Intensive hemodialysis for cardiomyopathy associated with end-stage renal disease
Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, ML 7022, Cincinnati, OH 45229, USA.Pediatric Nephrology (Impact Factor: 2.86). 05/2011; 26(10):1909-12. DOI: 10.1007/s00467-011-1921-y
Heart and kidney dysfunction often coexist, and increasing evidence supports the interaction of these two organs, as demonstrated by the clinical condition known as cardiorenal syndrome (CRS). We report a pediatric patient with end-stage renal disease (ESRD) who developed a dilated cardiomyopathy and decompensated heart failure after undergoing unilateral nephrectomy and while on maintenance peritoneal dialysis. He showed marked improvement in his cardiac function with the addition of intensive hemodialysis. We discuss the pathophysiology of cardiorenal syndrome in patients with ESRD and suggest that intensive dialysis may be an effective therapy for this condition.
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ABSTRACT: The occurrence and progression of cardiomyopathy is well known in patients with end-stage renal disease (ESRD). However, the feasibility of renal transplantation in the setting of cardiac dysfunction and the effect of renal transplantation on this progression remain poorly studied in pediatric patients. A single-center, retrospective review of pediatric renal transplants between January 1, 2001, and December 31, 2010, was conducted. Six children with ESRD and severe systolic dysfunction underwent renal transplantation. Clinical data were collected and compared for the pretransplant, peritransplant, and posttransplant periods. Nutritional support, dialysis, and chronic kidney disease and heart failure therapy led to improved cardiac function before transplantation (ejection fraction 28.8%±9.6% vs. 44.4%±11.5%; fractional shortening 12.7%±5.1% vs. 23.6%±6.2%); however, normal systolic function was not achieved before transplantation in any patient. After transplantation, two patients had normalization of systolic function by hospital discharge, while the systolic function of the remaining four patients normalized during the first posttransplant year. Mean ejection fraction 1 year posttransplant was 22 units greater than before transplant. All patients experienced excellent allograft function in the peritransplant period. Mean estimated creatinine clearance 1 year posttransplant was 93.2±33.3 mL/min/1.73 m(2). Renal transplantation can be performed safely in children with ESRD and severe systolic dysfunction. After transplantation, systolic function continues to improve and may reach normal levels during the first posttransplant year. The presence of severe systolic dysfunction in pediatric dialysis patients should not deter referral for renal transplantation.
Article: Kidney Transplantation[Show abstract] [Hide abstract]
ABSTRACT: Kidney transplantation is the treatment of choice for end-stage renal disease (ESRD) in children. Although long-term survival on dialysis has improved over the past three decades, survival remains better for children who undergo kidney transplantation. Children undergoing kidney transplantation frequently require post-operative care in the Pediatric Intensive Care Unit (PICU). For example, it is frequently necessary to infuse large volumes of fluid, plasma, and blood to prevent hypovolemia, acute tubular necrosis, and venous thrombosis of the renal allograft. These problems are compounded when a relatively young child receives an adult allograft. Because a large volume of blood is shifted to the renal allograft, the recipient's heart will have to work harder to circulate a relatively higher cardiac output (CO) to the adult-sized renal allograft. Post-operative fluid management and hemodynamic monitoring is therefore of crucial importance. Finally, there are several potential complications in the early and late post-operative period that are relevant to the pediatric critical care physician.
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ABSTRACT: Left ventricular (LV) systolic dysfunction is a relatively uncommon but serious complication of pediatric chronic kidney disease, and may be related to uremia and uncontrolled hypertension. There is limited information on the strategy for managing these children. In some cases, combined heart-kidney transplant may be considered or kidney transplant delayed until cardiac function improves. It is unknown whether these patients are at increased risk for poor outcomes after kidney transplantation. We conducted a retrospective, multicenter study on the outcomes of children with severe and symptomatic cardiomyopathy who underwent kidney transplantation. Eleven patients receiving maintenance dialysis with systolic dysfunction underwent kidney transplantation without simultaneous heart transplant. Nine patients had congestive heart failure in the pre-transplant period. There were no identified complications post-transplant related to the underlying cardiac dysfunction. LV systolic function normalized in all patients and the mean shortening fraction increased from 19.0 ± 4.6 % to 32.0 ± 4.4 % (p < 0.0001). Kidney transplantation should be considered for children receiving maintenance dialysis with severe LV dysfunction.
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