Renal Replacement Therapy in Children after Surgery for Congenital Heart Disease Ri 董奎廷
Contents <ul><li>Introduction </li></ul><ul><li>Risk factors for development of acute renal failure </li></ul><ul><li>Rena...
Introduction <ul><li>Acute renal failure is an important complication following surgery for congenital heart disease (CHD)...
<ul><li>Well studied cohorts available </li></ul><ul><li>Timing of event (CPB) leading to ARF is precisely known </li></ul...
Incidence and Mortality (PD) Kwok-lap Chan, et al.  Peritoneal Dialysis After Surgery for Congenital Heart Disease in Infa...
Acute Renal Failure <ul><li>Definition: </li></ul><ul><ul><li>decline in GFR and an inability of the kidneys to appropriat...
Risk factors for development of acute renal failure <ul><li>Young age </li></ul><ul><li>High RACHS-1 Score </li></ul><ul><...
Managment <ul><li>Diuretic Therapy </li></ul><ul><li>Inotropic Agents </li></ul><ul><li>Renal Replacement Therapy </li></u...
Indication of RRT <ul><li>In general: </li></ul><ul><li>1. Anuria or oliguria (<1ml/kg/h) > 4 hours despite intervention <...
Fleming F,,  et al :  Renal replacement therapy after repair of congenital heart disease in children:   A comparison of he...
Fleming F,,  et al :  Renal replacement therapy after repair of congenital heart disease in children: A comparison of hemo...
Fleming F,,  et al :  Renal replacement therapy after repair of congenital heart disease in children: A comparison of hemo...
Discussion/Summary <ul><li>Hemofiltration  superior to PD due to: </li></ul><ul><ul><li>Better fluid removal </li></ul></u...
Hemofiltration (1) A. Jander et al.  Continuous veno-venous hemodiafiltration in children after cardiac surgery  European ...
Peritoneal dialysis Kwok-lap Chan, et al.  Peritoneal Dialysis After Surgery for Congenital Heart Disease in Infants and Y...
Comparison Fewer Reports Well studied 1.  Hemorrhage/thrombosis  2. e- imbalance 1.  Peritonitis 2.  Catheter failure/leak...
Timing of renal replacement therapy rather than method?
Survival and early initiation of RRT Elahi MM, et al.  Early hemofiltration improves survival in post-cardiotomy patients ...
 
Post-operative Prophylactic PD <ul><li>Method: </li></ul><ul><ul><li>Neonate and infants (n=756, age 0-1) </li></ul></ul><...
<ul><li>Indications of PD </li></ul><ul><li>1. Anuria or oliguria despite intervention </li></ul><ul><li>2. Increased Crea...
Alkan et al.  Postoperative Prophylactic Peritoneal Dialysis in Neonates and Infants After Complex Congenital Cardiac Surg...
Comparison Kwok-lap Chan, et al.  Peritoneal Dialysis After Surgery for Congenital Heart Disease in Infants and Young Chil...
Discussions/Summary <ul><li>ARF  is an important  complication  of pediatric cardiac surgery </li></ul><ul><ul><li>High mo...
Comparison Fewer Reports Well studied 1.  Hemorrhage/thrombosis  2. e- imbalance 1.  Peritonitis 2.  Catheter failure/leak...
Thank you for your attention!!
Risk Adjustment for Congenital  Heart Surgery 1 (RACHS-1) Jenkins KJ, et al.  Consensus-based method for risk adjustment f...
K. R. Pedersen et al,  Risk factors for acute renal failure requiring dialysis after surgery for congenital heart disease ...
K. R. Pedersen et al,  Risk factors for acute renal failure requiring dialysis after surgery for congenital heart disease ...
Kwok-lap Chan, et al.  Peritoneal Dialysis After Surgery for Congenital Heart Disease in Infants and Young Children .   An...
