Pediatric hd dr. mohammed zedan

2. Willem (Pim) Kolff (1911–2009)
Kolff and Berk’s first artificial kidney with
a drum of aluminium slats and a static open
dialysate bath, 1942

3. J. P. MERRILL
Merrill’s pediatric patient received a single 4-h dialysis
treatment and was said to had “…modest improvement,
but of short duration.

4. Hemodialysis In Children Is Different
From Adults

5. AgendaAgenda

6. When Should Dialysis Start?When Should Dialysis Start?

7. Requires 2 or more GFR, 3 or more months apart
Other markers kideny disease: Complications Complications Renal
Proteinuria, hematuria, anatomic Possible Evident Replacement
GFR 90 60 30 15
1 2 3 4 5
Stage
When Should Dialysis Start?
K/DOQI CKD Staging
Renal replacement therapy should start when:
eGFR < 15ml/min/1.73m2 with symptoms or signs of
uremia, fluid overload or malnutrition in spite of
medical therapy
or
Before an asymptomatic patient has an eGFR
<6ml/min/1.73m2.
Earlier dialysis
Poor growth
Poor development
Worsening school performance
Deteriorating nutrition
When Not to Dialyze?
 Severe peripheral arterial disease
 Hypotensive heart failure.
 Severe mental illness, so the patient has no awareness
of the treatment and is unable to comply
 Malignant disease with poor prognosis
No dialysis does not mean ‘no care’, but rather full
conservative and supportive management. However, it can be
difficult to identify such patients, and a trial of dialysis for
1-2 months should be considered to establish

8. eGFR= k x
Length (cm)
Serum Creatinine (mg/dl)
LBW infants <1yr 0.2-0.5
Term infants <1 yr 0.3-0.7
Children 2-12 yr 0.4-0.7
Females 13-21 yr 0.4-0.7
Males 13–21 yr 0.5-0.9
Schwartz formula
Estimated Creatinine Clearance

9. Hemodialysis FacilitiesHemodialysis Facilities
- Dialysis Unit- Dialysis Unit
- Water Management Unit- Water Management Unit

10. Hemodialysis should be delivered in a “pediatric” dialysis centerHemodialysis should be delivered in a “pediatric” dialysis centerHemodialysis should be delivered in a “pediatric” dialysis centerHemodialysis should be delivered in a “pediatric” dialysis center
Kids are not little adults–
they need pediatric
expertise!!!
New family
Dialysis Unit

11. Dialysis Unit

12. Dialysis Unit
 The travel time to a haemodialysis facility
should be less than 30 minutes or a
haemodialysis facility should be located
with 25 miles of the patient’s home.

13. Dialysis Unit
 The required number of haemodialysis
stations should be based on using each
station for 2 patients per day three times
per week.

14.  Home HD is generally not recommended
at present for the young child.
Dialysis Unit

15. Dialysis Unit
 A transfer process for adolescents
must be in place and agreed by
referring and receiving units.

16. Frequency of assessment
BacterialBacterial
growthgrowth
(cfu mL(cfu mL-1-1
))
EndotoxinEndotoxin
(IU mL(IU mL-1-1
))
CytokineCytokine
--
inductioninduction
Regular waterRegular water
Ultra-pureUltra-pure
100100
<0.1<0.1
0.250.25
0.030.03
++
--
 Adequate in terms of biochemical compositionAdequate in terms of biochemical composition
 Free from microbiological contaminationFree from microbiological contamination
 Adequate in terms of biochemical compositionAdequate in terms of biochemical composition
 Free from microbiological contaminationFree from microbiological contamination
Water Quality
Bacterial & endotoxins: More regularly,
depending in part on the mode of
dialysis, weekly for high-flux membrane
use).
Chemical composition: At least
once/year.

17. Vascular AccessVascular Access

18. Vascular AccessVascular Access
 The preferred mode: Double-lumen central venous catheters.
Temporary Vascular Access
 The preferred site:

Internal jugular vein NOTthe same side as a planned or
maturing upper limb fistula.

The subclavian vein should be avoided because damage
to it may preclude an arteriovenous fistula in that arm.

