Early initiation of peritoneal dialysis in neonates and infants with acute kidney injury following cardiac surgery is associated with a significant decrease in mortality
2012; Elsevier BV; Volume: 82; Issue: 4 Linguagem: Inglês
10.1038/ki.2012.172
ISSN1523-1755
AutoresMirela Bojan, Simone Gioanni, Pascal Vouhé, Didier Journois, Philippe Pouard,
Tópico(s)Cardiac Arrest and Resuscitation
ResumoAssociation between early renal replacement therapy and better survival has been reported in adults with postoperative kidney injury, but not in children undergoing cardiac surgery. We conducted a retrospective cohort study of 146 neonates and infants requiring peritoneal dialysis following cardiac surgery in a tertiary referral hospital. A propensity score was used to limit selection bias due to timing of dialysis, and included baseline and intraoperative characteristics, requirement for postoperative extracorporeal membrane oxygenation, and creatinine clearance variation. Inverse probability of treatment weighting resulted in good balance between groups for all baseline and intraoperative variables. After weighting, 30-day and 90-day mortality were compared between the 109 patients placed on dialysis early, within the first day of surgery, and those with delayed dialysis, commencing on the second day of surgery or later, using logistic regression and survival analysis. Mortality was 28.1% at 30 days, and was 36.3% during follow-up. Early dialysis was associated with a 46.7% decrease in the 30-day and a 43.5% decrease in the 90-day mortality rate when compared with delayed dialysis. All other short-term outcome variables were similar. Thus, initiation of peritoneal dialysis on the day of or the first day following surgery was associated with a significant decrease in mortality in neonates and infants with acute kidney injury. Association between early renal replacement therapy and better survival has been reported in adults with postoperative kidney injury, but not in children undergoing cardiac surgery. We conducted a retrospective cohort study of 146 neonates and infants requiring peritoneal dialysis following cardiac surgery in a tertiary referral hospital. A propensity score was used to limit selection bias due to timing of dialysis, and included baseline and intraoperative characteristics, requirement for postoperative extracorporeal membrane oxygenation, and creatinine clearance variation. Inverse probability of treatment weighting resulted in good balance between groups for all baseline and intraoperative variables. After weighting, 30-day and 90-day mortality were compared between the 109 patients placed on dialysis early, within the first day of surgery, and those with delayed dialysis, commencing on the second day of surgery or later, using logistic regression and survival analysis. Mortality was 28.1% at 30 days, and was 36.3% during follow-up. Early dialysis was associated with a 46.7% decrease in the 30-day and a 43.5% decrease in the 90-day mortality rate when compared with delayed dialysis. All other short-term outcome variables were similar. Thus, initiation of peritoneal dialysis on the day of or the first day following surgery was associated with a significant decrease in mortality in neonates and infants with acute kidney injury. Reported incidence rates of acute kidney injury (AKI) requiring renal replacement therapy (RRT) after pediatric cardiac surgery have varied from 2.1 to 17% over the past decade.1.Pedersen K.R. Povlsen J.V. Christensen S. et al.Risk factors for acute renal failure requiring dialysis after surgery for congenital heart disease in children.Acta Anaesthesiol Scand. 