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Renal Failure in Pediatric Cardiac Surgery.ppt

  1. 1. Renal Replacement Therapy in Children after Surgery for Congenital Heart Disease Ri 董奎廷
  2. 2. Contents <ul><li>Introduction </li></ul><ul><li>Risk factors for development of acute renal failure </li></ul><ul><li>Renal replacement therapy options </li></ul><ul><li>Outcome and survival </li></ul><ul><li>Discussions </li></ul>
  3. 3. Introduction <ul><li>Acute renal failure is an important complication following surgery for congenital heart disease (CHD) </li></ul><ul><li>Incidence: 1.6-32.8% (~10% ) </li></ul><ul><li>Mortality: 20-79% (~50% ) </li></ul>
  4. 4. <ul><li>Well studied cohorts available </li></ul><ul><li>Timing of event (CPB) leading to ARF is precisely known </li></ul><ul><li>Peritoneal dialysis (PD) predominant form of renal replacement therapy (RRT) </li></ul><ul><li>Continuous Hemofiltration (CVVH 、 CAVH) </li></ul>
  5. 5. 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
  6. 6. Acute Renal Failure <ul><li>Definition: </li></ul><ul><ul><li>decline in GFR and an inability of the kidneys to appropriately regulate fluid, electrolytes, and acid-base homeostasis (Benfield MR, Pediatric Nephrology, 5th ed) </li></ul></ul><ul><ul><li>Sudden decline in renal function with increasing BUN/Cr ratio; with or without changes in urine output (Johns Hopkins: The Harriet Lane Handbook, 17th ed. - 2005 ) </li></ul></ul><ul><li>Clinical Definition: </li></ul><ul><ul><li>Creatinine > 75  mol/L (0.85 mg/dL) </li></ul></ul><ul><ul><li>Oliguria (<1ml/kg/h) for more than 4 hours despite aggressive diuretic/inotropic agent </li></ul></ul>
  7. 7. Risk factors for development of acute renal failure <ul><li>Young age </li></ul><ul><li>High RACHS-1 Score </li></ul><ul><li>Long cardio-pulmonary bypass time </li></ul><ul><li>Need for circulatory arrest </li></ul><ul><li>Low cardiac output syndrome </li></ul>
  8. 8. Managment <ul><li>Diuretic Therapy </li></ul><ul><li>Inotropic Agents </li></ul><ul><li>Renal Replacement Therapy </li></ul><ul><ul><li>Peritoneal Dialysis </li></ul></ul><ul><ul><li>Hemofiltration </li></ul></ul><ul><ul><ul><li>CAVH </li></ul></ul></ul><ul><ul><ul><li>CVVH </li></ul></ul></ul>
  9. 9. Indication of RRT <ul><li>In general: </li></ul><ul><li>1. Anuria or oliguria (<1ml/kg/h) > 4 hours despite intervention </li></ul><ul><li>2. Creatinine > 75  mol/L (0.85 mg/dL) </li></ul><ul><li>3. Increased Creatinine level with: </li></ul><ul><ul><li>Clinical signs of fluid overload </li></ul></ul><ul><ul><li>Hyperkalemia: Serum K+ > 5.5 mmol/L </li></ul></ul><ul><ul><li>Persistent acidosis </li></ul></ul><ul><ul><li>Low cardiac output syndrome </li></ul></ul>
  10. 10. 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.
  11. 11. 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. -17.7 -23 -9.2 Mean fluid deficit (mL/Hr) CVVH CAVH PD
  12. 12. 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. - Hemorrhage (2) - Limb ischemia (1) CAVH - SVC thrombosis (1) CVVH <ul><li>Failure of dialysate drainage (3) </li></ul><ul><li>Peritonitis (2) </li></ul>PD
  13. 13. Discussion/Summary <ul><li>Hemofiltration superior to PD due to: </li></ul><ul><ul><li>Better fluid removal </li></ul></ul><ul><ul><li>Superior decrease of BUN/Cre </li></ul></ul><ul><li>However: </li></ul><ul><ul><li>Relatively high mortality in hemofiltration due to slower initiation of RRT </li></ul></ul><ul><ul><li>Hesitation due to: </li></ul></ul><ul><ul><ul><li>new technique </li></ul></ul></ul><ul><ul><ul><li>vascular access </li></ul></ul></ul><ul><ul><ul><li>Anticoagulation </li></ul></ul></ul><ul><li>Possibly lower mortality with early hemofiltration therapy (~30%) </li></ul><ul><ul><li>(Book et al 1982, Zobel et al 1991) </li></ul></ul>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.
