1. Renal replacement (supportive) therapy in infants
Patrick D. Brophy MD, Associate Professor
Director Pediatric Nephrology
University of Iowa Children’s Hospital PCRRT Rome 2010
Brophy University of Iowa

2. Brophy University of Iowa
Outline:
Renal Replacement/Supportive Therapy: Options & Technical challenges & Costs
Neonatal AKI/CKD/ESRD- Outcomes
Neonatal ESRD- summary
Brophy University of Iowa

3. 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
Brophy University of Iowa

4. 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
Brophy University of Iowa

5. 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
Brophy University of Iowa

6. 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
Brophy University of Iowa

7. 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
Brophy University of Iowa

8. Brophy University of Iowa

9. 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
Brophy University of Iowa

10. 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
Brophy University of Iowa

11. Brophy University of Iowa
Neonatal/Pediatric Co-Morbidities: Considerations Approaching 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
Brophy University of Iowa

12. 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
Brophy University of Iowa

13. Hemodialysis in Infants
Brophy University of Iowa

14. 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
Brophy University of Iowa

15. Choices for Infant Vascular Access
Potential Pts.
Manufacturer
Catheter Type
6 – 30 Kg
Kendall
Arrow
Double-lumen 8Fr
3 – 6 Kg
Medcomp
Triple-lumen 7Fr
Cook
Double-lumen 7Fr
Small Neonates
Single-lumen 5Fr
Brophy University of Iowa

16. 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 *****
Brophy University of Iowa

17. 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
Brophy University of Iowa

18. Potential Complications of Infant HD/CRRT
Volume related problems
Biochemical and nutritional problems
Hemorrhage
Infection
Technical problems
Logistical problems
Bradykinin release syndrome
Brophy University of Iowa

19. 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
Brophy University of Iowa

20. 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”
Brophy University of Iowa

21. 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
Brophy University of Iowa

22. CRRT in Pediatric Patients <10Kg
Multi-center, retrospective study
5 pediatric centers
85 patients
Demographic data
Technique description
Outcome
Am J Kid Dis, 18: , 2003
Brophy University of Iowa

23. Which Babies Require CRRT?
16.5%
15.3%
14.1%
10.6%
5.9%
4.7%
3.5%
2.4%
2.3%
Congenital heart disease
Metabolic disorder
Multiorgan dysfunction
Sepsis syndrome
Liver failure
Malignancy
Congenital nephrotic syndrome
Congenital diaphragmatic hernia
Congenital renal/urological disease
Hemolytic uremic syndrome
Heart failure
Other
N=85
Am J Kid Dis, 18: , 2003
Brophy University of Iowa

24. 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
Brophy University of Iowa
Am J Kid Dis, 18: , 2003

25. CRRT in Infants <10Kg: Outcome
38% Survival
41% Survival
25% Survival
Patients <10kg
Patients 3-10kg
Patients <3kg
Brophy University of Iowa
Am J Kid Dis, 18: , 2003

26. Brophy University of Iowa
Survival by Diagnosis
Am J Kid Dis, 18: , 2003
36%
71%
15%
42%
22%
50%
100%
60%
Totals: N=85; Survivors=32
Percentages instead of numbers
Brophy University of Iowa

27. Retrospective Study of Infant CRRT: 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: , 2003
Brophy University of Iowa

28. Brophy University of Iowa

29. Brophy University of Iowa
78%
68%
63%
CRF
62%
60%
ARF
53%
Deaths due to co-morbid
conditions
Brophy University of Iowa

30. Brophy University of Iowa

31. Brophy University of Iowa

32. Brophy University of Iowa

33. Brophy University of Iowa

34. Brophy University of Iowa

35. Brophy University of Iowa

36. Brophy University of Iowa
Co-Morbidity
Mortality Risk
1.8X greater
<1 vs 1-5 yrs
Mortality Risk
2.7X greater
<1 vs >5 yrs
This increases to 7.5X when co-morbid factors present
Co-Mobidity:
Lung hypoplasia
Liver cirrhosis
Cong Heart DZ
Brophy University of Iowa

37. 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
Brophy University of Iowa

38. Brophy University of Iowa
Thank You
NICU colleagues
Nursing staff
Dietitians
Brophy University of Iowa