Hemodialysis in
Children
DR. KHALID AL-ALSHEIKH MD
Director of Nephrology & Dialysis Center
Consultant Pediatric Nephrologist
AFHSR, Khamis Mushayt, KSA
Introduction
• In children with chronic kidney disease as GFR declines to less 30ml/min/1.73 m2 ( Stage 4 CKD)
• Preparation for renal replacement therapy are needed.
• The child and his family should be provided with information related to preemptive kidney
transplantation
• Peritoneal dialysis
• Hemodialysis
• Renal replacement therapy is initiated in children with CKD stage 5 in some children with CKD stage 4
• Hemodialysis in children progress over last 20 years
• Morbidity of the session has decreased
• Technological progress, the availability of ESA and GH enhanced dialysis dose and increase quality of
life
• Technically all children can underwent HD even infants
2
Indication of RRT
• Renal function, ?GFR
• Before uremic symptoms
• Fluid status
• Biochemical abnormalities
• Acute renal failure
• Oligoanuric
• Resistant volume overload to medical treatment
• Hyperkalamia resistant to medical treatment
• Persistent metabolic acidosis resistant to medical treatment
• Uremic encephalopathy
• Uremic pericarditis
• Inborn error of metabolism
• Intoxication
3
Incidence of ESRD in Children
• ESRD in children is uncommon
• Incidence in USA 14.8 / Million
New Zealand 13.6 / million
Japan 4 / million
• The choice of RRT children:
• ¼ underwent preemptive renal transplantation
• ½ started in peritoneal dialysis
• ¼ started in hemodialysis
• Preemptive kidney transplantation which is performed prior to the
need of dialysis.
• Renal transplantation is associated with better quality of life (Growth
and Development)
4
Pediatric Dialysis in Saudi Arabia
• HD Patients above 75 years and below 15 years of age 2012
• Below 15 years
223 (1.8%)
• 15-75
11739 (91.4%)
• Above 75
878 (6.8%)
• PD patients adult and children 2012
• Children 172/1327 = 13%
• Adults 1155/1327 = 87%
SCOT Annual Report 2012
5
Epidemiology of chronic kidney disease in children
Pediatr Nephrol (2012) 27:363–373‫و‬Jérôme Harambat & Karlijn J. van Stralen &Jon Jin Kim & E. Jane Tizard
6
Chronic Renal failure in children in Asir Region of
Saudi Arabia
N. Alharbi Saudi Journal of Kidney Disease and Transplantation 1997 V8 Issue 3 pp 294-297
7
Chronic Renal failure in children in Western
Area of Saudi Arabia
Jameela A. Kari Saudi Journal of Kidney Disease and Transplantation year 2006 V17 Issue I pp 19-24
8
9
Comparison of RRT Modalities in Children
10
Choices of Dialysis
• When preemptive transplantation is not an option
• the choices between the two forms of dialysis is generally
dictated by patients age, technical, social, compliance issues
and family preference.
11
12
Principle of Vascular Access
• Deliver adequate flow rate
• Has long use life
• Has low rate of complications
• - Infection
• - Stenosis
• - Thrombosis
• - Aneurysm
• - Limb ischemia
13
• The best is AVF
• USA
- CVC used most often more than AVF and graft
- CVC 89% For children<13 Years
64% 13-19 YEARS
• Review of 2006 annual reports (NAPRTCS) reveals that in a
family of pediatric patients 78.9% receiving HD have CVC as
primary access.
• AVF 12.3%
• AVG 8.5%
14
AV Fistula con’t.