2007; 51: 1344-1349Crossref PubMed Scopus (95) Google Scholar, 2.Boigner H. Brannath W. Hermon M. et al.Predictors of mortality at initiation of peritoneal dialysis in children after cardiac surgery.Ann Thorac Surg. 2004; 77: 61-65Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar, 3.Chan K.L. Ip P. Chiu C.S. et al.Peritoneal dialysis after surgery for congenital heart disease in infants and young children.Ann Thorac Surg. 2003; 76: 1443-1449Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar, 4.Xinjin L. Jianping X. Xiangdong S. et al.Peritoneal dialysis after repair of congenital heart disease in children.Chin Med Sci J. 2003; 18: 100-104PubMed Google Scholar AKI following cardiac surgery is a major determinant of short- and long-term survival in adults and children2.Boigner H. Brannath W. Hermon M. et al.Predictors of mortality at initiation of peritoneal dialysis in children after cardiac surgery.Ann Thorac Surg. 2004; 77: 61-65Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar, 3.Chan K.L. Ip P. Chiu C.S. et al.Peritoneal dialysis after surgery for congenital heart disease in infants and young children.Ann Thorac Surg. 2003; 76: 1443-1449Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar, 5.Kuitunen A. Vento A. Suojaranta-Ylinen R. et al.Acute renal failure after cardiac surgery: evaluation of the RIFLE classification.Ann Thorac Surg. 2006; 81: 542-546Abstract Full Text Full Text PDF PubMed Scopus (349) Google Scholar, 6.Loef B.G. Epema A.H. Smilde T.D. et al.Immediate postoperative renal function deterioration in cardiac surgical patients predicts in-hospital mortality and long-term survival.J Am Soc Nephrol. 2005; 16: 195-200Crossref PubMed Scopus (388) Google Scholar, 7.Lassnigg A. Schmid E.R. Hiesmayr M. et al.Impact of minimal increases in serum creatinine on outcome in patients after cardiothoracic surgery: do we have to revise current definitions of acute renal failure?.Crit Care Med. 2008; 36: 1129-1137Crossref PubMed Scopus (249) Google Scholar, 8.Leacche M. Rawn J.D. Mihaljevic T. et al.Outcomes in patients with normal serum creatinine and with artificial renal support for acute renal failure developing after coronary artery bypass grafting.Am J Cardiol. 2004; 93: 353-356Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar, 9.Blinder J.J. Goldstein S.L. Lee V.V. et al.Congenital heart surgery in infants: effects of acute kidney injury on outcomes.J Thorac Cardiovasc Surg. 2012; 143: 368-374Abstract Full Text Full Text PDF PubMed Scopus (295) Google Scholar and was associated with mortality rates as high as 40% in children requiring RRT.2.Boigner H. Brannath W. Hermon M. et al.Predictors of mortality at initiation of peritoneal dialysis in children after cardiac surgery.Ann Thorac Surg. 2004; 77: 61-65Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar Mortality in patients with severe AKI has remained stable despite improvements in surgical technique, perfusion, and postoperative support, and the factors associated with death in children are: hemodynamic impairment and hyperlactatemia,2.Boigner H. Brannath W. Hermon M. et al.Predictors of mortality at initiation of peritoneal dialysis in children after cardiac surgery.Ann Thorac Surg. 2004; 77: 61-65Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar respiratory distress and mechanical ventilation at the time of RRT commencement,2.Boigner H. Brannath W. Hermon M. et al.Predictors of mortality at initiation of peritoneal dialysis in children after cardiac surgery.Ann Thorac Surg. 2004; 77: 61-65Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar,3.Chan K.L. Ip P. Chiu C.S. et al.Peritoneal dialysis after surgery for congenital heart disease in infants and young children.Ann Thorac Surg. 2003; 76: 1443-1449Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar and chromosomal disorders.3.Chan K.L. Ip P. Chiu C.S. et al.Peritoneal dialysis after surgery for congenital heart disease in infants and young children.Ann Thorac Surg. 2003; 76: 1443-1449Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar The literature contains several observational studies and three randomized controlled trials in adults with multiorgan failure and AKI, showing a survival benefit with early RRT.10.Bagshaw S.M. Uchino S. Bellomo R. et al.Timing of renal replacement therapy and clinical outcomes in critically ill patients with severe acute kidney injury.J Crit Care. 2009; 24: 129-140Abstract Full Text Full Text PDF PubMed Scopus (255) Google Scholar, 11.Bouman C.S. Oudemans-Van Straaten H.M. Tijssen J.G. et al.Effects of early high-volume continuous venovenous hemofiltration on survival and recovery