Acute kidney injury after neonatal heart surgery, prevention and management

Transcription

1 Acute kidney injury after neonatal heart surgery, prevention and management Mirela Bojan, Simone Gioanni, Philippe Pouard, Department of Anaesthesiology and Intensive Care Necker-Enfants Malades, Paris, France

2 «Ischemia associated with congenital heart disease was the most common ARF cause in neonates, 9 of which were attributed to hypoplastic left heart syndrome» Am J Kidney Dis, 2005

3 Prevalence of neonatal AKI after CHD repair Varies with definition : 17.5% when AKI defined as >50% increase of SCr from baseline on postoperative Day 3 5.5% requiring RRT (n=200 neonates) Guzzetta, Anesth Analg % according to the RIFLE and prifle I+F calculated from the peak postoperative SCr 41.5% according to RIFLE R+I+F 56.4% according to prifle R+I+F 8% requiring RRT (n=289 neonates) Necker,

4 RIFLE prifle Bellomo R, Crit Care 2004 Akcan-Arican, Kidney Int, 2007

5 Mortality in patients with AKI following CHD repair Pedersen, Acta Anaest Scand, % mortality when AKI defined by prifle I+F, 6.7% when AKI defined by RIFLE I+F, 30.4% among patients requiring RRT (n=289 neonates) Necker,

6 Risk factors for neonatal AKI after CHD repair CPB time DHCA Postoperative low output syndrome Age Loss of pulsatility Guzzetta, Anesth Analg, 2009

7 Adjusted OR of AKI for CPB time : 1.16, 95CI :[ ] Guzzetta, Anesth Analg 2009

8 200 neonates, 156 with, 44 without aprotinin AKI defined as >50% in preoperative Cr concentration at 72h postoperatively 20.1% AKI with vs 9.3% AKI without aprotinin, p= % RRT with vs 6.8% RRT without aprotinin, p=0.71 Anesth Analg 2009 Anesth Analg patients, 55% with, 45% without aprotinin, 17% neonates Propensity score adjustment to account for preoperative difference No association between aprotinin and AKI (RIFLE: R+I+F) : OR 1.32, 95%CI CPB duration was the only variable associated with AKI

9 293 neonates 193 CPB, excluding ECMO 1:3 match Without aprotinin (n=38) With aprotinin (n=114) TGA, TGA+VSD Aortic arch repair ± interrupted 3 9 Norwood procedure 2 3 Truncus arteriosus repair 1 4 Aortic valvuloplasty 1 7 RV to PA patch / pulmonary atresia-vsd 5 10 renal structural anomaly, n, % 3, 7.9 2, age (days), mean, sd 9, , weight (kg), mean, sd 3.2, , CPB (min), mean, sd 118.3, , Aortic cross-clamp (min), mean, sd 64.1, , With HCA, n, % 6, , prifle No AKI Risk Injury 8 20 Failure 3 18 RRT 3 (7.9%) 18 (15.8%) day mortality, n, % 2, 5.3 7, p OR for assessment to a superior strata of the RIFLE ; 1.26, 95%CI [ ] Necker,

10 174 survivors, 3 following CHD repair 29 children assessed for CKI: microalbuminuria, GFR) by Schwartz formula, hypertension, and hematuria -> 59% had at least one sign Kidney Int, 2006

11 Is there a best timing for RRT? PICU, n=116 MOF, FO=fluid overload before RRT 58% survival if <20% FO vs 40% survival if >20% FO Kidney Int, 2005

12 Delay to RRT onset and survival in the neonate after CHD repair 95 neonates 5 postoperative ECMO excluded 30-day survivors (n=63) non survivors (n=27) TGA, TGA+VSD 13 1 Aortic arch repair ± interrupted 19 6 Norwood procedure 7 9 Aortic valvuloplasty 5 0 TAPVC repair 10 5 With CPB CPB (min), mean, sd 156.3, , Aortic cross-clamp(min) 73.9, , HCA Lactate (mmol/l) 8.9, , Lowest postoperative Cr Clearance 18.2, , (mmol/min/1.7m2) Delay to PD onset : mean, sd 0.9, , Complic to PD p Necker,

13 Early RRT on operative or first postoperative day, and survival Survival Probability early PD delayed PD Logrank P = 0.02 No. at risk: early PD delayed PD Days of follow-up Necker,

14 Serum creatinine is not a reliable marker for neonatal AKI Kidney Int, 2009 n=390, 1/3 < 3month old A small rise in SCr on day 1 or 2 predicts progression to AKI (>50%SCr rise), within 48h AUC for day 1 SCr rise : 0.68, AUC for day 2 SCr rise : 0.65 SCr rise is not related to RRT requirement in the neonate (n=289) No AKI 'Risk' 'Injury' 'Failure' Sensitivity RIFLE 169 (58,5% ) 61(21% ) 47(16% ) 12(4,5% ) 25% RRT prifle 126 (43,5% ) 104(36%) 58(20% ) 1(0,5% ) RRT % Peak SCr attained on postoperative Day 2 or later Necker,

15 New plasma biomarkers for early diagnosis of AKI ASN, 2006

16 New urinary biomarkers for early diagnosis of AKI Kidney Int, 2006

17 Lancet 2005 Prediction of the need for RRT in children after CHD repair? Am J Kidney Dis, 2009

18 Pediatr Nephrol, 2009

19 n=42, 12 neonates in the PD group, 6 in the hemofiltration group, hemofiltration >PD, mortality 58-67%, only minor complications : hypothermia, hypophosphoremia, hypokaliemia, thrombocytopenia J Thorac Cardiovasc Surg 1995 n=25, age : 7days-11years ; 76% mortality rate 68% rate of complications : hypothermia, gastro-intestinal bleeding (7), thrombocytopenia Eur J Cardiothoracic Surg 2007 n=95 neonates overall 1 complication every 12.8 days of PD, 1 complication every 45 days of PD when considering peritonitis, hemoperitoneum or bowel perforation Necker,

20 Conclusion Neonatal AKI following CHD repair is frequent Long CPB times are a major risk factor When AKI occurs, the early onset of RRT is the only intervention that has been shown to improve outcome We need to develop new AKI definitions using early biomarkers of renal injury in addition to functional markers, and provide them for intervention The choice between RRT methods is multifactorial, but experience with the oldest one, PD, proves safety and effectiveness in the neonate after CHD repair.