Acute renal failure following cardiopulmonary bypass in children: results of treatment

Neutrophil Phenotype Correlates With Postoperative Inflammatory Outcomes in Infants Undergoing Cardiopulmonary Bypass

OBJECTIVES

Infants with congenital heart disease frequently require cardiopulmonary bypass, which causes systemic inflammation. The goal of this study was to determine if neutrophil phenotype and activation status predicts the development of inflammatory complications following cardiopulmonary bypass.

DESIGN

Prospective cohort study.

SETTING

Tertiary care PICU with postoperative cardiac care.

PATIENTS

Thirty-seven patients 5 days to 10 months old with congenital heart disease requiring cardiopulmonary bypass.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Laboratory and clinical data collected included length of mechanical ventilation, acute kidney injury, and fluid overload. Neutrophils were isolated from whole blood at three time points surrounding cardiopulmonary bypass. Functional analyses included measurement of cell surface protein expression and nicotinamide adenine dinucleotide phosphate oxidase activity. Of all patients studied, 40.5% displayed priming of nicotinamide adenine dinucleotide phosphate oxidase activity in response to N-formyl-Met-Leu-Phe stimulation 24 hours post cardiopulmonary bypass as compared to pre bypass. Neonates who received steroids prior to bypass demonstrated enhanced priming of nicotinamide adenine dinucleotide phosphate oxidase activity at 48 hours. Patients who displayed priming post cardiopulmonary bypass were 8.8 times more likely to develop severe acute kidney injury as compared to nonprimers. Up-regulation of neutrophil surface CD11b levels pre- to postbypass occurred in 51.4% of patients, but this measure of neutrophil priming was not associated with acute kidney injury. Subsequent analyses of the basal neutrophil phenotype revealed that those with higher basal CD11b expression were significantly less likely to develop acute kidney injury.

CONCLUSIONS

Neutrophil priming occurs in a subset of infants undergoing cardiopulmonary bypass. Acute kidney injury was more frequent in those patients who displayed priming of nicotinamide adenine dinucleotide phosphate oxidase activity after cardiopulmonary bypass. This pilot study suggests that neutrophil phenotypic signature could be used to predict inflammatory organ dysfunction.

Acute kidney injury according to pediatric RIFLE criteria is associated with negative outcomes after heart surgery in children

BACKGROUND

The aim of this study was to investigate the association between the occurrence of acute kidney injury (AKI) according to pediatric RIFLE (pRIFLE) criteria and adverse outcomes in children after heart surgery.

METHODS

Children undergoing heart surgery in a tertiary hospital in Southern Brazil were followed during their stay in the pediatric intensive care unit (PICU) or until death. The exposure variable was occurrence of AKI according to pRIFLE criteria which place AKI in three categories: R (risk), I (injury), and F (failure). The outcomes studied were death, length of mechanical ventilation (MV), and length of PICU stay.

RESULTS

Eighty-five children were enrolled in the study. Of these, 47 (55.3 %) did not have AKI, while 22 (25.9 %), seven (8.2 %), and nine (10.6 %) were classified into pRIFLE categories R, I, and F, respectively. The incidence of death was 18.4 and 4.2 % in patients with and without AKI, respectively. Compared to children who did not develop AKI, the adjusted odds ratio for death was 1.05 [95 % confidence interval (CI) 0.09-11.11], 8.36 (95 % CI 1.32-52.63), and 7.85 (95 % CI 1.53-40.29) in the R, I, and F groups, respectively (p = 0.022). Duration of MV and of PICU stay were significantly higher in those children with AKI.

CONCLUSIONS

The occurrence of AKI according to pRIFLE criteria is associated to adverse outcomes in children after heart surgery.

Predictors of acute kidney injury post-cardiopulmonary bypass in children

OBJECTIVE

To investigate the incidence, implicating factors and outcome of acute kidney injury (AKI) after cardiopulmonary bypass (CPB) in patients admitted to a pediatric cardiothoracic intensive care unit (ICU).

MATERIALS AND METHODS

DESIGN

A retrospective review study.

SETTING

A 10-bed cardiothoracic ICU.

PATIENTS

One hundred and twenty-four children (<18 years of age) admitted to the cardiothoracic ICU following CPB between January 2007 and December 2009.

