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

Brophy University of Iowa

Renal replacement (supportive) therapy in infants

Patrick D. Brophy MD, Associate Professor Director Pediatric NephrologyUniversity of Iowa Children’s Hospital PCRRT Rome 2010


Outline:

Renal Replacement/Supportive Therapy: Options & Technical challenges & Costs

Neonatal AKI/CKD/ESRD- Outcomes Neonatal ESRD- summary


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


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


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


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


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



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


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


Neonatal/Pediatric Co-Morbidities: ConsiderationsApproaching 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


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


Hemodialysis in Infants


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


Choices for Infant Vascular Access

Potential Pts.

ManufacturerCatheter Type

6 – 30 KgKendallArrow

Double-lumen 8Fr

3 – 6 KgMedcompTriple-lumen 7Fr

3 – 6 KgCookMedcomp

Double-lumen 7Fr

Small Neonates

CookSingle-lumen 5Fr


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 *****


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


Potential Complications of Infant HD/CRRT

Volume related problems Biochemical and nutritional

problems Hemorrhage Infection Technical problems Logistical problems Bradykinin release syndrome


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


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”


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


CRRT in Pediatric Patients <10Kg

Multi-center, retrospective study 5 pediatric centers 85 patients

Demographic data Technique description Outcome

Am J Kid Dis, 18:833-837, 2003


Which Babies Require CRRT?

16.5%16.5%15.3%14.1%10.6%5.9%4.7%3.5%2.4%2.3%2.3%5.9%

Congenital heart diseaseMetabolic disorderMultiorgan dysfunctionSepsis syndromeLiver failureMalignancyCongenital nephrotic syndromeCongenital diaphragmatic herniaCongenital renal/urological diseaseHemolytic uremic syndromeHeart failureOther

N=85

Am J Kid Dis, 18:833-837, 2003


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, 18:833-837, 2003


CRRT in Infants <10Kg: Outcome

85

69

16

32 28

4

N

Survivors

Patients <10kg Patients 3-10kg Patients <3kg

38% Survival 41%

Survival

25% Survival

Am J Kid Dis, 18:833-837, 2003


Survival by Diagnosis14

14

13

12

9

5

4

3

2

2

1

1

5

5

10

2

5

2

0

2

0

1

1

1

0

3

Congen Ht Dz

Metabolic

Multiorg Dysfxn

Sepsis

Liver failure

Malignancy

Congen Neph Synd

Congen Diaph Hernia

HUS

Ht Failure

Obstr Urop

Renal Dyspl

Other

N

Survivors

Totals: N=85; Survivors=320

36%

71%

15%

42%

22%

0

50%

50%

50%

100%

0

60%

Am J Kid Dis, 18:833-837, 2003


Retrospective Study of InfantCRRT: 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, 18:833-837, 2003



62%

60%53%

Deaths due to co-morbidconditions

ARF

CRF

78%

63%

68%








Co-Morbidity

Co-Mobidity:Lung hypoplasiaLiver cirrhosisCong Heart DZ

Mortality Risk1.8X greater<1 vs 1-5 yrs

Mortality Risk2.7X greater<1 vs >5 yrs

This increases to 7.5X when co-morbid factors present


Data Summary

Infants with Stand alone renal disease can be effectively dialyzed to transplant

The mortality increases significantly after adding in co-morbid conditions


Thank You

NICU colleagues Nursing staff Dietitians

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

Documents

fr slide

brophy md

patient volume

time consuming slide

presumed hypoxia slide

placental abruption

heating system slide

smartest nephrologist