Hemodialysis In Children Research Articles

Changes in vascular access profile for pediatric hemodialysis patients over time: A registry-based study from Catalonia.

The criteria for vascular access (VA) selection in pediatric hemodialysis (HD) population has changed over time until the current patient-centered approach using the individualized Life-Plan. We analyzed the type of VA used by incident and prevalent end-stage kidney disease (ESKD) pediatric patients (pts) treated with HD in Catalonia. Data from the Catalan Renal Registry of ESKD pts under 18 years of age undergoing kidney replacement therapy (KRT) were examined for a 22-year period (1997-2018). ESKD children starting KRT through HD decreased progressively from 55.6% (1997-2001) to 38.2% (2012-2018) and, conversely, there was an increase in pts starting KRT by preemptive kidney transplantation (KT) from 28.9% to 42.6% between the same periods (for both comparisons, p = 0.007). Most ESKD pts started HD by fistula (AVF) from 1997 to 2001 (56.5%) but this percentage decreased over time and no AVFs were used to start HD in children from 2012 to 2018. Likewise, the percentage of children starting HD by tunneled catheter increased progressively from 8.7% to 72.2% between the same periods (for both comparisons, p < 0.001). Regarding prevalent ESKD pts, children on HD decreased from 34.9% in 1997 to 4.7% in 2018 and, conversely, pts with a functioning kidney graft increased from 62.8% to 92.4% during the same periods (for both comparisons, p < 0.001). There was a progressive decrease in the percentage of children dialyzed by AVF from 100% in 1997 to 0% in 2018 (p < 0.001). The KT rate increased from 5.4 per million population (pmp) in 1997 to 17.1 pmp in 2018 (p = 0.007). The median time on HD prior to the first KT progressively decreased to 6.6 months (2014-2018). The high KT rate was a determining factor in choosing the VA type in the incident and prevalent pediatric population treated with HD in Catalonia.

Switching from continuous veno-venous hemodiafiltration to intermittent sustained low-efficiency daily hemodiafiltration (SLED-f) in pediatric acute kidney injury: A prospective cohort study.

Continuous kidney replacement therapy (CKRT) is the preferred modality in critically ill children with acute kidney injury. Upon improvement, intermittent hemodialysis is usually initiated as a step-down therapy, which can be associated with several adverse events. Hybrid therapies such as Sustained low-efficiency daily dialysis with pre-filter replacement (SLED-f) combines the slow sustained features of a continuous treatment, ensuring hemodynamic stability, with similar solute clearance along with the cost effectiveness of conventional intermittent hemodialysis. We examined the feasibility of using SLED-f as a transition step-down therapy after CKRT in critically ill pediatric patients with acute kidney injury. A prospective cohort study was conducted in children admitted to our tertiary care pediatric intensive care units with multi-organ dysfunction syndrome including acute kidney injury who received CKRT for management. Those patients receiving fewer than two inotropes to maintain perfusion and failed a diuretic challenge were switched to SLED-f. Eleven patients underwent 105 SLED-f sessions (mean of 9.55 +/- 4.90 sessions per patient), as a part of step-down therapy from continuous hemodiafiltration. All (100%) our patients had sepsis associated acute kidney injury with multiorgan dysfunction and required ventilation. During SLED-f, urea reduction ratio was 64.1 +/- 5.3%, Kt/V was 1.13 +/- 0.1, and beta-2 microglobulin reduction was 42.5 +/-4%. Incidence of hypotension and requirement of escalation of inotropes during SLED-f was 18.18%. Filter clotting occurred twice in one patient. SLED-f is a safe and effective modality for use as a transition therapy between CKRT and intermittent hemodialysis in children in the PICU.

Clinical profile and outcome of arteriovenous fistulae in children onmaintenance hemodialysis from a low-resource setting.

