Renal substitution steady treatment in babies

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Renal substitution (strong) treatment in newborn children. Patrick D. Brophy MD, Partner Educator Chief Pediatric Nephrology College of Iowa Youngsters' Healing center PCRRT Rome 2010. Layout:. Renal Substitution/Steady Treatment: Alternatives and Specialized difficulties and Expenses

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Renal substitution (steady) treatment in babies Patrick D. Brophy MD, Associate Professor Director Pediatric Nephrology University of Iowa Children's Hospital PCRRT Rome 2010 Brophy University of Iowa

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Outline: Renal Replacement/Supportive Therapy: Options & Technical difficulties & Costs Neonatal AKI/CKD/ESRD-Outcomes Neonatal ESRD-synopsis Brophy University of Iowa

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Case 36 wk newborn child destined to 36 yr old mother G1 P1 Parents told they couldn't imagine had embraced youngsters and discovered they were pregnant Pregnancy went well until rising C-sec required for placental unexpectedness Brophy University of Iowa

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Case Infant volume revived (apgars 1, 3 & 6) & intubated Multiple transfusions-settled the baby, exchanged to NICU Birth weight 2831 gm Patient entered in cooling (cerebrum/body cooling study) for assumed hypoxia Brophy University of Iowa

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Case Patient stayed anuric for length of mind/body cooling-Pediatric Nephrology counseled day 4 of life Pediatric Surgery not intrigued by putting lines or PD cath for dialysis as of now: Patient oversaw conservatively with constrained sustenance Family counseled wished maximal treatment Brophy University of Iowa

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Case Issues: Does this newborn child have Acute Kidney harm? (or, on the other hand Cortical putrefaction) What degree of CNS damage? Specialized issues encompassing renal substitution treatment Timing getting to be distinctly basic patient anuric with restricted nourishment What are the results from RRT in such patients? Should we continue Brophy University of Iowa

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RRT Options Hemodialysis, Peritoneal Dialysis, CRRT Each has focal points & hindrances Choice is guided by Patient Characteristics Disease/Symptoms Hemodynamic soundness Goals of treatment Fluid expulsion Electrolyte revision Both Availability, skill and cost Walters et. al. Peds Neph 2008 Brophy University of Iowa

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Brophy University of Iowa

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Technical Issues: Resources: what systems are you ready to give Catheter arrangement, ability What might be the best for the patient What co-morbidities does the patient have What are the objectives for the treatment Metabolic control, liquid, both Brophy University of Iowa

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Resources-exceptionally costly Facility expense day by day (for neonates) CRRT-$2200 USD + Profee PD-$1200 USD + Profee HD-$3200 USD + Profee Team: particular Nursing Dietary, Social work, Physician Therapy is an extreme attempt not much patient volume but rather exceptionally tedious Brophy University of Iowa

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Not present Diabetes Older age Atherosclerotic infection Hypertension Volume of patients Present Size/Access variety Less incessant than grown-ups/less experience Machinery is adjusted (not made) for pediatrics Blood preparing UF, thermic controls Neonatal/Pediatric Co-Morbidities: Considerations Approaching Renal Replacement Therapy Brophy University of Iowa

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Peritoneal Dialysis Catheter situation might be intense or changeless Dictated by the stomach area of the patient-can be troublesome in Prune Belly, patients requiring nephrectomy (ARPKD, CNS) Those with respiratory issues May be perfect for those with unadulterated renal issues (intrinsic) and some pee yield Usually very much endured and tender: can move from intense care to constant effectively Brophy University of Iowa

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Hemodialysis in Infants Brophy University of Iowa

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Smaller patients require littler catheters Difficulty accomplishing access Difficulty keeping up get to Limited get to destinations Femoral veins Jugular veins Subclavian veins Umbilical vessels Vascular Access for Infant HD/CRRT Brophy University of Iowa

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Catheter Type Manufacturer Potential Pts. Single-lumen 5Fr Cook Small Neonates Double-lumen 7Fr Cook Medcomp 3 – 6 Kg Triple-lumen 7Fr Medcomp 3 – 6 Kg Double-lumen 8Fr Kendall Arrow 6 – 30 Kg Choices for Infant Vascular Access Brophy University of Iowa

