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Early Peritoneal Dialysis and Major Adverse Events After Pediatric Cardiac Surgery: A Propensity Score Analysis*

Namachivayam, Siva P. MBBS, MEpi1–3; Butt, Warwick MBBS1–3; Millar, Johnny PhD1–3; Konstantinov, Igor E. PhD2–4; Nguyen, Cattram PhD3,5; d’Udekem, Yves MD, PhD2–4

Pediatric Critical Care Medicine: February 2019 - Volume 20 - Issue 2 - p 158-165
doi: 10.1097/PCC.0000000000001793
Cardiac Intensive Care

Objectives: Early peritoneal dialysis may have a role in modulating the inflammatory response after cardiopulmonary bypass. This study sought to test the effect of early peritoneal dialysis on major adverse events after pediatric cardiac surgery involving cardiopulmonary bypass.

Design: In this observational study, the outcomes in infants post cardiac surgery who received early peritoneal dialysis (within 6 hr of completing cardiopulmonary bypass) were compared with those who received late peritoneal dialysis. The primary outcome was a composite of one or more of cardiac arrest, emergency chest reopening, requirement for extracorporeal membrane oxygenation, or death. Secondary outcomes included duration of mechanical ventilation, length of intensive care, and hospital stay. A propensity score methodology utilizing inverse probability of treatment weighting was used to minimize selection bias due to timing of peritoneal dialysis.

Setting: Cardiac ICU, The Royal Children’s Hospital, Melbourne, VIC, Australia.

Patients: From 2012 to 2015, infants who were commenced on peritoneal dialysis after cardiac surgery were included.

Measurements and Main Results: Among 239 eligible infants, 56 (23%) were commenced on early peritoneal dialysis and 183 (77%) on late peritoneal dialysis. At 90 days, early peritoneal dialysis as compared with late peritoneal dialysis was associated with a decreased risk of primary outcome (relative risk, 0.16; 95% CI, 0.05–0.47; p < 0.001 and absolute risk difference, –18.1%; 95% CI, –25.1 to –11.1; p < 0.001). Early peritoneal dialysis was also associated with a decrease in duration of mechanical ventilation and intensive care stay. Among infants with a cardiopulmonary bypass greater than 150 minutes, early peritoneal dialysis was also associated with a survival advantage (relative risk, 0.14; 95% CI, 0.03–0.84; p = 0.03 and absolute risk difference, –7.8; 95% CI, –13.6 to –2; p = 0.008).

Conclusions: Early peritoneal dialysis in infants post cardiac surgery is associated with a decrease in the rate of major adverse events. The role of early peritoneal dialysis warrants the conduct of randomized trials both in high and low-to-middle income countries; any beneficial effects if confirmed have the potential to strongly influence outcomes for children born with congenital heart disease.

1Cardiac Intensive Care Unit, Royal Children’s Hospital, Melbourne, VIC, Australia.

2Murdoch Children’s Research Institute, Melbourne, VIC, Australia.

3Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia.

4Cardiac Surgery, Royal Children’s Hospital, Melbourne, VIC, Australia.

5Clinical Epidemiology and Biostatistics Unit, Murdoch Children’s Research Institute, Melbourne, VIC, Australia.

*See also p. 197.

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Dr. Namachivayam received funding from the Murdoch Children’s Research Institute Melbourne, and he is supported by a Health professional Scholarship (award number 101603) from the National Heart Foundation (Australia). Dr. d’Udekem’s institution received funding from Actelion, and he received funding from Merck, Sharp & Dohme Corp. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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Copyright © 2018 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies