Temporary peritoneal dialysis in newborns and children: a single-center experience over five years

Pediatric Simplified Acute Physiology Score II: Establishment of a New, Repeatable Pediatric Mortality Risk Assessment Score

Objectives: In critical care it is crucial to appropriately assess the risk of mortality for each patient. This is especially relevant in pediatrics, with its need for accurate and repeatable scoring. Aim of this study was to evaluate an age-adapted version of the expanded Simplified Acute Physiology Score II; (p-SAPS II), a repeatable, newly-designed scoring system compared to established scores (Pediatric Sequential Organ Failure Assessment Score/pSOFA, Pediatric Logistic Organ Dysfunction Score-2/PELOD-2 and Pediatric Index of Mortality 3/PIM3). Design: This retrospective cohort pilot study included data collected from patients admitted to the Pediatric Intensive Care Unit (PICU) at the Medical University of Vienna between July 2017 through December 2018. Patients: 231 admissions were included, comprising neonates (gestational age of ≥ 37 weeks) and patients up to 18 years of age with a PICU stay longer than 48 h. Main Outcomes: Mortality risk prediction and discrimination between survivors and non-survivors were the main outcomes of this study. The primary statistical methods for evaluating the performance of each score were the area under the receiver operating characteristic curve (AUROC) and goodness-of-fit test. Results: Highest AUROC curve was calculated for p-SAPS II (AUC = 0.86; 95% CI: 0.77-0.96; p < 0.001). This was significantly higher than the AUROCs of PELOD-2/pSOFA but not of PIM3. However, in a logistic regression model including p-SAPS II and PIM3 as covariates, p-SAPS II had a significant effect on the accuracy of prediction (p = 0.003). Nevertheless, according to the goodness-of-fit test for p-SAPS II and PIM3, p-SAPS II overestimated the number of deaths, whereas PIM3 showed acceptable estimations. Repeatability testing showed increasing AUROC values for p-SAPS II throughout the clinical stay (0.96 at day 28) but still no significant difference to PIM 3. The prediction accuracy, although improved over the days and even exceeded PIM 3. Conclusions: The newly-created p-SAPS II performed better than the established PIM3 in terms of discriminating between survivors and non-survivors. Furthermore, p-SAPS II can be assessed repeatably throughout a patient's PICU stay what improves mortality prediction. However, there is still a need to optimize calibration of the score to accurately predict mortality sooner throughout the clinical stay.

Serial Amnioinfusion as Regenerative Therapy for Pulmonary Hypoplasia in Fetuses With Intrauterine Renal Failure or Severe Renal Anomalies: Systematic Review and Future Perspectives

The aim of this study was to investigate the effect of serial amnioinfusion therapy (SAT) for pulmonary hypoplasia in lower urinary tract obstruction (LUTO) or congenital renal anomalies (CRAs), introduce patient selection criteria, and present a case of SAT in bilateral renal agenesis. We conducted a search of the MEDLINE, EMBASE, Web of Science, and Scopus databases for articles published from database inception to November 10, 2017. Eight studies with 17 patients (7 LUTO, 8 CRA, and 2 LUTO + CRA) were included in the study. The median age of the mothers was 31 years (N=9; interquartile range [IQR], 29-33.5 years), the number of amnioinfusions was 7 (N=17; IQR, 4.5-21), gestational age at first amnioinfusion was 23 weeks and 4 days (N=17; IQR, 21-24.07), gestational age at delivery was 32 weeks and 2 days (N=17; IQR, 30 weeks to 35 weeks and 6.5 days), birthweight of newborns was 3.7 kg (N= 9; IQR, 2.7-3.7 kg), Apgar score at 1 minute was 2.5 (N=8; IQR, 1-6.5), and Apgar score at 5 minutes was 5.5 (N=8; IQR, 0-7.75). In conclusion, SAT may provide fetal pulmonary palliation by reducing the risk of newborn pulmonary compromise secondary to oligohydramnios. Multidisciplinary research efforts are required to further inform treatment and counseling guidelines. We propose a multidisciplinary approach to prenatal classification of fetuses with LUTO to inform patient selection.