Arteriovenous fistula (AVF) is the recommended access of choice in children on maintenance hemodialysis. The challenges of creating and maintaining a fistula in children are many. The objective of our study was to describe the clinical profile and outcomes of AVFs in children from a resource-limited setting. A retrospective analysis of children who have had an AVF for maintenance hemodialysis from 2010 to 2020 was performed. The center protocol for creation and management of complications was followed. Failure of fistula to mature was defined as primary failure. Primary patency was defined as the time from creation of access to the first complication requiring intervention. The primary failure rate, duration of primary patency and associated risk factors, and 1- and 3-year primary fistula patency rates were studied. Thirty-six children (38 AVFs) with the median (interquartile range) age of 11 (8, 13) years were included. Brachiocephalic anastomosis was the most common site (75%) of AVF. The primary failure rate was 5.5% (2 of 36). The mean (95% confidence interval) duration of primary patency was 42.3 (29.9, 54.7) months. There were no particular factors associated with the duration of primary patency. The 1- and 3-year primary patency rate was 91% and 73%, respectively. In resource-limited settings, AVF had good primary patency and is a feasible and durable access for maintenance hemodialysis in children.

Computational investigation of the haemodynamics shows criticalities of central venous lines used for chronic haemodialysis in children.

Haemodialysis is a life-saving treatment for children with kidney failure. The majority of children have haemodialysis through central venous lines (CVLs). The use of CVLs in pediatric patients is often associated to complications which can lead to their replacement. The aim of this study is to investigate haemodynamics of pediatric CVLs to highlight the criticalities of different line designs. Four models of CVLs for pediatric use were included in this study. The selected devices varied in terms of design and sizes (from 6.5 Fr to 14 Fr). Accurate 3D models of CVLs were reconstructed from high-resolution images including venous and arterial lumens, tips and side holes. Computational fluid dynamics (CFD) analyses were carried out to simulate pediatric working conditions of CVLs in ideal and anatomically relevant conditions. The arterial lumens of all tested CVLs showed the most critical conditions with the majority of blood flowing through the side-holes. A zone of low flow was identified at the lines' tip. The highest shear stresses distribution (>10 Pa) was found in the 8 Fr line while the highest platelet lysis index in the 10 Fr model. The analysis on the anatomical geometry showed an increase in wall shear stress measured in the 10 F model compared to the idealised configuration. Similarly, in anatomical models an increased disturbance and velocity of the flow was found inside the vein after line placement. This study provided a numerical characterization of fluid dynamics in pediatric CVLs highlighting performance criticalities (i.e. high shear stresses and areas of stagnation) associated to specific sizes (8 Fr and 10 Fr) and conditions (i.e. anatomical test).

Efficacy Evaluation of Ultrasound with Active Contour Model for Hemodialysis in Children with Renal Failure.

This study was aimed to explore the efficacy of ultrasound with active contour model (ACM) for hemodialysis in children with renal failure. The pulse coupled neural network (PCNN) was used to extract the initial contour of the ultrasound images, and the cloud model-based ACM was used to accurately segment the images, whose effect was compared with the classic Snake model. 84 children with chronic renal failure who received hemodialysis treatment in hospital were selected as research objects. There were 42 cases in the control group who were diagnosed by conventional ultrasound and 42 cases in the observation group who were diagnosed by ultrasound with the algorithm. Then, 42 children who underwent healthy physical examination (health group) were selected for comparison of related analysis indicators. The error rates of different algorithms were compared to analyze the levels of inflammatory factors in different groups of patients after hemodialysis. The results showed that the error rate of classical Snake model was 18.87% and that of ACM algorithm model was 11.01%, and the error rate of ACM algorithm model was significantly lower (P < 0.05). After hemodialysis, the level of tumor necrosis factor (TNF)-α was 38.76 pg/mL in the observation group and 40.05 pg/mL in the control group, which was notably decreased in both groups, especially in the observation group (P < 0.05). After hemodialysis, transforming growth factor (TGF)-β1 was 7.76 ng/mL in the observation group and 7.60 ng/mL in the control group, which was significantly reduced in both groups. After treatment, UA and Scr in both groups were significantly reduced, and the reduction was more significant in the observation group (P < 0.05). HGB and RBC were significantly increased in both groups, and the increase was more significant in the observation group (P < 0.05). In summary, ACM algorithm had a good segmentation effect on the ultrasonic images of children with renal failure. This study provided guidance for clinicians to choose the algorithm for the application of ultrasonic imaging diagnosis.

