1. PCRRT in HUS: Role of peritoneal dialysis Thomas J Neuhaus and GF Laube, JF Falger, EM Rüth, MJ Kemper, O Bänziger University Children’s Hospital, Zurich

2. Zurich: Local History
1955: Gasser et al: Hemolytic-Uremic Syndromes: HUS
1964: Peritoneal dialysis for acute renal failure: HUS
1970: Hemodialysis and renal transplantation
1979: Continuous PD for chronic renal failure
1995: Continuous veno-venous hemofiltration for ARF

3. HUS = Hemolytic-Uremic Syndromes
Hemolytic microangiopathic anemia:
fragmentocytes, LDH , neg. Coombs
Thrombocytopenia
Uremia: acute renal failure
Further symptoms / complications:
Central nervous system (seizures, hemorrhages)
Hypertension and heart failure
Liver / Pancreas (with diabetes mellitus)
Eye: retinal bleedings

4. HUS: D+ and D- D+ = Diarrhea-positive
Verotoxin (or Shigatoxin)-producing E. Coli
Other bacteria, e.g. Shigella …. („Big Mc disease“)
Hemorrhagic colitis: mild – severe, intussusception
D- = Diarrhea-negative
Pneumococcal infections (T-antigen positive)
Inherited and/or recurrent forms: e.g. complement (factor I/H) or vWF-cleavage protease deficiency
Others: Pregnancy, drugs …
„Many“ cases of unknown cause

5. Zurich: Epidemiology of HUS
HUS: most frequent cause of acute renal
failure in our hospital

6. HUS: Indications for dialysis modality since 1995 (1)
Peritoneal dialysis: „in general“ first choice
On ICU: CAPD
On ward: mainly automated PD
Hemodialysis if
„older“ patient in „good general condition“ not requiring care in intensive care unit
D-HUS and plasma-exchange (PEX) anticipated
life-threatening hyperkalemia

7. HUS: Indications for dialysis modality since 1995 (2)
Continuous veno-venous hemo(dia)filtration if
„in bad general condition“ (+/- PEX)
severe colitis
Plasma-exchange (PEX) or plasma infusion if
D-HUS and inherited type / complement deficiency
suspected
D- or D+ HUS with severe central nervous
system symptoms, e.g. impaired consciousness,
neurological deficit

8. Acute renal failure and peritoneal dialyis among adults ?!
Recent review on „Renal replacement therapy of acute renal failure in ICU adult patients“
… Peritoneal dialysis is not further discussed … because of
missing data
no significant role
1 study showing a very high mortality ….

9. HUS: 1995 – 2005 (1) N = 68: 30 males, 38 females
Age: median 2.3 years (2 months – 12 years)
D+: 52 = 76%: 5 months – 12 years
D- : 16 = 24%: 2 months – 10 years
6: pneumoccocal infection, 5 with septicemia
1: acute systemic lupus erythematodes
1: complement I deficiency (Dg: 9 yrs after onset !)
1: familial occurrence (mother / grandmother)
7: unknown cause

10. HUS: 1995 – 2005 (2) „Extreme“ values median range
Creatinine μmol/l (4.3 mg/dl) 50 – 995
Urea mmol/l (192 mg/dl) 6 – 76
Hemoglobin g/l 29 – 108
Platelets G/l – 271
Sodium mmol/l – 142

11. HUS and dialysis: 54 / 68 (79%)
16: D-HUS
52: D+HUS

12. HUS and PD: 44 / 54 dialysed (81%)
11: D-HUS
43: D+HUS

13. Acute PD before 1995: „stiff“ Cook-catheter or
„soft“(„peel away“) catheter, inserted with trocar or
Tenckhoff
since 1995:
only Tenckhoff catheter
surgically placed by the surgeon (and the
nephrologist also in theatre) under general
anasthetic; at the same time insertion of
central venous line

