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Zurich: Local History

PCRRT in HUS: Role of peritoneal dialysis Thomas J Neuhaus and GF Laube, JF Falger, EM Rüth, MJ Kemper, O Bänziger University Children’s Hospital, Zurich. Zurich: Local History. 1955: Gasser et al: H emolytic- U remic S yndrom es : HUS

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Zurich: Local History

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  1. PCRRT in HUS:Role of peritoneal dialysisThomas J Neuhausand GF Laube, JF Falger, EM Rüth, MJ Kemper, O Bänziger University Children’s Hospital, Zurich

  2. Zurich: Local History • 1955: Gasser et al: Hemolytic-Uremic Syndromes: HUS • 1964: Peritoneal dialysis for acute renal failure: HUS • 1970: Hemodialysis and renal transplantation • 1979: Continuous PD for chronic renal failure • 1995: Continuous veno-venous hemofiltration for ARF

  3. HUS = Hemolytic-Uremic Syndromes • Hemolytic microangiopathic anemia: fragmentocytes, LDH , neg. Coombs • Thrombocytopenia • Uremia: acute renal failure • Further symptoms / complications: • Central nervous system (seizures, hemorrhages) • Hypertension and heart failure • Liver / Pancreas (with diabetes mellitus) • Eye: retinal bleedings

  4. HUS: D+ and D- • D+ = Diarrhea-positive • Verotoxin (or Shigatoxin)-producing E. Coli • Other bacteria, e.g. Shigella …. („Big Mc disease“) • Hemorrhagic colitis: mild – severe, intussusception • D- = Diarrhea-negative • Pneumococcal infections (T-antigen positive) • Inherited and/or recurrent forms: e.g. complement (factor I/H) or vWF-cleavage protease deficiency • Others: Pregnancy, drugs … • „Many“ cases of unknown cause

  5. Zurich: Epidemiology of HUS HUS: most frequent cause of acute renal failure in our hospital

  6. HUS: Indications for dialysismodality since 1995 (1) • Peritoneal dialysis: „in general“ first choice • On ICU: CAPD • On ward: mainly automated PD • Hemodialysis if • „older“ patient in „good general condition“ not requiring care in intensive care unit • D-HUS and plasma-exchange (PEX) anticipated • life-threatening hyperkalemia

  7. HUS: Indications for dialysismodality since 1995 (2) • Continuous veno-venous hemo(dia)filtration if • „in bad general condition“ (+/- PEX) • severe colitis • Plasma-exchange (PEX) or plasma infusion if • D-HUS and inherited type / complement deficiency suspected • D- or D+ HUS with severe central nervous system symptoms, e.g. impaired consciousness, neurological deficit

  8. Acute renal failure andperitoneal dialyis among adults ?! • Recent review on „Renal replacement therapy of acute renal failure in ICU adult patients“ • … Peritoneal dialysis is not further discussed … because of • missing data • no significant role • 1 study showing a very high mortality ….

  9. HUS: 1995 – 2005 (1) • N = 68: 30 males, 38 females • Age: median 2.3 years (2 months – 12 years) • D+: 52 = 76%: 5 months – 12 years • D- : 16 = 24%: 2 months – 10 years • 6: pneumoccocal infection, 5 with septicemia • 1: acute systemic lupus erythematodes • 1: complement I deficiency (Dg: 9 yrs after onset !) • 1: familial occurrence (mother / grandmother) • 7: unknown cause

  10. HUS: 1995 – 2005 (2) „Extreme“ values median range • Creatinine 375 μmol/l (4.3 mg/dl) 50 – 995 • Urea 32 mmol/l (192 mg/dl) 6 – 76 • Hemoglobin 62 g/l 29 – 108 • Platelets 36 G/l 7 – 271 • Sodium 132 mmol/l 109 – 142

  11. HUS and dialysis: 54 / 68 (79%) 16: D-HUS 52: D+HUS

  12. HUS and PD: 44 / 54 dialysed (81%) 11: D-HUS 43: D+HUS

  13. Acute PD • before 1995: • „stiff“ Cook-catheter or • „soft“(„peel away“) catheter, inserted with trocar or • Tenckhoff • since 1995: • only Tenckhoff catheter • surgically placed by the surgeon (and the nephrologist also in theatre) under general anasthetic; at the same time insertion of central venous line