  14. 14. 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 <ul><li>Complications: </li></ul><ul><li>Hypothermia (32%) </li></ul><ul><li>Significant hemorrhage (28%) </li></ul><ul><li>Thrombocytopenia (92%) </li></ul>Mortality: 76%
  15. 15. Peritoneal 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
  16. 16. Comparison Fewer Reports Well studied 1. Hemorrhage/thrombosis 2. e- imbalance 1. Peritonitis 2. Catheter failure/leakage 3. e- imbalance Complications Significant Reduction Non-significant BUN/Cre More efficient Effective Fluid Removal Heparin Not needed Anticoagulation Vascular access Peritoneal catheter Access ~50% (28-79%) ~30% (20-79%) Mortality Hemofiltration (CVVH/CAVH) Peritoneal Dialysis
  17. 17. Timing of renal replacement therapy rather than method?
  18. 18. Survival and early initiation of RRT Elahi MM, et al. Early hemofiltration improves survival in post-cardiotomy patients with acute renal failure . Eur J Cardiothorac Surg 2004;26:1027—31
  19. 20. Post-operative Prophylactic PD <ul><li>Method: </li></ul><ul><ul><li>Neonate and infants (n=756, age 0-1) </li></ul></ul><ul><ul><li>All underwent periopertaive ultrafiltration </li></ul></ul><ul><ul><li>186/756 “high risk” patients received (24.6%) received (prophylactic) PD </li></ul></ul><ul><li>Results: </li></ul><ul><ul><li>23/186 (12.3%) of pPD, 23/756 (3%) of all developed ARF </li></ul></ul><ul><ul><li>Mortality of ARF (17.3%) </li></ul></ul>Alkan et al. Postoperative Prophylactic Peritoneal Dialysis in Neonates and Infants After Complex Congenital Cardiac Surgery ASAIO Journal 2006; 52: 693–697
  20. 21. <ul><li>Indications of PD </li></ul><ul><li>1. Anuria or oliguria despite intervention </li></ul><ul><li>2. Increased Creatinine level with: </li></ul><ul><ul><li>Clinical signs of fluid overload </li></ul></ul><ul><ul><li>Hyperkalemia: Serum K+ > 5.5 mmol/L </li></ul></ul><ul><ul><li>Persistent acidosis </li></ul></ul><ul><ul><li>Low cardiac output syndrome </li></ul></ul>
  21. 22. Alkan et al. Postoperative Prophylactic Peritoneal Dialysis in Neonates and Infants After Complex Congenital Cardiac Surgery ASAIO Journal 2006; 52: 693–697
  22. 23. Comparison 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
  23. 24. Discussions/Summary <ul><li>ARF is an important complication of pediatric cardiac surgery </li></ul><ul><ul><li>High mortality rate (20-79%) ; Incidence (~1-10%) </li></ul></ul><ul><ul><li>However, a definite diagnostic criteria does not exist </li></ul></ul><ul><li>PD/Hemofiltration are effective RRT </li></ul><ul><ul><li>PD: </li></ul></ul><ul><ul><ul><li>Predominant, with more studies/evidence </li></ul></ul></ul><ul><ul><ul><li>better survival? </li></ul></ul></ul><ul><ul><li>Hemofiltration: </li></ul></ul><ul><ul><ul><li>Fewer studies </li></ul></ul></ul><ul><ul><ul><li>Increasing use in critically ill patients with superior survival </li></ul></ul></ul><ul><ul><li>Both methods lack large prospective or randomized control scales. Few head to head comparisons </li></ul></ul><ul><ul><li>Timing and indications for RRT? </li></ul></ul><ul><li>Early initiation RRT may be a more important predictor of survival than RRT modality </li></ul>
  24. 25. Comparison Fewer Reports Well studied 1. Hemorrhage/thrombosis 2. e- imbalance 1. Peritonitis 2. Catheter failure/leakage 3. e- imbalance Complications Significant Reduction Non-significant BUN/Cre More efficient Effective Fluid Removal Heparin Not needed Anticoagulation Vascular access Peritoneal catheter Access ~50% (28-79%) ~30% (20-79%) Mortality Hemofiltration (CVVH/CAVH) Peritoneal Dialysis
  25. 26. Thank you for your attention!!
  26. 27. Risk Adjustment for Congenital 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.
  27. 28. 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
  28. 29. 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
  29. 30. 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 <ul><li>Independent Risk Factors: </li></ul><ul><li>Circulatory arrest </li></ul><ul><li>Duration of CPB </li></ul><ul><li>Low cardiac output syndrome </li></ul>
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