• PREFERRED SITE FOR AVF IN CHILDREN
1.Radiocephalic
2.Brachiocephalic
3.Brachiobasilic with or without transposition
• Alternative:
- Ulnar artery to basilic vein
- Femoral artery to saphenous vein
- Nondominant forearm
15
Definite guidelines regarding
minimal vessel sites don’t exist
• General consensus preferred of minimum 2.5 mm venous
diameter
• Doppler U/S scanning or venography can provide
information regarding adequate:
A) vessel size
B) venous stenosis
16
AVG
AVG Should be considered an option for HD access in children especially who
require replacement of native vessels to perform an adequate anastamosis
Alternative materials:
1.Saphenous vein
2.Bovine
3.Umbilical
4.Darcon
5.Polyurethane, cryopreserved femoral vein
6.Polytetrafluorethylene (PTFE) is most commonly used
17
• One study compare bovine with PTFE graft demonstrated
fewer complications with PTFE ones:
• - Lower infections
• - Lower thrombosis
• - Easier to obtain and easier to repair
• 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
18
• Advantage of AVG
1.Shorter time to use
2.High primary potency rate
3.Ease of technical creation
• Sheath et al reported creation of 24 AVF and 28 AVG
respectively .
• The most common site of AVG is the thigh -50% of patients
• Disadvantages of AVG
1.Thrombosis
2.Stenosis
3.Infection
Sheath et al permanent vascular access survival in children and adolescent with end stage renal disease 2002 Kidney Int 62:1864-1869
19
• Ramage et al reported long term complications rate of AVF compare
with AVG in retrospective study conducted over 20 years
- Intervention rate 17.8% AVF compared to 33% of AVG
Reason of discontinuation of AVG were:
1. Infection 20%
2. Thrombosis 73%
• Chant et al evaluated dialysis adequacy , KT/V , URR, anemia
management and albumin status based on vascular access. No difference
between AVF & AVG
• Possible Complications of graft
1. Thrombosis
2. Stenosis
3. Infection
4.Steal syndrome
Ramage et al Vascular access survival in children and young adults receiving long term hemodilaysis 2005 AJKD 45:708-714
Chant et al Comparison of vascular access type for pediatric HD with respect to urea clearance, anemia management, & serum
albumin conc. 2005 AJKD 45:303-308
20
COMPARISON BETWEEN AVF & AVG
AVF
AVG
Lower infection
Higher infection
Lower thrombosis rate
Higher thrombosis rate
May take 3-6 months to mature
Can be use within few weeks
Primary Failure rate is higher
Primary Failure is lower
Secondary Failure rate is lower
Secondary Failure rate is higher
21
CENTRAL VENOUS CATHETER
• Central venous catheter are the most commonly used vascular access in
children in north America data from USRDS 40% of children who were
receiving chronic HD continued to use catheter
• Data from ANZDATA 2008 showed the catheters were used exclusively below
10 years of age
• NAPRTCS 2008
• 78% catheters
• 12% AVF
• 7% AVG
• European Pediatric Dialysis Working Group
• 60% catheters
• 38% AVF
• 2%AVG
22
CENTRAL VENOUS CATHETER
First choice in patient require urgent HD
2. Stage V CKD
3. As abridge from a patient who is expected to receive planned
transplant
4. Is training to transfer to PD
- Advantage
- It can be used immediately
- Disadvantage
1. Short life span
2. Thrombosis
3.Infection
4. Malfunction
5. Possible fibrin sheath formation
- Median survival times of CVC is 4 months – 10.6 months
23
CENTRAL VENOUS CATHETER
• Goldstein et al evaluated catheter survival time in 58
uncuffed & 22 cuffed CVCs
• Median survival time of uncuffed catheter is 31 days and
cuffed catheter is 123 days
• 1 year survival of long term cuffed catheter 27%
• CVC in children whose vasculature is too small <10 kg, CVC
may be the best temporary solution
•
Goldstein et al 1997 HD catheter survival and complications in children and adolescent pediatric nephrology 11: 74-77
24
• Two questions to be answered:
• What size of catheter to use?
• Where to put it?
25
“SIZE MATTERS!”
