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Early initiation of peritoneal dialysis in neonates and infants with acute kidney injury following cardiac surgery is
Mirela Bojan1, Simone Gioanni, Pascal R Vouhé
1Department of Anesthesia and Critical Care, Necker–Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France. mirela.bojan@nck.aphp.fr
Insights
Early initiation of peritoneal dialysis (PD) after cardiac surgery significantly reduces mortality in infants with acute kidney injury. This finding contrasts with adult studies, highlighting a critical difference in pediatric care for kidney support.
Area of Science:
- Pediatric Cardiology
- Nephrology
- Critical Care Medicine
Background:
- Postoperative kidney injury (AKI) in children undergoing cardiac surgery is associated with high mortality.
- Evidence linking early renal replacement therapy (RRT) to improved survival in adult AKI is established, but not in pediatric cardiac surgery patients.
- Peritoneal dialysis (PD) is a common RRT modality in neonates and infants.
Purpose of the Study:
- To investigate the association between the timing of PD initiation and mortality in neonates and infants with AKI following cardiac surgery.
- To compare early PD (within 1 day of surgery) versus delayed PD (≥2 days post-surgery).
Main Methods:
- Retrospective cohort study of 146 neonates and infants requiring PD post-cardiac surgery.
- Propensity score matching (including baseline, intraoperative variables, ECMO, and creatinine clearance variation) and inverse probability of treatment weighting (IPTW) were used to minimize selection bias.
- Logistic regression and survival analysis compared 30-day and 90-day mortality between early and delayed PD groups.
Main Results:
- Overall 30-day mortality was 28.1% and 90-day mortality was 36.3%.
- After IPTW, early PD initiation was associated with a significant reduction in mortality: 46.7% decrease at 30 days and 43.5% decrease at 90 days compared to delayed PD.
- No significant differences were observed in other short-term outcomes between the groups.
Conclusions:
- Initiating PD on the day of or the first day following cardiac surgery is associated with significantly decreased mortality in neonates and infants with AKI.
- This study provides critical evidence supporting early RRT in pediatric patients with AKI after cardiac surgery.
Abstract:
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.
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