19. Vascular AccessVascular Access
 Fistula creation:
 6-12 months before hemodialysis is expected to start.
 Should be undertaken by appropriately trained and skilled
surgeon.
 Psychological preparation is needed for the child and family
before a fistula is created.
 Fistula first cannulation:
 2-4 weeks after its creation (variable).
 Local anesthetic creams must be applied before needling to avoid
pain.
Permanent Access
• PREFERRED SITE FOR AVF IN CHILDREN
1.Radiocephalic
2.Brachiocephalic
3.Brachiobasilic with or without transposition

20. Vascular AccessVascular Access
- AVG Should be considered an option for HD access in children
especially who require replacement of native vessels to perform
an adequate anastomosis
- Alternative materials:
1. Saphenous vein
2. Bovine
3. Umbilical
4. Darcon
5. Polyurethane, cryopreserved femoral vein
6. Polytetrafluorethylene (PTFE) is most commonly used
Permanent Access

21. • Graft are most commonly placed in forearm between brachial
artery & basilic to brachial vein.
• The thigh can be used femoral artery and saphenous to femoral
vein in small children
• -Higher infection rates been noted with thigh graft than with upper extremity grafts
Vascular AccessVascular Access
Permanent Access

22.  Advantage of AVG
1. Shorter time to use
2. High primary potency rate
3. Ease of technical creation
 Disadvantages of AVG
1. Thrombosis
2. Stenosis
3. Infection
Vascular AccessVascular Access
Permanent Access

23. HemodialysisHemodialysis EquipmentEquipment
- hemodialysis machine- hemodialysis machine
- dialysate- dialysate

25. Hemodialysis Machine
High-tech innovations:
 Control of ultrafiltration and
dialysate solute concentration (i.e.
sodium, bicarbonate).
 Polyvalency machine which enable
HF & HDF.
 Monitoring of hematocrit variation.
 Direct urea kinetic monitoring &
blood thermal monitoring.
Volumetric ultrafiltration control.Volumetric ultrafiltration control.
Option for both single and double-needle dialysis.Option for both single and double-needle dialysis.
Volumetric ultrafiltration control.Volumetric ultrafiltration control.
Option for both single and double-needle dialysis.Option for both single and double-needle dialysis.

26.  Small solute
clearance and
more, from diffusion
process (urea) to
convection mass
transport (other
uremic toxins
“middle molecules”)

27.  In HD, blood
purification depends
mostly on a diffusion
process secondary to
a concentration
gradient.
 HD clearance (KHD)
correlates directly with
blood flow rate.

28.  In HF, uremic toxin
extraction is mostly
dependent on
convection mass
transport secondary
to a pressure
gradient.
 HF clearance (KHF)
directly correlates
with ultrafiltration
flow rate

29.  HDF combines HD
and HF
simultaneously,
which enables blood
purification by both a
diffusive process
and convective
mass transport.

30.  HDF with a highly
permeable membrane is
as efficient as HD for low
MW compounds, but is
more efficient than HF
for low MW compounds.
 Moreover, HDF is
associated with a lower
intradialytic morbidity
rate, as is HF.
Hemodiafiltration is an option to
consider to obtain “maximum”
dialysis efficiency

31. Thanks to hemodifiltration, children, parents and team care discovered a new
way of life with motivated children, showing natural compliance (no diet
restriction, no or few drugs), and most of all children developing with catch-up
of growth

32. Hemodialysis Machine
Machines should be replaced after 7-10
years’ service or after completing between 25,000 and
40,000 hours of use for hemodialysis, depending upon an
assessment of machine condition
Machines should be replaced after 7-10
years’ service or after completing between 25,000 and
40,000 hours of use for hemodialysis, depending upon an
assessment of machine condition

33. • Bicarbonate buffered,
• Low calcium level (1.25 mmol L)
becomes the standard,
• Low (1– 1.5 mmol L), “normal” (2–
2.5 mmol L), or “high” (3–3.5 mmol
L) potassium dialysate
Dialysate

34. •Sodium concentrations at
physiological level (138 to 144
mmol L).
• Glucose concentration at
physiological level,
• Dialysate quality
control (germs and endotoxins)
is required
Dialysate

35. The dialysate flow rate can
be usually in the range 300 to
800 m/min-1. In general
practice, 500 mL min is used.
 New mechanism: Na, HCO-
profiles, water filtrate profile,
thermal exchange.
Dialysate

36. * Estimation of Dry Weight* Estimation of Dry Weight
* Dialyzer* Dialyzer
* Blood Lines* Blood Lines
* Blood Pump Rate* Blood Pump Rate
* Anticoagulants* Anticoagulants
Hemodialysis PrescriptionsHemodialysis Prescriptions

37. Estimation of Dry
Weight

38. Estimation of Dry WeightEstimation of Dry Weight
 Definition:It is the weight at the termination of
a regular dialysis session, below which the
patient will become symptomatically hypotensive.
It is difficult
•The hypotensive tendency during a dialysis session is
multifactorial and not only related to the ultrafiltration rate but
also to the plasma refilling rate capacity → regular assessment in
growing child is needed.
•Body composition is variable with age especially during infancy and
puberty.
•No “unique” optimum method.

