dr.

Pringgodigdo Nugroho, SpPD-KGH

HEMODIALYSIS IN CHILDREN Nephrology Division

Internal Medicine Department
FMUI-RSCM
OUTLINE

Indication Vascular Equipment

and Goal Access

Complications Adequacy Dialysis

Prescription
INDICATIONS TO INITIATE DIALYSIS
Absolute Relative
 Neurologic symptoms due to uremia  Less severe uremic symptoms
 Pericarditis  Metabolic disturbances that can not
 Tendency to bleed be treated conservatively:
 Hyperkalemia
 Refractory nausea or vomiting  Growth failure
 Hypertension unresponsive to  Hyperphosphatemia
antihypertension  Malnutrition
 Pulmonary edema unresponsive to
diuretic
KDIGO Board Members. Kidney Int Suppl 2013;3:117-8.
Daugirdas JT, et al. Handbook of dialysis. 5th Edition. Philadelphia: Wolters Kluwer Health; 2015.
GOAL OF HEMODIALYSIS IN CHILDREN

Remove excessive fluid

Remove uremic toxins safely and

effectively

Preservation of blood vessels for a

lifetime renal replacement therapy (RRT)

Rees L. Hemodialysis for children with chronic kidney disease. UpToDate. 2017.
CHOICES OF VASCULAR ACCESS FOR
HEMODIALYSIS IN CHILDREN

Tunneled CVC

AV Fistula

AV Graft
Rees L. Hemodialysis for children with chronic kidney disease. UpToDate. 2017.
Daugirdas JT, et al. Handbook of dialysis. 5th Edition. Philadelphia: Wolters Kluwer Health; 2015.
TUNNELED CENTRAL VENOUS CATHETER (CVC)
 Limitations:  Most used vascular access
 Malposition can lead to malfunction or  79% patient in North American
Infection, due to repeated disconnection (NAPRTCS) 2011 (subclavian 51%, jugular
and flushing  increased exposure to 44%, femoral 4%)
organisms
 Need replacement: damage central vein  United States (USRDS) 2009: 40%
and preclude future fistula formation
 Australian and New Zealand (ANZDATA)
 Temporary; suitable for patient with 2008: all of children < 10 years old, and
short period of time 90% in older children

 Avoid needling issue in children  European: 60%

Rees L. Hemodialysis for children with chronic kidney disease. UpToDate. 2017.
TUNNELED CENTRAL VENOUS CATHETER (CVC)
 Commonly used: double lumen catheter
(silicone or polyurethane composites)
 Smaller children: joined proximally and
separated distally catheter
 Very small children: single lumen
 Double pump method that pumps alternately
 Single pump that pumps intermittently, using gravity to
let blood flow back into child
 Need expansion chamber to allow pressure changes
 increased volume of blood in circuit
 Larger degree of recirculation
Rees L. Hemodialysis for children with chronic kidney disease. UpToDate. 2017.
Daugirdas JT, et al. Handbook of dialysis. 5th Edition. Philadelphia: Wolters Kluwer Health; 2015.
 TUNNELED CENTRAL VENOUS CATHETER (CVC)
Weight of child (kg) Catheter gauge (Fr) Catheter length (cm)  Increased gauge will allow
Double lumen higher blood flow rates
3-12 8 12 or 18  Too large catheter can
10-25 10 or 12.5 12 or 19 lead to vessels obstruction
15-30 10 or 12.5 19 or 28  reduced venous return
> 25 14 24
> 30 12 or 13.5 23 or 26
> 40 12 40
Single lumen
<5 6.5 29 or 32
> 10 10 36 or 40
Rees L. Hemodialysis for children with chronic kidney disease. UpToDate. 2017.
TUNNELED CENTRAL VENOUS CATHETER (CVC)
 Position: internal jugular vein; tunneled superficially to exit on upper anterior chest
 Catheter tip should be at junction of superior vena cava and right atrium or in
right atrium to provide adequate dialysis
 For small children: use ultrasound as guide
 Neonates:
 Femoral vein  limitations: damage to inferior vena cava
 Through umbilical vessel to inferior vena cava; if the umbilical vessel is patent

