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Brophy University of Iowa Renal replacement (supportive) therapy in infants Patrick D. Brophy MD, Associate Professor Director Pediatric Nephrology University.

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Presentation on theme: "Brophy University of Iowa Renal replacement (supportive) therapy in infants Patrick D. Brophy MD, Associate Professor Director Pediatric Nephrology University."— Presentation transcript:

1 Brophy University of Iowa Renal replacement (supportive) therapy in infants Patrick D. Brophy MD, Associate Professor Director Pediatric Nephrology University of Iowa Childrens Hospital PCRRT Rome 2010

2 Brophy University of Iowa Outline: Renal Replacement/Supportive Therapy: Options & Technical challenges & Costs Neonatal AKI/CKD/ESRD- Outcomes Neonatal ESRD- summary

3 Brophy University of Iowa Case 36 wk infant born to 36 yr old mother G1 P1 Parents told they could not conceive had adopted children and found out they were pregnant Pregnancy went well until emergent C-sec required for placental abruption

4 Brophy University of Iowa Case Infant volume resuscitated (apgars 1, 3 & 6) & intubated Multiple transfusions- stabilized the infant, transferred to NICU Birth weight 2831 gm Patient entered in cooling (brain/body cooling study) for presumed hypoxia

5 Brophy University of Iowa Case Patient remained anuric for duration of brain/body cooling- Pediatric Nephrology consulted day 4 of life Pediatric Surgery not interested in placing lines or PD cath for dialysis at this time: Patient managed conservatively with limited nutrition Family consulted- wished maximal therapy

6 Brophy University of Iowa Case Issues: Does this infant have Acute Kidney injury? (or Cortical necrosis) What extent of CNS injury? Technical issues surrounding renal replacement therapy Timing becoming critical- patient anuric with limited nutrition What are the outcomes from RRT in such patients? Should we proceed

7 Brophy University of Iowa RRT Options Hemodialysis, Peritoneal Dialysis, CRRT Each has advantages & disadvantages Choice is guided by Patient Characteristics Disease/Symptoms Hemodynamic stability Goals of therapy Fluid removal Electrolyte correction Both Availability, expertise and cost Walters et. al. Peds Neph 2008

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9 Technical Issues: Resources: what techniques are you able to provide Catheter placement, expertise What would be the best for the patient What co-morbidities does the patient have What are the goals for the therapy Metabolic control, fluid, both

10 Brophy University of Iowa Resources- very expensive Facility fee daily (for neonates) CRRT- $2200 USD + Profee PD- $1200 USD + Profee HD- $3200 USD + Profee Team: specialized Nursing Dietary, Social work, Physician Therapy is an intense endeavor- not much patient volume but very time consuming

11 Brophy University of Iowa Neonatal/Pediatric Co-Morbidities: Considerations Approaching Renal Replacement Therapy Not present Diabetes Older age Atherosclerotic disease Hypertension Volume of patients Present Size/Access variation Less frequent than adults/less experience Machinery is adapted (not made) for pediatrics Blood priming UF, thermic controls

12 Brophy University of Iowa Peritoneal Dialysis Catheter placement may be acute or permanent Dictated by the abdomen of the patient- can be difficult in Prune Belly, patients requiring nephrectomy (ARPKD, CNS) Those with respiratory issues May be ideal for those with pure renal issues (congenital) and some urine output Usually well tolerated and gentle: can transition from acute care to chronic quite easily

13 Brophy University of Iowa Hemodialysis in Infants

14 Brophy University of Iowa Vascular Access for Infant HD/CRRT Smaller patients require smaller catheters Difficulty achieving access Difficulty maintaining access Limited access sites Femoral veins Jugular veins Subclavian veins Umbilical vessels

15 Brophy University of Iowa Choices for Infant Vascular Access Potential Pts.ManufacturerCatheter Type 6 – 30 Kg Kendall Arrow Double-lumen 8Fr 3 – 6 KgMedcompTriple-lumen 7Fr 3 – 6 Kg Cook Medcomp Double-lumen 7Fr Small Neonates CookSingle-lumen 5Fr

