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

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Presentation on theme: "PCRRT in HUS: Role of peritoneal dialysis Thomas J Neuhaus and GF Laube, JF Falger, EM Rüth, MJ Kemper, O Bänziger University Childrens Hospital, Zurich."— Presentation transcript:

1 PCRRT in HUS: Role of peritoneal dialysis Thomas J Neuhaus and GF Laube, JF Falger, EM Rüth, MJ Kemper, O Bänziger University Childrens 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 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 HUS: Indications for dialysis modality since 1995 (2)

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 375 μmol/l (4.3 mg/dl) 50 – 995 Urea 32 mmol/l (192 mg/dl) 6 – 76 Hemoglobin 62 g/l29 – 108 Platelets 36 G/l 7 – 271 Sodium 132 mmol/l109 – 142

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

12 HUS and PD: 44 / 54 dialysed (81%) 43: D+HUS 11: 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- 6/11 (55%) Only PD:35/54 (65%) D+30/43 (70%) D- 5/11 (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 6 patients: switch from PD to CVVH: 21: D+, general deterioration: 1: D+, rectumperf. 2° peritonitis HD: 21: D+, insufficient ultrafiltration despite 3.86% glucose 1: D-, ESRF plus PEX: 2 D+, cerebral involvement: 1 HUS and PD:

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 infectionn = 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 Hemofiltration: 7 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 ICU: 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: 40 concentrate: 20 CVVH: 1 set / 3 days175 – – set:225 – 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

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