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20 years of PCRRT: changing indications and diagnoses ?

20 years of PCRRT: changing indications and diagnoses ?. Ekkehard Ring Department of Pediatrics Medical University of Graz Austria. Historical background of pediatric continuous renal replacement therapy (PCRRT). 1977 Kramer et al. Klin. Wochenschr.

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20 years of PCRRT: changing indications and diagnoses ?

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  1. 20 years of PCRRT:changing indications and diagnoses ? Ekkehard Ring Department of Pediatrics Medical University of Graz Austria

  2. Historical background of pediatric continuous renal replacement therapy (PCRRT) • 1977 Kramer et al. Klin. Wochenschr. • First report of arteriovenous hemofiltration (CAVH) in adult patients • 1986 Ronco et al. Kidney Int. • Four critically ill neonates with ARF and successful CAVH-treatment • Starting point for intensified development in PCRRT

  3. In Graz: first CAVH 05/1985 Diabetic coma, rhabdomyolysis

  4. Development of pediatric continuous renal replacement therapy (PCRRT) • „Self-made“ arteriovenous devices and circuits (CAVH), partially with suction support • Addition of dialysate countercurrent • Hemodiafiltration (CAVHDF)

  5. Development of pediatric continuous renal replacement therapy (PCRRT) • Pump-assisted veno-venous devices • CVVH, CVVHDF • Initially leading to hemodynamic instability • Inaccuracies of blood flow and ultrafiltration

  6. Development of pediatric continuous renal replacement therapy (PCRRT) • Improvement of • Vascular catheters, hemofilters, blood lines • Accuracy of pumps for blood flow and UF • Replacement solutions (bicarbonate) • Anticoagulation (regional, citrate) Minimizing bleeding risk

  7. Development of pediatric continuous renal replacement therapy (PCRRT) Nowadays • High sophisticated automatic devices enabling the optimal technical support for critically ill children and neonates with ARF and need for RRT • Further development needed • Devices for neonates and prematures • Optimal dosage of HF, HDF

  8. Method of choice for acute RRT ? • Questionnaire survey among nephrologists • „ ...CRRT will soon be used at virtually all pediatric centers“. • European Guidelines • Strazdins et al. Pediatr Nephrol 2004; 19:199 • „choice of dialysis depend upon clinical circumstancies, location of the patient, and expertise available... Hemofiltration increasingly employed in the intensive care situation“

  9. Indications for RRT • Acute renal failure (ARF) PD, HD, HF available • Primary renal disorders (isolated ARF) • Extremely low mortality rate (HUS as most frequent diagnosis) • ARF as part of multiple organ system failure (MOSF) • Chronic renal failure (CRF) • PD, HD,intermittent use of CRRT (HDF) ? • At least 2 of 3 modalities needed in large pediatric clinics • Cost effectiveness of HD-Units in smaller centers • CRRT being established in an open pediatric ICU • HF (HDF) as treatment for CRF to be considered • A time for rediscovery: chronic hemofiltration for end-stage renal disease. McCarthy et al. Semin Dial (2003) 16:199

  10. Non-renal indications for CRRT • Metabolic crisis - inborn errors of metabolism • Organic acidurias, Urea cycle disorders (hyperammonemia) • Rapid elimination of toxic metabolites • Disease specific treatment • CVVHDF treatment of choice(Highest clearance rates) • Outcome correlates with rapid elimination rate • Schäfer et al. NDT 1999; 14:910 • Outcome correlates with coma duration before CRRT • Picca et al. Pediatr Nephrol 2001; 16:862 • Intoxications with drugs • Sepsis • With or without ARF, HF-dosage, removal of mediators ....

  11. Non-renal indications for CRRT • Liver support in fulminant hepatic failure • Molecular Adsorbents Recycling System (MARS) • Promising results • Open for discussion • Tissieres et al. Liver support for fulminant hepatic failure: is it time to use the molecular adsorbents recycling system in children? Pediatr Crit Care Med 2005; 6:616 • Tumor lysis syndrome • Significant cause of morbidity and mortality in oncology • Continuous, massive release of intracellular solutes • CRRT is the method of choice • „preventive CRRT“ in high-risk patients

  12. Outcome after CRRTChange of overall mortality rate ? • 9 publications (1x 1995), 2000-05 and own data • Mortality rates 32% - 89% (21 – 226 children) • 416 / 834 non-survivors = mortality rate 50% • Data divided by 3 time-periods of patient sampling

  13. Long-term surveys of ARF / RRTTrends in diagnoses and outcome • Just 1 single-center study • Williams et al. Arch Pediatr Adolesc Med (2002) 156:893 • Retrospective examination 1979 – 1998 • divided in 2 periods 1979-1988 and 1989-1998 • 228 children with ARF • Admission to PICU: n = 154 (68%) • Acute RRT: n = 93 (41%) [60% of PICU admission] • ARF-mortality rate 27% (no difference between decades) • Mortality rate of 67% in patients with RRT