16 Brophy University of Iowa Ultrafiltration Rate for Infant CRRT As tolerated by the patient Potentially limited by dialyzer/hemofilter, blood flow rates Small errors have a larger effect in a tiny patient *****

17 Brophy University of Iowa Other Special Considerations for HD/CRRT in Infants Large extracorporeal volume compared to small patient Blood prime (1:1 PRBC:Albumin 5%) at initiation frequently required Risk of thermic loss often requires heating system

18 Brophy University of Iowa Potential Complications of Infant HD/CRRT Volume related problems Biochemical and nutritional problems Hemorrhage Infection Technical problems Logistical problems Bradykinin release syndrome

19 Brophy University of Iowa Logistical Issues for Infant HD/CRRT Infrequently performed procedure in neonatal units Vascular access can be difficult to organize and obtain Neonatology staff may be unfamiliar with equipment, procedure, risks Written procedures may improve coordination and results of therapy

20 Brophy University of Iowa OUTCOMES How successful are we? Some Neonates will start with AKI and progress to ESRD Others will seemingly have ESRD but eventually come off of dialysis the dumbest kidneys are always smarter than the smartest Nephrologist

21 Brophy University of Iowa Outcomes for Neonatal CRRT Data are scant Most studies are single-center, retrospective No randomized controlled trials Small numbers limit power Extension from adult studies may not be appropriate

22 Brophy University of Iowa CRRT in Pediatric Patients <10Kg Multi-center, retrospective study 5 pediatric centers 85 patients Demographic data Technique description Outcome Am J Kid Dis, 18: , 2003

23 Brophy University of Iowa Which Babies Require CRRT? 16.5% 15.3% 14.1% 10.6% 5.9% 4.7% 3.5% 2.4% 2.3% 5.9% Congenital heart disease Metabolic disorder Multiorgan dysfunction Sepsis syndrome Liver failure Malignancy Congenital nephrotic syndrome Congenital diaphragmatic hernia Congenital renal/urological disease Hemolytic uremic syndrome Heart failure Other N=85 Am J Kid Dis, 18: , 2003

24 Brophy University of Iowa Why do Babies Need CRRT? 1%Volume overload and hyperammonemia 4%Other (e.g., medication overdose) 9%Biochemical abnormalities of renal failure 14% Metabolic imbalance unrelated to renal failure (e.g., hyperammonemia) 18%Volume overload 54% Combined volume overload and biochemical abnormalities of renal failure N=85 Am J Kid Dis, 18: , 2003

25 Brophy University of Iowa CRRT in Infants <10Kg: Outcome Patients <10kgPatients 3-10kgPatients <3kg 38% Survival 41% Survival 25% Survival Am J Kid Dis, 18: , 2003

26 Brophy University of Iowa Survival by Diagnosis Totals:N=85; Survivors= % 71% 15% 42% 22% 0 50% 100% 0 60% Am J Kid Dis, 18: , 2003

27 Brophy University of Iowa Retrospective Study of Infant CRRT: Summary Overall outcome acceptable 3 – 10kg: outcome similar to that for older patients Metabolic disorders: good outcome <3kg, selected diagnoses: poor outcome Am J Kid Dis, 18: , 2003

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29 62% 60% 53% Deaths due to co-morbid conditions ARF CRF 78% 63% 68%

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36 Co-Morbidity Co-Mobidity: Lung hypoplasia Liver cirrhosis Cong Heart DZ Mortality Risk 1.8X greater <1 vs 1-5 yrs Mortality Risk 2.7X greater 5 yrs This increases to 7.5X when co-morbid factors present

37 Brophy University of Iowa Data Summary Infants with Stand alone renal disease can be effectively dialyzed to transplant The mortality increases significantly after adding in co-morbid conditions

38 Brophy University of Iowa Thank You NICU colleagues Nursing staff Dietitians

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