Continuous hemodiafiltration in children

Continuous arteriovenous hemofiltration is a form of renal replacement therapy whereby small molecular weight solutes and water are removed from the blood via convection, alleviating fluid overload and, to a degree, azotemia. It has been used in many adults and several children. However, in patients with multisystem organ dysfunction and acute renal failure, continuous arteriovenous hemofiltration alone may not be sufficient for control of azotemia; intermittent hemodialysis or peritoneal dialysis may be undesirable in such unstable patients. Recently, the technique of continuous arteriovenous hemodiafiltration has been used in many severely ill adults. We have used continuous arteriovenous hemodiafiltration in four patients at Children's Hospital Medical Center. Patient 1 suffered perinatal asphyxia and oliguria while on extracorporeal membrane oxygenation. Patients 2 and 4 both had Burkitt lymphoma and tumor lysis syndrome. Patient 3 had septic shock several months after a bone marrow transplant. All had acute renal failure and contraindications to hemodialysis or peritoneal dialysis. A blood pump was used in three of the four patients, while spontaneous arterial flow was adequate in one. Continuous arteriovenous hemodiafiltration was performed for varying lengths of time, from 11 hours to 7 days. No patient had worsening of cardiovascular status or required increased pressor support during continuous arteriovenous hemodiafiltration. The two survivors (patients 2 and 4) eventually recovered normal renal function. Continuous arteriovenous hemodiafiltration is a safe and effective means of renal replacement therapy in the critically ill child. It may be ideal for control of the metabolic and electrolyte abnormalities of the tumor lysis syndrome.     

Management of acute renal failure

Acute renal failure (ARF) is defined as an abrupt decline in the renal regulation of water, electrolytes, and acid-base balance. It continues to be an important factor contributing to the morbidity and mortality of critically ill infants and children. The frequency of specific diseases that result in ARF differs among different age-groups and geographical areas. The common causes in Indian children include hemolytic uremic syndrome, acute tubular necrosis, glomerulonephritis and urinary tract obstruction. Though the hallmark of renal failure is oliguria, there is increasing recognition of non-oliguric ARF often associated with the use of nephrotoxic drugs. The basic principles of management are avoidance of life-threatening complications, maintenance of fluid and electrolyte balance and nutritional support. Specific management of the underlying disorder is possible only in a minority of cases. All the major dialysis modalities—peritoneal dialysis (PD), hemodialysis (HD) and continuous hemofiltration—can be used to provide equivalent solute clearance and ultrafiltration. Peritoneal dialysis requires minimal equipment and infrastructure, and is easy to perform; this makes it the favoured modality in developing countries where resources for HD or continuous therapies may not be accessible. However, continuous hemofiltration is an excellent alternative to PD in patients with ARF and severe fluid overload. The prognosis of children with renal failure depends on the underlying condition and associated medical complications.     

Renal replacement therapy and acute renal failure

PURPOSE OF REVIEW: Acute renal failure (ARF) is a syndrome that occurs when there is a sudden decline in the glomerular filtration rate. The purpose of this review is to examine new developments and clinical applications of renal replacement therapies including hemodialysis, continuous renal replacement therapy, the bioartificial kidney, and peritoneal dialysis in the management of this complicated syndrome. RECENT FINDINGS: New developments in hemodialysis include in-line hematocrit monitoring and improved biocompatible dialyzer membranes. While recent studies indicate that increased delivery of dialysis improves the outcome of patients with ARF, the optimal regimen of intermittent dialysis or continuous renal replacement therapy remains to be determined. The bioartificial kidney, combining hemofiltration with a device containing human tubular cells, is currently in clinical trials and represents another alternative in the management of ARF. In peritoneal dialysis, new solutions using icodextrin may improve fluid removal and blood pressure. SUMMARY: The optimal choice of renal replacement therapy depends on many factors. Use of new options in renal replacement therapy and early initiation of dialysis may help to improve survival and outcome of patients with ARF.     

儿童急性肾衰竭透析疗法比较

目的　为探讨儿童急性肾衰竭透析疗法效果 ,对我院腹膜透析和血液透析情况进行比较。方法　总结 1994年至 2 0 0 2年在我院行PD或HD的急性肾衰竭患儿的临床资料。结果　PD与HD改善肾功能、电解质紊乱和酸中毒的近期效果无显著性差异 (P >0 0 5 ) ,但HD组的肾功能、电解质和HCO3 -复常时间短于PD组 (P <0 0 5 )。结论　HD奏效快 ,ARF患儿病情紧急或合并多脏器衰竭时选用HD较适合 ,小年龄儿童HD治疗亦有可行性。但PD与HD对于改善肾功能、电解质紊乱和酸中毒同样有效 ,且适合基层医院开展     