of renal function in intensive care patients with acute renal failure: a prospective, randomized trial.Crit Care Med. 2002; 30: 2205-2211Crossref PubMed Scopus (521) Google Scholar, 12.Durmaz I. Yagdi T. Calkavur T. et al.Prophylactic dialysis in patients with renal dysfunction undergoing on-pump coronary artery bypass surgery.Ann Thorac Surg. 2003; 75: 859-864Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar, 13.Elahi M.M. Lim M.Y. Joseph R.N. et al.Early hemofiltration improves survival in post-cardiotomy patients with acute renal failure.Eur J Cardiothorac Surg. 2004; 26: 1027-1031Crossref PubMed Scopus (195) Google Scholar, 14.Liu K.D. Himmelfarb J. Paganini E. et al.Timing of initiation of dialysis in critically ill patients with acute kidney injury.Clin J Am Soc Nephrol. 2006; 1: 915-919Crossref PubMed Scopus (262) Google Scholar, 15.Pursnani M.L. Hazra D.K. Singh B. et al.Early haemodialysis in acute tubular necrosis.J Assoc Physicians India. 1997; 45: 850-852PubMed Google Scholar, 16.Shiao C.C. Wu V.C. Li W.Y. et al.Late initiation of renal replacement therapy is associated with worse outcomes in acute kidney injury after major abdominal surgery.Crit Care. 2009; 13: R171Crossref PubMed Scopus (148) Google Scholar The exact criteria for ‘early’ differed, however, in all studies, and preventive interventions in AKI have been disappointing. Thus, current data in the literature remain inadequate to answer the question related to optimal timing of RRT. Continuous veno-venous hemofiltration commenced within 1 day of surgery appeared to be linked to better survival in a study in adults with AKI following cardiac surgery.13.Elahi M.M. Lim M.Y. Joseph R.N. et al.Early hemofiltration improves survival in post-cardiotomy patients with acute renal failure.Eur J Cardiothorac Surg. 2004; 26: 1027-1031Crossref PubMed Scopus (195) Google Scholar To date, there is no data linking timing of RRT to survival in children with AKI. Before evaluating the potential effect of early RRT prospectively, we conducted a retrospective cohort study to asses associations between the time from surgery to peritoneal dialysis (PD) and mortality in neonates and infants undergoing cardiac surgery at our institution. Overall, 3550 cardiac procedures were performed in patients younger than 1 year during the study period: 95 of 1510 neonates (6.3%) and 51 of 2040 infants (2.5%) required PD. The surgical complexity increased, the time to dialysis shortened and the mortality rate decreased over the study period in patients with PD, as shown in Figure 1. Time to PD ranged between 0 and 21 days, median 1 day. The most prevalent surgical procedures in patients with PD are shown in Table 1.Table 1Most common procedures performed in neonates and infants with AKI placed on peritoneal dialysis during the study periodTotal anomalous pulmonary venous connection repair18Norwood procedure16Arterial switch operation and ventricular septal defect repair12Arterial switch operation10Tetralogy of Fallot repair9Arterial switch operation, ventricular septal defect, and coarctation repair8Shunt, systemic to pulmonary8Aortic arch repair7Aortic stenosis in the neonate, valvuloplasty7Coarctation repair6Truncus arteriosus repair5Anomalous origin of coronary artery from pulmonary artery repair5Complete atrioventricular canal repair5Ventricular septal defect and coarctation repair5Ventricular septal defect5Valvuloplasty, mitral4Konno procedure3Absent pulmonary valve repair2Other11Abbreviation: AKI, acute kidney injury. Open table in a new tab Abbreviation: AKI, acute kidney injury. There were 46 deaths (28.1%) at 30 days and 53 deaths (36.3%) during follow-up among patients with PD. The median follow-up was 55 days, interquartile range: 15–378 days. The median follow-up among survivors was 188 days, interquartile range: 59–552 days and the 90-day follow-up completed in 76.7% subject. Eight patients died after day 30, and one patient died after hospital discharge. Overall causes of death were: extensive myocardial injury, pulmonary hemorrhage, modified Blalock shunt thrombosis, sepsis, severe pulmonary hypertension, pneumonia, multiorgan