Renal Failure in Pediatric Cardiac Surgery.ppt

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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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