• Pousielle’s law-
Q = ∆Pπr4
8l
• Smaller diameters offer greater resistance to flow
• Longer lengths offer greater resistance to flow
• Decreasing the diameter by 1/5th is the same as doubling the length
(roughly a 2 French size difference)
27
Catheter Specifications
French
Size
5
7
8
10
12
Flow Rate
(ml/min)
?
80-100
150-200
250-300
285-330
28
Catheter Specifications
French
Size
5
7
8
10
12
Diameter
(mm)
1.67
2.3
2.7
3.3
4.0
29
Vascular Access
• Central Venous catheter
• Cuffed catheter
• Uncuffed catheter
type
Weight
size
Uncuffed catheter dual
lumen
Up to 20
8
20-30
10
Above 30
11.5
20-40
7
40-60
10
Above 60
12
20-40
10
Tesio Catheter
Ash Split
30
Complications of CVC
• USRDS data have shown sepsis rate with CVCs approximate 80/100
patient as compared to 10/100 patient for AVF
• Potential sequences of CVC include:
- Septic shock
- Subacute bacterial endocarditis
- Osteomyelitis
- Epidural abscess
• One study evaluated potential differences in infection rate based on
use of three agents for exit site care
- 2% chlorhexidine found infection rate is 0.5%
- 10% povidine iodine found infection rate is 2.5%
- 70% alcohol found infection rate is 2.3%
• Different antimicrobial catheter lock studies suggest that citrate is
ideal
31
PROS AND CONS OF CENTRAL VENOUS
CATHETER FOR HD IN CHILDREN
PROS
CONS
Easily placed
Infection rate high
Can be use immediately
Failure rate and replacement rate high
Painless to the patient
Blood flow rates are variable
Require little planning prior to placement
Permanent damage to central venous system
(stenosis/thrombosis)
Easily removed if used as transitional access for
future PD on transplant patients
Damage to central vessels can prohibit future
AVF/AVG placement in ipsilateral extremity
No vascular Steal
Possible arrythmia
Decreased risk of high outpatient cardiac failure
32
Monitoring of vascular access
• Goldstein et al described use of dilution technique on regular basis
on pediatric patient population to date improve the life of access.
• Use of ultrasound 50% reduction in number of hospitalized patient.
• This further supported by NFK/K-DOQI guidelines for pediatric
vascular access .
• Based on review of current literature the authors would propose the
following as tools for ongoing monitoring of AVFs and AVGs.
33
Access Monitoring
• 1. Inspection: the access should be assessed weekly
through inspection, palpation, and auscultation by the
nursing staff.
• - With specific attention to arm swelling.
• - Prolonged bleeding after needle removal.
• - Change in thrills or bruits.
• -The nephrologist should inspect the access at each physical examination.
• 2. Surveillance ↓KT/V or URR. Determination of access
recirculation should be documented on a monthly basis.
• Ultrasound dilution/month if not available do Doppler U/S /month.
34
Access Monitoring
• 3. Referral: Fistulogram with possible angioplasty if:
- Inadequate blood flow comprising adequacy.
- Elevate access recirculation >20% after needle connection.
- Corrected access flow less than 650ml/min/1.73m2 by U/S dilution.
- Consistent abnormality on Doppler U/S.
-Pseudoaneurysm has formed, rotation of puncture site can help minimize risk of
pseudoaneurysm.