failure, and sudden cardiac arrest without obvious cause. No death was directly attributable to PD. Patients in the early PD group had a lower 30-day mortality rate, 22.9% vs. 43.2%, P=0.02, and a lower 90-day mortality rate, 27.5% vs. 51.3%, P=0.02 when compared with the delayed PD group. Survival probabilities are shown in Figure 2. After adjusting for the year of operation, the 30-day and 90-day mortality rates were lower in the early PD group when compared with the delayed PD group, adjusted odds ratio=0.40, 95% confidence interval (0.18–0.93), P=0.03, and adjusted hazard ratio=0.52, 95% confidence interval (0.29–0.85), P=0.03, respectively. The lowest creatinine clearance (CCr) was attained within a median delay of 3 days, interquartile range=2–4 days. Overall, 83.5% of the study patients met the CCr criteria for the pRIFLE ‘Injury’ or ‘Failure’ stages. At discharge, 38 patients were classified pRIFLE ‘Risk’, 20 were classified ‘Injury’, and no patient was classified ‘Failure’. No patient was at the ‘loss of function’ stage but one patient required PD for more than 4 weeks and died on day 76. The propensity score model that resulted in the best balance between groups included the variables shown in Table 2. Early PD was found to be associated with age, with complex procedures requiring long aortic cross-clamping durations and deep hypothermic circulatory arrest. The postoperative extracorporeal membrane oxygenation requirement was associated with delayed commencement of PD. When PD was commenced early, the concomitant variation of CCr relative to baseline was smaller. The propensity score model had good discrimination, c index=0.78, and explained 31% of the variability in the data set (R2=0.31). There was a good overlap of the propensity score among groups: mean=0.81, s.d.=0.15 in the early PD group, and mean=0.56, s.d.=0.27 in the delayed PD group. All baseline, intraoperative, and early postoperative variables were well balanced between groups after inverse probability of treatment weighting (IPTW), as shown in Table 3. Thus, groups were rendered comparable with regard to all these covariates, and no further adjustment was required for the outcome analysis.Table 2Variables included in the propensity score model along with their estimates and standard errorsVariableCoefficient estimates.e.P-valueAge (days)1.460.930.07Duration of aortic cross-clamping0.010.0050.02With deep hypothermic circulatory arrest1.030.540.06Conventional ultrafiltration rate (ml/kg/min of bypass)0.090.170.59Requiring extracorporeal membrane oxygenation postoperatively-2.810.82 8)86 (79.8)21 (56.8)0.480.0060.230.40Redo procedure5 (4.6)2 (5.4)0.040.990.200.34With cardiopulmonary bypass106 (97.2)32 (86.5)0.380.010.020.90Duration of cardiopulmonary bypass (min)178.4±81.5146.1±121.80.310.140.090.78With aortic cross-clamping104 (95.4)31 (83.8)0.370.020.010.93Duration of cross-clamp (min)80.0±39.763.7±49.50.360.070.230.40With deep hypothermic circulatory arrest42 (38.5)6 (16.2)0.480.010.130.64Conventional ultrafiltration (ml/kg/min)1.8±1.21.7±1.10.070.690.020.92Requiring delayed sternal closure84 (77.1)25 (67.6)0.210.250.030.89Requiring extracorporeal membrane oxygenation3 (2.7)8 (21.6)0.55<0.0010.020.67Requiring surgical revision within 24h7 (6.4)5 (13.5)0.230.170.020.78Creatinine clearance at initiation of PD (ml/min per 1.73m2)31.0±13.326.2±13.00.370.050.200.96Creatinine clearance variation at initiation of PDaRelative to baseline. (%)46.8±23.259.6±15.20.65<0.0010.050.58pRIFLE ‘Injury’ or ‘Failure’ at initiation of PDbPediatric RIFLE classification.2458 (53.2)28 (75.7)0.460.020.010.56Abbreviation: PD, peritoneal dialysis.Data are shown as means±s.d, or as numbers (percentages).a Relative to baseline.b Pediatric RIFLE classification.24.Akcan-Arikan A. Zappitelli M. Loftis L.L. et al.Modified RIFLE criteria in critically ill children with acute kidney injury.Kidney Int. 2007; 71: 1028-1035Abstract Full Text Full Text PDF PubMed Scopus (958) Google Scholar Open table in a new tab The propensity score accounted for the probability of being placed on peritoneal dialysis on the day of surgery or on the first day