Clinical outcome in children with acute renal failure treated with peritoneal dialysis after surgery for congenital heart disease

Abstract

The present single-center cohort study was based on a clinical intensive care unit database containing data on 1128 consecutive children undergoing their first operation for congenital heart disease between 1993 and 2002 at Aarhus University Hospital, Skejby, Denmark. A total of 130 (11.5%) children developed postoperative acute renal failure (ARF) managed with peritoneal dialysis (PD). Logistic regression analysis was used to examine risk factors for complications related to PD and to compare mortality between ARF and non-ARF patients controlling for potential confounding factors. A total of 43 complications related to PD were registered in 27 (20.8%) patients. Major complications were seen in eight (6.2%) patients, and only two (1.5%) patients were switched to hemodialysis after peritonitis and hemicolectomy due to bowel perforation. The main risk factors for complications to PD were duration of PD, high RACHS-1 score (Risk Adjusted Classification for Congenital Heart Surgery), and hyperkalemia at initiation of PD. Overall, in-hospital mortality was 6.8% (76/1128). Mortality of ARF patients was 20.0% compared to 5.0% among non-ARF patients (adjusted odds ratio=1.91, 95% confidence interval=1.10-3.36). After stratification, ARF was strongly associated with increased mortality in the subgroups of patients with the lowest overall risk of dying (age> or =1 year, body weight> or =5 kg, RACHS-1 score <3, and no preoperative cyanosis). For patients at high risk of dying (age <1 year, body weight <5 kg, RACHS-1 score> or =3, cardiopulmonary bypass time> or =60 min, and preoperative cyanosis), the association between ARF and mortality was substantially weaker. In conclusion, postoperative ARF was associated with increased mortality in children operated for congenital heart disease. Major complications to PD were few, and our data strongly support that PD is a simple, safe, feasible, and robust dialysis modality for the management of ARF in children.

Lesão renal aguda em crianças: incidência e fatores prognósticos em pacientes gravemente enfermos

“…In a pediatric study, Perdensen et al (27) found a 11.5% incidence. Kuitunen et al (28) , evaluating adult patients, found a 19.3% rate, and these patients had less severe renal injury.…”

Use of Peritoneal Dialysis after Surgery for Congenital Heart Disease in Children

“…Even if the presence of AKI is usually associated with an increased rate of complications, longer hospital stay, and worse prognosis in this setting, the association between AKI and mortality must take into account the overall risk of death because of the underlying cardiac condition (19). In low-risk patients, the correlation between AKI and mortality was strong; in those with higher risk, the association was weaker, because death was attributable not only to AKI but also to other organ failure, especially cardiac failure (4). As in other series (19), we also found that longer bypass time was a predictive factor for a subsequent need for PD, although in our cohort, the severity of the cardiac disease did not correlate with the likelihood of RRT or mortality.…”

“…In this setting, PD or continuous venovenous hemodiafiltration can be offered to (3,4). In smaller children, PD may have some advantages because it obviates the need for a vascular catheter and is well tolerated in patients with hemodynamic instability (9).…”

“…One of the largest series on PD after surgery for congenital cardiac problems found an overall rate of complications of 21%, of which 6.2% were major complications; the remaining problems were minor (4). Complexity of cardiac lesions and duration of PD were among the factors associated with an increased risk for PD problems (4).…”

“…However, when volume overload and oliguria or anuria supervenes, renal replacement therapy (RRT) should be considered. In this setting, peritoneal dialysis (PD) has long been advocated as the preferred technique because of better hemodynamic stability, no requirement for vascular access, simplicity, and low cost (4).…”