METHODS

Age, sex, diagnosis, baseline and post-surgery hemoglobin, total leukocyte count, platelet count and biochemistry were recorded. Baseline and postoperative urea (mg/dl), creatinine (mg/dl), urine output (ml/kg/h) and inotrope dose were also recorded daily. The duration of CPB was noted. Postoperative cardiac, renal, hepatic, neurologic and respiratory dysfunctions were recorded.

RESULTS

Seven (5%) children developed AKI stage I, five children (4%) developed AKI stage II and two children developed AKI stage III (2%). All patients with AKI had a longer stay in hospital and increased mortality. Two children required dialysis for AKI and none developed chronic renal impairment. All patients with AKI stage III died during the ICU stay. Using stepwise regression, younger age (<1 year), weight <10 kg, pump failure, sepsis and duration of CPB >90 min were significant risk factors identified for developing AKI.

CONCLUSIONS

AKI is common and occurred in 11% of our patients following CPB; however, AKI requiring renal replacement therapy is uncommon.

Perioperative renal failure in pediatric heart transplant recipients: outcome and risk factors

PRF is encountered in 10-13% of adult heart transplants. Only one study of a single center's experience with PRF has been reported in pediatric patients. This study examines the effect of PRF on pediatric heart transplant outcome using the UNOS database. A total of 3598 patients met inclusion criteria, of whom 254 (7%) had PRF. The PRF group comprised 31 recipients requiring PRE and 223 recipients requiring POST. Compared with No-PRF patients, PRE patients had similar survival rate and POST patients had decreased survival rate at 30 days, one, five, and 10-yr post-transplant (p < 0.001). PRF patients also had significantly lower graft survival at one, five, and 10 yr (p < 0.001). Risk factors for developing PRF included ECMO, ventilator, and inotropic support at listing and CHD as the listing diagnosis. PRF increased the duration of hospital stay and the incidence of chronic severe renal dysfunction. PRF that requires POST (whether or not it began pretransplant) has a significant negative impact on pediatric heart transplant outcome. Specific characteristics identify patients at particular high risk of developing PRF.

Use of peritoneal dialysis after surgery for congenital heart disease in children

Acute kidney injury (AKI) is a common complication in children after surgery for congenital heart disease, and peritoneal dialysis (PD) is usually the renal replacement therapy (RRT) of choice, especially in very young children. The aim of the present study was to describe our experience of using PD to treat AKI after cardiac surgery. We retrospectively analyzed children 1 week to 16 years of age undergoing cardiac surgery during 2000-2008 and found the incidence of AKI treated with PD to be 2.3%. In the 23 patients treated with PD (13 male; average age: 29 ± 48.4 months; weight: 9.1 ± 8.1 kg), the indications for PD initiation were oliguria (n = 13), anuria (n = 9), and acidosis (n = 1). The average time between cardiac surgery and AKI was 4.8 ± 16.8 hours, and between AKI and PD initiation, it was 12 ± 16.8 hours. Patients were treated for a mean of 4.8 ± 3.8 days. Two patients developed peritonitis, and mechanical dysfunction of the PD catheter occurred in 1 patient. In-hospital mortality was 43.4%. Patients treated with PD weighed less (p = 0.004) and had longer bypass time (p = 0.004), inotrope use (p = 0.000), and mechanical ventilation (p = 0.000). However, in a regression analysis, only cardiopulmonary bypass time (odds ratio: 1.021; 95% confidence interval: 0.998 to 1.027; p = 0.032) remained predictive of a subsequent need for PD. We conclude that PD is an efficacious RRT for AKI in children undergoing cardiac surgery and that, in this setting, bypass time is the strongest predictor of a subsequent need for RRT.

Low renal oximetry correlates with acute kidney injury after infant cardiac surgery

Acute kidney injury (AKI) is a frequent complication after cardiopulmonary bypass surgery during infancy. Standard methods for evaluating renal function are not particularly sensitive nor are proximate indicators of renal dysfunction that allow intervention in real time. Near-infrared spectroscopy (NIRS) is a newer noninvasive technology that continuously evaluates regional oximetry and may correlate with renal injury and adverse outcomes after cardiac surgery in infants. This prospective observational study enrolled 40 infants (age, <12 months) undergoing biventricular repair. Continuous renal oximetry data were collected for the first 48 postoperative hours and correlated with postoperative course, standard laboratory data, and the occurrence of acute renal injury. Subjects with low renal oximetry (below 50% for >2 h) had significantly higher postoperative peak creatinine levels by 48 h (0.8 ± 0.4 vs. 0.52 ± 0.2; p = 0.003) and a higher incidence of AKI (50 vs. 3.1%; p = 0.003) than those with normal renal oximetry. These subjects also required more ventilator days and greater vasoactive support, and they had elevated lactate levels. Prolonged low renal near-infrared oximetry appears to correlate with renal dysfunction, decreased systemic oxygen delivery, and the overall postoperative course in infants with congenital heart disease undergoing biventricular repair.