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Ultrafiltration Rate for Infant CRRT As endured by the patient Potentially constrained by dialyzer/hemofilter, blood stream rates Small blunders have a bigger impact in a modest patient ***** Brophy University of Iowa

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Other Special Considerations for HD/CRRT in Infants Large extracorporeal volume contrasted with little patient Blood prime (1:1 PRBC:Albumin 5%) at start every now and again required Risk of thermic misfortune frequently requires warming framework Brophy University of Iowa

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Potential Complications of Infant HD/CRRT Volume related issues Biochemical and wholesome issues Hemorrhage Infection Technical issues Logistical issues Bradykinin discharge disorder Brophy University of Iowa

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Logistical Issues for Infant HD/CRRT Infrequently performed methodology in neonatal units Vascular get to can be hard to compose and get Neonatology staff might be new to gear, system, dangers Written strategies may enhance coordination and aftereffects of treatment Brophy University of Iowa

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OUTCOMES How fruitful would we say we are? A few Neonates will begin with AKI and advance to ESRD Others will apparently have ESRD however in the end fallen off of dialysis "the stupidest kidneys are constantly more quick witted than the sharpest Nephrologist" Brophy University of Iowa

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Outcomes for Neonatal CRRT Data are inadequate Most reviews are single-focus, review No randomized controlled trials Small numbers constrain control Extension from grown-up studies may not be suitable Brophy University of Iowa

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CRRT in Pediatric Patients <10Kg Multi-focus, review ponder 5 pediatric focuses 85 patients Demographic information Technique depiction Outcome Am J Kid Dis, 18:833-837, 2003 Brophy University of Iowa

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Congenital coronary illness Metabolic issue Multiorgan brokenness Sepsis disorder Liver disappointment Malignancy Congenital nephrotic disorder Congenital diaphragmatic hernia Congenital renal/urological infection Hemolytic uremic disorder Heart disappointment Other 16.5% 15.3% 14.1% 10.6% 5.9% 4.7% 3.5% 2.4% 2.3% 5.9% Which Babies Require CRRT? N =85 Am J Kid Dis, 18:833-837, 2003 Brophy University of Iowa

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Combined volume over-burden and biochemical variations from the norm of renal disappointment 54% Volume over-burden 18% Metabolic lopsidedness random to renal disappointment ( e.g. , hyperammonemia) 14% Biochemical variations from the norm of renal disappointment 9% Other ( e.g. , prescription overdose) 4% Volume over-burden and hyperammonemia 1% Why do Babies Need CRRT? N =85 Brophy University of Iowa Am J Kid Dis, 18:833-837, 2003

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CRRT in Infants <10Kg: Outcome 38% Survival 41% Survival 25% Survival Patients < 10kg Patients 3-10kg Patients < 3kg Brophy University of Iowa Am J Kid Dis, 18:833-837, 2003

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36% 71% 15% 42% 22% 0 half 0 half 100% 0 60% Survival by Diagnosis Am J Kid Dis, 18:833-837, 2003 Totals: N=85; Survivors=32 Brophy University of Iowa

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Retrospective Study of Infant CRRT: Summary Overall result adequate 3 – 10kg: result like that for more established patients Metabolic issue: great result <3kg, chose analyze: poor result Am J Kid Dis, 18:833-837, 2003 Brophy University of Iowa

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Brophy University of Iowa

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78% 68% 63% CRF 62% 60% ARF 53% Deaths because of co-grim conditions Brophy University of Iowa

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Brophy University of Iowa

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Brophy University of Iowa

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Brophy University of Iowa

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Brophy University of Iowa

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Brophy University of Iowa

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Brophy University of Iowa

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Co-Morbidity Mortality Risk 1.8X more prominent <1 versus 1-5 yrs Mortality Risk 2.7X more noteworthy <1 versus >5 yrs This increments to 7.5X when co-sullen elements show Co-Mobidity: Lung hypoplasia Liver cirrhosis Cong Heart DZ Brophy University of Iowa

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Data Summary Infants with Stand alone renal illness can be viably dialyzed to transplant The mortality increments essentially in the wake of including co-dreary conditions Brophy University of Iowa

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Thank You NICU associates Nursing staff Dietitians Brophy University of Iowa

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