Developing a trigger tool to monitor adverse events during haemodialysis in children: a pilot project

BackgroundWe developed a paediatric haemodialysis trigger tool (pHTT) for application per haemodialysis (HD) session in children receiving intermittent in-centre HD and systematically monitored adverse events.MethodsSingle-centre quality improvement study performed over two 8-week cycles. Data collected prospectively using a ‘per-dialysis session’ pHTT tool including 54 triggers across six domains, adapted from a recently described haemodialysis trigger tool (HTT) for adults. Each trigger was evaluated for level of harm following assessment by two authors. Following a period of training, HD nurses completed the HTT at the end of each dialysis session.ResultsThere were 241 triggers over 182 dialysis sessions, with 139 triggers in 91 HD sessions for 15 children, age range 28–205 months, over an 8-week period (first cycle) and 102 triggers in 91 HD sessions for 13 children, age range 28–205 months, over a further 8-week period (second cycle). After interventions informed by the pHTT, the harm rate per session was significantly reduced from 1.03 (94/91) to 0.32 (29/91), P < 0.001. There was a significant difference between the distribution of triggers by harm category (P < 0.001) and between the proportion of triggers across the various domains of the pHTT (P = 0.004) between the two cycles. No triggers were evaluated as causing permanent harm.ConclusionsThis pilot study demonstrates potential benefits of a bedside tool to monitor adverse events during haemodialysis in children. Thus, following interventions informed by the pHTT, the harm rate per session was significantly reduced. Under standard patient safety systems, the vast majority of triggers identified by the pHTT would remain unreported and perhaps lead to missed opportunities to improve patient safety. We propose the use of a paediatric HTT as part of standard care by centres providing HD to children in the future.Graphical A higher resolution version of the Graphical abstract is available as Supplementary information

Good outcomes for arteriovenous fistula with buttonhole cannulation for chronic hemodialysis in children and adolescents.

Arteriovenous fistula (AVF) is the preferred access for chronic hemodialysis (HD) in children and adolescents, but central venous catheter use is still high. Retrospective chart review of children and adolescents with AVF created between January 2003 and December 2015 was performed to assess primary failure (PF), maturation time, functional primary and functional cumulative patency, and potential risk factors for AVF dysfunction. Ninety-nine AVF were created in 79 patients (54% male; 7-24 years; 16-147 kg) by experienced surgeons. Duplex ultrasonography vein mapping was used to assist with site selection. PF occurred in 17 AVF (17%) in 14 patients. Patient age, gender, ethnicity, underlying disease, time on dialysis, and AVF site were not associated with PF or patency. Coagulation abnormality was positively associated with PF (p = 0.03). Function was achieved in 82 AVF (83%) in 77 patients (97%). Median maturation time was 83 days (range 32-271). AVF were accessed via buttonholes. Functional primary patency was 95%, 84%, and 53% at 1, 2, and 5 years. Overall 1- and 2-year functional cumulative patency was 95%, but lower for small patients 16-30 kg (88%) and those greater than 80 kg (91%). The 5-year patency rate was 80%, but significantly lower for 16-30 kg (59%) and greater than 80 kg (55%). Risk analysis showed significantly better patency for 31-45 kg and 46-80 kg groups (p < 0.01), non-obese BMI (p = 0.01), and buttonhole self-cannulation (p = 0.03). This study provides more information about successful AVF with buttonhole cannulation in pediatric hemodialysis patients lending additional support for AVF use in pediatrics. A higher resolution version of the Graphical abstract is available as Supplementary information.