 Subclavian vein should be avoided: stenosis may prevent successful fistula

formation
Rees L. Hemodialysis for children with chronic kidney disease. UpToDate. 2017.
Daugirdas JT, et al. Handbook of dialysis. 5th Edition. Philadelphia: Wolters Kluwer Health; 2015.
ARTERIOVENOUS (AV) GRAFT
 Usually used whenever other options have failed or blood vessel is too small
to make an adequate AV fistula
 Limitations:
 Complications (infection, stenosis, thrombosis) lead to shorter vascular access survival time

Rees L. Hemodialysis for children with chronic kidney disease. UpToDate. 2017.
Daugirdas JT, et al. Handbook of dialysis. 5th Edition. Philadelphia: Wolters Kluwer Health; 2015.
ARTERIOVENOUS (AV) FISTULA
 Best form of vascular access: more  Vein to artery anastomosis
effective with fewer complications  Most common: radiocephalic/wrist
 Brachiocephalic/upper arm
 Longer lifetime: 2/3 still functioning
after 5 years whereas survival of  2 stage basilic vein transposition for small
children
tunneled lines 30-85%
 Limitations:
 Require time to mature
 Needling issue in children

Recommendation: initiate HD through AV fistula when there is time to mature,

feasible, needling is tolerated, and not likely to receive transplant in 6 months
Rees L. Hemodialysis for children with chronic kidney disease. UpToDate. 2017.
EQUIPMENT: EXTRACORPOREAL CIRCUIT
 Composed of arterial (inflow), venous (outflow), and dialyzer
 Volume in the circuit is limited by upper safe limit for extracorporeal blood volume, a
child can tolerate 8% of his/her blood in extracorporeal circuit
 Total blood volume is calculated 80 mL/kg estimated optimum weight
Patient weight (kg) Venous (mL) Arterial (mL) Total (mL)
Mini-neonatal <6 21 8 29
Neonatal 6-12 22 18 40
Pediatric > 12 42 30 72

 Infants: PD is preferable due to higher risk of HLA sensitization that occurred

because of priming with donated blood (smallest circuit may exceed safe
extracorporeal volume)
Rees L. Hemodialysis for children with chronic kidney disease. UpToDate. 2017.
EQUIPMENT
Dialyzer HD Machine
 Minimize blood volume, provides  Blood pump: move blood between patient
reliable and predictable solute and machine
clearance and ultrafiltration  Delivery system: transport dialysis solution
coefficient (KUf)
 Monitoring devices: pressure monitors
 Choice of dialyzer depends on located proximal to blood pump and distal
 Surface area of child: ranging 0.25-1.7 to dialyzer guard
m2
 Volumetric fluid removal system
 Type of hemodialysis: standard or
hemodiafiltration  Ability to keep low blood flow speeds and
use lines of varying blood
Rees L. Hemodialysis for children with chronic kidney disease. UpToDate. 2017.
 EQUIPMENT: SMALL INFANTS AND HOME HD

NxStage System One:

NIDUS Machine: • Home HD
CARPEDIEM Machine: • Single lumen catheter with
• Dialyzer surface areas: extracorporeal circuit volume < 10 mL
0.075-0.25 m2 • High flux polysulfone 0.045 m2
• Flow rates: 5-50 mL/min
Rees L. Hemodialysis for children with chronic kidney disease. UpToDate. 2017.
• Dual lumen catheter 4-4.5 Fr
DIALYSIS PRESCRIPTION

Dialyzer Hemodialysis or
selection hemodiafiltration Tubing selection Blood flow rate
(HDF)