39. Technique Mechanism Advantages Disadvantages
Serum atrial
natriuretic peptide
Released from atrial tissue
with increased pressure;
levels increase with
overhydration
Ease of use
Sensitive flar water as
well as intravascular or
volume overload
No use in patients with
heart failure
Cannot detect
underhydration
Normal range?
Vena cava diameter Measured by ECHO or U/S.
Increased diameter with
overhydration
Reflects intravascular
volume
Sensitive for
overhydration
Difficult in heart failure
Interoperator variation
Large interpatient
variation
Bioimpedance Electrical impedance in the
body is proportional to total
body water.
Spectral analysis can
distinguish intra-from
extracellular water
Ease of use
Reproducible
Detects underhydration
Can be used continuously
during dialysis
Measures interstitial and
intravascular
Confounded by
temperature and ion
effects
Insensitive at detecting
volume removal from
(main source)
BVM Change in Hct or protein
concentration (detected
optically) is inversely
proportional to change in
blood volume
Ease of use
Continuous (real time)
measure
Allows for prevention of
hypotension
Plasma volume not only
dependent on hydration
state
Interpatient variability
IVCD is expressed as index to SA (mm/m2
) - ↓ on deep inspiration (collapse index) expressed as %
(normovolumia: IVCD= 8-11.5 mm/m2
& collapse index= 40-75%)
Estimation of Dry WeightEstimation of Dry Weight

40. Dialyzers

41. Types of Dialyzer
◦Types of Membrane
◦Blood volume capacity
◦Service area
◦UF coefficient (KUF)
◦Molecular “hydraulic” permeability
(CUF): allow maximum Clearance of various
substances
◦Sterilization

42. Types of Dialyzer
◦Low flux (KUF <10 ml/hr/mmHg)
◦High flux (KUF 15-60 ml/mmHg)
◦Hollow fiber (capillary)
◦Parallel Plate
Types of Membranes
◦Unmodified cellulose low flux
◦Modified cellulose (Low & high flux)
◦Synthetic (low & high flux)

43. Synthetic non-cellulose
membranes are more biocompatible.
Size of dialyzer shouldn’t exceed 75-
100% of patient service area
Types of Dialyzer

44. Advantages
• Remove urea and other dialysis uremic
toxins.
• Reduction of uremia related amyloidosis.
• Maintenance of residual renal function.
• Reduction of inflammation, malnutrition,
anemia, dyslipidemia, and mortality.
High-flux membrane should be considered
especially in chronic long-term dialysis
2C
Types of Dialyzer

45. 1C
1B
Types of Dialyzer

46. Surface
Ares (m2
)
Priming
Volume
Weight of
Patient
0.22
0.3
0.5
0.7
0.9
0.9
18mL
30mL
38mL
51mL
62mL
63mL
<6kg
2.5-15kg
10-15kg
15-20kg
>20kg
>20kg
Blood volume priming requirement, which is
membrane area-related
Types of Dialyzer

48. Blood Lines

49. Blood Lines
SizeSize Priming volumePriming volume Weight of patientWeight of patient
Medisystem neonatal
Medisystem pediatric
Adult
29 mL
58 mL
125 mL
<7kg
7-20kg
>20kg
 Available in infants/babies sizeAvailable in infants/babies size
 Biocompatible materialBiocompatible material
 Type of sterilization: ethylene oxide-freeType of sterilization: ethylene oxide-free

50. Blood Pump Rate

51. 11stst
session 90 ml / m2 Or 2-3 ml/kg/minsession 90 ml / m2 Or 2-3 ml/kg/min
 Latter: 150-200 mL/min/mLatter: 150-200 mL/min/m22
Or 5-7 mL/kg/minOr 5-7 mL/kg/min
small children (mL/min): (BW+10) x 2.5small children (mL/min): (BW+10) x 2.5
 The total extracorporeal blood volume
(needles, tubing, and dialyser) should
preferably be less than 10% of patient
total blood volume.
 System priming with saline, albumin, and
sometimes blood should be applied in the
first dialysis sessions with babies or
small infants.
Blood Pump Rate

52. Anticoagulants

53. Anticoagulants
Unfractionated heparin or Low molecular weight
heparin
1A
Heparin free dialysis:
Active bleeding, pericarditis, coagulopathy,
thrombocytopenia, intracerebral hemorrhage, recent
surgery, recent renal transplant.