Left ventricular strain and left atrial strain are impaired during hemodialysis in children

We aimed to investigate intradialytic changes in ventricular and atrial function using speckle tracking echocardiography (STE) in pediatric hemodialysis (HD). Children with HD vintage > 3months were enrolled, and echocardiography was performed prior to, during, and after HD. STE was analyzed using GE EchoPAC. Left ventricular (LV) global longitudinal strain (GLS), strain rate (Sr), and mechanical dispersion index (MDI) were calculated as the average from 3 apical views; diastolic strain (Ds) and Sr from 4-chamber tracing; left atrial strain (LAS) and Sr from the 4- and 2-chamber views. A total of 15 patients were enrolled at a median age of 12years (IQR 8, 16) and median HD vintage of 13months (IQR 9, 25). GLS worsened during HD (-15.8 ± 2.2% vs -19.9 ± 1.9%, p < 0.001). Post-HD GLS was associated with BP decrease (coefficient = 0.62, p = 0.01). LV MDI and systolic Sr did not change. LV Ds progressively worsened (-8.4% (-9.2, -8.0) vs -11.9% (-13.4, -10.3), p < 0.001). LAS changes at mid-HD returned to baseline post-HD. Ds, DSr, LAS, LASr were not associated with BV removal or BP decrease (p > 0.1). In conclusions, intradialytic LV strain and LAS changes consistent with subclinical systolic and diastolic dysfunction were observed during HD in children. Changes in Ds, DSr, LAS, and LASr were not associated with BP change or BV removal and may be related to the disease progression. Longitudinal study using these novel indices may unfold the effect of these subclinical changes on long-term cardiovascular health in children requiring chronic HD.

Hemodiafiltration Is Associated With Reduced Inflammation and Increased Bone Formation Compared With Conventional Hemodialysis in Children: The HDF, Hearts and Heights (3H) Study

BackgroundPatients on dialysis have a high burden of bone-related comorbidities, including fractures. We report a post hoc analysis of the prospective cohort study HDF, Hearts and Heights (3H) to determine the prevalence and risk factors for chronic kidney disease-related bone disease in children on hemodiafiltration (HDF) and conventional hemodialysis (HD).MethodsThe baseline cross-sectional analysis included 144 children, of which 103 (61 HD, 42 HDF) completed 12-month follow-up. Circulating biomarkers of bone formation and resorption, inflammatory markers, fibroblast growth factor-23, and klotho were measured.ResultsInflammatory markers interleukin-6, tumor necrosis factor-α, and high-sensitivity C-reactive protein were lower in HDF than in HD cohorts at baseline and at 12 months (P < .001). Concentrations of bone formation (bone-specific alkaline phosphatase) and resorption (tartrate-resistant acid phosphatase 5b) markers were comparable between cohorts at baseline, but after 12-months the bone-specific alkaline phosphatase/tartrate-resistant acid phosphatase 5b ratio increased in HDF (P = .004) and was unchanged in HD (P = .44). On adjusted analysis, the bone-specific alkaline phosphatase/tartrate-resistant acid phosphatase 5b ratio was 2.66-fold lower (95% confidence interval, −3.91 to −1.41; P < .0001) in HD compared with HDF. Fibroblast growth factor-23 was comparable between groups at baseline (P = .52) but increased in HD (P < .0001) and remained unchanged in HDF (P = .34) at 12 months. Klotho levels were similar between groups and unchanged during follow-up. The fibroblast growth factor-23/klotho ratio was 3.86-fold higher (95% confidence interval, 2.15–6.93; P < .0001) after 12 months of HD compared with HDF.ConclusionChildren on HDF have an attenuated inflammatory profile, increased bone formation, and lower fibroblast growth factor-23/klotho ratios compared with those on HD. Long-term studies are required to determine the effects of an improved bone biomarker profile on fracture risk and cardiovascular health.

MO768VASCULAR ACCESS FOR PEDIATRIC HEMODIALYSIS PATIENTS IN CATALONIA: ANALYSIS OF DATA FROM THE CATALAN RENAL REGISTRY (1997-2018)

