Renal Replacement Therapy for Acute Renal Failure
26
Renal Replacement Therapy for Acute Renal Failure Timothy E. Bunchman Professor Pediatrics
description
Renal Replacement Therapy for Acute Renal Failure. Timothy E. Bunchman Professor Pediatrics. 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. - PowerPoint PPT Presentation
Transcript of Renal Replacement Therapy for Acute Renal Failure
Renal Replacement Therapy for Acute Renal Failure
Timothy E. Bunchman Professor Pediatrics
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
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
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
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
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
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
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
bunchman
New Dialysis Patients 1992-1998 (total 354)
72
282
ESRDARF
bunchman
Demographics
Total (354) ARF (282)Age 79 mos 74 mosWeight 27. 5 kg 25 kgSex 54% male 51% maleHypotension atonset
27% 32%
Pressor use duringtherapy
53% 65%
bunchman
Modality of Choice at onsetRRT modality Total (354) ARF (282)
Hemofiltration (HF) 106 106
Peritoneal Dial (PD) 107 59
Hemodialysis (HD) 107 83
HF on ECMO 34 34
bunchman
Diagnosis
2614
22
12
22
16
487
18
14
40
392
BMTTLS/MalHLHSHt TxCyanotic HtHUSARF/ATNARDSLiver TxInborn Error MetSepsisCRFOther
bunchman
ARF-282 patients
• Time on therapy– HF-8.7 days– HD-9.5 days– PD-9.6 days NS
• Heparin Free Therapies– HF-51%– HD-28% < 0.01
bunchman
Survivors: Analysis by weight
27.9
23.7
0
5
10
15
20
25
30
Survivors Non Survivors
Weight (kg)
bunchman
Survivors: Analysis byBP at onset
33%
61%
100%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Low BP Nl BP High BP
bunchman
Survivors: Analysis by use of Pressors
35%
89%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
+ Pressors - Pressors
bunchman
Survivors: Analysis by RRT modality
40%
49%41%
81%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
HF PD HF/ECMO HD
bunchman
Survivors: Analysis by RRT modality and weight
0
5
10
15
20
25
30
35
40
HF PD HF/ECMO HD
Survivor wtNon Survivor wt
bunchman
21% 19%
33%
50%
78%
50%42%
33%
0%
10%
20%
30%
40%
50%
60%
70%
80%
HF PD HD Overall
BMTSepsis
Survivors: Analysis by Diagnosis and RRT Modality
bunchman
79%
95%
100%90%
60%50%
0%
10%
20%30%
40%
50%
60%
70%80%
90%
100%
HF PD HD
BMTSepsis
Analysis by Diagnosis RRT Modality and Pressors
bunchman
50%
22%
82%
0%
82%
0%
67%
17%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
HF PD HD Overall
ARFLiver Tx
Survivors: Analysis by Diagnosis and RRT Modality
bunchman
75% 79%
64%
100%
31%
50%
0%
10%
20%30%
40%
50%
60%
70%
80%90%
100%
HF PD HD
ARFLiver Tx
Analysis by Diagnosis RRT Modality and Pressors
bunchman
67%
33%
0%
33%
0%
100%
41%36%
0%
10%
20%
30%40%
50%
60%
70%
80%
90%100%
HF PD HD Overall
HLHSCyan Ht Dis
Survivors: Analysis by Diagnosis and RRT Modality
bunchman
100%100% 100%
83%100%
0%
10%20%
30%
40%
50%60%
70%
80%90%
100%
HF PD HD
HLHSCyan Ht Dis
Analysis by Diagnosis RRT Modality and Pressors
bunchman
RRT for ARF
• Best RRT is one that’s 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
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