following surgery. Abbreviation: PD, peritoneal dialysis. Data are shown as means±s.d, or as numbers (percentages). Short-term outcome and mortality rates were compared between the groups after IPTW weighting. Table 4 shows a significant 46.7% relative decrease of 30-day mortality rate and a significant 43.5% relative decrease of 90-day mortality rate in the early PD group when compared with the delayed PD group. Both CCr variation at initiation of PD and the largest variation over time were lower in the early PD group before weighting, but after IPTW-weighting, groups became similar with regard to severity of AKI, as shown in Tables 3 and 4. Albeit not statistically significant, the delay to sternal closure, and durations of mechanical ventilation and intensive care unit stay were shorter in the early PD group.Table 4Short-term outcome and characteristics of peritoneal dialysis among the early and the delayed PD groups, before and after inverse probability of treatment weightingBefore weightingAfter IPTW weightingEarly PD (n=109)Delayed PD (n=37)P-valueEarly PDDelayed PDAverage treatment effect (95% CI)P-valueLowest creatinine clearance (ml/min per 1.73m2),aDuring hospital stay. mean±s.d.22.9±13.720.4±9.50.2221.8±13.024.6±11.610.59 (-4.41 to 4.30)0.32Largest relative drop in creatinine clearance (%)aDuring hospital stay., mean±s.d.46.8±23.259.6±15.2<0.00163.9±16.662.6±12.0-1.28 (-7.48 to 6.94)0.70pRIFLE ‘Injury’ or ‘Failure’,aDuring hospital stay. n (%)88 (84.7)34 (91.9)0.1382.982.60.43 (-19.80 to 25.04)0.97Duration of peritoneal dialysisbIn hospital survivors. (days), mean±s.d.3.5±3.04.1±4.00.573.6±2.92.8±2.80.73 (-0.71 to 1.99)0.08Patients with complications of peritoneal dialysis, n (%)32 (32.4)12 (29.3)0.7228.534.6-6.08 (-25.91 to 12.97)0.61Patients with severe complications of peritoneal dialysis,cSuch as hydrothorax, hemoperitoneum, bowel perforation, and peritonitis. n (%)21 (18.9)7 (19.3)0.9618.723.8-5.10 (-25.67 to 11.24)0.65Delay to sternal closurebIn hospital survivors. (days), mean±s.d.3.7±3.75.8±5.60.163.7±3.73.8±4.1-0.12 (-2.32 to 1.50)0.41Number of days on catecholamine infusion,bIn hospital survivors. mean±s.d.12.4±9.015.8±11.30.2512.5±8.816.0±14.3-3.51 (-13.06 to 3.87)0.45Peak plasma lactate (mmol/L),dDuring hospital stay, after replacement of missing measurement by the median of the recorded measurements. mean±s.d.8.2±5.09.8±6.50.188.7±5.67.9±5.50.78 (-1.37 to 2.90)0.53Duration of mechanical ventilationbIn hospital survivors. (days), mean±s.d.12.2±9.118.6±14.00.0812.3±8.916.5±13.9-4.24 (-14.13 to 2.63)0.49Length of the intensive care unit staybIn hospital survivors. (days), mean±s.d.17.7±11.925.8±16.20.0617.8±11.825.2±17.9-7.33 (-17.60 to 2.26)0.7530-Day mortality rate, n (%)25 (22.9)16 (43.2)0.0224.145.2-21.10 (-40.50 to -0.80)0.0490-Day mortality rate, n (%)30 (27.5)19 (51.3)0.0228.650.6-22.10 (-42.11 to -2.02)0.002Abbreviations: CI, confidence interval; IPTW, inverse probability of treatment weighting; PD, peritoneal dialysis.a During hospital stay.b In hospital survivors.c Such as hydrothorax, hemoperitoneum, bowel perforation, and peritonitis.d During hospital stay, after replacement of missing measurement by the median of the recorded measurements. Open table in a new tab Abbreviations: CI, confidence interval; IPTW, inverse probability of treatment weighting; PD, peritoneal dialysis. Overall 52 complications related to PD were recorded in 44 patients, mainly mechanical: dysfunction of the catheter (leakage at the insertion site, displacement, or insufficient drainage), hydrothorax, but also hemoperitoneum at insertion or withdrawal of the catheter, and bowel perforation. Peritonitis was the only infectious complication recorded. Most complications were minor, such as leakage, spontaneously resolved hydrothorax, and mechanical dysfunction requiring replacement of the catheter. In all, 14 patients had severe complications such as hemoperitoneum, bowel perforation, and peritonitis. With an overall cumulative PD duration of 636 days, complications occurred every 12.2 days, but severe complications occurred only every 45.4 days. Table 4 shows that there was no difference