Abstract Background The vascular access (VA) is the life-line for children with kidney failure (KT) on hemodialysis (HD). The European Society for Paediatric Nephrology Dialysis Working Group suggested that children requiring HD start with a functioning arteriovenous fistula (AVF) but a tunnelled catheter (TC) can be placed instead where a short period on HD is anticipated before kidney transplantation (KT) (NDT 2019; 34: 1746–1765). Aims To analyze the type of VA used by incident and prevalent KF pediatric patients (pts) treated with HD in Catalonia Method Data from the Catalan Renal Registry of KF pts younger than 18 years of age undergoing kidney replacement therapy (KRT) were examined for a 22-year period. Results The modality of KRT used by incident KF pediatric pts has changed significantly over time: the percentage of children who started KRT through HD decreased progressively from 89.9% during the 1984-1989 period to 38.2% during the 2014-2018 period and, conversely, the percentage of children who started KRT by using pre-emptive KT increased progressively from 5.1% to 42.6% between the same periods (for both comparisons, p&amp;lt;0.001). During 2018, 18 children started KRT (rate: 12.8 per milion of population, pmp) by using pre-emptive KT (n=8, 44.4%), peritoneal dialysis (n=5, 27.8%) or HD (n=5, 27.8%). From 1997 to 2018, 112 KF pediatric pts started KRT by using HD (mean age 9.4±6,0 yr, male 58.9%, glomerular disease 36.8%). Most children started HD through an AVF during the 1997-2001 period (56.5%) but this percentage decreased over time and no children used an AVF for starting HD during the 2012-2018 period. On the contrary, the percentage of children starting HD through a TC increased progressively from 8.7% to 72.2% between the same periods (for both comparisons, p&amp;lt;0.001). No significant changes over time were recorded regarding untunnelled catheter (UC) utilization from 34.8% (1997-2001 period) to 27.8% (2012-2018 period) (p=0.57). Considering two age groups (0-6 vs 7-18 years), VA distribution was the following (%): 23.3 vs 76.7 for UC, 47.2 vs 52.8 for TC and 26.3 vs 73.7 for AVF (p=0.058). Regarding KF presentation, UC was used mainly to initiate HD in crashlanders (53.3%) and AVF was used mainly to start HD in children with steady kidney disease progression (63.2%) (p=0.003). The KRT modality of using prevalent KF pediatric pts has also changed significantly over time: pts on HD decreased from 34.9% (n=15, mean age 13.5 yr) in 1997 to 4.7% (n=5, mean age 11.6 yr) in 2018 and, conversely, pts with a kidney graft increased from 62.8% (n=27, mean age 13.7 yr) to 92.4% (n=98, mean age 11.2 yr) during the same period (for both comparisons, p&amp;lt;0.001). The percentage of children dialyzed through an AVF decreased progressively from 1997 (100%) to 2018 (0%) (p&amp;lt;0.001). All prevalent HD pts were dialyzed through a catheter in 2018. The KT rate increased significantly from 5.4 pmp (n=6) in 1997 to 17.1 pmp (n=24) in 2018 (p=0.007). The median time on HD (months) prior to the first KT decreased progressively from 23.1 during the 1984-1989 period to 6.6 during the 2014-2018 period (p&amp;lt;0.001). Conclusions 1) The VA profile of pediatric population treated with HD in Catalonia has radically changed over time. 2) Since 2012, AVF has practically disappeared as the VA in the incident and prevalent pediatric population on HD. 3) Almost all children treated by HD since 2012 were dialyzed through a catheter due to the short waiting time before receiving a kidney graft. 4) The high KT rate was a determining factor in choosing the AV type in the pediatric population treated with HD in Catalonia.

Comparison of Efficacy of First Haemodialysis Session for Correction of Metabolic Disturbances in Acute Kidney Injury and Chronic Kidney Disease in Children

