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  • 1. PCRRT in HUS: Role of peritoneal dialysis Thomas J Neuhaus and GF Laube, JF Falger, EM Rüth, MJ Kemper, O Bänziger University Children’s Hospital, Zurich
  • 2. Zurich: Local History
    • 1955: Gasser et al: H emolytic- U remic S yndrom es : 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
  • 3.
    • HUS = H emolytic- U remic S yndrome s
    • 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
  • 4. 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
  • 5. Zurich: Epidemiology of HUS HUS: most frequent cause of acute renal failure in our hospital
  • 6. 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
  • 7.
    • 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)
  • 8. 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 ….
  • 9. 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
  • 10. HUS: 1995 – 2005 (2)
    • „ Extreme“ values median range
    • Creatinine 375 μ mol/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
  • 11. HUS and dialysis: 54 / 68 (79%) 52: D+HUS 16: D-HUS
  • 12. HUS and PD: 44 / 54 dialysed (81%) 43: D+HUS 11: D-HUS
  • 13. 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
  • 14. Acute and chronic PD
    • Tenckhoff catheter:
      • coil
      • 2 sizes: < / > 1 year
      • 1 cuff (glued by ourselves)
      • upward facing
  • 15.
    • 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
  • 16.
    • Acute PD on ward:
    • Baxter system
    • mainly automated PD
    • Bicarbonate (Physioneal)
    • P rescription:
      • up to 40 ml / kg
      • exchange: 2 – 4 hours
      • 1000 IU Heparin/l
      • 1.36% Glucose
      • no antibiotics
    • Run by ward / renal nurses
  • 17. 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%)
  • 18. 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
  • 19.
    • 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% glucose
      • 1: D-, ESRF
      • plus PEX: 2 D+, cerebral involvement: 1 †
    HUS and PD:
  • 20. 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)
  • 21. 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.
  • 22. 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
  • 23. 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+
  • 24. 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
  • 25. 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+)
  • 26. HUS: stay in ICU / hospital
    • ICU:
      • median: 5 days (0 – 30)
    • Hospital:
      • median: 17 days (1 – 93)
  • 27. 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…
  • 28. Outcome: D+ HUS: n = 52
  • 29. Outcome: D- HUS: n = 16
  • 30. Conclusions (1): HUS
    • Incidence:
      • D+ >>> D- (over the last 35 years)
    • 80% require dialysis
    • Outcome: D+ >> D-
      • Patient survival
      • Recovery of renal function
  • 31. 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
  • 32.