Length and Fluid removal Dialysate Heparinization

frequency amount composition

Rees L. Hemodialysis for children with chronic kidney disease. UpToDate. 2017.
DIALYSIS PRESCRIPTION
Dialyzer Selection Blood Flows
 Depends on use of conventional  Speed of which blood is pumped out
hemodialysis or hemodiafiltration of child and around circuit
(HDF)
 High blood flow
 Ultrafiltration coefficient (KUf):
ability to remove water; depends on Increase solute
surface of area of dialyzer and clearance Compromise
membrane characteristics cardiovascular
stability
 < 10 mL/hr per mmHg: low flux
 15-60 mL/hr per mmHg: high flux;  Should not exceed his/her maximum
improved permeability for middle and
larger molecules extracorporeal volume
Rees L. Hemodialysis for children with chronic kidney disease. UpToDate. 2017.
DIALYSIS PRESCRIPTION: LENGTH AND
FREQUENCY
 Conventional: 3 times/week, rarely  Types of children who benefit the
< 4 hours most from intensified HD
 Remained on long term HD
 Intensified: increase dialysis time
 Chronic fluid overload,
 Several studies reported that the hyperphosphatemia, and/or poor growth
longer the dialysis time, the better  Genetic metabolic disorders
the outcomes  Infants

 Home HD can be applied in smaller  Longer hours of HD is implemented

children with availability of circuits for infants, in whom fluid balance is
to dialyze children with weights from difficult to control with conventional
25 kg thrice weekly
Rees L. Hemodialysis for children with chronic kidney disease. UpToDate. 2017.
DIALYSIS PRESCRIPTION: FLUID REMOVAL
 Depends on differences between predialtytic weight and optimal weight of patient
 Safe starting point: 10 mL/kg/hr; > 5% of BW (0.2 mL/kg/min) can lead to
hypovolemia
 Assess optimum weight with conventional HD is difficult
 Infants who are maintained on liquid diet Require large
 Children who have difficulty to comply interdialytic fluid restriction ultrafiltration (UF) volume

Require more frequent Symptomatic

dialysis session hypovolemia

Rees L. Hemodialysis for children with chronic kidney disease. UpToDate. 2017.
DIALYSIS PRESCRIPTION: FLUID REMOVAL
Estimation of optimum weight: regular ongoing
assessment
 Young infant: per week
 Older child: per month
 Weight below which the child become
symptomatically hypotensive
 Several method to assess
 Bioimpedance spectroscopy
 Echocardiographic of inferior vena cava dimension
 Lung ultrasound assessing B lines alongside clinical examination
and BP measurements
Rees L. Hemodialysis for children with chronic kidney disease. UpToDate. 2017.
DIALYSIS PRESCRIPTION
Heparinization Dialysate Composition
 Prevent blood clot within circuit  Standard: bicarbonate dialysate
 Standard anticoagulant:  Patient with congenital anomaly of
unfractionated heparin (UFH) kidney and urinary tract (CAKUT):
ongoing urinary losses of
 Rate: 5-50 U/kg/hr through arterial bicarbonate  high concentration of
site of circuit dialysate bicarbonate
 Low molecular weight heparin  Higher normal range of calcium
(LMWH): bolus at the beginning of within 12 months: determine calcium
concentration of dialysate
session
Rees L. Hemodialysis for children with chronic kidney disease. UpToDate. 2017.
Daugirdas JT, et al. Handbook of dialysis. 5th Edition. Philadelphia: Wolters Kluwer Health; 2015.
HEMODIALYSIS ADEQUACY
 Types of uremic toxins: free and URR  urea reduction ratio
water soluble molecules, middle
molecules, substances that are bound URR > 65%
to circulating proteins (1 – [postdialysis BUN : predialysis BUN])
 Measurement of adequacy: urea
and small solute clearance
 Daily or frequent short HD  higher
 Kt/V  dialyzer clearance of urea Kt/V
1.2 < Kt/V ≤ 1.4  Protein catabolic rate (PCR) to
assess dietary protein intake in
K: clearance coefficient for urea (mL/min) steady state; it should be measured
t: duration of dialysis (min) monthly (target 1-1.4 g/kg)
V: distribution of urea in the body (mL
Rees L. Hemodialysis for children with chronic kidney disease. UpToDate. 2017.
HEMODIALYSIS ADEQUACY
 PCR is more sensitive and specific than albumin as marker of nutritional status
in hemodialysis children
 Measure of middle molecule clearance: beta-2 microglobulin
 Other assessment of hemodialysis adequacy
Growth Biochemical Functional status Optimal BP
parameters parameters control
• Height • Anemia • Hospitalizations • To assess
• Weight • Acid-base • School adequacy of
• Head (acidosis) attendance ultrafiltration
circumference • Electrolyte
• Pubertal stage