Acute Renal Failure and Mortality After Open-Heart Surgery in Infants

Acute renal failure (ARF) is a major complication in infants who undergo cardiac surgery. The aim of this investigation was to identify possible risk factors for ARF and mortality in this patients group. Out of 64 patients, 21 (32.8%) cases developed acute renal failure and overall mortality rate was 25%. The mortality rate was higher in the infants who developed ARF than those who did not (66.7% and 4.7%, respectively, p<0.05). Also, ARF was positively correlated with mortality (r:0.70, p<0.0001). The nonsurvivors had lower mean serum albumin than did the survivors (p<0.05), and serum albumin level was negatively correlated with mortality (r= -0.34, p< 0.05). For the patients with serum albumin level <3.5 g/dL, the unadjusted odds ratio for mortality was 4.3 (CI 95%:1.05-17.86). Total bypass time and aorta clamping time were significantly longer in the nonsurvivor group than in the survivor group (p<0.05 for both). In conclusion, the significant risk factors for mortality in these patients were development of ARF, low serum albumin level, and long total bypass and aorta clamping times, which may be predictive of poor prognosis.

Acute renal failure and outcome of children with solitary kidney undergoing cardiac surgery

The aim of this study was to investigate the risk of acute renal failure (ARF), the need for renal replacement therapy, and the outcome of children with a solitary functioning kidney undergoing open heart surgery. The study was performed retrospectively on all children diagnosed with solitary functioning kidney and who required open heart surgery between January 2003 and January 2007. Demographic, perioperative renal function and intensive care course data were documented. Eight patients (six females) fulfilled the study criteria and were included in the study. Their median age and weight were 4.5 months and 3.6 kg, respectively. Their mean +/- standard deviation (SD) preoperative blood urea nitrogen (BUN) and creatinine levels were 3.7 +/- 1.6 mmol/L and 55 +/- 10 micromol/L, respectively. Postoperatively, the mean BUN and creatinine levels peaked on the first postoperative day to reach 7.8 +/- 2.6 mmol/L and 76 +/- 22 micromol/L, respectively, before starting to return to their preoperative values. Two out of eight patients (25%) developed ARF after surgery, but only one of them (12.5%) required renal replacement therapy. Open heart surgery on bypass can be performed safely for children with solitary functioning kidney with a good outcome. ARF requiring renal replacement therapy might occur temporarily after bypass surgery in a minority of cases.

Risk factors for acute renal failure requiring dialysis after surgery for congenital heart disease in children

BACKGROUND

Limited data exist on the risk factors for acute renal failure (ARF) following cardiac surgery in children with congenital heart disease. This cohort study was conducted to examine this subject, as well as changes in the incidence of ARF from 1993 to 2002, the in-hospital mortality and the time spent in the intensive care unit (ICU).

METHODS

One thousand, one hundred and twenty-eight children, operated on for congenital heart disease between 1993 and 2002, were identified from our prospectively collected ICU database to obtain data on potential risk factors.

RESULTS

A total of 130 children (11.5%) developed ARF after surgery. A young age [> or =1.0 vs. <0.1 year; odds ratio (OR), 0.23; 95% confidence interval (CI), 0.12-0.46], high Risk Adjusted Classification of Congenital Heart Surgery (RACHS-1) score (OR, 2.72; 95% CI, 1.66-4.45) and cardiopulmonary bypass (CPB) (<90 min vs. none; OR, 2.68; 95% CI, 1.03-6.96; > or =90 min vs. none; OR, 12.94; 95% CI, 5.46-30.67) were independent risk factors for ARF. The risk of ARF decreased during the study period. Children with ARF spent a significantly longer time in the ICU (2-7 days vs. <2 days, P = 0.002; > or =7 days vs. <2 days, P < 0.001) compared with non-ARF patients, and showed increased in-hospital mortality (20% vs. 5%, P < 0.001).

