Outcomes of dialysis in newborns Gianni Celsi Pediatric Nephrology Unit Karolinska University Hospital, Stockholm, Sweden

Causes of ARF in neonates hypovolemia, sepsis, low cardiac output Prerenal 75-80% Intrinsic 10-15% Postrenal 5-10% PUV,PJO

How is the prognosis of pre- and postrenal ARF in neonates?

Prognosis of ARF 40-60 % survival Depending on underling disease Depending on co-morbidity Reversible

What about ESRD?

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

What is the general consensus for intrinsic ESRD in neonates?

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)

How is the prognosis of ESRD in neonates?

Survival after dialysis in neonates with ESRD Age at start n Survival % Matthews et al, J Ped Surg1990 <2 m 31 39 infants whose renal failure was isolated were more likely to undergo successful dialysis Blowey et al, JPerinatol. 1993 <1 y 23 65 Ellis et al, Adv Perit Dial. 1995 21 80-36 infants with anuria or oliguria had a higher mortality (64%) than did infants with adequate urine output (20%). Warady et al, Pediatr Nephrol 99 <3 m 34 76 Coulthard et al, Arch Dis Child 2002 <1 m 55 Williams et al, Arch Pediatr Adolesc Med 2002 1 d-1 y 35 53 Laakkonen et al Nephrol Dial Transplant 2008 1d-2 m 9 90

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%

n TOP % Survival % ARPKD 20 45 30 ADPKD 7 28 71 Others 9 67 33 Prenatal diagnosis of bilateral isolated fetal hyperechogenic kidneys. Is it possible to predict long term outcome? Brit J Obs Gyn 2002 n TOP % Survival % ARPKD 20 45 30 ADPKD 7 28 71 Others 9 67 33

Congenital renal tract anomalies: outcome and follow-up of 402 cases detected antenatally between 1986 and 2001 Ultrasound Obstet Gynecol 2005 n TOP % Survival % Bilateral agenesis, MCDK, PDCK, dysplasia 76 48 3 Unilateral agenesis,MCDK, dysplasia 74 6 83

How is the prognosis of ESRD in preterms?

Renal failure, comorbidity and mortality in preterm infants Wien Klin Wochenschr (2008) 120/5–6: 153–157 16 RF/ 359 <37 GA (4,5%) n Survival % Pre/post 14 33 Cong. anomalies 2

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)

Age at onset of dialysis in preterms with ESRD

Survival of preterms with dialysis onset at birth GA Oligohydr. Diuresis Survival 36 + KT 37 - No 31 35 +/- 33

What shall we do?

Renal replacement therapy in neonates/preterms with ESRD Feasible Aim: Improve quality of life Caveat: Avoid damage Respect autonomy Be fair