Outcomes of dialysis in newborns

1
Outcomes of dialysis in newborns

• Gianni Celsi
• Pediatric Nephrology Unit
• Karolinska University Hospital,
• Stockholm, Sweden

2
Causes of ARF in neonates
hypovolemia, sepsis, low cardiac output

• Prerenal 75-80
• Intrinsic 10-15
• Postrenal 5-10

PUV,PJO
3
How is the prognosis of pre- and postrenal ARF in
neonates?
4
Prognosis of ARF

• 40-60 survival
• Depending on underling disease
• Depending on co-morbidity
• Reversible

5
What about ESRD?
6
Causes of ESRD in neonates

• Prerenal
• Intrinsic
• Postrenal

7
Causes of intrinsic renal ESRD in neonates

• Prenatal
• Agenesis
• Hypoplasia
• Dysplasia
• Cystic diseases
• Obstruction
• Postnatal
• DIC, ATN

8
What is the general consensus for intrinsic ESRD
in neonates?
9
Intrinsic renal ESRD in neonates

• Rare
• Extremely poor prognosis

Renal replacement therapy not always recommended.
As recently as 1998, only 40 of international
pediatric nephrologists would offer dialysis to
infants lt 1 month (J. Pediatr 1998, 133, 154-65)
10
How is the prognosis of ESRD in neonates?
11
Survival after dialysis in neonates with ESRD
Age at start n Survival
Matthews et al, J Ped Surg1990 lt2 m 31 39 infants whose renal failure was isolated were more likely to undergo successful dialysis
Blowey et al, JPerinatol. 1993 lt1 y 23 65
Ellis et al, Adv Perit Dial. 1995 lt1 y 21 80-36 infants with anuria or oliguria had a higher mortality (64) than did infants with adequate urine output (20).
Warady et al, Pediatr Nephrol 99 lt3 m 34 76
Coulthard et al, Arch Dis Child 2002 lt1 m 31 55
Williams et al, Arch Pediatr Adolesc Med 2002 1 d-1 y 35 53
Laakkonen et al Nephrol Dial Transplant 2008 1d-2 m 9 90
12
Outcomes of dialysis initiated during the
neonathal period for treatment of ESRD a
NAPRTCS special analysis. Pediatrics 2007
468-473 119
13
For physicians and parents alike, the decision to
initiate long-term dialysis for a neonate with
presumptive ESRD poses a complex ethical
quandary.This dilemma derives,at least in part,
from the paucity of published reports describing
the outcomes of infants who initiate dialysis
during the first month of life.
Neonates were as likely to terminate dialysis
during the study period as were older children.
However, the reason for terminating dialysis
differed significantly between the 2 age groups.
Neonates were more likely to terminate because of
death, and they were less likely to terminate
because of transplantation.
14
Death 17/193

Recovery of function 23/193
Neonates with renal dysplasia or obstructive
uropathy are at risk for associated congenital
anomalies, either true malformations or
deformations, because of severe oligohydramnios.
In such cases, the presence of significant
comorbid conditions may preclude long-term
dialysis as a bridge to renal transplantation,
thus excluding these neonates from the NAPRTCS
database.
15
Aetiology and outcome of acute and chronic renal
failure in infants
Nephrol Dial Transplant (2008) 23 15751580
Between 1997 and 2004 all children lt1 year of age
with a serum creatinine gt100 µmol/l were
followed up for up to 6 years. - 49 infants
with ESRD
- 21 started dialysis between 5-531 days of age

• 4 neonates were not offered RRT because of
  parents wish
• mortality ARPKD 100
• dysplasia 22
• obstraction 6

16
Prenatal diagnosis of bilateral isolated fetal
hyperechogenic kidneys. Is it possible to predict
long term outcome?
Brit J Obs Gyn 2002
n TOP Survival
ARPKD 20 45 30
ADPKD 7 28 71
Others 9 67 33
17
Congenital renal tract anomalies outcome and
follow-upof 402 cases detected antenatally
between 1986 and 2001
Ultrasound Obstet Gynecol 2005
n TOP Survival
Bilateral agenesis, MCDK, PDCK, dysplasia 76 48 3
Unilateral agenesis,MCDK, dysplasia 74 6 83
18
How is the prognosis of ESRD in preterms?
19
Renal failure, comorbidity and mortality in
preterm infants
Wien Klin Wochenschr (2008) 120/56 153157
16 RF/ 359 lt37 GA (4,5)
n Survival
Pre/post 14 33
Cong. anomalies 2 0
20
Antenatal oligohydramnios of renal origin
long-term outcome
Nephrol Dial Transplant (2007) 22 432439

• A total of 23 infants (16 males, 7 females) with
  an antenatal
• diagnosis of oligohydramnios were retrospectively
  studied
• - Survival 70
• 4 children were not offered RRT (GA 34-39)
• only 2 children started dialysis at birth (GA
  38-40)

21
Age at onset of dialysis in preterms with ESRD
22
Survival of preterms with dialysis onset at birth
GA Oligohydr. Diuresis Survival

36 KT
37 - No
31 - No
35 /- No
33 - No
37 /- No
23
What shall we do?
24
Renal replacement therapy in neonates/preterms
with ESRD
Feasible
Aim Improve quality of life
Caveat Avoid damage Respect
autonomy Be fair