RENAL

REPLACEMENT
THERAPY IN THE
NEONATAL
INTENSIVE CARE
UNIT

JURNAL REVIEW
OLEH
NAMA : CLARA PARANNUAN
NIM : C 105192001
 ABSTRACT

Background:Renal replacement therapy (RRT) is becoming increasingly necessary for support-ing

critically ill neonates. Few studies have reported the use of RRT in the neonatal intensivecare unit
(NICU). Therefore, we performed a retrospective study to describe the use of RRT inour NICU and its
associated efficacy, complications, and outcomes.
Methods:We identified patients requiring RRT between January 2009 and January 2017. Demo-graphic
data, mode of RRT, and associated factors were recorded. Efficacy was calculated asthe percentage
reduction in the blood urea nitrogen (BUN) or toxic metabolite level after 24 hof RRT.
Complications including hypotension,electrolyte disturbance, and technical and catheter-related
complications were documented. Measures of clinical outcome included in-hospital survival, presence of
neurological sequelae, and chronic kidney disease.
The chi-squaretest and ManneWhitney U test were used for categorical and continuous variables,
respectively.Results:We included 17 neonates in our study. The median gestational age at birth was 37
weeks(32e39 weeks), and the median birth weight was 2.7 kg (1.5e3.6 kg). Twelve neonates,
includingthree with inborn errors of metabolism (IEM), received continuous RRT (CRRT), and five
neonates underwent peritoneal dialysis (PD).
The percentage reduction in ammonia in neonates with IEM who received CRRT was 87.2% at 24 h.
The percentage reductions in BUN in the non-IEM neonatesin the CRRTand PD groups were 33.7% and
23.7% at 24 h, respectively. The main complication waselectrolyte disturbance including hypokalemia,
hypocalcemia, and hypophosphatemia. All neo-nates with IEM survived, whereas the mortality rates for
the non-IEM neonates in the CRRT andPD groups were 78% and 80%, respectively
SUMBER:
INTRODUCTION (1)

• Renal replacement therapy (RRT) is an

uncommon and challenging intervention in
neonatal intensive care units(NICUs)
Peritoneal
Dialysis
• RRT increases the chances of survival of such (PD)

patients by preventing fluid overload, allowing

Continuous RRT
optimal use of parenteral nutrition, and (CRRT)
correcting acid-base status and electrolyte
imbalance
Hemodialy
• RRT for treating AKI, multiorgan dysfunction, sis (HD)
inborn errors of metabolism presenting with
hyperammonemia
INTRODUCTION (2)
Peritoneal Dyalisis CRRT

 hemofiltration still remains the key mode of

 The modality of choice for neonates who
need RRT
 Not feasiblefor certain infants such as
those with an abdominal walldefect or
those who have had recent abdominal
surge
CRRT in neonatal patient
 continuous ultrafiltration and solute clearance
canbe achieved even in a hemodynamically
unstable patient
 CRRT in neonatal patients continues to
encounter limitations from vascularaccess,
bleeding complications, and a lack of
neonatal-specific hemofiltration devices

We performed a review to compare the efficacy, complications, and outcomes of these

modalities on patients in our institute
 • Neonates admitted to the NICU of Chang Gung Memorial
Hospital,Taiwan, between January 2009 and January
2017
METHODS • Neonates on RRT for less than 24 h were excluded

• Patients
• Biochemical data and
• Clinical information  demographic data, diagnosis,
genetic sequencing
• Modality of renal vital signs, medications, mode of RRT used, labora-
replacement therapy tory measurements (BUN, Cr, Na, K, Ca, P, Cl,
• Efficacy and clinical
outcomes
ammonia, BGA) and CRRT or PD data is recorde.
• Complications • Px susp IEM  DNA samples
• Statistical Analysis • Apx diffuse mesangial sclerosis  PCR  direct
sequencing
 CRRT

• Access for CRRT was either a double-lumen catheter or

two single-lumen catheter, sites for insertion  jugular
vein, subclavian vein, femoral vein.
METHODS • Procedures were performed using HF440 machines
withD150 filters (Infomed, Geneva, Switzerland)
• Patients • The exchange volume was25-40 mL/kg/h and the blood
• Biochemical data and
genetic sequencing flow rate was set at 3-10 mL/kg/min.
• Modality of renal • Neonates with IEM  high dose CRRT
replacement therapy • Fluid removal rate according to the degree of fluid
• Efficacy and clinical
outcomes overload
• Complications • Dialyzate  CVVH solution A and B
• Statistical Analysis • Anticoagulan  continuous infusion of heparin (5-
12mg/kg/h)
 PD

