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  • Title: Peritoneal Dialysis vs Furosemide for Prevention of Fluid Overload in Infants After Cardiac Surgery: A Randomized Clinical Trial.
    Author: Kwiatkowski DM, Goldstein SL, Cooper DS, Nelson DP, Morales DL, Krawczeski CD.
    Journal: JAMA Pediatr; 2017 Apr 01; 171(4):357-364. PubMed ID: 28241247.
    Abstract:
    IMPORTANCE: Fluid overload after congenital heart surgery is frequent and a major cause of morbidity and mortality among infants. Many programs have adopted the use of peritoneal dialysis (PD) for fluid management; however, its benefits compared with those of traditional diuretic administration are unknown. OBJECTIVE: To determine whether infants randomized to PD vs furosemide for the treatment of oliguria have a higher incidence of negative fluid balance on postoperative day 1, as well as avoidance of 10% fluid overload; shorter duration of mechanical ventilation, intensive care unit stay, and inotrope use; and fewer electrolyte abnormalities. DESIGN, SETTING, AND PARTICIPANTS: This single-center, unblinded, randomized clinical trial compared methods of fluid removal after cardiac surgery from October 1, 2011, through March 13, 2015, in a large tertiary pediatric hospital in Ohio. The parents or guardians of all eligible infants (aged <6 months) undergoing cardiac surgery with catheter placement for PD were approached for inclusion. No patients were withdrawn for adverse effects. Recruitment was powered for the primary outcome, and analysis was based on intention to treat. Patients randomized to PD were hypothesized to have superior outcomes. INTERVENTIONS: Infants received intravenous furosemide (1 mg/kg every 6 hours) or a standardized PD regimen. MAIN OUTCOMES AND MEASURES: The primary end point was incidence of negative fluid balance on postoperative day 1. Secondary end points included incidence of fluid overload, duration of mechanical ventilation and intensive care unit stay, electrolyte abnormalities and repletion doses, duration of inotropic administration, and mortality. RESULTS: Seventy-three patients (47 boys [64%] and 26 girls [35%]; median age, 8 [interquartile range (IQR), 6-14] days) received treatment and completed the trial. No difference was found between the PD and furosemide groups in the incidence of negative fluid balance on the first postoperative day. The furosemide group was 3 times more likely to have 10% fluid overload (odds ratio [OR], 3.0; 95% CI, 1.3-6.9), was more likely to have prolonged ventilator use (OR, 3.1; 95% CI, 1.2-8.2), and had a longer duration of inotrope use (median, 5.5 [IQR, 4-8] vs 4.0 [IQR, 3-6] days) and higher electrolyte abnormality scores (median, 6 [IQR, 4-7] vs 3 [IQR, 2-5]) compared with the PD group. No statistically significant differences in mortality (3 patients [9.4%] in the furosemide group vs 1 patient [3.1%] in the PD group) or length of cardiac intensive care unit (median, 7 [IQR, 6-12] vs 9 [IQR, 5-15] days) or hospital (15 [IQR, 10-28] vs 14 [IQR, 9-22] days) stay were observed. No serious complications were observed. Dialysis was discontinued early in 9 of 41 patients in the PD group for pleural-peritoneal communication. CONCLUSIONS AND RELEVANCE: Use of PD is safe and allows for superior fluid management with improved clinical outcomes compared with diuretic administration. Use of PD should be strongly considered among infants at high risk for postoperative acute kidney injury and fluid overload. TRIAL REGISTRATION: clinicaltrials.gov Identifer: NCT01709227.
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