2. Dialysis
• Dialysis is the diffusion of solute molecules
through a semipermiable membrane, passing
from higher concentration to that of lower
concentration. It is the process of separating
colloids and crystalline substances in solution by
the difference in their rate of diffusion through a
semi permeable membrane.
• The purpose of dialysis is to remove endogenous
and exogenous toxins and to maintain fluid
electrolyte and acid- base balance till the renal
function recovers. It is a substitute for some
excretory functions of kidneys but does not
replace the endocrine and metabolic functions.
4. INDICATIONS
• Uremic symptoms with neurologic
abnormalities
• Persistent hyperkalemia, above 6.5 mEq/L
• Blood urea level more than 150 mg./dl
• Severe acidosis, pH less than 7.2, TCO2 less
than 10-12 mEq/L
• Hyperphosphatemia
• Pulmonary edema and CCF
6. 1.Hemodialysis
Pediatric hemodialysis is referred to
extracorporeal renal replacement therapy in
children under the age of 15 years. The
neonates, infants and smaller children have
special requirements for dialysis. Pediatric dialysis
program could start even from a neonate who is
less than 1 kg. The treatment requirements
almost are similar to adults but there are certain
differences as:
– Renal replacement therapies
– Growth and development
– Psychological demands.
7.
8. SPECIFIC CONSIDERATIONS:
1. The extracorporeal circuit
The amount of blood occupied by the blood
vessels and the dialyser should not exceed more
than 10% of the total blood volume of the child.
If the child is severely anaemic ( Hb < 5-6g/dL)
the extracorporeal circuit volume should not
exceed 7%. The total blood volume can be
calculated by multiplying the child’s weight by
80mls.
9. 2. Blood lines and dialysers
-The surface area of the dialyser should not exceed the body
surface area (BSA) of the child.
-BSA (Mostellar equation) =Multiply the height by weight
Divide the result by 3600
Determine the square root of
result
-i.e., SA(m2)= √([Ht in cms x Wt in kgs]÷3600)
3. Blood flow rate
It is determined by the child’s size, blood volume, blood
pressure and tolerance for dialysis.
-Blood flow rate should not exceed 2.5 x weight (kg) ÷ 100
12. TREATMENT PARAMETERS:
• Fluid replacement for hypotension should not
exceed a maximum of 10ml/kg body weight
and may given in divided doses.
• Ultra filtration should not exceed 5% of total
body weight for each dialysis session.
• Clearance rates for urea should not exceed 3
mls/min/kg body weight with 1.5 to
2ml/min/kg body weight for extremely uremic
children.
13. VASCULAR ACCESS:
Vascular access are of the three types:
• Fistulas
Arterio vascular fistula is an access in which a vein and
artery are connected surgically. The preferred site is the
radial artery and a forearm vein that produces dilation and
thickening of superficial vessels of the forearm to provide
easy access for repeated venipuncture.
• Grafts
Subcutaneous (internal) arteriovenous graft is a
synthetic prosthetic graft for circulatory access made by the
anastomosis of artery and vein.
• External vascular access
For this percutaneous catheters are inserted in the
femoral, subclavian or internal jugular veins. A central
catheter into internal jugular vein is more permanent form.
14.
15. COMPLICATIONS
• more prone to cardiovascular instability due
to small blood volume.
• Excessive weight loss
• Hypotension
• Hypothermia in infants
• Dialysis equilibrium syndrome
16. Dialysis equilibrium syndrome:
Fluid removal and decrease in BUN during hemodilaysis
cause changes in blood osmolarity. These changes trigger a fluid
shift from the vascular compartment into the cells. In the
brain, this can cause cerebral edema, resulting in increase
intracranial pressure and visible signs of decreasing level of
consciousness.
Symptoms:
Sudden onset of headache, nausea and
vomiting, nervousness, muscle
twitching, palpitation, disorientation and seizures
Treatment:
Hypertonic saline, Normal saline
If immediate treatment for disequilibrium is not provided it
leads to:
– Convulsions
17. ADVANTAGES
• suited for children who
do not have someone
in family to perform
home peritoneal
dialysis
• easy for those who live
near dialysis center
• achieves rapid
correction of fluid and
electrolyte abnormality
DISADVANTAGES
• associated to the rapid
change, it can cause
muscle cramping and
hypotension
• school absence during
dialysis
• strict fluid and dietary
restrictions
• boredom for child
during the session
18. 2. Peritoneal dialysis
Peritoneal dialysis is a technique that
employs the patient’s peritoneal membrane as
a dialyzer. Excess body water is removed by an
osmotic gradient created by the high dextrose
concentration in the dialysate; wastes are
removed by diffusion from the peritoneal
capillaries into the dialysate.
Because peritoneal dialysis is not as efficient
as hemodialysis, it must be performed daily
rather than 3 times weekly as in hemodialysis.
19.
