Presentation on theme: "Renal Replacement Therapy Options for Children"— Presentation transcript:
1 Renal Replacement Therapy Options for Children Timothy E. Bunchman, MDProfessor & DirectorHelen DeVos Children’s HospitalGrand Rapids, MI
2 Questions?Is there an optimal form of RRT in children independent of cause of AKI?Are there studies comparing outcome randomized by RRT modality in children?
3 RRT Options (all are reasonable to use) PD (continuous or intermittent)Acute, CAPD, CCPDHD (intermittent)Standard vs High FluxCRRT (continuous)CVVH, CVVHD, CVVHDF
4 Dialysis (diffusive) PD vs. HD vs. CVVHD Works with solute clearance across a semi-permeable membraneThe greater the gradient the greater the clearanceThe greater the solution exposure per unit of time the greater the clearance
5 Diffusive Clearance CVVHD/HD/PD Diffusive clearance Dialysate Physiologic sterile solution that is infused countercurrent to the blood flow rate (Qd)
6 Replacement (Convective) Due to mass transfer (push) of solute thru a semi-permeable membraneThe pore size of the membrane may effect clearanceAN-69 membrane > PolysulphoneThe greater the solution exposure per unit of time the greater the clearance
7 Convective Clearance CVVH Convective clearance Replacement Solutions Physiologic sterile solution that is either infused pre filter (NA) or post filter (outside of NA) that infused at a set rate (Qr)
8 Convective and Diffusive Clearance CVVHDFConvective clearanceReplacement SolutionsDiffusive clearanceDialysis solution
10 Impact of urea Clearance CVVH vs CVVHD (Maxvold et al, Crit Care med Impact of urea Clearance CVVH vs CVVHD (Maxvold et al, Crit Care med Apr;28(4):1161-5)Study designFixed blood flow rate-4 mls/kg/minHF-400 (0.3 m2 polysulfone)Cross over for 24 hrs each to prefilter replacement fluid (CVVH) or Dx (CVVHD) flow at 2000 mls/hr/1.73 m2
11 Comparison of Urea Clearance: CVVH vs CVVHD (Maxvold et al, Crit Care med. 2000 Apr;28(4):1161-5) p = NS(mls/min/1.73 m2)Urea ClearanceBFR = 4 mls/kg/minFRF/Dx FR = 2 l/1.73 m2/hrSAM = 0.3 m2
12 Solute clearance vs UF Solute Clearance/unit of time HD > HF > PD(30-50 l/hr vs 2 l/hr vs 1-2 /hr Dx)UF with regard to hemodyamicsHF > PD > HD(24 hrs/day vs 3-4 hrs/day or QO Day)
13 Dialysis Dose Adapted from Gotch et al. Kidney Int 2000;58:S3-18 1 2 3 35ml/kg45ml/kg20ml/kgCRRT12345678910234567EDDWeekly stdKt/VNo. of Days/weekPD0.30.50.70.22.214.171.124eKt/V each dialysisAdapted from Gotch et al. Kidney Int 2000;58:S3-18
14 Dialysis Dose and Outcome Ronco et al. Lancet 2000; 351: 26-30 Conclusions:Minimum UF rates should be ~ 35 ml/kg/hrSurvivors had lower BUNs than non-survivors prior to commencement of hemofiltration
15 Relative Advantages (+) and Disadvantages (-) of CRRT, IHD, and PD Variable CRRT IHD PDContinuous RRTHemodynamic stabilityFluid balance achievement
16 Relative Advantages (+) and Disadvantages (-) of CRRT, IHD, and PD Variable CRRT IHD PDUnlimited nutritionSuperior metabolic controlContinuous removal of toxinsSimple to perform ±
17 Relative Advantages (+) and Disadvantages (-) of CRRT, IHD and PD cont. Variable CRRT IHD PDStable intracranial pressureRapid removal of poisonsLimited anticoagulation /
18 Relative Advantages (+) and Disadvantages (-) of CRRT, IHD and PD cont. Variable CRRT IHD PDIntensive care nursing supportHemodialysis nursing support ±Patient mobility
19 Percent of Patients (%) Fleming et al., J Thorac Cardiovasc Surg, 1995 PATIENT MORTALITYPercent of Patients (%)N=21N=9N=12Modality(NS in mortality)Fleming et al., J Thorac Cardiovasc Surg, 1995
20 Modality(* p < 0.05 compared to PD) CALORIC INTAKE% Change From BaselineCAVH *CVVH *PDModality(* p < 0.05 compared to PD)Fleming et al., J Thorac Cardiovasc Surg, 1995
21 Renal Replacement Therapy in the PICU Pediatric Outcome Literature 122 children studiedNo PRISM scoresMost common diagnosisIHD: primary renal failureCRRT: sepsis31% survivalConclusion: patients who receive CRRT are more illMaxvold NJ et al: Am J Kidney Dis 1997 Nov;30(5 Suppl 4):S84-8
23 Pediatric ARF: Modality and Survival Patient survival on pressors (35%) lower than without pressors (89%) (p<0.01)Lower survival seen in CRRT than in patients who received HD for all disease statesPed Neph 16: , 2001
24 Unique Situations-PD Infants and Post Op Hearts Limited resources Ease of fluid managementChien et al Pediatr Neonatol 2009; 50:25-279Ease of administration at bedsideBonillis-Felix PDI SLimited resources
26 The etiology of acute renal failure- Nigeria ( Anochie & Eke Peds Neph 2005:20 1610-1614) 211 Patients with ARF over an 18 year periodDialysis indicated in 108 patientsOnly 24 had PD– due to resource availability and costPrimary causes of death- uremia, infection, anemia, hypertension andLACK of Dialysis
27 Unique Situations-HD (+/- CRRT) Conditions when maximal solute clearance is needed with less concern on hemodynamic stabilityAuron and BrophyCurrent opinions in Pediatrics :Quan and QuigleyCurrent opinions in Pediatrics :
