ACUTE PERITONEAL DIALYSISALTERNATIVE FORM OF CRRT

Mignon McCullochDepartments of Paediatric Nephrology & PICURed Cross Children’s Hospital & University of

Cape Town

Paediatric Modified RIFLE (pRIFLE) Criteria

eCreatinine clearance

(eCCL)*

Urine output

1 eCCL by 25 % <0.5 ml/kg/hr for 8 hrs

2 eCCL by 50 % <0.5 ml/kg/hr for > 16hrs

3 eCCL by 75 % <0.3 ml/kg/hr for > 24 hr or anuria for 12 hr

*eCCL = 40 x height (cm) / s-creatinine (μmol/L)

Akcan-Arikan A et al Kidney Int 2007; 71: 1028-1035

AKI: Treatment Modality Selection

Ashita Tolwani, M.D., M.Sc.University of Alabama at Birmingham

Critical Care Nephrology – Vicenza June 2015

Use of Peritoneal Dialysis in AKI: A Systematic Review

Ashita Tolwani

24 studies identified 19/24 from Asia, Africa, and

South America 13 studies with PD only 11 studies with PD and EBP

7 observational 4 randomized

Chionh CY et al. Clin J Am Soc Nephrol 8: 1649–1660, 2013

Clinical Problems Produced By AKI

H

L

3.5

4.0

4.5

5.0

5.5

6.0

6.5

7.0

7.5

8.0

Fri 9Mar 2007

Sat 10 Sun 11 Mon 12

Potassium Level

mm

ol/L

PAYNE, JONTY

Potassium Level (mmol/L)

PD as CRRT Alternative to Extracorporeal systems Difficult Venous access Small infants “Challenged” resources

No equipment No surgical back-up appropriate

Not about Chronic PD

London

Peritoneal Dialysis in PICU RRT in PICU

Dr Mignon McCullochEvelina Children’s Hospital, Guy’s & St Thomas’ NHS

Trust

Evelina Children’s HospitalAndrew Durward Personal Communication

PICU 8818 Admissions

413 deaths Mortality 4.7%

20 Beds

Staffing: 7 Consultants 20 Fellows 150 Nurses

Training in nurses: CVVH 30% trained PD in 100% nurses

Evelina Children’s Hospital PICU 2002 – 2009

CVVH PD

Nos of Cases 119 188139 Cardiac

Age in months 30 7.8Med 0.22

Weight in kg -- 5.3Med 3.3

Mortality 30% 17%

Red Cross Children’s Hospital(RXH)University of Cape Town Experience

Increasing incidence in association with multi-organ failure in paediatric ICU’s

1 200 – 1 400 admissions per year Acute medical cases 600/yr Cardiac cases 250/yr Burns 50/yr Head injuries 50/yr Other Rest

Mortality 6% predicted 10-12% Dialysis 3.5%

Causes of Acute Kidney Injury

Sepsis 46(22%)

Post-cardiac surgery 36(17%)

Undiagnosed chronic renal disease

21(10%)

Gastroenteritis 19(9%)

Haemolytic uraemic syndrome

19(9%)

Necrotizing enterocolitis 15(7%)

Causes of Acute Kidney Failure

Leukaemia/Lymphoma 14(6%)

Myocarditis 11(5%)

Rapidly progressive nephritis

10(5%)

Trauma/Burns 8(4%)

Toxin ingestion 7(3%)

Kwashiorkor** 6(3%)

Practicalities of PD Quick – really quick – 20 mins K+ 9! Bed-side insertion by Paeds

Nephrologist/Intensivist/Surgeons (Surgeons as backup) Cook/Peel Away Tenckhoff/Formal

Tenckhoff Empty Bladder Sedation + Local Anaesthetic

Practicalities of PD Prescription

10-20ml/kg increase as tolerated to 50ml/kg Dialysis fluid

1.5%/2.5%/4.25% Dianeal(Lactate buffered) or Bicarb based

Cycles: Fill/Dwell/Drain 10/30-90/20mins

Manual or Cycling Home choice > 3kg Adapted to ventilatory requirements

PD Catheters Art of Medicine? Innovative and

Creative Cannulaes Naso-gastric tubes/Chest Drains Venous Central lines Rigid ‘Stick’ catheters ‘Peel away’ Tenckhoff Flexible Multi-purpose drainage catheters

Auron A et al Am J Kidney Dis 2007

New Generation Cook Catheters

Kimal ‘Peel-away’ Tenckhoff

Complications of PD Dysequilibration Syndrome (rare in acute) Hypotension Infection Blocked / Displaced catheter Respiratory difficulties Diaphragmatic leak Hyperglycaemia

Equipment – Audit at RXHTotal catheters used 260

Cook - 5 Fr Neonatal- 8 Fr Paediatric- 11 Fr Adult

(62%)531064

Kimal “peel away” Percutaneous Tenckhoff

46 (18%)

Surgical inserted Tenckhoff 51 (20%)