between the number of complications or severe complications per day on PD among groups. No patient with bowel perforation required further surgery. Episodes of peritonitis were treated successfully with antibiotics. In this cohort of neonates and infants with AKI following cardiac surgery, initiation of PD on the day of surgery or on the first day following surgery was associated with a significant decrease in 30-day and 90-day mortality. The association between a shorter delay to PD and better survival after cardiac surgery has already been reported in adults,13.Elahi M.M. Lim M.Y. Joseph R.N. et al.Early hemofiltration improves survival in post-cardiotomy patients with acute renal failure.Eur J Cardiothorac Surg. 2004; 26: 1027-1031Crossref PubMed Scopus (195) Google Scholar but not in children. The propensity score strategy carried out in this study enabled us to limit bias due to the selection of subjects placed on PD early, a decision made by the attending physician, and which depended on patient and surgical characteristics, with earlier PD in the late period of the study. The incidence of PD in the present study, 6.3% in neonates and 2.5% in infants, was within the range of 2.1–17% generally reported over the past decade.1.Pedersen K.R. Povlsen J.V. Christensen S. et al.Risk factors for acute renal failure requiring dialysis after surgery for congenital heart disease in children.Acta Anaesthesiol Scand. 2007; 51: 1344-1349Crossref PubMed Scopus (95) Google Scholar, 2.Boigner H. Brannath W. Hermon M. et al.Predictors of mortality at initiation of peritoneal dialysis in children after cardiac surgery.Ann Thorac Surg. 2004; 77: 61-65Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar, 3.Chan K.L. Ip P. Chiu C.S. et al.Peritoneal dialysis after surgery for congenital heart disease in infants and young children.Ann Thorac Surg. 2003; 76: 1443-1449Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar, 4.Xinjin L. Jianping X. Xiangdong S. et al.Peritoneal dialysis after repair of congenital heart disease in children.Chin Med Sci J. 2003; 18: 100-104PubMed Google Scholar Variability in the reported incidence is probably multifactorial, with indication for PD being probably the most important factor. When providing the use of PD as a routine adjunctive therapy for postoperative fluid management, this guideline may result in PD rates as high as 53% in very young patients.9.Blinder J.J. Goldstein S.L. Lee V.V. et al.Congenital heart surgery in infants: effects of acute kidney injury on outcomes.J Thorac Cardiovasc Surg. 2012; 143: 368-374Abstract Full Text Full Text PDF PubMed Scopus (295) Google Scholar, 17.Sorof J.M. Stromberg D. Brewer E.D. et al.Early initiation of peritoneal dialysis after surgical repair of congenital heart disease.Pediatr Nephrol. 1999; 13: 641-645Crossref PubMed Scopus (125) Google Scholar, 18.Dittrich S. Dahnert I. Vogel M. et al.Peritoneal dialysis after infant open heart surgery: observations in 27 patients.Ann Thorac Surg. 1999; 68: 160-163Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar The lower PD incidence rate in the most recent reports is probably due to improvements in intraoperative fluid management. Second, there is no preset postoperative serum creatinine (SCr) threshold for RRT in young children, because SCr does not accurately depict kidney function until a steady state has been reached, which is unlikely in the early postoperative period.19.Bellomo R. Kellum J.A. Ronco C. Defining acute renal failure: physiological principles.Intensive Care Med. 2004; 30: 33-37Crossref PubMed Scopus (293) Google Scholar Therefore, the only generally accepted—but still subjective—criteria for RRT in young children remain fluid overload, low cardiac output syndrome, and an inadequate urine output. Unfortunately, literature shows that there is no consensus with regard to what different authors consider to be an appropriate urine output early after cardiac surgery, and the threshold to initiate RRT varies between 0.5 and 2ml/kg/h in this situation.1.Pedersen K.R. Povlsen J.V. Christensen S. et al.Risk factors for acute renal failure requiring dialysis after surgery for congenital heart disease in children.Acta Anaesthesiol Scand. 