF