DOI: 10.5301/ijao.5000294
Int J Artif Organs 2014; 37 ( 1 ): 39-47
ORIGINAL ARTICLE
Peritoneal dialysis does not adversely affect kidney function recovery after congenital heart surgery Alyssa A. Riley1, John L. Jefferies2,4, David P. Nelson2,4, Michael R. Bennett2, Joshua J. Blinder3, Qing Ma2, Prasad Devarajan2, Stuart L. Goldstein2,4 Pediatric Renal Section, Baylor College of Medicine, Houston, TX - United States Center for Acute Care Nephrology, Cincinnati Children’s Medical Center, Cincinnati, OH - United States 3 Department of Cardiology, Boston Children’s Hospital, Boston, MA - United States 4 The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH - United States 1 2
Purpose: Acute kidney injury (AKI) after cardiopulmonary bypass surgery to correct congenital heart disease is common. We prevent fluid overload and further cardiac compromise in oliguric infants with continuous peritoneal dialysis (CPD). The effect of CPD on kidney recovery is unknown, thus indications to discontinue CPD are unclear. We aimed to determine if CPD affects kidney recovery, measured by urine output and novel urinary AKI biomarker concentrations. Methods: Twenty infants 1 mg/dl; 3) an active urinary tract infection at the time of surgery; 4) requiring more than 72 h continuous use of nephrotoxic medications, including aminoglycosides, vancomycin, and non-steroidal anti-inflammatories, so as to prevent confounding by the potential for subclinical kidney injury, 5) prior extracorporeal membrane oxygenation (ECMO), prior surgery requiring CPB, prior renal replacement therapy, all of which may have introduced prior episodes of acute kidney injury, 6) or enrollment in another study deemed to be of conflicting interest. Patients were eligible for enrollment until five hours following admission to the CVICU after surgical correction of congenital heart disease.
Study design Demographics and data for this study were collected as standard clinical practice in our hospital for all patients who undergo surgical correction of congenital heart disease. Surgical complexity was categorized using the Risk Assessment Score for Congenital Heart Surgery 1 (RACHS-1) scoring system (25). All patients included in the study were treated as per Texas Children’s Hospital Cardiovascular Intensive Care Unit (TCH CVICU) standard of care with regards to post-operative management and the clinical need to initiate PD. Since 1996, PD initiation has been standard of care in the TCH CVICU for management of patients at high risk for AKI or early oliguria (50% difference in urine output, revealing adequate power would be achieved with only 20 randomized patients (10 per randomized group) (27, 28).
© 2014 Wichtig Editore - ISSN 0391-3988
41
Peritoneal dialysis and kidney recovery
Statistical analysis of data was performed with STATISTICA™ software version 9 (StatSoft, Tulsa, OK, USA). Descriptive analysis, including birth weight (kg), current weight (kg), gestational age (weeks), pre-operative SCr and BUN, RACHS-1 score, cardiopulmonary bypass time (min), aortic cross-clamp time (min), urine output (ml/kg per h) eight hours before and after surgery, inotrope scores, time to initiation of and time on PD (h), fluid intake (mL) before discontinuation of PD, is reported with mean and standard deviation for each variable. The Student’s t-test and MannWhitney U test were used to calculate differences between continuous data, and the χ2 or Fisher’s exact test were used for categorical variable. As our standard unit practice is to record urinary output in eight-hour increments, mean urine output (ml/kg per h) in eight-hour intervals was calculated for 24 h before and after randomization, along with standard deviation. Student’s t-test was used to assess the difference in change in urine output between the randomized groups. Median urinary biomarker concentrations (normalized for urine creatinine) were aggregated in 12-h intervals, interquartile ranges were calculated, and data was compared over 24 h before and after randomization using the Mann-Whitney U-test, since the Shapiro-Wilkes test was used to determine that urinary biomarker data were not normally distributed. Urinary biomarker concentrations were also compared between single and biventricular cardiac physiologies. A p-value