35
Hemodialysis Prescription
• Hemodialysis Equipment:
• Tubing
• Dialyzer
• Dialysis Machine
• Tubing:
Tubing
Pt. weight
Venous (ml)
Arterial (ml)
Total
Mini Neonatal
<6 kg
21
8
29
Neonatal
6-12 kg
22
18
40
Pediatric
>12 kg
42
30
72
Adult
>30 kg
70
60
132
36
Types of Dialyzer
• Dialyzer:
• Types of Membrane
• Blood volume capacity
• Service area
• UF coefficient
• Clearance of various substances
• Sterilization
37
Hemodialysis Prescription
• Types of Dialyzer
• Low flux (KUF <10 ml/hr/mmHg)
• High flux KUF 15-60 ml/mmHg
• Hallow fiber (capillary)
• Parallel Plate
• Types of Membranes
• Unmodified cellulose low flux
• Modified cellulose (Low & high flux)
• Synthetic (low & high flux)
• Synthetic noncellulose membranes are more biocompatible, size of
dialyzer shouldn’t exceed 75-100% of patient service area
38
Selection of Dialyzer that can be used in children
UF Coefficient
(ml/min/mmHg)
Fill Volume
(ml)
Surface Area
(m2)
Dialyzer
9.5
77
1.3
Gambro
12.5
103
1.7
Polyflux 17L
53
81
1.1
Polyflux 11S
62
102
1.4
Polyflux 14S
71
121
1.7
Polyflux 17S
15
17
0.2
2H (HF)
33
52
0.6
6H (HF)
1.7
28
0.4
4.3
42
0.7
F4 HPS
6.2
63
1.0
F5 HPS
8.5
82
1.3
F6 HPS
9.8
102
1.6
F7 HPS
11.1
114
1.8
F8 HPS
49
69
1.1
62
78
1.3
130 (HF)
63
91
1.5
150(HF)
80
126
2.1
210(HF)
2.5
35
0.5
8.1
65
1.1
Fresenius
Xenium
Baxter
Polyflux 14L
F3
110 (HF)
CA-50 (LF)
FB 110GA
39
Hemodialysis Prescription con’t.
• Dialysis Machine:
• Precise control of UF, volumetric assessment
• Capable of low blood flow speeds
• Ability to use lines of varying blood volume
• Measure removal of very small amount of fluids
• Continuous blood volume monitoring
40
Hemodialysis Prescription
• Blood Flow rate
• 1st session 90 ml/m2
2-3 ml/kg/min
• Latter
5-7 ml/kg/min
150-200 ml/m2
• Dialysate: It compose
• Treated water
• Electrolytes Na 140 mmol/L, K 2-3 mmol/L. Cl 100-102 meq/L,
HCO3 40 meq/L, Mg 1.5-2 meq/L, Ca 1.25-1.5 mmol/L
• Acid Buffers
• Glucose 100 g/L
• Dialysate Flow rate 2 times more than blood flow rate, standard 500
ml/min
• UF: Standard weight 1.5-2 % of BW/hr. not more than 5% BW/HD
session
41
Hemodialysis Prescription cont.
• Anticoagulation
• 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
aPTT 120-160 or more than 50% above baseline of ACT
• Heparin lock: with concentrated heparin 50 U/kg/lumen for weight less than
10 kg
• 1000 U/ml
• 2500 U/ml
BW (10-20 kg)
BW>20 kg
42
Hemodialysis Prescription Components
Comments
Components
Pediatric/Neonatal according to the patient’s size
Blood Line
The size of the dialyzer should not exceed
75-100% of the patient SA
Dialyzer Size
90mL/m2/min to maximum of 150-200
ml/m2/min*
Blood-flow rate
500 ml./min is the standard, may vary 300-800
ml/min
Dialysate-flow rate
140 mmol/l
2-3 mmol/l
40mEq/l
1.25-1.5 mmol/L
Dialysate Composition* Sodium
Potassium
Bicarbonate
Calcium
1.5 to 2% of body weight/hr and not more than 5%
body weight/dialysis session*
Ultrafiltration Rate
Heparin is the standard; Loading dose 2000 IU/m2
followed by 400 IU/m2/hr*
Anticoagulation
Three sessions per week for 3 to 4 h per session to
achieve the minimum target prescription of 1.2 to
1.4 Kt/V
Treatment duration and Frequency of Hemodialysis
Sessions
43
Hemodialysis Adequacy
• Hemodialysis adequacy: Minimum adequate dose of HD