• Access for PD was a coiled single-cuff infant Tenckhoff

catheter
METHODS • Using a twin bag system with 1.5% or 2.5% Dianeal
dialysate
• Patients • Dwell volume 10mg/kg with gradual increase to 20-
• Biochemical data and 25ml/kg
genetic sequencing
• Modality of renal
replacement therapy
• Efficacy and clinical
outcomes
• Complications
• Statistical Analysis
 • Efficacy  Achieving the goal associated with the
indications for RRT
• Efficacy was calculated using the percentage decrease in
METHODS BUN or toxic metabolite after 24 h of RR
• Main outcome  Survival to hospital discharge
• Patients • Secondary outcome  presence of neurologic sequelae
• Biochemical data and
genetic sequencing
and chronic kidney disease
• Modality of renal
replacement therapy
• Efficacy and clinical
outcomes
• Complications
• Statistical Analysis
 • Hypotension, electrolyte imbalance, technical and catheter
related complication
• Hypotension  fall in the mean BP of more than
METHODS 20mmHg from baseline during first 60 min after
connection to RRT
• Patients • Electrolyte imbalance  hypocalcemia (Ca <
• Biochemical data and
genetic sequencing
8.4mg/dL), hypokalemia (Potassium <3.5mEq/L), and
• Modality of renal hypophosphatemia (P<3.8mg/dL)
replacement therapy • Catheter related complications  sepsis,
• Efficacy and clinical
outcomes
malfunction, and leakage
• Complications
• Statistical Analysis
 • Quantitative variables  median and interquartile range
• Categorical variableswere compared using the chi-square
test, and continuous variables were compared using the
METHODS Mann-Whitney U test
• Statistical analyses were performed using SPSS,
• Patients version20.0 (IBM SPSS, Chicago, Illinois, USA)
• Biochemical data and
genetic sequencing
• Modality of renal
replacement therapy
• Efficacy and clinical
outcomes
• Complications
• Statistical Analysis
 Place Your Picture Here

RESULT
PATIENTS
12 CRRT group
• 9 were due to AKI following perinatal asphyxia
(4), renal parenchymal diseases (2), abdominal
compartment syndrome (1), liver laceration (1),
and hydrops fetalis (1)
• 3 were due to IEM with hyperammonemia

5 PD group
• All five were due to AKI : after surgical
correction of congenital heart diseases (2), from
perinatal asphyxia (1), and bilateral renal
dysplasia (1) and ureterovesical junction
obstruction (1)
EFFICACY AND CLINICAL OUTCOMES

9 patients CRRT Median serum BUN level 19.1mg/dL  13.2 mg/dL (33.7%)
with uremia Median duration for CRRT was 20 days (1-65 days)
Two patients (22%) survived

Mean ammonia reduction ratio was 87.2% at 24h

3 patients with
hyperammonemia
Median duration for CRRT was 3 days (1-3 days)
Three patients (100%) survived

PD group Median serum BUN level 60.5 mg/dL  33 mg/dL (23.75%)

Median duration for CRRT was 41 days (25-84 days)
One patients (20%) survived

Among the six survivors, only one neonate developed CKD and required long-
term PD after discharge. No neurologic sequelae were documented.
EFFICACY OF
RRT
MORTALITY
OF NEONATES
WHO
RECEIVED
RRT
COMPLICATIO
N OF RRT
• Electrolyte disturbance was easily corrected by adjusting the concentration of
electrolytes in the dialysis and replacement fluids and intravenous
supplement
• Hypotensive episodes were corrected following use of vasoactive agents
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DISCUSSION
DISCUSSION
 The smallest neonates on CRRT and PD weighed 1935 and 1480 g
 For neonates with AKI, CRRT was more efficient in lowering BUN than PD after 24
h of therapy
 CRRT achieved high efficacy in lowering serum ammonia, reaching a mean reduction
of 87.3% and resulting in levels less than 250mmol/L within 24 h in neonates with
IEM presenting with hyperammonemia.
 The main complication encountered in both the CRRT and PD groups was electrolyte
disturbance, which was transient and correctable
 Neonates with IEM had the highest survival rate
DISCUSSION

RRT is feasible in neonates, but the smaller the neonate is, the more difficult to
establish an access. Our study results reveal that it can be used in LBW infants
(<2kg). Utysol et al. described the successful application of PD to ELBW (580gr)

Primary therapi for severe cases of AKI is RRT.