28 Vancomycin clearance High efficiency dialysis membrane RxRxRxReboundReboundVanc level(mic/dl)Time of therapy
29 Unique Situations-CRRT When hemodynamic instability and highly catabolic conditions are presentSepsisBone Marrow TransplantationGoldstein SL Seminars in Dialysis 2009; 22;Walters et al Pediatr Neph ; 37-38
30 Stem Cell Transplant: ppCRRT 51 patients in ppCRRT with SCTMean %FO = %.45% survivalConvection: 17/29 survived (59%)Diffusion: 6/22 (27%), p<0.05Survival lower in MODS and ventilated patientsFlores FX et al: Pediatr Nephrol Apr;23(4):625-30
31 Intensive vs non Intensive RRT HD and CRRT at 6 days per week and 35 mls/kg/hr dailyVs.HD and CRRT at 3 days per week and 20 mls/kg/hr dailyIntensity of Renal Support in Critically Ill Patients with Acute Kidney Injury The VA/NIH Acute Renal Failure Trial Network*NEJM july 3, 2008 vol. 359 no. 1
32 Enrollment, Randomization, and Follow-up of Study Patients Figure 1. Enrollment, Randomization, and Follow-up of Study Patients.The VA/NIH Acute Renal Failure Trial Network. N Engl J Med 2008;359:7-20
34 Primary and Secondary Outcomes Table 3. Primary and Secondary Outcomes.The VA/NIH Acute Renal Failure Trial Network. N Engl J Med 2008;359:7-20
35 Kaplan-Meier Plot of Cumulative Probabilities of Death (Panel A) and Odds Ratios for Death at 60 Days, According to Baseline Characteristics (Panel B)Figure 2. Kaplan-Meier Plot of Cumulative Probabilities of Death (Panel A) and Odds Ratios for Death at 60 Days, According to Baseline Characteristics (Panel B). Panel A shows the cumulative probability of death from any cause in the entire study cohort. Panel B shows odds ratios (and 95% confidence intervals [CI]) for death from any cause by 60 days in the group receiving the intensive treatment strategy as compared with the group receiving the less-intensive treatment strategy, as well as P values for the interaction between the treatment group and baseline characteristics. P values were calculated with the use of the Wald statistic. Higher Sequential Organ Failure Assessment (SOFA) scores indicate more severe organ dysfunction. There was no significant interaction between treatment and subgroup variables, as defined according to the prespecified threshold level of significance for interaction (P=0.10). Sex was not recorded for one patient receiving less-intensive therapy.The VA/NIH Acute Renal Failure Trial Network. N Engl J Med 2008;359:7-20
36 Summary of Complications Associated with Study Therapy Table 4. Summary of Complications Associated with Study Therapy.The VA/NIH Acute Renal Failure Trial Network. N Engl J Med 2008;359:7-20
37 Conclusion of ATN Study Intensive renal support in critically ill patients with AKI did not decrease mortality, improve recovery of kidney function, or reduce the rate of non-renal organ failure as compared with less-intensive therapy involving a defined dose of IHD three times per week and CRRT at 20 ml per kilogram per hour.
38 Flow chart of the SHARF 4 study Lins, R. L. et al. Nephrol. Dial. Transplant : ; doi: /ndt/gfn560Copyright restrictions may apply.
39 Outcome in patients randomized to intermittent (IRRT) or continuous (CRRT) renal replacement therapy Lins, R. L. et al. Nephrol. Dial. Transplant : ; doi: /ndt/gfn560Copyright restrictions may apply.
40 Survival curves in patients randomized to intermittent (IRRT) or continuous (CRRT) renal replacement therapy investigating ICU mortality and hospital mortalityLins, R. L. et al. Nephrol. Dial. Transplant : ; doi: /ndt/gfn560Copyright restrictions may apply.
41 Cost of Dialysis Equipment (in U.S. dollars) Manual Peritoneal DialysisDevice: Dialy-Nate Manual PD setManufacturer: Utah Medical ProductsCost per Unit: $88.75 (New set Required every h)Cost of additional Supplies: 1.5% Dineal (Baxter) $24.43/2.0L
42 Cost of Dialysis Equipment (in U.S. dollars) cont. Manual Peritoneal DialysisDevice: Ultra Set (Y-set)Manufacturer: BaxterCost per unit: $6.95 (New unit required for each exchange)Cost of additional Supplies: 1.5% Dianeal (Baxter) $24.43/2.0L
43 Cost of Dialysis Equipment (in U.S. dollars) cont. Automated Peritoneal DialysisDevice: Freedom CyclerManufacturer: FreseniusCost per unit: $12,295.00Cost of additional supplies: Pediatric Tubing set $32.00 each
44 Cost of Dialysis Equipment (in U.S. dollars) cont. Intermittent HemodialysisDevice: C3Manufacturer: GambroCost per unit: $18,000.00Cost of additional Supplies: 100HG dialyzer $50.00 each;pediatric bloodlines $11.40 each
45 Cost of Dialysis Equipment (in U.S. dollars) cont. Continuous HemofiltrationDevice: PrismaManufacturer: GambroCost per unit: $25,000.00Cost of additional supplies: M60 hemofilter set(includes filter and bloodlines) $160.00Normocarb dialysate concentrate(Dialysis Solutions) $20.00/3.0L
46 ConclusionRRT modality comparison shows that the dose of RRT and the choice of RRT may not effect survivalIndication to begin, end is still of questionDo what you do well and improve your care of patient with AKI
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