  14. Long-term surveys of ARF / RRTTrends in diagnoses and outcome • Study of Williams et al. Arch Pediatr Adolesc Med (2002) 156:893 • CRRT starting in the second decade (14% of RRT) • Unchanged between decades: • HUS as leading diagnosis with favourable outcome (2% mortality) • Young age < 1 y represents 57% of non-survivors • Changes between decades: • Cardiac surgery main and increasing cause of death (27% >> 44%) • Decreasing mortality rate in sepsis and burns • Oncologic complications increasing • No death with tumor lysis syndrome in the second decade • Complications with bone marrow transplantation as new disease

  15. 20 years of PCRRT in Graz (1985 – 2004) • Retrospective analysis of 115 consecutive children • Two periods (1985-1994 and 1995-2004) • Decreasing incidence of CRRT in the second decade • Decreasing mortality rate aside from infants

  16. 20 years of PCRRT in Graz (1985 – 2004) • Underlying disorders [No. of patients (mortality rate)]

  17. 20 years of PCRRT in Graz (1985 – 2004) • Changes of CRRT technique • Period 1: 75% treated with CAVH or CVVH • Period 2: 75% treated with CVVHDF • No influence of CRRT-modality on outcome of patients • Cardiac failure after cardiac surgery • Leading cause of secondary ARF in both decades • Increasing mortality rate (neonates !) • Responsible for 46% of non-survivors • Decreasing number of patients with • Sepsis, oncologic disease • No CRRT after burns • Young age < 1 year highest mortality rate • 46% of non-survivors are infants and neonates

  18. 20 years of PCRRT in Graz (1985 – 2004) • Evaluation with scores (scoring systems) • Number of organ failures • Pediatric Risk of Mortality (PRISM-score)

  19. 20 years of PCRRT in Graz (1985 – 2004) • Ventilation and vasopressor support • Associated with high mortality • Non-resolving MOSF is the leading cause of death • Period 1: 67% died within 3 to 7 days of CRRT • Period 2: 55% died after more than 7 days of CRRT • Our data seem to indicate • Advances in intensive care treatment • Advances in diagnosis and treatment of underlying disorders • High sophisticated CRRT modalities • Leading to slowly decreasing mortality of critically ill children • Specific local situations to be considered

  20. Determinants of non-survival after CRRT • Age (body weight) • Technical complications decreasing • Worse survival < 3 kg compared to 3-10 kg • Symons et al. Am J Kidney Dis 2003; 41:984 • Hemodynamic instability • Vasopressor support • Low mean arterial pressure (MAP) • Smoyer JASN 1995; 6:1401 • Bunchman et al. Pediatr Nephrol 2001; 16:1067 • PRISM score: good prognostic capacity • Zobel et al. Child Nephrol Urol 1990; 10:14 • Fernandez et al. Pediatr Nephrol 2005; 20:1473

  21. Determinants of non-survival after CRRTDialytic modality • Development of 20 years should be of importance • No systematic review available • No influence of RRT modality was found • Bunchman et al. Pediatr Nephrol 2001; 16:1067 • Goldstein et al. Kidney Int. 2005; 67:653 • We did a good job even in the early years • Underlying disorders of importance

  22. Determinants of non-survival after CRRTUnderlying disorder • Cardiac surgery 35% of non-survivors (Williams 2002) • Postop. Cardiac surgery 42% of CRRT (Fernandez 2005) • Left-heart hypoplasia 80% mortality (Smoyer 1995) • Causes leading to CRRT • Cardiogenic shock (20%) • Sepsis (39%) • Organ Tx (Liver, Bone marrow) 22% (Goldstein 2005)

  23. Determinants of non-survival after CRRTDegree of fluid overload (%FO) • %FO = (Fluid in – Fluid out)/PICU admission weight x 100 • Foland et al., Crit Care Med 2004; 32:1771 • Survival associated with lower PRISM-score and lower %FO • Goldstein et al., Kidney Int 2005; 67:653 • First report of the Prospective Pediatric CRRT Registry Group • 116 patients, PRISM higher in non-survivors • %FO higher in non-survivors 25.4% vs 14.2% in survivors • Patiens with <20%FO survival 58% vs 40% survival if %FO>20% • %FO may serve as an important parameter for fluid status • Guidance of fluid management • Timing of CRRT (early initiation)

  24. Conclusions • 20 years of PCRRT – a story of success • Development of high sophisticated equipment • Changing indications • Timing of CRRT in established indications • New indications even without ARF • Changing diagnoses • Decreasing and increasing incidence of disease • „New“ disorders like BMT • Slowly decreasing mortality rates • Prospective Pediatric CRRT Registry Group (Data) • Intensive care treatment is always on the border-line

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