14. Acute and chronic PD Tenckhoff catheter: coil
2 sizes: < / > 1 year
1 cuff (glued by ourselves)
upward facing

15. Acute PD on ICU: Fresenius system Lactate (march 2006: bicarbonate)
Initial prescription:
> ml / kg
exchange: every hour
1000 IU Heparin/l
1.36% Glucose
no antibiotics
run by ICU-nurses

16. Acute PD on ward: Baxter system mainly automated PD
Bicarbonate (Physioneal)
Prescription:
up to 40 ml / kg
exchange: 2 – 4 hours
1000 IU Heparin/l
1.36% Glucose
no antibiotics
Run by ward / renal nurses

17. HUS and PD: 44 / 54 with dialysis
Start with PD: 41/54 (76%)
D+ 35/43 (81%)
D /11 (55%)
Only PD: 35/54 (65%)
D+ 30/43 (70%)
D /11 (45%)

18. HUS and PD: 3 patients: switch to PD from
HD: 1 D+, transfer ICU  ward and
end-stage renal failure
CVVH: 1 D-, transfer ICU  ward
HD/PEX: 1 D-, transfer ICU  ward and
ESRF

19. HUS and PD: 6 patients: switch from PD to
CVVH : 2 1: D+, general deterioration: †
1: D+, rectumperf.  2° peritonitis
HD: 2 1: D+, insufficient ultrafiltration
despite 3.86% glucose
1: D-, ESRF
plus PEX: D+, cerebral involvement: 1 †

20. HUS and PD: technical aspects
Time span between emergency room entry and
onset of PD in ICU:
median 4 hours (2 – 20)
Duration of PD:
median 10 days (1 – 35)

21. HUS and PD: technical complications
Peritonitis: n = 9 (all in ICU)
Exit-site infection n = 3
Insufficient ultrafiltration: n = 1  switch: HD
Catheter obstruction: n = 0
Insufficient dialysis: n = 0
 No catheter had to be replaced.

22. HUS and hemofiltration
Only CVVH: 2
1 D+: presentation with epileptic state
1 D-: pneumoccocal septicemia
CVVH and PD: 3
CVVH and HD: 2

23. HUS and hemodialysis / PEX
Only HD: 5, all D+ HUS
3: older patients – 12 years – in „good condition“
1: recurrent intussusception and bowel resection
before onset of ARF
1: severe hemorrhagic colitis
Plus PEX: 4
2 D-, 2 D+

24. HUS: clinical complications (1)
Hypertension: requiring medication
40 / 68 (59%), 28 / 44 with PD
 16 patients with PD: „no medication, only PD“
Cardiomyopathy:
6: impaired ventricular function
Pancreatitis: Amylase ↑
24: but no diabetes mellitus
Hepatopathy: Transaminases ↑
43: but no liver failure

25. HUS: clinical complications (2)
Gastrointestinal tract: n = 4 (all D+)
2 intussusception
1 rectum perforation
1 severe colitis
Severe central nervous system: n = 7
4 D+: 3: remission, 1: †
3 D-: 2: sequelae (pneumococcal meningitis,
massive hemorrhage), 1: † (SLE)
Retinal bleeding: n = 2 (all D+)

26. HUS: stay in ICU / hospital
median: 5 days (0 – 30)
Hospital:
median: 17 days (1 – 93)

27. HUS: daily running costs: Pat  20 kg
CHF US$ Ratio to PD
PD:
2 x 5 l bag:
HD:
set:
concentrate:
CVVH:
1 set / 3 days 175 – –
set: 225 – 325
4 x 5 l filtrate: 100
HD and CVVH: plus costs of hardware…

28. Outcome: D+ HUS: n = 52

29. Outcome: D- HUS: n = 16

30. Conclusions (1): HUS Incidence:
D+ >>> D- (over the last 35 years)
80% require dialysis
Outcome: D+ >> D-
Patient survival
Recovery of renal function

31. Conclusions (2): HUS – PD
Surgically placed Tenckhoff-catheter:
Simple technique
High efficacy
Low frequency of side effects / complications
PD in HUS is
safe
efficient
convenient
economic