Automated DialysisHome choice machine

Manual Dialysis with Fluid Warmer

Acute Peritoneal Dialysis January 1999 to January 2004

TOTAL NUMBER OF PATIENTS

212

Male: Female 102:110

Age at dialysis:< 3 months3 months - 1yr1 – 6 years6 – 12 years> 12 years

 79(38%)45(21%)38(18%)30(14%)20(9%)

Acute PDLong term outcome

Survival following Acute PD

130(61% )

Chronic PD required following Acute PD

26(12%)

Total nos of patients requiring CVVHD (PD not possible)  Survival following CVVHD

20(9%)

11(55%)

Acute PD in PICU 1999-2009 Presented IPNA Aug 2010 New York

Red Cross Children’s Hospital, Cape Town SA

Total 406 cases/10years Wt range 900g – 70kg Age 1 day – 16yrs Diphtheria – Liver Transplant

PD IN PICU Total Nos 406 Neonates(<1mth) 85(21%) Infants(<1yr) 221(54%) Cardiac 95(23%)

Overall Mortality Rate

0

10

20

30

40

50

60

7020

00

2001

2002

2003

2004

2005

2006

2007

2008

2009

Overall 42%

Rat

e %

Vesna Stojanović, MD, PhD

Institute for Child and Youth Health Care of Vojvodina, Intensive Care

Unit

Novi Sad, Serbia

Peritoneal Dialysis in NICU

Peritoneal Dialysis as a Form of CRRT for Infants in a Developing Country

Specific Paeds Management IssuesVery Low Birth Weight InfantsKoralkar R et al. Ped Research 2011;69:4:354-8

AKI reduces survival in infants <1500g Independent risk factor

Very low glomerular filtration rate Mild exposure – high degree of injury High rates of infection Nephrotoxic drugs

Premature infants <1000g Increase SCr of 1.0mg/dL(88.5umol/l) Doubles the odds of death

Duration Of Dialysis

OUTCOME 15/25(60%) Infants survived to

come off dialysis No bleeding complications 2/15 catheters blocked - day 3 & 4

on dialysis Nil required long term dialysis

Manual Dialysis with Fluid Warmer

PD Paed system

Quick and Easy

Post Cardiac Surgery Nitric Oxide, Oscillator & PD

Contra-indication?Post Abdominal Surgery

8Fr Cook PD Catheter

8Fr CookPigtail multi-purpose drainage device

Improvised equipment and solution used in the procedure

04/22/23 Dr S. Antwi: Paediatric Nephrologist -KNUST-SMA/KATH

44

CFPD• Performed with two

bedside placed catheters:▫ the first

conventionally placed in the midline below the umbilicus

▫ the second one placed midway between the superior iliac crest and the umbilicus

Continuous Flow Peritoneal Dialysis Clin J Am Soc Nephrol. 2011 Feb;6(2):311-8

CFPD useful for ARF Ronco C Perit Dial Int 27:251-3, 2007

Especially in children Especially if small haemodynamically infant Developing and Developed countries

Future Larger studies in Paeds Higher flow volumes Improved catheter technology

Patient

PD Solution

Blue pump BM 14

Fluid Heater

Venous bubble trap

transducer toBM 11

Air detector

Pressure transducer to BM

11

Yellow pump

BM 14

BM 14

Waste Bag

Schematic drawing of CFPD

Overall recommendations: Critically ill patient with AKI

Early fluid resuscitation in acute hypovolaemia + septic shock states

Early consultation and assessment of %FO Early initiation of CRRT + Inotropes over fluid

administration to maintain BP Appropriate expertise in management of

RRT DO what you are good at! Do not delay Call a friend

Take Home Message

PD is available in resource poor environment PD is appropriate in acute setting in PICU

Not dependant on large nos and well trained staff members

Certain patient groups more suitable for PD Practical for small infants – access + stability

Even in ‘resource rich’ hospital settings, there is a role for acute PD

CLINICAL SKILLS COURSEIn conjunction with Saving Young Lives (SYL)

Including Airway & Resuscitation, Vascular Access, Acute Peritoneal Dialysis

Aimed at Pairs of Doctor and Nurse Team9 – 12 March 2015

Registration: www.surgicalskills.co.za

Surgical Skills Training CentreUniversity of Cape Town

Red Cross War Memorial Children’s HospitalDepartments of Paediatrics, Anaesthetics & Paediatric Surgery

2015

Surgical Support

Learning is fun !

Doctor Nurse Teams

Bloemfontein, SA

Ghana

Malawi + Zambia

KenyaNigeria

Foreign Faculty

Nursing Training

Tim Bunchman pic

IMG_5847.JPG

Thank you to all my colleagues @ RXH

Acute Kidney Injury:The Future is now

The past of acute kidney injury was observation,

and the present is intervention with renal replacement therapy,

but perhaps the future is the use of biomarkers to identify AKI sooner and intervene early.Bunchman TE. Oct 2009. Nephrology Times 15-16.