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J Thorac Cardiovasc Surg 1995;109:322-331
© 1995 Mosby, Inc.

SURGERY FOR CONGENITAL HEART DISEASE

Renal replacement therapy after repair of congenital heart disease in childrenA comparison of hemofiltration and peritoneal dialysis

Toronto, Ontario, Canada

From the Pediatric Intensive Care Unit and the Divisions of Nephrology, Cardiology, and Cardiac Surgery, The Hospital for Sick Children, Toronto, and the Department of Anesthesia, Pediatrics and Surgery, The University of Toronto, Toronto, Ontario, Canada.

Received for publicaiton Feb. 9, 1994 Accepted for publication Sept. 29, 1994. Address for reprints: D. J. Bohn, MB, FRCPC, Department of Critical Care Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.

Abstract

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. (J THORACCARDIOVASCSURG1995;109:322-31)

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