I. I. Maizlin1, M. C. Shroyer1, L. Perger2, M. K. Chen1, E. A. Beierle1, C. A. Martin1, S. A. Anderson1, V. E. Mortellaro1, D. A. Rogers1, R. T. Russell1 1Children’s Hospital Of Alabama, University Of Alabama,Division Of Pediatric Surgery,Birmingham, Alabama, USA 2Scott & White Healthcare/Texas A&M Health Science Center College Of Medicine,Department Of Surgery,Temple, Texas, USA
Introduction: Recent advances in renal replacement therapy (RRT) have allowed for significant increase in rates of dialysis initiation for neonates with kidney failure or inborn errors of metabolism. Methods of RRT in neonates include peritoneal dialysis (PD), continuous renal replacement therapy (CRRT) and intermittent hemodialysis (HD). The purpose of this study was to assess morbidity and mortality following initiation of dialysis in newborn patients (<30 days) on those modalities.
Methods: Retrospective chart review was performed on all patients who had RRT initiated in the first 30 days of life between 2006 and 2014, excluding patients receiving RRT following congenital heart surgery. All charts were queried for birth history, underlying etiology for RRT, operative history, and route of RRT (HD and/or PD). We also reviewed the surgical complications associated with RRT and mortality rate.
Results: Total of 49 patients were identified, 39 boys and 10 girls. Median gestational age and birth weight were 36 (30-41) weeks and 2.85 (1.66-4.52) kg respectively. Thirty-two patients (65%) had end stage renal disease (ESRD), 11 (22%) had inborn errors of metabolism and 6 (12%) required dialysis due to other pathologies. Initial therapy was continuous veno-venous hemofiltration (CVVH) in all patients. Median age at onset of RRT was 6 (4-14) days and median weight of 3.1 (2.7-4.0) kg. Patients with ESRD spent a median of 8.5 (2-38) days on CVVH, while metabolic error and other etiology patients spent a median of 4 (3-7) days and 4.5 (1-10) days respectively. Overall mortality was 65.3% (71.9% among ESRD patients, 45.5% metabolic disease). Fifty-six percent (18 of 32 total deaths) of all deaths occurring within the 1st 30 days of life and 94% (30 of 32) occurred within the 1st year of life. Most common cause of death was sepsis (30%) among ESRD patients, and ARDS (40%) among metabolic patients. Total of 201 surgeries were performed. Excluding catheter revisions, 83 new HD lines and 28 new PD catheters placed, with a maximum of 6 HD lines and 4 PD lines placed in a single patient. Two patients died within 24 hours of catheter placement due to respiratory failure. Catheter-associated morbidities occurred in 100% of patients. Most common complications for HD included circuit clotting (87%), bleeding (68%) and bacteremia (40%), and for PD patients included peritonitis (83%), catheter complications (72%), and PD catheter leaks (55%). Among 9 survivors that required long term RRT (median follow-up of 5.3 years), 4 were severely and 2 were moderately developmentally delayed.
Conclusion: RRT is increasingly utilized for the neonatal population with renal and metabolic diseases. However, while RRT is becoming more technically feasible, it remains associated with significant morbidity and mortality. Pediatric surgeons must be aware of the challenges of neonatal dialysis and take them into account when considering the care of these critically ill children.