1 TREATMENT STRATEGIES FOR AKI AFTER CPB (FENOLDOPAM, EARLY PD) STEFANO PICCA and ZACCARIA RICCI...
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Transcript of 1 TREATMENT STRATEGIES FOR AKI AFTER CPB (FENOLDOPAM, EARLY PD) STEFANO PICCA and ZACCARIA RICCI...
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TREATMENT STRATEGIES FOR AKI AFTER CPB (FENOLDOPAM, EARLY PD)
STEFANO PICCA and ZACCARIA RICCIDialysis Unit- Dept of Nephrology and Urology
CICU- Dept of Cardiology, “Bambino Gesù” Pediatric Research Hospital
ROMA, Italy
In post- heart surgery AKI, which is (are?) the time window (windows?) suitable for a worthy intervention?
OUTLINE
Peritoneal Dialysis in pediatric post-heart surgery AKI• Does PD provide inflammation mediators removal?• Does PD provide suitable fluid removal?
Fenoldopam in pediatric post-heart surgery AKI• Does Fenoldopam provide “nephroprotection” ?• What Fenoldopam dosages are required to induce “nephroprotection”?
TIME WINDOWS FOR AKI MANAGEMENT
RRT
Nephroprotection?
Modified from Sutton, 2002
Fluids
Drugs
Diuretics
• 61 children/2262 CPB heart surgery operations underwent PD (2.7%)
• Time from end of surgery to PD start: 2 hrs - 15 days (median 24 hrs)
• 48/61 (79%) did not survive
author n Time to PD start Pts with negative fluid balance
Survivors
Lowrie (2000) 17 NA 35% 24%
Fleming (1995) 21 2.5 days (1-6) after surgery
36% 38%
Golej (2002) 116 NA, but 43% of pts started on PD when CVP>10 mmHg
53% 47%
Werner (1996) 23 2.6±0.6 days 100% 53%
Santos (2012) 23 4.8±16.8 hrs 100% 56.6%
Chien (2009) 7 1.2±0.4 days after AKI onset
NA 57%
Dittrich (1999) 27 In the OR or first hrs in ICU
100% 73%
Sorof (1999) 20 22 hrs 100% 80%
PD AFTER HEART SURGERY IN CHILDREN: FLUID BALANCE AND SURVIVAL THROUGH THE YEARS
• PD in 146 neonates and infants after surgery
• “early” PD: at the end of surgery or day after surgery
• Significant better survival at 30 and 90 days with early PD
• Unfortunately, no fluid overload measurement
Bojan, Kidney Int, 2012
FENOLDOPAM AND NEPHROPROTECTION: MECHANISM
FENOLDOPAM MESYLATE Short-acting selective
DA-1 dopaminergic receptor agonist
INDUCES: • Increased cAMP-PKA
production in renal arteries smooth muscle:
arterial relaxation and increased renal blood flow• Increased cAMP
concentration in tubular cells and inhibition of Na-H and Na-K ATPase: increased natriuresis
• Decreased aldosterone production:
increased natriuresis
M Ranucci Minerva Anestesiol 2010Z Ricci Interact CardioVasc Thorac Surg 2008
PCCM 2006
LIMITATIONS:• RANDOMIZATION• FENOLDOPAM 0,1 mcg/Kg/min• LATE AKI MARKERS WITH LOW SENSIBILITY AND SPECIFICITY
Fenoldopam in newborn patients undergoing cardiopulmonary bypass: controlled clinical trialRicci Z et al. Interactive CardioVascular and Thoracic Surgery 7 (2008) 1049–1053
80 patients (<1 yr)
40 group F 40 group CFenoldopam 1mcg/kg/min Placebo
No difference:• Age• BW• Heart defect• RACHS score and operation duration• CPB, PAM, mean CPB flow, mean Hb media
and lowest T in CPB• Inotropic score
RESULTS (1)
RESULTS (2)
No difference between group F and controls in:• Plasma NGAL and CysC• plasma creatinine levels and urine output• pRIFLE 50% in group F and 72% in group P (p = 0.08)• Inotropic score• ISVR and IDO2 Significant difference between group F and controls in:• Furosemide and phentolamine administration in group F (p = 0.0085)
• In pediatric post-heart surgery AKI, early PD can provide better survival than late PD application
• This occurs in spite of less performing fluid removal and consequent worst nutrition management compared with CRRT
• Early fluid overload management and/or the less negative patient selection are probably the clue issues to explain this
CONCLUSIONS (1)
• In pediatric open-heart surgery, Fenoldopam at 1 mcg/kg/min during CPB is safe
• With this dosage, Fenoldopam is able to prevent the acute rise of proved urinary AKI markers
• Patients treated with Fenoldopam require lower diuretic and vasodilator dosages than controls
• Although high- dose Fenoldopam cannot still be recommended in all children undergoing heart surgery, it potentially represents a nephroprotection in these patients.
CONCLUSIONS (2)
CRRT AND PD IN PEDIATRIC POST-HEART SURGERY AKI: PROS AND CONS
Fluid removal
Caloric intake
application anticoagulation
CV tolerance costs
CRRT
Higher Higher complex needed Possibly worst high
PD lower lower easy none Possibly better low
No prospective study has evaluated the effect of dialysis modality on the outcome of children with AKI in the ICU setting.
HIGH DOSE FENOLDOPAM CONTROLLED STUDY: METHODS
INCLUSION CRITERIA:• Age < 1 yr• Correction in
biventricular anatomy• RACHS > 1• CPB
EXCLUSION CRITERIA• DHCA• Pre-surgery high
creatinine levels
Rx:• High dose fenoldopam (1 mcg/kg/min) during CPBPrimary Outcomes:• Decreased NGAL and Cystatin C urine levels• Increased UO and decreased plasma creatinine• Decreased diuretics and vasodilator drugs
Time
AKI
mortalityFO
CRRT?
PD?
PDCRRT
PD IN AKI: LIMITED FLUID REMOVAL AND (LOGICAL) EARLY APPLICATION