given 3/times/week to patient with Kr less than
2ml/min/173m2, spkt/v 1.2/dialysis
• URR of 65%
• Target dose HD 3 times/week
• spkt/v 1.4/dialysis not including residual kidney
function
• URR 70% single port kt/v
44
Methods of Measurement of Delivered Dose of Hemodialysis
Single-pool Kt/V calculated by Daugirdas II Formula
• Equation I:
• spKt/V = - In (C1/C0 – 0.008 x t) + (4 – 3.5 x C1/C0) x UF/W
• Equilibrated kt/V
• Equation II:
• estBUN = ([BUN15min – BUN30secs]/0.69) + BUN30secs
KDOQI Guidelines 2006
Cherry Mammen, Goldstein White Standard kt/V threshold to accurately predict single pool kt/V target for children
receiving thrice weekly maintenance HD. Nephrology Dialysis Transplant 2010
45
Methods of Measurement of Delivered Dose of Hemodialysis
• Equation III:
• cKt/V (Goldstein) = -1n (estBUN/CO – 0.008 x t)+ (4-3.5 x estBUN/C0) x UF/W
• Equation IV:
• stdKt/V = 168 * [1-exp[-eKt/V]/t]/
• [1 – exp [ - eKt/V]/spKt/V] + [168/(N * t) – 1]
• Equation V:
• URR = 100x(estBUN – BUN30secs)/ BUN30secs
• Equation VI:
• %UFF = 100 – [(pre-treatment weight – post-treatment weight)/post-treatment
weight]
Cherry Mammen, Goldstein White Standard kt/V threshold to accurately predict single pool kt/V target for children
receiving thrice weekly maintenance HD. Nephrology Dialysis Transplant 2010
46
Recommended Methods vs Treatment Type for
2-3 HD per week
• For 2 or 3 dialysis Treatment per week
• Single pool Kt/Vurea determined by:
• Urea kinetic modeling
• Simplified multivariable equation
• Equilibrated Kt/V (eKt/V)
• Bloodless measurements of dialyzer clearance using ionic conductance or
dialysate urea monitoring URR
• Double pool Kt/Vurea by formal kinetic modeling (used only for research
purposes)
• Solute removal index (SRI) from dialysate collections
• For more frequent dialysis: a continuous equivalent of kidney
clearance
• Standard Kt/Vurea
• Normalized Kt/Vurea
47
Maintaining Hemodialysis Adequacy
• Preservation of residual renal function
• Aggressive Management of HTN
• Avoidance of Excessive UF
• Avoidance of potential insults to RRF (contrast,
medications, infection, volume, contraction)
48
Lower Kt/V causes
• If spKt/V is lower than expected:
• Blood flow rate
• Duration of treatment
• Dialysate flow
• Dialyzer specification and KoA
• Intradialytic hypotension
• Undetected early termination of treatment
• Was the anticoagulation adequate?
• Was post dialysis blood sampling appropriate?
• Was the needle size and placement appropriate and optimal?
• Was the blood pump adequately calibrated?
• Was the blood pump segment wrong?
• Was parenteral nutrition infused during treatment?
49
Practical example of hemodialysis adequacy
Month
Weight (kg)
spKt/V
nPCR
1
34.3
1.40
1.20
2
35.2
1.32
1.15
3
36.1
1.20
1.18
50
Practical example of hemodialysis adequacy
Month
Weight (kg)
spKt/V
nPCR
1
34.3
1.40
1.20
2
35.2
1.32
0.90
3
36.1
1.20
0.65
51
Practical example of hemodialysis adequacy
Month
Weight (kg)
spKt/V
nPCR
1
34.0
1.40
1.05
2
32.5
1.32
0.95
3
31.3
1.45
0.88
52
Anemia Management in ESRD in children
• Hb 11-12 g/dl
• Serum ferritin target level >100 mg/ml
• Tsat >20%
• Monthly (CBC & reticulocyte count)
• Every 3/12 serum ferritin, serum Tsat and serum iron.