20. 3 steps in peritoneal dialysis
Infusion :
A sterile, dialysis solution flows into your peritoneal cavity by gravity via a
catheter or tube that has been surgically placed into the abdomen. The
filling takes about 10 minutes. Once the filling is complete, the catheter is
shut so that it does not leak.
Dwell :
The lining of the peritoneal cavity called the peritoneum acts as a natural
filter. It lets the waste products and excess fluids in the blood filter
through into the dialysis solution, while holding back important
substances that the body needs. The length of time varies from 3 - 6
hours. While the solution is in the body you can move about.
Drain :
The dialysis solution containing the wastes is drained again by gravity from
your body through the catheter into an empty bag. This takes about 10-20
minutes. A bag containing sterile dialysis solution replaces the bag
containing waste products. The whole process is then repeated. Each of
these replacements is called a ' Bag Exchange'.
24. 1.Continuous ambulatory peritoneal dialysis
It is the most commonly used method of
peritoneal dialysis. The filtration process
occurs most hours of the day. The exchange
usually take about 3 minutes 3-4 times a day
and only require a solution bag with tubing
attached to it that connects to the child’s
blood stream. It gives freedom.
25. 2.Automated Peritoneal Dialysis
a)Continuous Cyclic Peritoneal Dialysis
Continuous regimen means that the dialysis
solution is present in the peritoneal cavity
continuously, with the exception of short
significant periods between exchange.
It uses duel lumen catheterization, i.e., 2
catheters, one for inflow and other for outflow.
26. b)Intermittent Peritoneal Dialysis
• It means the dialysis sessions are
performed several times a week.
• This technique uses one catheter for inflow
and outflow. Flow is interrupted after both
inflow and outflow during exchange.
- Nocturnal intermittent peritoneal
dialysis
27. PROCEDURE
The abdomen is cleaned in preparation for
surgery, and a catheter is surgically inserted with
one end in the abdomen and the other protruding
from the skin. Before each infusion the catheter
must be cleaned, and flow into and out of the
abdomen tested.
The warmed solution is allowed to enter the
peritoneal cavity by gravity and remains a variable
length of time (usually 10-15 minutes) according to
the rate of solute removal and glucose absorption in
individual patients. The total volume is referred to as
dwell while the fluid itself is referred to as dialysate.
28. The dwell can be as much as 2.5 litres, and
medication can also be added to the fluid
immediately before infusion. The dwell remains
in the abdomen and waste products diffuse
across the peritoneum from the underlying blood
vessels. After a variable period of time depending
on the treatment (usually 4–6 hours), the fluid is
removed and replaced with fresh fluid.
29. RISKS
• HTN & other cardiac complications
• Seizure
• Obstructed catheter
• Dialysate leakage
• Hyperglycemia
• Increased triglyceride levels
• Increased protein loss
• Parental stress and burnouts
30. ADVANTAGES
• Ability to perform dialysis treatment at home
• Technically easier than hemodialysis, especially
in infants
• Ability to live a greater distance from medical
center
• Freedom to attend school and after-school
activities
• Less-restrictive diet
• Less expensive than hemodialysis
• Independence (adolescents)
31. DISADVANTAGES
• Catheter malfunction
• Catheter-related infections (peritonitis, exit
site)
• Impaired appetite (due to full peritoneal
cavity)
• Negative body image
• Caregiver burnout
32. 3.Continuous Renal Replacement
Therapies
It is useful in patients with unstable
hemodynamic condition, sepsis etc. it is an
extra corporeal therapy in which fluid and
electrolytes are continuously removed from
blood using a special pump-driven machine. It
continuously pass patient’s blood across a
highly permeable filter.
33. 1. Continuous venovenous hemofiltration
Large amount of fluid moves by pressure across the
filter bringing with it by convection other molecules
such as urea, creatinine, uric acid and phosphorus. It is
replaced with desirable electrolyte composition similar
to blood.
2. Continuous venovenous hemodialysis
It utilizes the principle of diffusion by circulating
dialysate in a countercurrent direction on the ultra
filtrate side of the membrane, no replacement fluid is
used.
3. Continuous venovenous hemodiafiltration
It employs both the replacement fluid and
dialysate, offering the most effective solute removal of
all forms of renal replacement therapies.
34. ADVANTAGES
• Hemodynamic stability
– Avoid hypotension complicating hemodialysis
– Avoid swings in intravascular volume
• Easy to regulate fluid volume
– Volume removal is continuous
– Adjust fluid removal rate on an hourly basis
• Customize replacement solutions
• Lack of need of specialized support staff
35. DISADVANTAGES
• Lack of rapid fluid and solute removal
– GFR equivalent of 5 - 20 ml/min
– Limited role in overdose setting
• SLED – Developing role
• Filter clotting
– Take down the entire system
36. RENAL TRANSPLANTATION
• Kidney transplantation is recognized as the
optimal therapy for children with end-stage
renal disease (ESRD
• The child may achieve 40 – 80 % renal
function with the transplant and demonstrate
improved growth, enhanceded cognitive
development, and improved psychosocial
development and quality of life.