2007; 51: 1344-1349Crossref PubMed Scopus (95) Google Scholar, 3.Chan K.L. Ip P. Chiu C.S. et al.Peritoneal dialysis after surgery for congenital heart disease in infants and young children.Ann Thorac Surg. 2003; 76: 1443-1449Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar, 9.Blinder J.J. Goldstein S.L. Lee V.V. et al.Congenital heart surgery in infants: effects of acute kidney injury on outcomes.J Thorac Cardiovasc Surg. 2012; 143: 368-374Abstract Full Text Full Text PDF PubMed Scopus (295) Google Scholar, 17.Sorof J.M. Stromberg D. Brewer E.D. et al.Early initiation of peritoneal dialysis after surgical repair of congenital heart disease.Pediatr Nephrol. 1999; 13: 641-645Crossref PubMed Scopus (125) Google Scholar, 18.Dittrich S. Dahnert I. Vogel M. et al.Peritoneal dialysis after infant open heart surgery: observations in 27 patients.Ann Thorac Surg. 1999; 68: 160-163Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar, 20.Pedersen K.R. Hjortdal V.E. Christensen S. et al.Clinical outcome in children with acute renal failure treated with peritoneal dialysis after surgery for congenital heart disease.Kidney Int Suppl. 2008; 108: S81-S86Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar Finally, most reports have examined heterogeneous populations, including neonates as well as young adults. By selecting a homogeneous high-risk group, we avoided the strong confounding influence of age.1.Pedersen K.R. Povlsen J.V. Christensen S. et al.Risk factors for acute renal failure requiring dialysis after surgery for congenital heart disease in children.Acta Anaesthesiol Scand. 2007; 51: 1344-1349Crossref PubMed Scopus (95) Google Scholar However, other factors must affect the reported incidence of severe AKI in children with cardiac surgery, as in a population very similar to ours, albeit smaller (109 neonates and infants with a median age of 9.6 months), and applying similar PD criteria, Pedersen et al.1.Pedersen K.R. Povlsen J.V. Christensen S. et al.Risk factors for acute renal failure requiring dialysis after surgery for congenital heart disease in children.Acta Anaesthesiol Scand. 2007; 51: 1344-1349Crossref PubMed Scopus (95) Google Scholar reported a almost doubled incidence of 11.5%. Albeit criticized, mortality is the most popular and reliable outcome measure used to describe quality of care after congenital cardiac surgery.21.Jacobs J.P. Wernovsky G. Elliott M.J. Analysis of outcomes for congenital cardiac disease: can we do better?.Cardiol Young. 2007; 17: 145-158PubMed Google Scholar The 30-day and overall mortality rates during follow-up were 28.1% and 36.3%, respectively, within the recently reported range of 20 to 40%.1.Pedersen K.R. Povlsen J.V. Christensen S. et al.Risk factors for acute renal failure requiring dialysis after surgery for congenital heart disease in children.Acta Anaesthesiol Scand. 2007; 51: 1344-1349Crossref PubMed Scopus (95) Google Scholar, 2.Boigner H. Brannath W. Hermon M. et al.Predictors of mortality at initiation of peritoneal dialysis in children after cardiac surgery.Ann Thorac Surg. 2004; 77: 61-65Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar, 3.Chan K.L. Ip P. Chiu C.S. et al.Peritoneal dialysis after surgery for congenital heart disease in infants and young children.Ann Thorac Surg. 2003; 76: 1443-1449Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar, 4.Xinjin L. Jianping X. Xiangdong S. et al.Peritoneal dialysis after repair of congenital heart disease in children.Chin Med Sci J. 2003; 18: 100-104PubMed Google Scholar Several studies have shown a strong association between the incidence and severity of AKI, and mortality in adults with cardiac surgery.5.Kuitunen A. Vento A. Suojaranta-Ylinen R. et al.Acute renal failure after cardiac surgery: evaluation of the RIFLE classification.Ann Thorac Surg. 2006; 81: 542-546Abstract Full Text Full Text PDF PubMed Scopus (349) Google Scholar, 6.Loef B.G. Epema A.H. Smilde T.D. et al.Immediate postoperative renal function deterioration in cardiac
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