54. Unfractionated Heparin
Dose
Heparin loading – 2000 IU/m2
20 IU/kg
10 IU/kg in infant
Maintenance – 400 IU/m2
10-20 IU/kg to be
discontinued 30 minutes prior to the end of
dialysis
Heparin lock
With concentrated heparin 50 U/kg/lumen for
weight less than 10 kg
1000 U/ml BW (10-20 kg)
2500 U/ml BW>20 kg

55. Unfractionated Heparin
Limitations
Variable half-life (0.5 - 2.0 h), greatly at the
extremes of weight, particularly in infants < 10 kg.
Variable biological activity due to nonspecific binding to
the endothelium, leukocytes , and plasma proteins,
dialyzer capillary membrane surfaces.
Monitoring
• APTT: (120-160 s) Or
• more than 50% above baseline of Activated clotting
time (ACT): n=90-140s.
Complications
• Pruritus, thrombocytopenia (rare in HD),
hyperlipidaemia, osteoporosis, hair loss, allergy
(rare).

56. Low Molecular Weight Heparins
Monitoring
•Anti-Xa activity: 0.4–0.6 IU/ml, and <0.2
IU/ml at the end of dialysis.
OR
•Clinical: Adjustment of the initial bolus dose
according to visual inspection of clotting in the
venous air detector and dialyzer, and the time
needed for needle puncture sites to stop
bleeding.
Comparison of currently available LMWHs

57. Hemodialysis Prescription Components

58. Hemodialysis Frequency andHemodialysis Frequency and
DurationDuration

59. hree sessions per week: (GFR equivalency: 10 to 20 %).hree sessions per week: (GFR equivalency: 10 to 20 %).hree sessions per week: (GFR equivalency: 10 to 20 %).hree sessions per week: (GFR equivalency: 10 to 20 %).
Number of sessionsNumber of sessions
Length of sessionLength of session
 Length: 3-4 hours to achieve Kt/V of 1.2-1.4.Length: 3-4 hours to achieve Kt/V of 1.2-1.4.
 Weight loss:Weight loss: 1.5 to 2% of dry BW/h1.5 to 2% of dry BW/h
< 5% of dry BW/session< 5% of dry BW/session
 Interdialytic weight gain >10% dry BW= noncompliance.Interdialytic weight gain >10% dry BW= noncompliance.
 Length: 3-4 hours to achieve Kt/V of 1.2-1.4.Length: 3-4 hours to achieve Kt/V of 1.2-1.4.
 Weight loss:Weight loss: 1.5 to 2% of dry BW/h1.5 to 2% of dry BW/h
< 5% of dry BW/session< 5% of dry BW/session
 Interdialytic weight gain >10% dry BW= noncompliance.Interdialytic weight gain >10% dry BW= noncompliance.

60. Is intensified hemodialysis
more beneficial in
children?

61. Intensified hemodialysis modalities provide improvement in quality of life,
biochemical and cardiovascular parameters,and likely anemia and nutrition.
Provided that a solution to the reimbursement problem is found,
intensified dialysis is expected to become a prevalent choice in the
treatment of ESRD.

62. Dialysis Adequacy

63. Dialysis AdequacyDialysis Adequacy

64. Dialysis AdequacyDialysis Adequacy
Hemodialysis dose
Urea reduction ratio (URR): < 0.35 Or > 65%.
or
Equilibrated Kt/V: >1.2
Calculated from post dialysis sample.
Urea reduction ratio (URR): < 0.35 Or > 65%.
or
Equilibrated Kt/V: >1.2
Calculated from post dialysis sample.
Monthly

65. Dialysis AdequacyDialysis Adequacy
Laboratory indices
 Pre-dialysis serum.
 Mid-week HD session.
 Dry needle or syringe.

66. Dialysis AdequacyDialysis Adequacy
Laboratory indices
 Serum bicarbonate: 20 – 26 mmol/l.
 Serum potassium: 3.5 and 6.5 mmol/l .
 Serum phosphate: Within, and preferably nearer to the 50th centile, for the
age appropriate normal range.
 Serum calcium, adjusted for serum albumin,: within the age appropriate normal
range.
 Serum albumin corrected calcium x phosphate product: less than 4.8 mmol2/l2.
 Serum PTH: Controversial. (less than twice the upper limit of normal for the
intact PTH assay used).
 Serum aluminium: No patient whose ferritin level is <100 μg/l should have a
serum aluminium concentration >60 μg/l (2.2 μmol/l).
 Hemoglobin: Greater than the lower limit of the age appropriate normal range.
 Ferritin: 100 and 800 mcg/L

67. Severe
Moderate
Risk
Normal
Biochemical markers
•Serum albumin
•Serum pre albumin
•Serum transferin
Dialysis AdequacyDialysis Adequacy
Clinical indices
Assessment of Nutritional Status

68. Malnutrition/Cachexia in HemodialysisMalnutrition/Cachexia in Hemodialysis
IncidenceIncidence
 18 to 56% have malnutrition.
 33% have mild to moderate malnutrition.
 6-8% have severe malnutrition.
•Mortelmans AK, Duym P, Vandenbroucke J, et al. J Parenter Enteral Nutr 1999; 23:90±95.
•Kalantar-Zadeh K, Block G, Kelly MP, et al. s. J Ren Nutr 2001; 11:23±31.

