Outcomes of dialysis in newborns Gianni Celsi Pediatric Nephrology Unit Karolinska University Hospital, Stockholm, Sweden
Causes of ARF in neonates • Prerenal 75-80% • Intrinsic 10-15% • Postrenal 5-10% hypovolemia, sepsis, low cardiac output PUV,PJO
Prognosis of ARF 40-60 % survival Depending on underling disease Depending on co-morbidity Reversible
Causes of ESRD in neonates • Prerenal • Intrinsic • Postrenal
Causes of intrinsic renal ESRD in neonates • Prenatal Agenesis Hypoplasia Dysplasia Cystic diseases Obstruction • Postnatal DIC, ATN
Intrinsic renal ESRD in neonates • Rare • Extremely poor prognosis Renal replacement therapy not always recommended. As recently as 1998, only 40% of international pediatric nephrologists would offer dialysis to infants < 1 month (J. Pediatr 1998, 133, 154-65)
Outcomes of dialysis initiated during the neonathal period for treatment of ESRD: a NAPRTCS special analysis. Pediatrics 2007: 468-473; 119
For physicians and parents alike, the decision to initiate long-term dialysis for a neonate with presumptive ESRD poses a complex ethical quandary.This dilemma derives,at least in part, from the paucity of published reports describing the outcomes of infants who initiate dialysis during the first month of life. Neonates were as likely to terminate dialysis during the study period as were older children. However, the reason for terminating dialysis differed significantly between the 2 age groups. Neonates were more likely to terminate because of death, and they were less likely to terminate because of transplantation.
Death 17/193 Recovery of function 23/193 Neonates with renal dysplasia or obstructive uropathy are at risk for associated congenital anomalies, either true malformations or deformations, because of severe oligohydramnios. In such cases, the presence of significant comorbid conditions may preclude long-term dialysis as a bridge to renal transplantation, thus excluding these neonates from the NAPRTCS database.
Aetiology and outcome of acute and chronic renal failure in infants Nephrol Dial Transplant (2008) 23: 1575–1580 Between 1997 and 2004 all children <1 year of age with a serum creatinine >100 µmol/l were followed up for up to 6 years. - 49 infants with ESRD - 21 started dialysis between 5-531 days of age • 4 neonates were not offered RRT because of parents wish • mortality: ARPKD 100% • dysplasia 22% • obstraction 6%
Prenatal diagnosis of bilateral isolated fetal hyperechogenic kidneys. Is it possible to predict long term outcome? Brit J Obs Gyn 2002
Congenital renal tract anomalies: outcome and follow-upof 402 cases detected antenatally between 1986 and 2001 Ultrasound Obstet Gynecol 2005
Renal failure, comorbidity and mortality in preterm infants Wien Klin Wochenschr (2008) 120/5–6: 153–157 16 RF/ 359 <37 GA (4,5%)
Antenatal oligohydramnios of renal origin: long-term outcome Nephrol Dial Transplant (2007) 22: 432–439 • A total of 23 infants (16 males, 7 females) with an antenatal • diagnosis of oligohydramnios were retrospectively studied • - Survival 70% • 4 children were not offered RRT (GA 34-39) • only 2 children started dialysis at birth (GA 38-40)
Renal replacement therapy in neonates/preterms with ESRD Feasible Aim: Improve quality of life Caveat: Avoid damage Respect autonomy Be fair