Neuhaus HUS PCRRT 2006

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Neuhaus HUS PCRRT 2006

  1. 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. 2. Zurich: Local History <ul><li>1955: Gasser et al: H emolytic- U remic S yndrom es : HUS </li></ul><ul><li>1964: Peritoneal dialysis for acute renal failure: HUS </li></ul><ul><li>1970: Hemodialysis and renal transplantation </li></ul><ul><li>1979: Continuous PD for chronic renal failure </li></ul><ul><li>1995: Continuous veno-venous hemofiltration for ARF </li></ul>
  3. 3. <ul><li>HUS = H emolytic- U remic S yndrome s </li></ul><ul><li>Hemolytic microangiopathic anemia: </li></ul><ul><li>fragmentocytes, LDH  , neg. Coombs </li></ul><ul><li>Thrombocytopenia </li></ul><ul><li>Uremia: acute renal failure </li></ul><ul><li>Further symptoms / complications: </li></ul><ul><ul><li>Central nervous system (seizures, hemorrhages) </li></ul></ul><ul><ul><li>Hypertension and heart failure </li></ul></ul><ul><ul><li>Liver / Pancreas (with diabetes mellitus) </li></ul></ul><ul><ul><li>Eye: retinal bleedings </li></ul></ul>
  4. 4. HUS: D+ and D- <ul><li>D+ = Diarrhea-positive </li></ul><ul><ul><li>Verotoxin (or Shigatoxin)-producing E. Coli </li></ul></ul><ul><ul><li>Other bacteria, e.g. Shigella …. („Big Mc disease“) </li></ul></ul><ul><ul><li>Hemorrhagic colitis: mild – severe, intussusception </li></ul></ul><ul><li>D- = Diarrhea-negative </li></ul><ul><ul><li>Pneumococcal infections (T-antigen positive) </li></ul></ul><ul><ul><li>Inherited and/or recurrent forms: e.g. complement (factor I/H) or vWF-cleavage protease deficiency </li></ul></ul><ul><ul><li>Others: Pregnancy, drugs … </li></ul></ul><ul><ul><li>„ Many“ cases of unknown cause </li></ul></ul>
  5. 5. Zurich: Epidemiology of HUS HUS: most frequent cause of acute renal failure in our hospital
  6. 6. HUS: Indications for dialysis modality since 1995 (1) <ul><li>Peritoneal dialysis : „in general“ first choice </li></ul><ul><ul><li>On ICU: CAPD </li></ul></ul><ul><ul><li>On ward: mainly automated PD </li></ul></ul><ul><li>Hemodialysis if </li></ul><ul><ul><li>„ older“ patient in „good general condition“ not requiring care in intensive care unit </li></ul></ul><ul><ul><li>D-HUS and plasma-exchange (PEX) anticipated </li></ul></ul><ul><ul><li>life-threatening hyperkalemia </li></ul></ul>
  7. 7. <ul><li>Continuous veno-venous hemo(dia)filtration if </li></ul><ul><ul><li>„ in bad general condition“ (+/- PEX) </li></ul></ul><ul><ul><li>severe colitis </li></ul></ul><ul><li>Plasma-exchange (PEX) or plasma infusion if </li></ul><ul><ul><li>D-HUS and inherited type / complement deficiency </li></ul></ul><ul><ul><li>suspected </li></ul></ul><ul><ul><li>D- or D+ HUS with severe central nervous </li></ul></ul><ul><ul><li>system symptoms, e.g. impaired consciousness, </li></ul></ul><ul><ul><li>neurological deficit </li></ul></ul>HUS: Indications for dialysis modality since 1995 (2)
  8. 8. Acute renal failure and peritoneal dialyis among adults ?! <ul><li>Recent review on „Renal replacement therapy of acute renal failure in ICU adult patients“ </li></ul><ul><li>… Peritoneal dialysis is not further discussed … because of </li></ul><ul><ul><li>missing data </li></ul></ul><ul><ul><li>no significant role </li></ul></ul><ul><ul><li>1 study showing a very high mortality …. </li></ul></ul>
  9. 9. HUS: 1995 – 2005 (1) <ul><li>N = 68: 30 males, 38 females </li></ul><ul><li>Age: median 2.3 years (2 months – 12 years) </li></ul><ul><li>D+: 52 = 76%: 5 months – 12 years </li></ul><ul><li>D- : 16 = 24%: 2 months – 10 years </li></ul><ul><ul><li>6: pneumoccocal infection, 5 with septicemia </li></ul></ul><ul><ul><li>1: acute systemic lupus erythematodes </li></ul></ul><ul><ul><li>1: complement I deficiency (Dg: 9 yrs after onset !) </li></ul></ul><ul><ul><li>1: familial occurrence (mother / grandmother) </li></ul></ul><ul><ul><li>7: unknown cause </li></ul></ul>