&#x0D; &#x0D; &#x0D; &#x0D; Introduction: Acute kidney injury and chronic kidney disease present with various complications like electrolyte disturbances, metabolic acidosis and fluid overload in children. The objective of the study was to compare the efficacy of the first session of haemodialysis in children with acute kidney injury stage 3 and chronic kidney disease G5 treated by dialysis for immediate recovery of renal functions in terms of reduction in the level of azotemia, correction of fluid and electrolyte imbalances, metabolic acidosis, and improvement in clinical status.&#x0D; Methods: This was a cross-sectional comparative observational study conducted on 13 patients of acute kidney injury stage 3 and 46 patients with chronic kidney disease G5, who required haemodialysis. Their clinical assessment, fluid status, renal function tests, electrolyte, bicarbonate were done at admission and completion of the first session of heamodialysis.&#x0D; Results: The age group of children was six to 16 years (median 11.4 years). There were six males (46%) and seven females (54%) in the acute kidney injury group and 29 (63%) males and 17 (37%) females in chronic kidney disease G5 groups. Sepsis (31%) and glomerulonephritis (31%) were common etiologies detected for acute kidney injury while in chronic kidney disease G5, congenital anomalies of the kidney and the urinary tract were the commonest (50%). There were significant reductions in the levels of serum urea and creatinine and a rise in blood pH, bicarbonate level, and base excess following the first session of haemodialysis in comparison to pre-dialysis values in both AKI and CKD.&#x0D; Conclusions: The study demonstrated improvement in the clinical parameters and biochemical parameters equally after the first dialysis sessions in both groups. This is one of the effective renal replacement therapy and should be instituted wherever indicated to improve the immediate outcome of the patients.&#x0D; &#x0D; &#x0D; &#x0D;

Hemodiafiltration maintains a sustained improvement in blood pressure compared to conventional hemodialysis in children-the HDF, heart and height (3H) study.

Hypertension is prevalent in children on dialysis and associated with cardiovascular disease. We studied the blood pressure (BP) trends and the evolution of BP over 1year in children on conventional hemodialysis (HD) vs. hemodiafiltration (HDF). This is a post hoc analysis of the "3H - HDF-Hearts-Height" dataset, a multicenter, parallel-arm observational study. Seventy-eight children on HD and 55 on HDF who had three 24-h ambulatory BP monitoring (ABPM) measures over 1year were included. Mean arterial pressure (MAP) was calculated and hypertension defined as 24-h MAP standard deviation score (SDS) ≥95th percentile. Poor agreement between pre-dialysis systolic BP-SDS and 24-h MAP was found (mean difference - 0.6; 95% limits of agreement -4.9-3.8). At baseline, 82% on HD and 44% on HDF were hypertensive, with uncontrolled hypertension in 88% vs. 25% respectively; p < 0.001. At 12months, children on HDF had consistently lower MAP-SDS compared to those on HD (p < 0.001). Over 1-year follow-up, the HD group had mean MAP-SDS increase of +0.98 (95%CI 0.77-1.20; p < 0.0001), whereas the HDF group had a non-significant increase of +0.15 (95%CI -0.10-0.40; p = 0.23). Significant predictors of MAP-SDS were dialysis modality (β = +0.83 [95%CI +0.51 - +1.15] HD vs. HDF, p < 0.0001) and higher inter-dialytic-weight-gain (IDWG)% (β = 0.13 [95%CI 0.06-0.19]; p = 0.0003). Children on HD had a significant and sustained increase in BP over 1year compared to a stable BP in those on HDF, despite an equivalent dialysis dose. Higher IDWG% was associated with higher 24-h MAP-SDS in both groups.

Evolution and change in paradigm of hemodialysis in children: a systematic review.

There are similarities in hemodialysis (HD) between adults and children and also unique pediatric aspects. In this systematic review, we evaluated the existing HD literature, including vascular access, indications, parameters, and outcomes as a reflection on real-life HD practices. Medline, Embase, CINAHL, Web of Science, and Cochrane Library were systematically searched for literature on HD in children (1-20years). Two reviewers independently assessed the literature and data on indications; vascular access, outcomes, and specific parameters for HD were extracted. Fifty-four studies (8751 patients) were included in this review. Studies were stratified into age groups 1-5, 6-12, and 13-20years based on median/mean age reported in the study, as well as era of publication (1990-2000, 2001-2010, and 2011-2019). Across all age groups, both arteriovenous fistulas and central venous catheters were utilized for vascular access. Congenital abnormalities and glomerulopathy were the most common HD indications. HD parameters including HD session duration, dialysate and blood flow rates, urea reduction ratio, and ultrafiltration were characterized for each age group, as well as common complications including catheter dysfunction and intradialytic hypotension. Median mortality rates were 23.3% (3.3), 7.6% (14.5), and 2.0% (3.0) in ages 1-5, 6-12, and 13-20years, respectively. Median transplantation rates were 41.6% (38.3), 52.0% (32.0), and 21% (25.6) in ages 1-5, 6-12, and 13-20, respectively. This comprehensive systematic review summarizes available literature on HD in children and young adults, including best vascular access, indications, technical aspects, and outcomes, and reflects on HD practices over the last three decades.