CONCLUSION

A young age, high RACHS-1 score and CPB were independent risk factors for ARF after surgical procedures for congenital heart disease in children. The risk of ARF decreased during the study period. Children with severe ARF spent a longer time in the ICU, and the mortality in ARF patients was higher than that in non-ARF patients.

Adequacy of peritoneal dialysis in children following cardiopulmonary bypass surgery

Acute renal failure requiring renal replacement therapy can complicate cardiopulmonary bypass in children. Peritoneal dialysis has been shown to stabilize electrolytes and improve fluid status in these patients. To assess dialysis adequacy in this setting, we prospectively measured Kt/V and creatinine clearance in five patients (6-839 days of age) requiring renal replacement therapy at our institution. Median dialysis creatinine clearance was 74.25 L/week/1.73m(2) (range 28.28-96.63 L/week/1.73m(2)). Residual renal function provided additional solute clearance as total creatinine clearance was 215.97 L/week/1.73m(2) (range 108.04-323.25 L/week/1.73m(2)). Dialysis Kt/V of >2.1 (median 4.84 [range 2.12-5.59]) was achieved in all patients. No dialysis-associated complications were observed. We conclude that peritoneal dialysis is a safe, simple method of providing adequate clearance in children who develop acute renal failure following exposure to cardiopulmonary bypass.

Peritoneal dialysis after surgery for congenital heart disease in infants and young children

BACKGROUND

We determined the risk factors for peritoneal dialysis (PD) in young children undergoing open heart surgery and, in those patients requiring PD, factors associated with prolonged PD and mortality.

METHODS

The clinical records of 182 children, aged 3 years or younger, who had undergone open heart surgery during a 2-year period were reviewed. Demographic data, preoperative risk factors, intraoperative variables, and postoperative complications were compared between patients requiring PD and those who did not, and between survivors and nonsurvivors of PD.

RESULTS

Of the 182 patients, 31 (17%) required PD. Patients requiring PD were lighter and more likely to have required preoperative ventilation; had undergone more complex surgery requiring longer bypass and circulatory arrest; and had experienced a pulmonary hypertensive crisis (p < 0.01). Logistic regression identified circulatory arrest (relative risk, 9.4; p = 0.002), cardiopulmonary bypass duration (relative risk, 1.02; p = 0.028), and low cardiac output syndrome (relative risk, 12.9; p < 0.0001) as significant determinants. Peritoneal dialysis was effective in achieving negative fluid balance, although serum urea and creatinine levels remained static. Prolonged PD was associated with younger age, higher preoperative serum creatinine, higher postoperative oxygen requirement, postoperative pulmonary hypertensive crisis, and low cardiac output syndrome (p < 0.05). When compared with survivors (n = 22), nonsurvivors (n = 9) were more likely to have had syndrome disorders and required preoperative ventilation and higher postoperative ventilatory settings (p < 0.05).

CONCLUSIONS

Risk factors for PD in young children undergoing open heart surgery are circulatory arrest, cardiopulmonary bypass duration, and low cardiac output syndrome. The preoperative and postoperative cardiopulmonary status has a significant bearing on PD duration and patient survival.

Peritoneal dialysis after infant open heart surgery: observations in 27 patients

BACKGROUND

The role of peritoneal dialysis (PD) in the management of infants after heart operation is under discussion. The aim of this study was to investigate the effect of PD on fluid balance and outcome.

METHODS

Twenty-seven (33%) of 81 consecutive infants who underwent heart operation required PD. In 22 patients (81%), PD was started prophylactically at the end of the operation. We recorded hemodynamic data and fluid balance. Patients experiencing acute renal failure (ARF) were compared with the remaining infants.

RESULTS

Eleven of 81 patients (14%) experienced ARF; 3 of them died (4% of all patients undergoing operation, 27% of those with ARF). Complications of PD, present in 33%, were transitory and of minor significance. Patients with ARF had decreased cardiac function compared with those without ARF but similar fluid balance.

CONCLUSIONS

Peritoneal dialysis is an effective and safe method for the treatment of ARF in infants after open heart operation. As PD is helpful in modulating postoperative fluid balance, prophylactic use of PD can be recommended for selected patients who are at risk for low cardiac output syndrome.

Continuous versus intermittent furosemide infusion in critically ill infants after open heart operations

BACKGROUND

Use of intravenous furosemide is generally avoided in critically ill neonates and infants soon after open heart operations to prevent fluctuations in intravascular volume and resulting circulatory instability.