In our study, 14 neonates with AKI received RRT due to primary renal dan
nonrenal causes.

CRRT was chosen for neonates with unstable hemodynamics in order to achieve
effective solute and fluid clearance.
DISCUSSION
 Neonates with certain IEM and urea cycle disorders may present with hyperammonemia in the
neonatal period
 Ammonia neurotoxicity  Lethargy, somnolence, coma, or intractable seizures soon after birth
 Picca et al.observed that patients with a hyperammonemic coma duration of more than 33 h tended to
have a poor outcome, and that the most important determinant was the coma duration prior to RRT
initiation.
 CRRT is the modality of choice for patients with IEM  it can achieve a timely high clearance of
intermediates of metabolism.
 In our study, all three neonates with hyperammonemia were treated with high-dose CRRT, and high
efficacy of ammonia removal was observed, with ammonia levels dropping to less than 250mmol/L
within 24 h.and no neurologic sequelae had been observed in these three patients up to 1 year of age.
DISCUSSION
 PD and CRRT are useful and safe in critically ill children

 WHY NEONATES ARE AT A HIGHER RISK OF

COMPLICATIONS???

Large extracorporeal
Need for more
Difficult of venous volume of the circuit
accurate control
catheterization with compares with their
volumes to avoid
the large-caliber blood volume 
fluid and electrolyte
catheters technique predispose to
imbalance
hypotension
DISCUSSION
 The results of our study reveal that electrolyte imbalance, especially hypocalcemia and hypokalemia,
was the most common complication in both the CRRT and PD groups
 Santiago et al. reported that hypotension was the most common complication in critically ill children
receiving CRRT, occurring in 30.4% of their case
 In our study, hypotension occurred only in 16% (n=2) of the CRRT group and did not occur in the PD
group  treated uneventfully with volume expansion or with vasoactive agents. Lowering the
ultrafiltration rate, blood flow, and/or use of vasoactive agents could reduce the development of
hypotension
 The catheter-related complications were more common in the PD group. Other studies have also
reported a high incidence of complications associated with PD. Adjusting the dwell time and/or
volume could reduce the occurrence of catheter-related leakage and further prevent the development of
PD-related infections
MORTALITY The mortality rate for pediatric AKI
OF NEONATES requiring RRT is high and the rate
WHO could be even higher in the neonatal
RECEIVED population.
RRT
Utysol et al. found that the overall mortality rate was 54.8% and
could be as much as 81.3% in premature neonates

Report from the Prospective Pediatric Continuous RRT Registry

showed that the mortality rate was 57% among infants weighing <10
kg and 36% among infants weighing >10 kg

The survival rate of neonates with IEM treated with CRRT in our
study reached 100%, as compared with the 82% rate reported by
Arbeiter et
 LIMITATION

Single center
retrospective design

Thus, raising concerns

regarding the Small sample size also limits
generalizability of our the statistical precision of our
findings to the neonatal analysis
patient population in all
hospitals
 Place Your Picture Here

CONCLUSIONS
RRT in the form of CRRT and PD is feasible in
neonates,even in those weighing less than 2 kg

CRRT appears to have high efficacy in neonates with non-AKI

etiologies, and its associated complications are mostly reversible
with no severe clinical consequences.

Both PD and CRRT are associated with high mortality rates

in neonates with AKI

The recommendation of the RRT modality and timing of therapy

in such cases must be verified by further studies in larger patient
populations
TELAAH KRITIS JURNAL
 No HAL YANG CHECK LIST PENILAIAN YA TIDAK
DINILAI
1 Judul Makalah a. Apakah judul tidak terlalu panjang atau 
pendek?
b. Apakah judul menggambarkan isi utama 
penilaian?
c. Apakah judul cukup menarik? 
d. Apakah judul menggunakan singkatan
selain yang baku? 

2 Abstrak a. Apakah merupakan abstrak satu 

paragraf, atau abstrak terstruktur? 1 paragraf
b. Apakah sudah tercakup komponen
IMRAC (Introduction, methods, Results, 
Conclussion?)
c. Apakah secara keseluruhan abstrak
informatif? 
d. Apakah abstrak lebih dari 200 atau 250 
kata?
3 Pendahuluan a. Apakah mengemukakan alasan dilakukannya 
penelitian?
b. Apakah menyatakan hipotesis atau tujuan
penelitian? 
c. Apakah pendahuluan didukung oleh pustaka
yang kuat & relevan? 
4 Metode a. Apakah disebutkan desain, tempat & waktu
penelitian? 
b. Apakah disebutkan populasi sumber (populasi
terjangkau)? 
c. Apakah kriteria pemilihan (inklusi & eksklusi)
dijelaskan? 
d. Apakah cara pemilihan subjek (teknik
sampling) disebutkan? 
e. Apakah perkiraan besar sampel disebutkan &
disebut pula alasannya? Apakah perkiraan
besar sampel dihitung dengan meggunakan 
rumus yang sesuai?
5 Hasil a. Apakah disertakan tabel deskripsi subjek 
penelitian?
b. Apakah karakteristik subjek yang penting (data 
awal) dibandingkan kesetaraannya?
c. Apakah dilakukan uji hipotesis untuk kesetaraan 
ini?

