brophy university of iowa renal replacement (supportive) therapy in infants patrick d. brophy md,...
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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
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Brophy University of Iowa
Outline:
Renal Replacement/Supportive Therapy: Options & Technical challenges & Costs
Neonatal AKI/CKD/ESRD- Outcomes Neonatal ESRD- summary
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Brophy University of Iowa
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
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Brophy University of Iowa
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
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Brophy University of Iowa
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
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Brophy University of Iowa
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
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Brophy University of Iowa
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
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Brophy University of Iowa
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Brophy University of Iowa
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
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Brophy University of Iowa
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
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Brophy University of Iowa
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
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Brophy University of Iowa
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
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Brophy University of Iowa
Hemodialysis in Infants
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Brophy University of Iowa
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
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Brophy University of Iowa
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
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Brophy University of Iowa
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 *****
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Brophy University of Iowa
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
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Brophy University of Iowa
Potential Complications of Infant HD/CRRT
Volume related problems Biochemical and nutritional
problems Hemorrhage Infection Technical problems Logistical problems Bradykinin release syndrome
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Brophy University of Iowa
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
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Brophy University of Iowa
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”
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Brophy University of Iowa
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
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Brophy University of Iowa
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
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Brophy University of Iowa
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
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Brophy University of Iowa
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
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Brophy University of Iowa
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
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Brophy University of Iowa
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
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Brophy University of Iowa
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
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Brophy University of Iowa
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Brophy University of Iowa
62%
60%53%
Deaths due to co-morbidconditions
ARF
CRF
78%
63%
68%
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Brophy University of Iowa
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Brophy University of Iowa
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Brophy University of Iowa
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Brophy University of Iowa
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Brophy University of Iowa
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Brophy University of Iowa
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Brophy University of Iowa
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
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Brophy University of Iowa
Data Summary
Infants with Stand alone renal disease can be effectively dialyzed to transplant
The mortality increases significantly after adding in co-morbid conditions
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Brophy University of Iowa
Thank You
NICU colleagues Nursing staff Dietitians