METHODS

To assess and compare the safety and efficacy of continuous versus intermittent intravenous furosemide, we undertook a prospective, randomized trial in 26 consecutive patients less than 6 months of age. Inclusion criteria were presence of low-output syndrome requiring inotropic support (24/26 patients) or pulmonary hypertension requiring vasodilator therapy (10/26 patients) within 6 hours of discontinuation of cardiopulmonary bypass. Eleven patients received 0.1 mg x kg(-1) x h(-1) continuous intravenous furosemide (group 1) and 15 received 1 mg/kg bolus every 4 hours (group 2) for 24 hours. Mean age (3.7 +/- 3.4 versus 1.8 +/- 2.5 months) and weight (4.6 +/- 2.1 versus 4.3 +/- 1.7 kg) were comparable.

RESULTS

Group 2 infants showed slightly greater absolute urinary output (2.5 +/- 1.1 mL/kg per hour versus 3.3 +/- 1.1 mL/kg per hour, p = 0.05). However, urinary output per dose of drug was significantly larger in group 1 infants (1.0 +/- 0.4 versus 0.5 +/- 0.2 mL x kg(-1) x h(-1); p = 0.002) with lesser fluctuations (variance, 1.9 +/- 1.6 versus 3.8 +/- 2.1; p = 0.02) and fluid replacement needs (20.6 +/- 3.8 versus 51.8 +/- 14.4; p = 0.001). Electrolyte replacement requirements were similar. A trend toward greater hemodynamic instability in group 2 patients (heart rate variance 88.4 +/- 79.8 versus 128.3 +/- 82.7; p = 0.09; central venous pressure variance 2.8 +/- 1.90 versus 4.1 +/- 3.7; p = 0.07; mixed venous oxygen saturation variance, 32.3 +/- 27.6 versus 45.7 +/- 20.4; p = 0.06) was noted. All patients who completed the study protocol survived operation and were discharged home.

CONCLUSIONS

We conclude that (1) commonly used doses of both intermittent and continuous intravenous furosemide infusion can be safely administered to critically ill neonates and infants as early as 6 hours after operation, (2) continuous infusion yields an almost comparable urinary output with a much lower dose of furosemide, and (3) intermittent administration is associated with greater fluctuations in urinary output and greater needs for fluid replacement therapy.

Peritoneal dialysis in children after cardiopulmonary bypass

OBJECTIVE

We reviewed 5 years' experience with peritoneal dialysis in children with acute renal failure after cardiac operations. We hypothesized that peritoneal dialysis is safe and effective in children with low-output cardiac failure after cardiac operations.

RESULTS

Mortality in these patients with renal failure (n = 32) was 46.9%. Fluid removed by peritoneal dialysis was 48 +/- 28 ml/kg per 24 hours. Most complications of peritoneal dialysis were minor, hyperglycemia being the most frequent (53.1%). Peritoneal infection was suspected in 25%. Bowel perforation developed in two patients. None of the complications required early termination of dialysis. Hemodynamics and pulmonary function improved continuously during the study period.

CONCLUSION

The early institution of peritoneal dialysis in acute renal failure and low cardiac output after cardiac operations not only removes fluid, thus easing fluid restriction, but may also improve cardiopulmonary function.

Renal replacement therapy after repair of congenital heart disease in children. A comparison of hemofiltration and peritoneal dialysis

The development of renal failure necessitating peritoneal dialysis after cardiac operations is associated with a reported mortality greater than 50%. Improved fluid removal and nutritional support have been reported with the use of continuous arteriovenous hemofiltration and continuous venovenous hemofiltration techniques. We have compared our experience with all three techniques in managing children who required renal replacement therapy after cardiac operations in terms of efficacy (fluid removal, calorie intake, and clearance of urea and creatinine), complications, and outcome. Over a 5-year period renal replacement therapy was initiated in 42 children, and in 34 of them it was successfully established for more than a 24-hour period: 17 were managed with peritoneal dialysis, 8 with continuous arteriovenous hemofiltration, and 9 with continuous venovenous hemofiltration. A net negative fluid balance was achieved in only 6 (35%) patients treated with peritoneal dialysis compared with 50% of those treated with continuous venovenous hemofiltration and 89% of those treated with continuous venovenous hemofiltration. In terms of nutritional support, calorie intake increased by 43% after peritoneal dialysis was started compared with 515% and 409% in the arteriovenous and venovenous hemofiltration groups, respectively, (p < 0.005). The serum urea levels fell by 36% (p = 0.02) and 39% (p = 0.005) compared with pre-therapy levels with arteriovenous and venovenous hemofiltration, respectively, and the creatinine content was reduced by 19% and 33% (p = 0.003). Neither parameter was reduced in the peritoneal dialysis group. We conclude that the use of hemofiltration as a renal replacement therapy after surgical correction of congenital heart disease offers significant advantages over the more traditional approach of peritoneal dialysis. In addition, we suggest that a more aggressive approach to the management of fluid overload and nutritional depletion with hemofiltration may result in a decrease in the very high mortality seen in renal failure after cardiac operations.