Update on the creation and maintenance of arteriovenous fistulas for haemodialysis in children.

Arteriovenous fistulas (AVFs) are widely used for haemodialysis (HD) in adults with stage 5 chronic kidney disease (CKD 5) and are generally considered the best form of vascular access (VA). The 'Fistula First' initiative in 2003 helped to change the culture of VA in adults. However, this cultural change has not yet been adopted in children despite the fact that a functioning AVF is associated with lower complication rates and longer access survival than a central venous line (CVL). For children with CKD 5, especially when kidney failure starts early in life, there is a risk that all VA options will be exhausted. Therefore, it is essential to develop long-term strategies for optimal VA creation and maintenance. Whilst AVFs are the preferred VA in the paediatric population on chronic HD, they may not be suitable for every child. Recent guidelines and observational data in the paediatric CKD 5 population recommend switching from a 'Catheter First' to 'Catheter Last' approach. In this review, recent evidence is summarized in order to promote change in current practices.

Hemodiafiltration Maintains a Sustained Improvement in BP Compared with Conventional Hemodialysis in Children: The HDF, Heart and Height (3H) Study

Hemodiafiltration Maintains a Sustained Improvement in BP Compared with Conventional Hemodialysis in Children: The HDF, Heart and Height (3H) Study

The impact of home hemodialysis in children with severe cardiac failure

When faced with patients with deteriorating cardiac disease, nephrologists tend to accept that heart disease is unmodifiable, accepting mediocrity and opting for stabilization. Likewise cardiac patients with persistent renal failure are presented with a poor renal prognosis and prepared for renal transplantation. We present three dialysis dependent children with moderate-to-severe cardiac failure in whom home hemodialysis normalized the cardiac function and restored renal function. These cases highlight the medical benefits of home hemodialysis in severe cardio-renal cases but not without acknowledgement of the resource, commitment, and safety challenges that accompanies them.

SAT-232 HEMODIALYSIS IN CHILDREN AND ADOLESCENTS: A SYSTEMATIC REVIEW

Hemodialysis (HD) in children is often utilized in situations such as acute or chronic kidney disease, severe electrolyte imbalance, toxicities, and hyperammonemia. Proper HD in children require careful manipulation of technical parameters including blood and dialysate flow rate, type/size of dialyzer and dialysate composition. Although general principles of hemodialysis are similar between adults and children, there are several unique aspects of HD inherent to the pediatric population. Issues of hemodynamic stability, obtaining ideal vascular access and preventing complications from HD can prove challenging in this patient population. In this systematic review, we evaluate the existing literature regarding the use of hemodialysis in children and young adults (ages 1-20 years). Furthermore, we summarize this data to compile guidelines for best practice. A systematic search of all relevant studies and abstracts was conducted using several electronic databasesby utilizing appropriate key words by an expert hospital librarian. Eligible studies included children aged 1-20 years with acute or chronic indications for hemodialysis. Studies prior to Jan 1990 or on continuous renal replacement therapy, peritoneal dialysis, modified forms of hemodialysis (nocturnal, hemodiafiltration, etc.) were excluded. In addition, studies that were non-English or involved < 5 patients were excluded. Titles and abstracts were screened by two independent reviewers, followed by a full text review of included articles. Data on HD indications, specific parameters of the HD protocol, including dialysate composition, dialysate flow, blood flow, urea reduction rate and ultrafiltration goals were collected. We also collected data regarding medications, anticoagulation and blood transfusions required along with outcomes such as mortality and kidney transplantation. Preliminary results of this systematic search returned a total number of 16,196 papers. After screening for relevant titles and abstracts, and exclusion based on criteria defined above, a total of 102 papers remained. Further assessment of full text of articles led to inclusion of 55 papers in this review. Results showed that congenital abnormalities, glomerulopathy and obstructive uropathy were some of the most common indications of HD. The mean age of HD was 12.7 ±2.9 years. Mean dialysis session duration was 223.7 ±65.6 min/session, with 3.2 ±0.6 sessions/week. Mean dialysate flow was 480±46.8 ml/min and mean blood flow was 192.5±65.5 ml/min. A subset of studies (n=5) reported mean blood flow relative to body weight as 4.7±0.5 ml/kg/min. Mean urea reduction ratio was 44.9±30.0%. Most common types of vascular access were central venous catheters and arteriovenous fistulas. The most common complications were access-related infection and thrombosis. From studies with reported outcomes, 7.68% of children died and 42% were transplanted. The use of HD in children presents unique challenges due to age-related differences in physiology, risk of complications and increased emphasis on long-term health. This systematic review summarizes the available literature on HD, in terms of indication, technical aspects and outcomes. Ultimately, this data can help to guide safe, effective HD treatment in children and in formulating guidelines for best practice.