Peritoneal dialysis for the management of pediatric patients with acute kidney injury

Renal replacement therapy (RRT) is the most important supportive measure used in the management of acute kidney injury (AKI). Peritoneal dialysis (PD) is a safe, simple and inexpensive procedure and has been used in pediatric AKI patients, ranging from neonates to adolescents. It is the modality of choice for RRT in developing countries with cost constraints and limited resources. However, its use has declined with the availability of newer types of extracorporeal modalities for RRT in the developed world. Much controversy exists regarding the dosing and adequacy of PD in the management of AKI. Data in infants and children have shown that PD can provide adequate clearance, ultrafiltration and correction of metabolic abnormalities even in those who are critically ill. Although there are no prospective studies in children, data from retrospective studies reveal no differences in mortality rates between different modalities of RRT. In this review, we discuss the advantages and limitations of PD, indications for acute PD, strategies to improve the efficiency of acute PD and outcomes of PD in children with AKI.

Short-term renal support in postoperative repair of tetralogy of Fallot in the paediatric intensive care unit: can we predict those who need it?

INTRODUCTION

Fluid balance and renal function can be difficult to manage in the postoperative infant with tetralogy of Fallot. High fluid volumes are often needed to maintain cardiac output. Aims To stratify patients at risk for advanced renal support following tetralogy of Fallot repair.

METHODS

Retrospective analysis of all consecutive tetralogy of Fallot cases operated at a single centre in a 3-year period.

RESULTS

A total of 41 children were identified. All cases had loop diuretics administered. Of the cases, 17% required support with a peritoneal dialysis catheter, with only one complication of peritoneal dialysis catheter blockage. The mean length of paediatric intensive care unit stay in those receiving peritoneal dialysis catheter insertion was prolonged by an additional mean of 6 days (p<0.001). No statistical significance was found between those children requiring peritoneal dialysis and those who did not when considering patient age and weight at time of repair, cardiopulmonary bypass and aortic cross clamp times, the presence of a transannular patch, or junctional ectopic tachycardia. However, volume requirement of more than 35 ml/kg in the first 12 hours following repair did increase the likelihood to need peritoneal dialysis (p<0.0001). Furthermore, the higher the peak creatinine, the longer the stay on intensive care (p<0.01).

CONCLUSIONS

Peritoneal dialysis is an effective method of dealing with fluid balance in children after tetralogy of Fallot repair, with minimal complications. Early consideration should be given to peritoneal dialysis when it is clear that high fluid volumes are required postoperatively.

Successful in utero intervention for bilateral renal agenesis

BACKGROUND

We report a case of bilateral renal agenesis treated with serial amnioinfusion in which the newborn survived the newborn period and was able to undergo peritoneal dialysis as a bridge to planned renal transplantation.

CASE

A 34-year-old woman, gravida 1 para 0, presented at 23 1/7 weeks of gestation with a diagnosis of anhydramnios and bilateral renal agenesis. The patient underwent weekly serial amnioinfusion with the goal of improving fetal pulmonary development. At 28 weeks of gestation, the patient delivered a live newborn who required minimal respiratory support. The neonate is currently 9 months old and is undergoing daily peritoneal dialysis.

CONCLUSION

Serial amnioinfusion appears to have mitigated the severe pulmonary compromise that has, in the past, led to the death of newborns with bilateral renal agenesis.

Peritoneal dialysis in an extremely low-birth-weight infant with acute kidney injury

Critically ill neonates are at high risk for acute kidney injury (AKI). Renal supportive therapy (RST) can be an important tool for supporting critically ill neonates with AKI, particularly in cases of oliguria and fluid overload. There are few reports of RST for management of oligo-anuric AKI in the extremely low-birth-weight infant weighing <1000 g. We report successful provision of peritoneal dialysis (PD) to an 830-g neonate with oligo-anuric AKI through adaptation of a standard pediatric acute PD catheter.