Volumetric control of continuous haemodialysis in multiple organ failure

A system for precise volumetric control of continuous haemodialysis and its use in providing renal replacement treatment in the intensive care unit to 10 children with multiple organ failure are described. The system, termed slow efficient dialysis, provided effective clearance of urea, creatinine, potassium, and phosphate. It provided precise control of the volume of ultrafiltrate removed in a prospective manner ('dial up' fluid balance) to reduce haemodynamic instability and fluid management problems. The ease of use of this system for intensive care nurses meant that the system ran without the assistance of a second intensive care or renal nurse.

Long-term outcome for children with acute renal failure following cardiac surgery

Acute renal failure requiring dialysis occurred in 34 children (2.9%) following cardiac surgery over a five year period. 17 children (50%) recovered renal function with 11 (32%) long-term survivors. The long-term outcome for the survivors, in terms of renal function, was studied from 1 to 5 years after their episodes of acute renal failure. Three children had significant abnormalities of renal function despite normal urinalysis. Detailed assessment of renal function is advocated for children who survive acute renal failure following cardiac surgery.

Prognosis and risk factors in acute, dialysis-requiring renal failure after open-heart surgery

Of 1988 patients who underwent open-heart surgery from 1980 through 1988, 68 (3.4%) developed postoperative acute renal failure requiring dialysis (2.5% of adult and 8.3% of pediatric patients). Isolated aortocoronary bypass grafting was the operation with lowest incidence of this complication (0.6%). Acute renal failure usually appeared during the first 3 postoperative days. It carried a mortality rate of 63%, with half of the deaths occurring during the first few postoperative days, due to low cardiac output and progressive multiple organ failure. Logistic regression analysis in cases of aortic valve replacement demonstrated that significant independent preoperative risk factors for acute renal failure were renal insufficiency (serum creatinine greater than 110 mumol/l in greater than or equal to 2 samples) and increased cardiothoracic index/left ventricular end-diastolic dimension. Data from the literature indicated no time-related trend towards reduction of acute renal failure incidence or mortality. Prevention of low cardiac output is of major importance in these respects. Operative intervention before development of advanced disease with left ventricular dilatation and secondary kidney failure is advocated.

Peritoneal dialysis in the first 60 days of life

This report describes a 7-year experience with acute peritoneal dialysis in 31 neonates and infants less than 60 days of age. There were 20 boys and 11 girls, ages 3 to 60 days. Tenckhoff catheters of modified length were placed in the newborn intensive care unit (ICU), pediatric ICU, or surgery suites, and hourly exchanges (20 cc/kg) were started immediately postoperatively. Diagnoses included congenital metabolic disorders (11), acute tubular necrosis (6), postcardiopulmonary bypass with renal failure (5), renal cortical necrosis (5), obstructive uropathy (2), renal agenesis (1), and bilateral renal dysplasia (1). Complications included: peritonitis (4), bowel perforation (1), exit site infection (3), leaking dialysate (4), catheter obstruction (2), inguinal hernias (3), umbilical hernia (1), and retroperitoneal hemorrhage (1). There were 19 deaths (61.3%) from 1 to 90 days postinsertion in this high risk group. The (1), and post liver transplant (1). Effective dialysis (lowering of blood urea nitrogen (BUN) or ammonia, correction of acidosis, decrease in fluid overload) was possible in all cases. Five of the 12 survivors remain on chronic dialysis awaiting renal transplantation. Peritoneal dialysis is effective in the newborn period in the management of metabolic disturbances as well as renal failure. Morbidity and mortality (61.3%) is related to the near-morbid condition of the baby at the time of insertion and the severity of the complex underlying diagnosis often associated with multiorgan failure.