1. Renal Replacement Therapy for Acute Renal Failure Timothy E. Bunchman Professor Pediatrics

2. bunchman Infant ARF Single RRT Modality Ronco et al; Intens Care Med, 1995 45% survival-CRRT Sadowski et al; KI 1995 primary renal disease 71%-HD secondary renal disease 33%-HD

3. bunchman Pediatric ARF Single RRT Modality Niaudet et al; KI, 1985 80% survival-primary ARF all RRT Zobel et al; Ped Neph, 1989 65% survival-CRRT Zobel et al; Contrib Neph, 1991 60% survival-CAVH, 35%-survival- CVVH

4. bunchman Pediatric ARF Single RRT Modality Paret et al; J Thor Cardiovas Surg, 1992 33% survival-CAVH Gallego et al; Nephron, 1993 52% survival with PD/HD features of poorer prognosis –less then 1 mos of age –hypotension

5. bunchman Pediatric ARF Single RRT Modality Bradbury et al; Arch Dis Child, 1994 33% survival-CVVH Latta et al; Ped Neph, 1994 37% survival-CAVH Smoyer et al; JASN, 1995 43% survival-CRRT

6. bunchman Pediatric ARF Comparison of RRT modalities Fleming et al; J Thor Cardiovas Surg, 1995 38% survival-PD 33% survival-CAVH 42% survival-CVVH Maxvold et al; Am J Kid Dis, 1997 43% survival-CVVH 83% survival-HD

7. bunchman Pediatric ARF Comparison of RRT modalities Lowrie et al; Ped Neph, 2000 –evaluation of PD vs CVVHF in children with MOSF –survival equal but related to disease state and the number of organs non functioning

8. bunchman Adult ARF Comparison of RRT modalities Kruczynski et al; ASAIO, 1993 75% Survival-CAVH; 18% survival-HD Bellomo et al; ASAIO, 1993 40% Survival-CRRT; 30% survival-HD van Brommel et al: Am J Neph, 1995 43% Survival-CRRT; 59% survival-HD

9. bunchman New Dialysis Patients 1992-1998 (total 354)

10. bunchman Demographics

11. bunchman Modality of Choice at onset

12. bunchman Diagnosis

13. bunchman ARF-282 patients Time on therapy –HF-8.7 days –HD-9.5 days –PD-9.6 daysNS Heparin Free Therapies –HF-51% –HD-28%< 0.01

14. bunchman Survivors: Analysis by weight

15. bunchman Survivors: Analysis by BP at onset

16. bunchman Survivors: Analysis by use of Pressors

17. bunchman Survivors: Analysis by RRT modality

18. bunchman Survivors:Analysis by RRT modality and weight

19. bunchman Survivors: Analysis by Diagnosis and RRT Modality

20. bunchman Analysis by Diagnosis RRT Modality and Pressors

21. bunchman Survivors: Analysis by Diagnosis and RRT Modality

22. bunchman Analysis by Diagnosis RRT Modality and Pressors

23. bunchman Survivors: Analysis by Diagnosis and RRT Modality

24. bunchman Analysis by Diagnosis RRT Modality and Pressors

25. bunchman RRT for ARF Best RRT is one thats continuous, done with ease, and minimizes risk of hypotension, access complications, infectious risk, or coagulation risk Best local standard is the best modality Nutritional needs of the child need to be factored in and adjusted for RRT modality

26. bunchman Survival is related to diagnosis, hypotension, use of pressor agents and PRISM scores and may be influenced by RRT choice ARF management needs to be a cooperative effort between Nephrologists and Intensivists for the optimal care of children RRT for ARF