  10. 10. HUS: 1995 – 2005 (2) <ul><li>„ Extreme“ values median range </li></ul><ul><li>Creatinine 375 μ mol/l (4.3 mg/dl) 50 – 995 </li></ul><ul><li>Urea 32 mmol/l (192 mg/dl) 6 – 76 </li></ul><ul><li>Hemoglobin 62 g/l 29 – 108 </li></ul><ul><li>Platelets 36 G/l 7 – 271 </li></ul><ul><li>Sodium 132 mmol/l 109 – 142 </li></ul>
  11. 11. HUS and dialysis: 54 / 68 (79%) 52: D+HUS 16: D-HUS
  12. 12. HUS and PD: 44 / 54 dialysed (81%) 43: D+HUS 11: D-HUS
  13. 13. Acute PD <ul><li>before 1995: </li></ul><ul><ul><li>„ stiff“ Cook-catheter or </li></ul></ul><ul><ul><li>„ soft“(„peel away“) catheter, inserted with trocar or </li></ul></ul><ul><ul><li>Tenckhoff </li></ul></ul><ul><li>since 1995: </li></ul><ul><ul><li>only Tenckhoff catheter </li></ul></ul><ul><ul><li>surgically placed by the surgeon (and the </li></ul></ul><ul><ul><li>nephrologist also in theatre) under general </li></ul></ul><ul><ul><li>anasthetic; at the same time insertion of </li></ul></ul><ul><ul><li>central venous line </li></ul></ul>
  14. 14. Acute and chronic PD <ul><li>Tenckhoff catheter: </li></ul><ul><ul><li>coil </li></ul></ul><ul><ul><li>2 sizes: < / > 1 year </li></ul></ul><ul><ul><li>1 cuff (glued by ourselves) </li></ul></ul><ul><ul><li>upward facing </li></ul></ul>
  15. 15. <ul><li>Acute PD on ICU: </li></ul><ul><li>Fresenius system </li></ul><ul><li>Lactate (march 2006: </li></ul><ul><li>bicarbonate) </li></ul><ul><li>Initial prescription: </li></ul><ul><ul><li>>10 - 15 ml / kg </li></ul></ul><ul><ul><li>exchange: every hour </li></ul></ul><ul><ul><li>1000 IU Heparin/l </li></ul></ul><ul><ul><li>1.36% Glucose </li></ul></ul><ul><ul><li>no antibiotics </li></ul></ul><ul><li>run by ICU-nurses </li></ul>
  16. 16. <ul><li>Acute PD on ward: </li></ul><ul><li>Baxter system </li></ul><ul><li>mainly automated PD </li></ul><ul><li>Bicarbonate (Physioneal) </li></ul><ul><li>P rescription: </li></ul><ul><ul><li>up to 40 ml / kg </li></ul></ul><ul><ul><li>exchange: 2 – 4 hours </li></ul></ul><ul><ul><li>1000 IU Heparin/l </li></ul></ul><ul><ul><li>1.36% Glucose </li></ul></ul><ul><ul><li>no antibiotics </li></ul></ul><ul><li>Run by ward / renal nurses </li></ul>
  17. 17. HUS and PD: 44 / 54 with dialysis <ul><li>Start with PD: 41/54 (76%) </li></ul><ul><ul><li>D+ 35/43 (81%) </li></ul></ul><ul><ul><li>D- 6/11 (55%) </li></ul></ul><ul><li>Only PD: 35/54 (65%) </li></ul><ul><ul><li>D+ 30/43 (70%) </li></ul></ul><ul><ul><li>D- 5/11 (45%) </li></ul></ul>
  18. 18. HUS and PD: <ul><li>3 patients: switch to PD from </li></ul><ul><ul><li>HD: 1 D+, transfer ICU  ward and </li></ul></ul><ul><ul><li> end-stage renal failure </li></ul></ul><ul><ul><li>CVVH: 1 D-, transfer ICU  ward </li></ul></ul><ul><ul><li>HD/PEX: 1 D-, transfer ICU  ward and </li></ul></ul><ul><ul><li> ESRF </li></ul></ul>
  19. 19. <ul><li>6 patients: switch from PD to </li></ul><ul><ul><li>CVVH : 2 1: D+, general deterioration: † </li></ul></ul><ul><ul><li>1: D+, rectumperf.  2° peritonitis </li></ul></ul><ul><ul><li>HD: 2 1: D+, insufficient ultrafiltration </li></ul></ul><ul><ul><li> despite 3.86% glucose </li></ul></ul><ul><ul><li>1: D-, ESRF </li></ul></ul><ul><ul><li>plus PEX: 2 D+, cerebral involvement: 1 † </li></ul></ul>HUS and PD:
  20. 20. HUS and PD: technical aspects <ul><li>Time span between emergency room entry and </li></ul><ul><li>onset of PD in ICU: </li></ul><ul><ul><li>median 4 hours (2 – 20) </li></ul></ul><ul><li>Duration of PD: </li></ul><ul><ul><li>median 10 days (1 – 35) </li></ul></ul>