d. Apakah disebutkan jumlah subjek yang diteliti?

e. Apakah dijelaskan subyek yang drop out dengan 

alasannya?
f. Apakah semua hasil di dalam tabel disebutkan
dalam naskah? 
g. Apakah semua outcome yang penting disebutkan

dalam hasil?
h. Apakah subyek yang drop out diikutkan dalam
analisis? 
i. Apakah disertakan hasil uji statistik (x2,t) derajat

kebebasan (degree of freedom), dan nilai p?
j. Apakah dalam hasil disertakan komentar &
pendapat? 
6. Diskusi a. Apakah semua hal yang relevan dibahas ? 
b. Apakah dibahas keterbatasan penelitian, dan
kemungkinan dampaknya terhadap hasil ? 
c. Apakah disebutkan kesulitan penelitian,
penyimpangan dari protocol, dan kemungkinan 
dampaknya terhadap hasil?

d. Apakah pembahasan dilakukan dengan
menghubungkannya dengan teori dan hasil
penelitian terdahulu ?

e. Apakah dibahas hubungan hasil dengan praktek
klinis? 
f. Apakah disebutkan kesimpulan utama penelitian?
g. Apakah kesimpulan didasarkan pada data 
penelitian?
h. Apakah efek samping dikemukakan dan dibahas ? 
i. Apakah disebutkan hasil tambahan selama
diobservasi?
j. Apakah disebutkan generalisasi hasil penelitian?  
k. Apakah disertakan saran penelitian selanjutnya,
dengan anjuran metodologi yang tepat ? 
VALIDITY

1. Apakah dilakukan randomisasi ? ya

2. Apakah kelompok yang diperbandingkan setara pada awal studi? ya
3. Apakah dilakukan penyamaran (masking)? tidak
4. Bila tidak dilakukan penyamaran, apakah kelompok kelompok diperlakukan
sama kecuali untuk terapi yang diteliti? ya
5. Apakah ada faktor-faktor yang mempengaruhi hasil luaran ? ya
6. Apakah semua pasien yang dirandomisasi diperhitungkan dalam
simpulan akhir dan dianalisis sesuai dengan alokasi awalnya? ya
7. Uraikan unsur PICO
METODE PICO

VALIDITY
Patient, Population, Problem
 17 neonatus 2-30 days

Intervention
neonatus usia 2-30 hari, dirawat di nicu dengan
 RRT AND PD

Comparison
 Dibagi menjadi 2 kelompok: CRRT dan PD

Outcome
 Keefektifan renal repalcement therapy seperti CRRT dengan PD
IMPORTANCE

 
1. Apakah outcome / hasil dipaparkan secara jelas (hasil uji statistik
dengan
hasil nilai p)?Tidak
2. Seberapa besarkah pengaruh terapi tersebut ?( dengan menghitung
ARR & NNT serta NNH? ).
3. Hitung interval kepercayaan dari nilai NTT
IMPORTANCE

1. Apakah hasil penelitian ini dipaparkan dengan uji statistic dengan nilai
P?Ya, hasil penelitian dilakukan uji statistik dan dipaparkan dengan
nilai P (Student t test, X2 test, paired T test)

2. Seberapa besarkah estimasi hasil dengan nilai OR,RR,PR dengan

nilai korelasi 95% CI? Tidak dilakukan nilai OR,RR,PR.
LEVEL OF EVIDENCE

Level 1 : Systematic review / metaanalysis

Level 2: At least 1 randomized controlled trial (RCT)
Level 3: A non-RCT
Level 4: An analytical epidemiologic study (cohort study or case control study) or
single arm intervention study (no controls)
Level 5 : A descriptive study ( case reports or case series)
Level 6 : Opinion of an expert committee or an individual expert which is not
based on patient data
Level of Evidence 2
Level 2 : At least 1 randomized controlled trial (RCT)
THANK YOU!