Rees L. Hemodialysis for children with chronic kidney disease. UpToDate. 2017.
COMPLICATION
Disequilibrium and Seizure Hypotension and Cramp
 Occurred in rapid urea removal  Occurred in fluid removal > 5% of body
weight
 Prevention:
 Limited blood flow rate and session length  Caution: lower BP in children and narrower
margin of hypotension
 Keeping dialysate sodium at or slightly
above plasma level  Prevention:
 Prophylactic infusion with mannitol during  Lower dialysate temperature
session (0.5-1.0 g/kg BW)  Isolated ultrafiltration  monitored temperature
 IV albumin infusion in hypoalbuminemia (0.5-1.5
g/kg) to increase oncotic pressure
 Repeated treatment

Daugirdas JT, et al. Handbook of dialysis. 5th Edition. Philadelphia: Wolters Kluwer Health; 2015.
COMPLICATION: MALNUTRITION
 Common seen in chronic hemodialysis children and associated with increased
risk of poor growth and death
 Risk of death
 54% higher for each 1 g/dL fall of albumin
 2 times higher in patients with height SDS < 2.5
 57% reduced if serum albumin > 4 g/dL
 14% increased with each decrease of one height standard deviation score (SDS) below
normal at the beginning of dialysis

 Recommendation: normal carbohydrate intake with increased protein intake

(0.1 g/kg/day) depends on age

Rees L. Hemodialysis for children with chronic kidney disease. UpToDate. 2017.
COMPLICATION
Growth Neuropsychological Outcome
 North American Pediatric Renal  Higher incidence of syndromes and
Trials and Collaborative Study developmental abnormalities in
(NAPRTCS): decreased height SDS children with CKD
after one year dialysis
 Children with longer period of
 Early and intensive approach to
nutrition will improve or maintain dialysis are more likely to have
height SDS cognitive and learning impairment
 Several studies reported selective
use of recombinant growth hormone
(rhGH) has led to improvement in
growth
Rees L. Hemodialysis for children with chronic kidney disease. UpToDate. 2017.
COMPLICATION: MINERAL AND BONE DISORDER
 Altered bone structure and composition, abnormal mineral metabolism
 Clinical manifestations: bone and joint pain, vascular calcifications, fractures
 Management: different from adults because higher normal ranges of calcium
and phosphate, increased need of calcium, ability to prevent
hyperparathyroidism

Rees L. Hemodialysis for children with chronic kidney disease. UpToDate. 2017.
COMPLICATION: CARDIOVASCULAR
 Traditional risk factor for cardiovascular disease is uncommon in children
 The most important risk factor in hemodialysis children is hypertension, due to
excess fluid
 In case series of 624 children: 79% hypertension
 Markers of CVD is found in hemodialysis children: abnormal endothelial function and PWV,
vascular calcification, increased carotid intima media thickness, LV remodeling, LV
hypertrophy

 The next important risk factor: anemia

 Associated with increased risk of mortality, LV hypertrophy and/or decreased exercise
capacity

Rees L. Hemodialysis for children with chronic kidney disease. UpToDate. 2017.
THANK YOU 