  21. 21. HUS and PD: technical complications <ul><li>Peritonitis: n = 9 (all in ICU) </li></ul><ul><li>Exit-site infection n = 3 </li></ul><ul><li>Insufficient ultrafiltration: n = 1  switch: HD </li></ul><ul><li>Catheter obstruction: n = 0 </li></ul><ul><li>Insufficient dialysis: n = 0 </li></ul><ul><li> No catheter had to be replaced. </li></ul>
  22. 22. HUS and hemofiltration <ul><li>Hemofiltration: 7 </li></ul><ul><ul><li>Only CVVH: 2 </li></ul></ul><ul><ul><ul><li>1 D+: presentation with epileptic state </li></ul></ul></ul><ul><ul><ul><li>1 D-: pneumoccocal septicemia </li></ul></ul></ul><ul><ul><li>CVVH and PD: 3 </li></ul></ul><ul><ul><li>CVVH and HD: 2 </li></ul></ul>
  23. 23. HUS and hemodialysis / PEX <ul><li>Only HD: 5, all D+ HUS </li></ul><ul><ul><li>3: older patients – 12 years – in „good condition“ </li></ul></ul><ul><ul><li>1: recurrent intussusception and bowel resection </li></ul></ul><ul><ul><li> before onset of ARF </li></ul></ul><ul><ul><li>1: severe hemorrhagic colitis </li></ul></ul><ul><li>Plus PEX: 4 </li></ul><ul><ul><li>2 D-, 2 D+ </li></ul></ul>
  24. 24. HUS: clinical complications (1) <ul><li>Hypertension: requiring medication </li></ul><ul><ul><li>40 / 68 (59%), 28 / 44 with PD </li></ul></ul><ul><ul><li> 16 patients with PD: „no medication, only PD“ </li></ul></ul><ul><li>Cardiomyopathy: </li></ul><ul><ul><li>6: impaired ventricular function </li></ul></ul><ul><li>Pancreatitis: Amylase ↑ </li></ul><ul><ul><li>24: but no diabetes mellitus </li></ul></ul><ul><li>Hepatopathy: Transaminases ↑ </li></ul><ul><ul><li>43: but no liver failure </li></ul></ul>
  25. 25. HUS: clinical complications (2) <ul><li>Gastrointestinal tract: n = 4 (all D+) </li></ul><ul><ul><li>2 intussusception </li></ul></ul><ul><ul><li>1 rectum perforation </li></ul></ul><ul><ul><li>1 severe colitis </li></ul></ul><ul><li>Severe central nervous system: n = 7 </li></ul><ul><ul><li>4 D+: 3: remission, 1: † </li></ul></ul><ul><ul><li>3 D-: 2: sequelae (pneumococcal meningitis, </li></ul></ul><ul><ul><li> massive hemorrhage), 1: † (SLE) </li></ul></ul><ul><li>Retinal bleeding: n = 2 (all D+) </li></ul>
  26. 26. HUS: stay in ICU / hospital <ul><li>ICU: </li></ul><ul><ul><li>median: 5 days (0 – 30) </li></ul></ul><ul><li>Hospital: </li></ul><ul><ul><li>median: 17 days (1 – 93) </li></ul></ul>
  27. 27. HUS: daily running costs: Pat  20 kg <ul><li> CHF US$ Ratio to PD </li></ul><ul><li>PD: </li></ul><ul><ul><li>2 x 5 l bag: 44 34 1.0 </li></ul></ul><ul><li>HD: 60 46 1.5 </li></ul><ul><ul><li>set: 40 </li></ul></ul><ul><ul><li>concentrate: 20 </li></ul></ul><ul><li>CVVH: </li></ul><ul><ul><li>1 set / 3 days 175 – 210 135 – 160 4.5 </li></ul></ul><ul><ul><ul><li>set: 225 – 325 </li></ul></ul></ul><ul><ul><ul><li>4 x 5 l filtrate: 100 </li></ul></ul></ul><ul><li>HD and CVVH : plus costs of hardware… </li></ul>
  28. 28. Outcome: D+ HUS: n = 52
  29. 29. Outcome: D- HUS: n = 16
  30. 30. Conclusions (1): HUS <ul><li>Incidence: </li></ul><ul><ul><li>D+ >>> D- (over the last 35 years) </li></ul></ul><ul><li>80% require dialysis </li></ul><ul><li>Outcome: D+ >> D- </li></ul><ul><ul><li>Patient survival </li></ul></ul><ul><ul><li>Recovery of renal function </li></ul></ul>
  31. 31. Conclusions (2): HUS – PD <ul><li>Surgically placed Tenckhoff-catheter: </li></ul><ul><ul><li>Simple technique </li></ul></ul><ul><ul><li>High efficacy </li></ul></ul><ul><ul><li>Low frequency of side effects / complications </li></ul></ul><ul><li>PD in HUS is </li></ul><ul><ul><li>safe </li></ul></ul><ul><ul><li>efficient </li></ul></ul><ul><ul><li>convenient </li></ul></ul><ul><ul><li>economic </li></ul></ul>

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