37.
38. INCIDENCE AND ETIOLOGY
• Congenital, hereditary, and cystic diseases are
the cause in more than 52% of children 0 to 4 yr
of age,
• Glomerulonephritis, focal segmental
glomerulosclerosis account for 38% of cases in
10 to 19 yr of age.
• Structural disease (49%)
• Various forms of glomerulonephritis (14%)
• Focal segmental glomerulosclerosis (12%)
40. DONOR SELECTION
• Living related donor
Living related donor is preferred for a pediatric
patient because it allows transplantation to be planned
when the child ad donor is in optimal health. The
suitable donors include
parents, siblings, grandparents, uncles and aunts.
• Cadaveric donor
A cadaveric transplant is placed when there is no
availability of a related living donor. A cadaver is a
patient declared brain dead who had previously given
consent for organ donation. After permission for
donation is granted, the kidneys are removed and stored
until a recipient has been selected.
41.
42. PREPARATION FOR TRANSPLATATION
• A pre–emptive transplantation is preferred for
children.
• Clinical and laboratory evaluation of kidney
donor and recipient
- Blood Type Testing
- Tissue Typing
- Crossmatch
- Serology
43. CONTRAINDICATIONS
• Pre-existing metastatic malignancy or HIV
• Patients with remission of malignancy off
maintenance treatment for a minimum of 2 yr may
be reconsidered on an individual basis for
transplantation, with close post-transplantation
surveillance
• Patients with autoimmune diseases resulting in
ESRD are candidates for transplantation after a
period of immunologic quiescence of the primary
disease for a period of at least 1 year before
transplantation.
• Severe neurologic dysfunction
44. SPECIAL CONSIDERATIONS
• Dialysis may be required for a period before
transplantation to optimize nutritional and metabolic
conditions, to achieve an appropriate size in small
children or to keep a patient stable until a suitable
donor is available
• For young infants, a recipient may need to weigh at
least 8-10 kg to minimize the risk for vascular
thrombosis and to accommodate an adult-sized kidney.
This can require a period of dialysis support until the
child is at least 12 to 18 mo of age.
• It would be best match the recipient with an
appropriately sized cadaveric kidney. But it increases
the chance of vascular thrombosis. Sibling donors of
same size are best suitable.
45. • Transplantation with an adult-sized kidney has
been successful in children who weighed <10 kg or
were <6 months of age.
• For children weighing 20kg or more, the kidney is
placed extra peritoneally. Intraperitoneal approach
is required for those weighing less than 20 kg and
receiving adult kidney. If the donor is less than 2
years, the kidneys are transplanted ‘en-
block’, together with donor aorta and venacava.
• Many surgeons prefer to remove the appendix at
the time of transplantation as it will be difficult to
differentiate between appendicitis and tenderness
that accompanies acute rejection
46. PROCEDURE
This type of
operation is a
heterotopic transplant
meaning the kidney is
placed in a different
location than the
existing kidneys. The
kidney transplant is
placed in the front
(anterior) part of the
lower abdomen, in the
pelvis.
47.
48. The original kidneys are not usually
removed unless they are causing severe
problems such as uncontrollable high blood
pressure, frequent kidney infections, or are
greatly enlarged.
The artery that carries blood to the kidney
and the vein that carries blood away is
surgically connected to the artery and vein
already existing in the pelvis of the
recipient. The ureter, or tube, that carries
urine from the kidney is connected to the
bladder.
49.
50.
51. POST TRANSPLANTATION COMPLICATIONS
• Rejection
– Hyperacute rejection: occurs within minutes to hours after
transplantation
– Renal vessels thrombosis occurs and the kidney dies
– There is no treatment and the transplanted kidney is
removed
• Acute Rejection: occurs 4 days to 4 months after
transplantation
- It is not uncommon to have at least one rejection episode
-Episodes are usually reversible with additional
immunosuppressive therapy
Signs: increasing serum creatinine, elevated BUN, fever,
wt. gain, decrease output, increasing BP, tenderness
over the transplanted kidneys
52. • Chronic Rejection: occurs over months or years
and is irreversible.
₋ The kidney is infiltrated with large numbers of T
and B cells characteristic of an ongoing , low grade
immunological mediated injury
₋ Gradual occlusion renal blood vessels
Signs: proteinuria, HTN, increase serum
creatinine levels
Supportive treatment, difficult to manage
Replace on transplant list
54. NURSING MANAGEMENT
• Immediate post operative management:
• Preventing rejection and promoting renal function
• Administer immuno suppressants accurately on time.
• Focus on achieving graft functioning
• Early mobilization
• Monitor closely for few days with attention to fluid and
electrolyte replacement
• Assess for rejection and infections.
• Care should be given to central venous
catheter, arterial line, Indwelling urine catheter, Drain
tube to collect leakage from anastomoses.
• Fluid balance and central venous pressure should be
monitored to ensure appropriate renal perfusion
