Outcomes of dialysis in newborns

Gianni CelsiPediatric Nephrology Unit

Karolinska University Hospital,

Stockholm, Sweden

Causes of ARF in neonates

• Prerenal 75-80%

• Intrinsic 10-15%

• Postrenal 5-10%

hypovolemia, sepsis,

low cardiac output

PUV,PJO

How is the prognosis of pre- and postrenal ARF in

neonates?

Prognosis of ARF

40-60 % survival

Depending on underling disease

Depending on co-morbidity

Reversible

What about ESRD?

Causes of ESRD in neonates

• Prerenal

• Intrinsic

• Postrenal

Causes of intrinsic renal ESRD in

neonates

• Prenatal Agenesis Hypoplasia Dysplasia Cystic diseases Obstruction

• Postnatal DIC, ATN

What is the general consensus for intrinsic ESRD in neonates?

Intrinsic renal ESRD in neonates

• Rare• Extremely poor prognosis

Renal replacement therapy not always recommended. As recently as 1998, only 40% of international pediatric nephrologists would offer dialysis to infants < 1 month (J. Pediatr 1998, 133, 154-65)

How is the prognosis of ESRD in neonates?

Survival after dialysis in neonates with ESRD

Age at start

n Survival %

Matthews et al,J Ped Surg1990 <2 m 31 39

infants whose renal failure was isolated were more likely to undergo successful dialysis

Blowey et al, JPerinatol. 1993

<1 y 23 65

Ellis et al, Adv Perit Dial. 1995 <1 y 21 80-36

infants with anuria or oliguria had a higher mortality (64%) than did infants with adequate urine output (20%).

Warady et al, Pediatr Nephrol 99

<3 m 34 76Coulthard et al, Arch Dis Child 2002

<1 m 31 55

Williams et al, Arch Pediatr Adolesc Med 2002

1 d-1 y 35 53

Laakkonen et alNephrol Dial Transplant 2008

1d-2 m 9 90

Outcomes of dialysis initiated during the neonathal period for treatment of ESRD: a NAPRTCS special analysis.

Pediatrics 2007: 468-473; 119

For physicians and parents alike, the decision to initiate long-

term dialysis for a neonate with presumptive ESRD poses a

complex ethical quandary.This dilemma derives,at least in

part, from the paucity of published reports describing the

outcomes of infants who initiate dialysis during the first month

of life.

Neonates were as likely to terminate dialysis during the study

period as were older children. However, the reason for

terminating dialysis differed significantly between the 2 age

groups. Neonates were more likely to terminate because of death,

and they were less likely to terminate because of transplantation.

Death 17/193

Recovery of function 23/193

Neonates with renal dysplasia or obstructive uropathy are at risk for

associated congenital anomalies, either true malformations or

deformations, because of severe oligohydramnios. In such cases,

the presence of significant comorbid conditions may preclude long-

term dialysis as a bridge to renal transplantation, thus excluding

these neonates from the NAPRTCS database.

Aetiology and outcome of acute and chronic renal failure in infants

Nephrol Dial Transplant (2008) 23: 1575–1580

Between 1997 and 2004 all children <1 year of age with

a serum creatinine >100 µmol/l were followed up for up to 6 years.

- 49 infants with ESRD- 21 started dialysis between 5-531 days of age

- 4 neonates were not offered RRT because of parents wish

- mortality: ARPKD 100%

dysplasia 22%

obstraction 6%

Prenatal diagnosis of bilateral isolated fetal hyperechogenic

kidneys. Is it possible to predict long term outcome?

Brit J Obs Gyn 2002

n TOP % Survival %

ARPKD 20 45 30

ADPKD 7 28 71

Others 9 67 33

Congenital renal tract anomalies: outcome and follow-upof 402 cases detected antenatally between 1986 and 2001

Ultrasound Obstet Gynecol 2005

n TOP % Survival %

Bilateral agenesis,

MCDK, PDCK, dysplasia

76 48 3

Unilateral agenesis,MCDK,

dysplasia

74 6 83

How is the prognosis of ESRD in preterms?

Renal failure, comorbidity and mortality in preterm infants

Wien Klin Wochenschr (2008) 120/5–6: 153–157

n Survival %

Pre/post 14 33

Cong. anomalies 2 0

16 RF/ 359 <37 GA (4,5%)

Nephrol Dial Transplant (2007) 22: 432–439

Antenatal oligohydramnios of renal origin: long-term outcome

A total of 23 infants (16 males, 7 females) with an antenatal

diagnosis of oligohydramnios were retrospectively studied

- Survival 70%

- 4 children were not offered RRT (GA 34-39)

- only 2 children started dialysis at birth (GA 38-40)

Age at onset of dialysis in preterms with ESRD

02468

1012

1985 1990 1995 2000 2005 2010

Year

Ag

e (

m)

GA Oligohydr. Diuresis Survival

36 + + KT

37 + - No

31 + - No

35 + +/- No

33 + - No

37 + +/- No

Survival of preterms with dialysis onset at birth

What shall we do?

Renal replacement therapy in

neonates/preterms with ESRD

Feasible

Aim: Improve quality of life

Caveat: Avoid damage

Respect autonomy

Be fair