1 / 30

Renal Replacement Therapy in Children after Surgery for Congenital Heart Disease

Renal Replacement Therapy in Children after Surgery for Congenital Heart Disease Ri 董奎廷 Contents Introduction Risk factors for development of acute renal failure Renal replacement therapy options Outcome and survival Discussions Introduction

andrew
Télécharger la présentation

Renal Replacement Therapy in Children after Surgery for Congenital Heart Disease

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Renal Replacement Therapy in Children after Surgery for Congenital Heart Disease Ri董奎廷

  2. Contents • Introduction • Risk factors for development of acute renal failure • Renal replacement therapy options • Outcome and survival • Discussions

  3. Introduction • Acute renal failure is an important complication following surgery for congenital heart disease (CHD) • Incidence: 1.6-32.8% (~10% ) • Mortality: 20-79% (~50% )

  4. Well studied cohorts available • Timing of event (CPB) leading to ARF is precisely known • Peritoneal dialysis (PD) predominant form of renal replacement therapy (RRT) • Continuous Hemofiltration (CVVH、CAVH)

  5. Incidence and Mortality (PD) Kwok-lap Chan, et al. Peritoneal Dialysis After Surgery for Congenital Heart Disease in Infants and Young Children.Ann Thorac Surg 2003;76:1443–9

  6. Acute Renal Failure • Definition: • decline in GFR and an inability of the kidneys to appropriately regulate fluid, electrolytes, and acid-base homeostasis (Benfield MR, Pediatric Nephrology, 5th ed) • Sudden decline in renal function with increasing BUN/Cr ratio; with or without changes in urine output (Johns Hopkins: The Harriet Lane Handbook, 17th ed. - 2005 ) • Clinical Definition: • Creatinine > 75 mol/L (0.85 mg/dL) • Oliguria (<1ml/kg/h) for more than 4 hours despite aggressive diuretic/inotropic agent

  7. Risk factors for development of acute renal failure • Young age • High RACHS-1 Score • Long cardio-pulmonary bypass time • Need for circulatory arrest • Low cardiac output syndrome

  8. Managment • Diuretic Therapy • Inotropic Agents • Renal Replacement Therapy • Peritoneal Dialysis • Hemofiltration • CAVH • CVVH

  9. Indication of RRT In general: • 1. Anuria or oliguria (<1ml/kg/h) > 4 hours despite intervention • 2. Creatinine > 75 mol/L (0.85 mg/dL) • 3. Increased Creatinine level with: • Clinical signs of fluid overload • Hyperkalemia: Serum K+ > 5.5 mmol/L • Persistent acidosis • Low cardiac output syndrome

  10. Fleming F,, et al: Renal replacement therapy after repair of congenital heart disease in children:A comparison of hemofiltration and peritoneal dialysis J Thorac Cardiovasc Surg 109: 322–331, 1995.

  11. Fleming F,, et al: Renal replacement therapy after repair of congenital heart disease in children: A comparison of hemofiltration and peritoneal dialysis. J Thorac Cardiovasc Surg 109: 322–331, 1995.

  12. Fleming F,, et al: Renal replacement therapy after repair of congenital heart disease in children: A comparison of hemofiltration and peritoneal dialysis. J Thorac Cardiovasc Surg 109: 322–331, 1995.

  13. Discussion/Summary • Hemofiltration superior to PD due to: • Better fluid removal • Superior decrease of BUN/Cre • However: • Relatively high mortality in hemofiltration due to slower initiation of RRT • Hesitation due to: • new technique • vascular access • Anticoagulation • Possibly lower mortality with early hemofiltration therapy (~30%) • (Book et al 1982, Zobel et al 1991) Fleming F,, et al: Renal replacement therapy after repair of congenital heart disease in children: A comparison of hemofiltration and peritoneal dialysis. J Thorac Cardiovasc Surg 109: 322–331, 1995.

  14. Hemofiltration (1) • Complications: • Hypothermia (32%) • Significant hemorrhage (28%) • Thrombocytopenia (92%) Mortality: 76% A. Jander et al. Continuous veno-venous hemodiafiltration in children after cardiac surgery European Journal of Cardio-thoracic Surgery 31 (2007) 1022—1028

  15. Peritoneal dialysis Kwok-lap Chan, et al. Peritoneal Dialysis After Surgery for Congenital Heart Disease in Infants and Young Children.Ann Thorac Surg 2003;76:1443–9

  16. Comparison

  17. Timing of renal replacement therapy rather than method?

  18. Survival and early initiation of RRT Elahi MM, et al. Early hemofiltration improves survival in post-cardiotomy patients with acute renal failure. Eur J Cardiothorac Surg 2004;26:1027—31

  19. Post-operative Prophylactic PD • Method: • Neonate and infants (n=756, age 0-1) • All underwent periopertaive ultrafiltration • 186/756 “high risk” patients received (24.6%) received (prophylactic) PD • Results: • 23/186 (12.3%) of pPD, 23/756 (3%) of all developed ARF • Mortality of ARF (17.3%) Alkan et al. Postoperative Prophylactic Peritoneal Dialysis in Neonates and Infants After Complex Congenital Cardiac Surgery ASAIO Journal 2006; 52: 693–697

  20. Indications of PD • 1. Anuria or oliguria despite intervention • 2. Increased Creatinine level with: • Clinical signs of fluid overload • Hyperkalemia: Serum K+ > 5.5 mmol/L • Persistent acidosis • Low cardiac output syndrome

  21. Alkan et al. Postoperative Prophylactic Peritoneal Dialysis in Neonates and Infants After Complex Congenital Cardiac Surgery ASAIO Journal 2006; 52: 693–697

  22. Comparison Alkan et al. 3% 17.3%  Favorable results Kwok-lap Chan, et al. Peritoneal Dialysis After Surgery for Congenital Heart Disease in Infants and Young Children.Ann Thorac Surg 2003;76:1443–9

  23. Discussions/Summary • ARF is an important complication of pediatric cardiac surgery • High mortality rate (20-79%) ; Incidence (~1-10%) • However, a definite diagnostic criteria does not exist • PD/Hemofiltration are effective RRT • PD: • Predominant, with more studies/evidence • better survival? • Hemofiltration: • Fewer studies • Increasing use in critically ill patients with superior survival • Both methods lack large prospective or randomized control scales. Few head to head comparisons • Timing and indications for RRT? • Early initiation RRT may be a more important predictor of survival than RRT modality

  24. Comparison

  25. Thank you for your attention!!

  26. Risk Adjustment for Congenital Heart Surgery 1 (RACHS-1) Jenkins KJ, et al. Consensus-based method for risk adjustment for surgery for congenital heart disease. J Thorac Cardiovasc Surg 2002; 123 (1): 110–8.

  27. K. R. Pedersen et al, Risk factors for acute renal failure requiring dialysis after surgery for congenital heart disease in children, Acta Anaesthesiol Scand 2007; 51: 1344–1349

  28. K. R. Pedersen et al, Risk factors for acute renal failure requiring dialysis after surgery for congenital heart disease in children, Acta Anaesthesiol Scand 2007; 51: 1344–1349

  29. Independent Risk Factors: • Circulatory arrest • Duration of CPB • Low cardiac output syndrome Kwok-lap Chan, et al. Peritoneal Dialysis After Surgery for Congenital Heart Disease in Infants and Young Children.Ann Thorac Surg 2003;76:1443–9

More Related