Renal Replacement Therapy in Children after Surgery for Congenital Heart Disease

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Renal Replacement Therapy in Children after
Surgery for Congenital Heart Disease

• Ri???

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Contents

• Introduction
• Risk factors for development of acute renal
  failure
• Renal replacement therapy options
• Outcome and survival
• Discussions

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Introduction

• Acute renal failure is an important complication
  following surgery for congenital heart disease
  (CHD)
• Incidence 1.6-32.8 (10 )
• Mortality 20-79 (50 )

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• Well studied cohorts available
• Timing of event (CPB) leading to ARF is precisely
  known
• Peritoneal dialysis (PD) predominant form of
  renal replacement therapy (RRT)
• Continuous Hemofiltration (CVVH?CAVH)

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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
20037614439
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Acute Renal Failure

• Definition
• decline in GFR and an inability of the kidneys to
  appropriately regulate fluid, electrolytes, and
  acid-base homeostasis (Benfield MR, Pediatric
  Nephrology, 5th ed)
• 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 )
• Clinical Definition
• Creatinine gt 75 ?mol/L (0.85 mg/dL)
• Oliguria (lt1ml/kg/h) for more than 4 hours
  despite aggressive diuretic/inotropic agent

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Risk factors for development of acute renal
failure

• Young age
• High RACHS-1 Score
• Long cardio-pulmonary bypass time
• Need for circulatory arrest
• Low cardiac output syndrome

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Managment

• Diuretic Therapy
• Inotropic Agents
• Renal Replacement Therapy
• Peritoneal Dialysis
• Hemofiltration
• CAVH
• CVVH

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Indication of RRT

• In general
• 1. Anuria or oliguria (lt1ml/kg/h) gt 4 hours
  despite intervention
• 2. Creatinine gt 75 ?mol/L (0.85 mg/dL)
• 3. Increased Creatinine level with
• Clinical signs of fluid overload
• Hyperkalemia Serum K gt 5.5 mmol/L
• Persistent acidosis
• Low cardiac output syndrome

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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
322331, 1995.
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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 322331, 1995.
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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 322331, 1995.
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Discussion/Summary

• Hemofiltration superior to PD due to
• Better fluid removal
• Superior decrease of BUN/Cre
• However
• Relatively high mortality in hemofiltration due
  to slower initiation of RRT
• Hesitation due to
• new technique
• vascular access
• Anticoagulation
• Possibly lower mortality with early
  hemofiltration therapy (30)
• (Book et al 1982, Zobel et al 1991)

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 322331, 1995.
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Hemofiltration (1)

• Complications
• Hypothermia (32)
• Significant hemorrhage (28)
• Thrombocytopenia (92)

Mortality 76
A. Jander et al. Continuous veno-venous
hemodiafiltration in children after cardiac
surgery European Journal of Cardio-thoracic
Surgery 31 (2007) 10221028
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Peritoneal dialysis
Kwok-lap Chan, et al. Peritoneal Dialysis After
Surgery for Congenital Heart Disease in Infants
and Young Children. Ann Thorac Surg
20037614439
16
Comparison
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Timing of renal replacement therapy rather than
method?
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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
200426102731
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Post-operative Prophylactic PD

• Method
• Neonate and infants (n756, age 0-1)
• All underwent periopertaive ultrafiltration
• 186/756 high risk patients received (24.6)
  received (prophylactic) PD
• Results
• 23/186 (12.3) of pPD, 23/756 (3) of all
  developed ARF
• Mortality of ARF (17.3)

Alkan et al. Postoperative Prophylactic
Peritoneal Dialysis in Neonates and Infants After
Complex Congenital Cardiac Surgery ASAIO Journal
2006 52 693697
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• Indications of PD
• 1. Anuria or oliguria despite intervention
• 2. Increased Creatinine level with
• Clinical signs of fluid overload
• Hyperkalemia Serum K gt 5.5 mmol/L
• Persistent acidosis
• Low cardiac output syndrome

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Alkan et al. Postoperative Prophylactic
Peritoneal Dialysis in Neonates and Infants After
Complex Congenital Cardiac Surgery ASAIO Journal
2006 52 693697
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Comparison
Alkan et al. 3 17.3 ?
Favorable results
Kwok-lap Chan, et al. Peritoneal Dialysis After
Surgery for Congenital Heart Disease in Infants
and Young Children. Ann Thorac Surg
20037614439
24
Discussions/Summary

• ARF is an important complication of pediatric
  cardiac surgery
• High mortality rate (20-79) Incidence
  (1-10)
• However, a definite diagnostic criteria does not
  exist
• PD/Hemofiltration are effective RRT
• PD
• Predominant, with more studies/evidence
• better survival?
• Hemofiltration
• Fewer studies
• Increasing use in critically ill patients with
  superior survival
• Both methods lack large prospective or randomized
  control scales. Few head to head comparisons
• Timing and indications for RRT?
• Early initiation RRT may be a more important
  predictor of survival than RRT modality

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Comparison
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Thank you for your attention!!
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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)
1108.
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 13441349
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 13441349
30

• Independent Risk Factors
• Circulatory arrest
• Duration of CPB
• Low cardiac output syndrome

Kwok-lap Chan, et al. Peritoneal Dialysis After
Surgery for Congenital Heart Disease in Infants
and Young Children. Ann Thorac Surg
20037614439