Renal replacement therapy after repair of congenital heart disease in children

Abstract

The development of renal failure necessitating peritoneal dialysis after cardiac operations is associated with a reported mortality greater than 50%. Improved fluid removal and nutritional support have been reported with the use of continuous arteriovenous hemofiltration and continuous venovenous hemofiltration techniques. We have compared our experience with all three techniques in managing children who required renal replacement therapy after cardiac operations in terms of efficacy (fluid removal, calorie intake, and clearance of urea and creatinine), complications, and outcome. Over a 5-year period renal replacement therapy was initiated in 42 children, and in 34 of them it was successfully established for more than a 24-hour period: 17 were managed with peritoneal dialysis, 8 with continuous arteriovenous hemofiltration, and 9 with continuous venovenous hemofiltration. A net negative fluid balance was achieved in only 6 (35%) patients treated with peritoneal dialysis compared with 50% of those treated with continuous venovenous hemofiltration and 89% of those treated with continuous venovenous hemofiltration. In terms of nutritional support, calorie intake increased by 43% after peritoneal dialysis was started compared with 515% and 409% in the arteriovenous and venovenous hemofiltration groups, respectively, (p < 0.005). The serum urea levels fell by 36% (p = 0.02) and 39% (p = 0.005) compared with pre-therapy levels with arteriovenous and venovenous hemofiltration, respectively, and the creatinine content was reduced by 19% and 33% (p = 0.003). Neither parameter was reduced in the peritoneal dialysis group. We conclude that the use of hemofiltration as a renal replacement therapy after surgical correction of congenital heart disease offers significant advantages over the more traditional approach of peritoneal dialysis. In addition, we suggest that a more aggressive approach to the management of fluid overload and nutritional depletion with hemofiltration may result in a decrease in the very high mortality seen in renal failure after cardiac operations.

Outcome of acute renal failure associated with cardiac surgery in infants

“…The mortality rate in children with acute renal failure following heart surgery has been reported ranging from 10% to 90% [1][2][3][4][5][6]10,12,20 , and our data confirm these values. This prognosis has been most determined by the underlying disease, intercurrent infections, and hemodynamic changes than by the dialytic method employed.…”

“…Several authors have reported that peritoneal dialysis may not be effective in removing fluids or nitrogen debris in hypercatabolic patients and also that the competence of the peritoneal membrane may be impaired in patients in shock 10 . These facts may be challenged either by clinical demonstration of this or by other studies 1,2,4,6,14 , or by data showing that in patients in shock peritoneal blood perfusion is not reduced enough to impair the efficacy of dialysis 23 .…”

“…Former studies reported mortality above 70% in children undergoing heart surgery and requiring dialysis, showing that dialysis could not benefit the evolution of these patients. This has resulted in a certain reluctance to indicate and start dialysis 10 . More recent studies have reported much lower mortality rates (even below 50%) in children undergoing dialysis soon after surgery and in a more intense manner [26][27][28] .…”

“…Recent evidence suggests that active fluid removal in patients with acute renal failure and low cardiac output after cardiopulmonary surgery may improve hemodynamic variables 8,9 . Several studies have emphasized, mainly in the last few years, the use of extracorporeal therapeutics to treat these children [8][9][10][11][12] . In our service, however, children with acute renal failure following cardiac surgery are routinely treated with intermittent or continuous peritoneal dialysis, which is an effective and safe method that requires no advanced technology.…”

Peritoneal Dialysis for Acute Kidney Injury

“…Finally, there have been improvements in dialysate solutions with the use of low glucose degradation products (GDP), bicarbonate-buffered solutions which are asso-, bicarbonate-buffered solutions which are associated with reduced inflow pain; unfortunately, these solutions are not available in many countries. (68,(77)(78)(79). However, in 1 study, CVVH was associated with better fluid control and was superior to PD in the management of hypercatabolic AKI due to sepsis (79).…”