  14. Acute and chronic PD • Tenckhoff catheter: • coil • 2 sizes: < / > 1 year • 1 cuff (glued by ourselves) • upward facing

  15. Acute PD on ICU: • Fresenius system • Lactate (march 2006: • bicarbonate) • Initial prescription: • >10 - 15 ml / kg • exchange: every hour • 1000 IU Heparin/l • 1.36% Glucose • no antibiotics • run by ICU-nurses

  16. Acute PD on ward: • Baxter system • mainly automated PD • Bicarbonate (Physioneal) • Prescription: • up to 40 ml / kg • exchange: 2 – 4 hours • 1000 IU Heparin/l • 1.36% Glucose • no antibiotics • Run by ward / renal nurses

  17. HUS and PD: 44 / 54 with dialysis • Start with PD: 41/54 (76%) • D+ 35/43 (81%) • D- 6/11 (55%) • Only PD: 35/54 (65%) • D+ 30/43 (70%) • D- 5/11 (45%)

  18. HUS and PD: • 3 patients: switch to PD from • HD: 1 D+, transfer ICU  ward and end-stage renal failure • CVVH: 1 D-, transfer ICU  ward • HD/PEX: 1 D-, transfer ICU  ward and ESRF

  19. HUS and PD: • 6 patients: switch from PD to • CVVH : 2 1: D+, general deterioration: † 1: D+, rectumperf.  2° peritonitis • HD: 2 1: D+, insufficient ultrafiltration despite 3.86% glucose 1: D-, ESRF • plus PEX: 2 D+, cerebral involvement: 1 †

  20. HUS and PD: technical aspects • Time span between emergency room entry and onset of PD in ICU: • median 4 hours (2 – 20) • Duration of PD: • median 10 days (1 – 35)

  21. HUS and PD: technical complications • Peritonitis: n = 9 (all in ICU) • Exit-site infection n = 3 • Insufficient ultrafiltration: n = 1  switch: HD • Catheter obstruction: n = 0 • Insufficient dialysis: n = 0  No catheter had to be replaced.

  22. HUS and hemofiltration • Hemofiltration: 7 • Only CVVH: 2 • 1 D+: presentation with epileptic state • 1 D-: pneumoccocal septicemia • CVVH and PD: 3 • CVVH and HD: 2

  23. HUS and hemodialysis / PEX • Only HD: 5, all D+ HUS • 3: older patients – 12 years – in „good condition“ • 1: recurrent intussusception and bowel resection before onset of ARF • 1: severe hemorrhagic colitis • Plus PEX: 4 • 2 D-, 2 D+

  24. HUS: clinical complications (1) • Hypertension: requiring medication • 40 / 68 (59%), 28 / 44 with PD  16 patients with PD: „no medication, only PD“ • Cardiomyopathy: • 6: impaired ventricular function • Pancreatitis: Amylase ↑ • 24: but no diabetes mellitus • Hepatopathy: Transaminases ↑ • 43: but no liver failure

  25. HUS: clinical complications (2) • Gastrointestinal tract: n = 4 (all D+) • 2 intussusception • 1 rectum perforation • 1 severe colitis • Severe central nervous system: n = 7 • 4 D+: 3: remission, 1: † • 3 D-: 2: sequelae (pneumococcal meningitis, massive hemorrhage), 1: † (SLE) • Retinal bleeding: n = 2 (all D+)

  26. HUS: stay in ICU / hospital • ICU: • median: 5 days (0 – 30) • Hospital: • median: 17 days (1 – 93)

  27. HUS: daily running costs: Pat  20 kg CHF US$ Ratio to PD • PD: • 2 x 5 l bag: 44 34 1.0 • HD: 60 46 1.5 • set: 40 • concentrate: 20 • CVVH: • 1 set / 3 days 175 – 210 135 – 160 4.5 • set: 225 – 325 • 4 x 5 l filtrate: 100 • HD and CVVH: plus costs of hardware…

  28. Outcome: D+ HUS: n = 52

  29. Outcome: D- HUS: n = 16

  30. Conclusions (1): HUS • Incidence: • D+ >>> D- (over the last 35 years) • 80% require dialysis • Outcome: D+ >> D- • Patient survival • Recovery of renal function

  31. Conclusions (2): HUS – PD • Surgically placed Tenckhoff-catheter: • Simple technique • High efficacy • Low frequency of side effects / complications • PD in HUS is • safe • efficient • convenient • economic

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