Int J Artif Organs 2014; 37 ( 1 ): 39-47
ORIGINAL ARTICLE
Peritoneal dialysis does not adversely affect kidney function recovery after congenital heart surgery Alyssa A. Riley1, John L. Jefferies2,4, David P. Nelson2,4, Michael R. Bennett2, Joshua J. Blinder3, Qing Ma2, Prasad Devarajan2, Stuart L. Goldstein2,4 Pediatric Renal Section, Baylor College of Medicine, Houston, TX - United States Center for Acute Care Nephrology, Cincinnati Children’s Medical Center, Cincinnati, OH - United States 3 Department of Cardiology, Boston Children’s Hospital, Boston, MA - United States 4 The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH - United States 1 2
Purpose: Acute kidney injury (AKI) after cardiopulmonary bypass surgery to correct congenital heart disease is common. We prevent fluid overload and further cardiac compromise in oliguric infants with continuous peritoneal dialysis (CPD). The effect of CPD on kidney recovery is unknown, thus indications to discontinue CPD are unclear. We aimed to determine if CPD affects kidney recovery, measured by urine output and novel urinary AKI biomarker concentrations. Methods: Twenty infants 1 mg/dl; 3) an active urinary tract infection at the time of surgery; 4) requiring more than 72 h continuous use of nephrotoxic medications, including aminoglycosides, vancomycin, and non-steroidal anti-inflammatories, so as to prevent confounding by the potential for subclinical kidney injury, 5) prior extracorporeal membrane oxygenation (ECMO), prior surgery requiring CPB, prior renal replacement therapy, all of which may have introduced prior episodes of acute kidney injury, 6) or enrollment in another study deemed to be of conflicting interest. Patients were eligible for enrollment until five hours following admission to the CVICU after surgical correction of congenital heart disease.
Study design Demographics and data for this study were collected as standard clinical practice in our hospital for all patients who undergo surgical correction of congenital heart disease. Surgical complexity was categorized using the Risk Assessment Score for Congenital Heart Surgery 1 (RACHS-1) scoring system (25). All patients included in the study were treated as per Texas Children’s Hospital Cardiovascular Intensive Care Unit (TCH CVICU) standard of care with regards to post-operative management and the clinical need to initiate PD. Since 1996, PD initiation has been standard of care in the TCH CVICU for management of patients at high risk for AKI or early oliguria (50% difference in urine output, revealing adequate power would be achieved with only 20 randomized patients (10 per randomized group) (27, 28).
© 2014 Wichtig Editore - ISSN 0391-3988
41
Peritoneal dialysis and kidney recovery
Statistical analysis of data was performed with STATISTICA™ software version 9 (StatSoft, Tulsa, OK, USA). Descriptive analysis, including birth weight (kg), current weight (kg), gestational age (weeks), pre-operative SCr and BUN, RACHS-1 score, cardiopulmonary bypass time (min), aortic cross-clamp time (min), urine output (ml/kg per h) eight hours before and after surgery, inotrope scores, time to initiation of and time on PD (h), fluid intake (mL) before discontinuation of PD, is reported with mean and standard deviation for each variable. The Student’s t-test and MannWhitney U test were used to calculate differences between continuous data, and the χ2 or Fisher’s exact test were used for categorical variable. As our standard unit practice is to record urinary output in eight-hour increments, mean urine output (ml/kg per h) in eight-hour intervals was calculated for 24 h before and after randomization, along with standard deviation. Student’s t-test was used to assess the difference in change in urine output between the randomized groups. Median urinary biomarker concentrations (normalized for urine creatinine) were aggregated in 12-h intervals, interquartile ranges were calculated, and data was compared over 24 h before and after randomization using the Mann-Whitney U-test, since the Shapiro-Wilkes test was used to determine that urinary biomarker data were not normally distributed. Urinary biomarker concentrations were also compared between single and biventricular cardiac physiologies. A p-value