Nocturnal home hemodialysis in children: Advantages, implementation, and barriers.

Chronic kidney disease and end-stage renal disease (ESRD) in children are major health concerns worldwide with increasing incidence and prevalence. Renal replacement therapies and kidney transplants have remarkably improved the management of patients with ESRD in both adult and pediatric populations. Kidney transplant has the best patient outcomes, but many a time it has a considerable waiting period. In the meantime, the majority of patients with pediatric ESRD are dependent on dialysis. The conventionally utilized hemodialysis regimen is the three times weekly, in-center hemodialysis. Many studies have demonstrated the unfavorable long-term morbidity associated with the conventional regimen. Intensified dialysis programs, which include extended nocturnal hemodialysis or short daily hemodialysis, are being increasingly advocated over the past two decades. In addition to having much better clinical outcomes as compared with the conventional regimen, the flexibility to provide dialysis at home serves as a great incentive. PubMed/Medline, Embase and Cochrane databases for literature on nocturnal home hemodialysis in children with ESRD were extensively searched. Contrary to the noticeable literature available on adult home hemodialysis, a small number of studies exist in the pediatric population. In this review, the benefits, implementation and associated barriers of nocturnal home hemodialysis in children were addressed.

Treatment factors and interventions that may influence outcome of chronic Hemodialysis in children, A multicenter study: (Cross-section study)

Treatment factors and interventions that may influence outcome of chronic Hemodialysis in children, A multicenter study: (Cross-section study)

Effect of High Flux Versus Low Flux Hemodialysis on Some Cardiovascular Risk Factors in Egyptian Children with End Stage Renal Disease.

Background Cardiovascular disease remains as the main cause of mortality in children with end stage renal disease (ESRD).Among the cardiovascular risk factors, dyslipidemia and inflammation are of great importance as they are both prevalent and modifiable risk factors. We aim to evaluate the effect of permeability of low-flux versus high-flux dialyzer on such 2 factors in children on regular hemodialysis (HD). Patients and Methods 48 children with ESRD were randomized into 2 groups. Group A used low-flux dialyzer, group B used high-flux dialyzer for 6 months. An initial and 6th month blood samples for lipid profile, serum albumin and serum high sensitivity CRP (hs CRP) were obtained. Statistical analysis was done. Results In the high flux group, there was a statistically significant difference in total cholesterol, HDL-cholesterol, triglyceride and hs CRP levels after 6 months when compared to baseline values of the same group, while LDL cholesterol and serum albumin showed no significant change. In the low flux group, results after 6 months didn’t show significant change in previously mentioned parameters when compared with its baseline values of the same group. Comparing these parameters between the 2 groups at 6 months, shows that high flux group has significantly lower total cholesterol, triglyceride, and hs CRP levels. Conclusion This study has demonstrated for the first time improvement of some markers of dyslipidemia and inflammation by using high-flux HD in children with ESRD. These results suggest that high-flux dialysis may benefit such young suffering population by reducing the atherogenic risk, cardiovascular morbidity and mortality.