KIDNEY FOUNDATION FOR CHILDREN
SAVING YOUNG LIVES
The team has created and successfully used a miniaturized Cardio-Renal Pediatric Dialysis Emergency Machine (CARPEDIEM) designed specifically for neonates and small infants.Its main characteristics are the low priming volume of the circuit (<30ml), miniaturized roller pumps,accurate ultrafiltration controls via calibrated scales with a precisison of 1 g.They treated a 2.9 Kg neonate with hemorrhagic shock,multiple organ dysfunction and severe fluid overload with CARPEDIEM for more than 400 hours,using continuous venovenous hemofiltration,single pass albumin dialysis,blood exchange and plasma exchange.The patient's 65% fluid overload,raised serum creatinine ,bilirubin concentrationsand severe acidosis were all managed safely and effectively.Despite the severity of illness,organ function was restoredand the neonate was discharged from the hospital with only mild renal insufficiency.
Seize the day ! A laudable innovation for acutely sick neonates !
Continuous Renal Replacement Therapy in neonates and small infants
Development and first in-human use of a miniaturised machine
Claudio Ronco, Francesco Gorzotto,Alessandra Brendolan, Monica Zanella,Massimo Bellettato,Stefania Vedovato,Fabio Chiarenza,Zaccaria Ricci, Stuart L Goldstein. Lancet 2014; 383: 1807-1813
- Hyperkalemia , especially moderate (6 -7.0 meq / l ) or severe (> 7.0 meq/l )is a potentially life threatening condition as it can cause cardiac arrythmias and cardiac arrest, with fatal outcome.Current management of hyperkalemia in CKD involves dietary restrictions,omission of drugs that can increase K levels (ACE-Is, ARBs ,CNIs ) and the use of Calcium polysterene sulfonate which exchanges potassium for calcium. Patients find it unpleasant to take the resin because of its taste and because it causes nausea.The option of using it as enema is even less appealing.Its use with sorbitol has even lead to colonic necrosis.
Mathew Weir et al conducted a single-blind-placebo controlled randomized study of Patiromer for management of hyperkalemia in patients on RAAS inhibitors who had hyperkalemia ranging from 5.1 to 6.5 meq/l. Patiromer is an oral suspension of a non absorbable polymer that binds K in exchange for Ca, predominantly in the distal colon , where the concentration of free K is the highest, thus increasing fecal K excretion and lowering serum K levels. At the end of 4 weeks of Patiromer treatment, patients whose K levels decreased to 3.8 to < 5.1 meq/l, entered a 8 week withdrawal phase in which they were randomly assigned to receive Patiromer or a placebo. At week 4, 76 % of the patients had reached the target K level of 3.8 to 5.1 meq/l.Thereafter 107 patients were reassigned to receive Patiromer (55) or placebo (52) for the randomized withdrawal phase.The median increase in the K level in that phase was greater with placebo than with Patiromer.(p <.001)
David Packham et al investigated the K lowering effect of zirconium cyclosilicate (ZS-9), a novel cation exchanger in a multi centre two- stage, double blind phase III trial.753 patients with hyperkalemia received ZS-9 or a placebo 3 times daily for 48 hours. Patients with normokalemia at 48 hours were randomly assigned to receive ZS-9 or placebo from days 3 to 14. Those who received ZS-9 as compared to placebo had significantly lower K levels at 48 hours with normokalemia maintained during 12 days of maintenance therapy. The K binding capacity of ZS-9 is 9 times that of organic polymer resins.
Adverse effects of both the new drugs were mild gastrointestinal symptoms.To be noted is the fact that both these drugs are not yet US FDA approved.Both studies were short term, adults only and did not include patients with K levels > 6.5 meq/l or those who had ECG changes, were hospitalized or were undergoing dialysis.
Management of Hyperkalemia
Two new kids on the Block
Novemeber 2014 NEJM org