69. Robert H. Mak et al. Pediatr Nephrol (2012) 27:173–181
Malnutrition/Cachexia in HemodialysisMalnutrition/Cachexia in Hemodialysis
MechanismMechanism

70. Malnutrition/Cachexia in HemodialysisMalnutrition/Cachexia in Hemodialysis
Management

71. Lazarus JM. Recommended criteria for initiating and discontinuing intradialytic parenteral nutrition therapy. Am J Kidney Dis 1999;
33:211±216.

72.  Patients treated with IDPN may develop hypophosphatemia,
hypomagnesemia and hypokalemia and they could experience
refeeding syndrome.
 IDPN solutions should contain 500 ml of 10±15% amino acids, 250 ml
of 10±20% lipids and 250 ml of 50±70% dextrose. This formula
provides between 50 and 90 g of protein and 650±1100 kcal per
infusion.

73. Dialysis AdequacyDialysis Adequacy
Clinical indices
Monthly Every 6 Months
2 weeks
Yearly
Assessment of Growth and Development

74. Growth Failure in CRFGrowth Failure in CRF
IncidenceIncidence
North American Pediatric Renal Transplant Cooperative Study (2005) Annual Report. Renal
transplantation, dialysis, chronic renal insufficiency. Available at: http://spitfire.emmes.com/
study/ped/resources/annlrept2005.pdf. Accessed 2 Sept 2005.
58%
43%
33%
23%
0-1 y 2-5 y 6-12 y >12 y

75. Growth Failure in CRFGrowth Failure in CRF
MechanismMechanism
 Endocrinal: disturbances in GH- IGF-I axis, the
gonadotropic hormone axis and thyroid hormone
axis.
 Presence of calorie–protein malnutrition.
 Metabolic acidosis.
 Renal osteodystrophy.
 Age at onset of renal disease.
 Etiology of renal disease.

76. Growth Failure in CRFGrowth Failure in CRF
treatment
Is there a room for growth
hormone therapy?

77. The indications for GH therapy in children with CKD are:
• Continuing growth retardation despite the correction of
insufficient nutrition, metabolic acidosis, fluid and
electrolyte disorders, anemia and renal osteodystrophy
• GFR less than 75 mL/min per 1.73 m2
• Being below the 3rd percentile for age and gender

78. Treatment must be stopped in the event of any of the
following:
• Excessive sensitivity to rhGH or its compounds.
• Closure of the epiphyses.
• If neoplasia is suspected.
• If intracranial pressure increases.
• Severe hyperparathyroidism (parathyroid hormone
level >400 pg/mL in stages 2-4 and >900 pg/mL in
stage 5).
• Non-cooperation with the treatment.
Dose:
0.045-0.05 mg/kg per day or 4 IU/m2 per day. SC
injections.

79. CONCLUSIONS: One year of 28 IU/m²/wk rhGH in children with CKD
resulted in a 3.88 cm increase in height velocity above that of untreated
patients. Studies were too short to determine if continuing treatment
resulted in an increase in final adult height.

80. Conclusion
Growth assessments should be performed with great care in the children
with CRF. rhGH therapy should be started at an early age and stage of
CRF. Follow-up should be based on the effects and side-effects of the
growth hormone therapy.

81. SummarySummary

82. SummarySummary
 HD for children should take place in specialized pediatric
centers able to provide multidisciplinary support.
 A transfer process for adolescents must be in place and agreed
by referring and receiving units.
 Dialyzers and lines must be available in neonatal, pediatric and
adult sizes.
 Synthetic and modified cellulose low flux membranes are
recommended but high-flux membranes should be considered
especially in chronic long-term dialysis.

83. SummarySummary
 A fistula should be considered in children on long-term
dialysis; psychological preparation is necessary before fistula
creation, and pain during needling prevented.
 Vascular access surgery should be undertaken by
appropriately trained and skilled staff.
 A Kt/V of 1.2 should be the minimum for children and should
be checked monthly.
 Measurement of nutritional status and growth and
development should be used regularly as part of the
assessment of dialysis adequacy.
 Dry weight needs regular reassessment in the growing child.