• with change therapy CBC weekly for 6/52
53
• Eryhtropoetin
• Initial dosing of HD below 5 years 250-300 unit/kg/week)
• Above 5 years 150-200 units/kg/week
• Darbapoetin 0.45 – 0.75 mcg/kg/week
• IF Hb above target level or increase by 1.3 g/dl in 2 weeks
decrease 25% of ESA
• IF Hb increase 1.6-2 g/dl isn’t achieved over 8 weeks increase
ESA by 25%
• Iron
• Iron dextran need test dose because of anaphylaxis
• Iron gluconate, sucrose. No need for test dose
KDOQI Guidelines 2006
54
Bone Mineral Management in ESRD
• Serum phosphorus
• Children 1-12 years 4-6 mg/dl (1.26-1.93 mmol/L)
• Children over 12 years – 3.5-5.5 mg/dl (1.13-1.78 mmol/L)
• Serum calcium
• 8.8-9.5 mg/dl
• 2.20-2.37 mmol/L
• Ca x phosphate products should be less than 5 mmol/L
• Total eliminated Ca should not exceed 2500 mg/day
• Metabolic acidosis HCO 22 mmol/L
KDOQI Guidelines 2006
55
Bone Mineral Management in CKD
CKD stage
GFR Range
(ml/min/1.73 meter square)
Target serum PTH
2
60-89
35-70 PG/ml, 3.85-7.7 pmol/l
3
30-59
35-70 pg/ml, 3.85-7.7 pmol/l
4
15-29
70-110 pg /ml, 7.7-12.01 pmol/l
5
<15 or dialysis
200-300pg/ml, 22-33 pmol/l
56
Bone Mineral Management in CKD
Stage
GFR
Calcium, PO4, total CO2
PTH, alkaline phosphatase
2
60-89
At least yearly
At least yearly
3
30-59
At least every 6 months
At least every 6 months
4
15-29
At least every 3 months
At least every 3 months
5
<15 or dialysis
At least every month
At least every 3 months
57
Nutritional Status
• Phosphorus – CKD 3 – 5 and 5D decrease dietary phosphate to 80% of DRI for age
when PTH above target range of CKD and phosphate exceed normal reference
• Protein – dietary protein 100-140 of daily protein requirement for CKD 3-5
• Carbohydrate: Normal carbohydrate compare to age match healthy child
• Vitamins – B1, B2, B3, B5, B6, B8, B12, vitamin C, A, K, folic acid, copper, zinc should
be 100% of daily requirement
• Trace elements 100% if clinical evidence of deficiency
• Free water & Na supplementation should be consider for polyuric child.
• Na supplements should be consider for all infants in PD due to substantial loss even
anuric and to be restricted for hypertensive child
• Potassium should be restricted for CKD 2-5
• Acidosis is to be corrected to HCO3 22 mmol/l
KDOQI Guidelines 2006
58
Nutritional Status
• Growth
• Growth hormone CKD 2-5 for short stature or height /age <3rd centile persist for 3
months despite adequate nutritional treatment and correction of metabolic abnormalities
• Calories should be 100% maintaining its chronological age
59
Complications During Hemodialysis
• Disequilibrium symptoms – movement of water to brain cell by
osmosis due to sudden drop of urea in plasma
• Presentation: Nausea, headache, dizziness and seizure, coma
• Treatment: Blood flow, dialyzer, duration of treatment
• Mannitol of infusion 1g/kg over 1 h
• 1st session 30% drop, increase 50%, target 70-75% urea reduction
• Ct/C0 = e –kt/V
• Ct urea after t minutes of dialysis
• C0 urea at initiation of dialysis
• K – specific dialyser urea clearance ml/min
• V = Patient urea volume of distribution
60
Complications During Hemodialysis
• Hypotension:
• Intravascular volume depletion due to slow refiling from extravascular space
• Use of dialysate Na lower than plasma
• Exchanging UF
• Impaired sympathetic activity
• Warm dialysate – vasodilation
• Splanching pooling of blood while eating during dialysis
• Use of antihypertensive medication on day of dialysis
• Treatment:
• NS 5 ml/kg
• Cessation of UF
• Reassessment of target eight daily fluid allowance review
• Separate UF from dialysis
• Na ramping
• Hct monitoring
61
Complications During Hemodialysis
• Intradialysis hemolysis
• Symptoms: Pain & nausea
• Presentation: Dark appearance to venous blood due to over heating, contamination,
hypertonicity of dialysate, kinking of line, malfunctioning of pump
• Treatment: Stop dialysis, check potassium
• Urticaria: antihistamine or hydrocort
• Air embolism: rare as air detection will clamp the return line 1 ml/kg
• Symptoms: Seizure, coma, chest symptoms
• Treatment: Clamp lines, stop pump, put head down, give 100% oxygen
• Air may need to be aspirated from ventricles
62
Complication Post-Dialysis
• Malnutrition is common is children receiving hemodialysis.
The risk of death is reported:
• 54% for each 1 g/dl fall in albumin
• 57% reduced if serum albumin >4g/dl
• 14% increased with each decrease of one height of
standard deviation score below normal at start of dialysis
• Neuropsychologial outcomes: One study showed children
below 18 months have:
• 42% neuropsychological impairment
• 58% attend regular school
63
64
65
Social & Psychological Issues
• Dialysis Unit
• Vacation
• School
• Economic status
• Transfer of Service
66
Complication Post-Dialysis
• Renal osteodystrophy
• Cardiovascular Disease
• Hypertension – in one case series 624 children in HD
79% of them was with hypertension and with 62%
receiving antihypertensive medications
• Left ventricular hypertrophy up to 80%
67
Mortality
• Mortality risk in children in dialysis is >30 times higher than age and gender match
normal children
• US 5 years survival of 2867 patient starting dialysis at age 1, 1-5, and >5 years was
60, 80, and 85%
• ANZATA- RRT 1963-2002 demonstrated a 10 years and 20 years survival 79% and
66%.
• Mortality is higher in children in dialysis and less post transplant as noted by
ANZATA
• UK Network 10 fold higher risk of death in children on dialysis compared to those
were transplanted
• Cause of Death is CVD 1000 fold higher in young adults on dialysis than age match
normal
• USRDS – 22.5% of death due to CVD
• ANZATA 45% of death due to CVD
• Dutch 41% of death due to CVD
68
Mortality
• Age at start of dialysis
• NAPRTCS report lower survival for children who begin
HD before 1 year of age with survival rate of 82, 73 63%
at 1, 2, 3 years after initiation of dialysis.
• Comparison of survival between Hemodialysis and PD
• Italian registry showed no difference between 5-15
years but below 5 years who were most exclusively
managed by PD had a poorer 5 years survival
• USRDS showed no difference in 5 years survival
between PD and hemodialysis at any age
69
Mortality
2013 USRDS Annual Data Report, Pediatric ESRD volume 2
70
Mortality
2013 USRDS Annual Data Report, Pediatric ESRD volume 2
71
Mortality
2013 USRDS Annual Data Report, Pediatric ESRD volume 2
72
Mortality
2013 USRDS Annual Data Report, Pediatric ESRD volume 2
73
Summary of Hemodialysis in Children
• Although principles of hemodialysis are similar for adult and
children there are fundamental differences in technical aspect of
procedures and complications
• Optimal care is provided by multidisciplinary team (Pediatric
Nephrologist, skilled nurses, dietician, vascular access
coordinator, vascular surgeon, radiologist, psychologist, and
social worker)
• Good vascular access is essential for the success of hemodialysis
• Hemodialysis equipment must be modified for pediatric patient
• Long-term quality of life is lower in children on dialysis
compared with normal healthy control and children receiving
renal transplant
74
75