Encouraging survival of infants with terminal renal failure combining dialysis and succeeding early transplantation

Dialysis in newborns and infants is a very challenging field in pediatric nephrology and still associated with high mortality. This article is designed for pediatricians who advise parents of newborns with renal failure. It aims to provide information about the difficulties during the period of dialysis and outcome after successful transplantation. We report upon five patients who proceeded to end-stage renal failure within the first year of life. All patients received peritoneal dialysis; however, two had to be switched to hemodialysis for several months. Four patients received percutaneous endoscopic gastric tubes (PEG) to enable high caloric diet. At the age of 1.5 to 5 years all children were successfully transplanted achieving good renal function. With regard to severe complications, hospitalisation time and somatic development all patients showed a substantial improvement after renal transplantation. Growth velocity increased to above SDS +2 after transplantation and all children reached the milestones of development in due time. In conclusion, after renal replacement therapy is initialised in infants with end-stage renal failure, sufficient nutrition to improve weight gain and to achieve the earliest possible transplantation is mandatory. Early transplantation results in a catch-up of developmental delay in short time.     

Pretransplant peritoneal dialysis and graft thrombosis following pediatric kidney transplantation: a NAPRTCS report

Graft thrombosis is a common cause of graft failure in pediatric renal transplantation. Several previous studies, including a North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) review of pretransplant dialysis status and graft outcomes, have described a potential correlation of peritoneal dialysis (PD) and graft thrombosis. This issue is of particular concern for pediatric transplant programs as more than 65% of children with end stage renal disease are treated with PD. We reviewed 7247 pediatric renal transplants performed between 1987 and 2001. Thrombosis was the cause of graft loss in 2.7% (199) of all the transplants performed. Among failed transplants, thrombosis was the third most common cause of graft loss in both index (11.6%) and subsequent transplants (14.5%). Thrombosis becomes the most common cause of graft failure (21%, 61/294) if one looks at transplants in the later cohort, from 1996 to 2001. This change is primarily because of a decrease in the incidence of acute rejection. In the PD group, 3.4% of all grafts were lost as a result of thrombosis. This compares with 1.9% in the hemodialysis group, 2.4% in the pre-emptive transplant group, and 4.1% among patients who received both dialysis modalities. There was a statistically significant difference in thrombosis failure risk in the different dialysis groups (p = 0.005) with those who received only peritoneal dialysis having the highest risk. Additional significant risk factors for graft thrombosis included; cadaver donor source (p < 0.001), cold ischemia time >24 h (p < 0.001), history of prior transplant (p < 0.001), donor age <6 yr (p < 0.001), and >5 pretransplant blood transfusions (p = 0.02). Using stepwise proportional hazards modeling, only pretransplant peritoneal dialysis, >24 h cold ischemia time, prior transplant, and donor age <6 yr were simultaneously associated with an increased risk of thrombosis. We conclude that pretransplant PD is associated with an increased risk of graft thrombosis. Special precautions should be undertaken in pediatric renal transplant patients who have received PD, especially infants and young children.     

End-stage renal insufficiency in children less than 4 months old. Survey of the French Pediatric Nephrology Club

One hundred and eleven cases of children with end-stage renal failure prior to 4 years of age were collected from a survey of the French Pediatric Nephrology Club. Clinical and epidemiological data stress the importance of certain etiologies such as 40 cases of renal hypoplasia. The necessity of planning extracorporeal dialysis from the first year of life in 37% of patients demonstrates the importance of difficulties to be overcome. The treatments used for the 82 treated children show the interest of conservative management. However, peritoneal dialysis remains the first treatment of choice (52 times). Besides the problems of hemodialysis vascular approach, related to the small caliber of vessels, the complications of the clearance techniques did not appear to be more frequent than in older children. Use of transplantation is not negligible as 25% of transplanted patients were under 4 years of age; however none was under one year or weighted less than 8 kg. Transplantation remains ultimate treatment, even more so as the actuarial survival at 5 years is clearly worse for children submitted to hemodialysis (68%) than to transplantation (91%) (p less than 0.05).     

小儿急性上尿路梗阻性肾衰的急诊处理

目的 探讨近期小儿急性上尿路结石梗阻致肾衰发病率升高的病因、临床特点、诊断及治疗.方法 我院近期收治40例急性上尿路梗阻致肾衰的病例,膀胱镜下行输尿管插管引流25例,腹膜透析8例,自行解除梗阻6例,肾盂造瘘1例.结果 所有40例急性肾功能衰竭患儿大部分有三鹿奶粉喂养史,主要表现为无尿,首选腹部B超检查;急性肾功能衰竭时及时解除结石梗阻,纠正酸碱失衡、水电解质紊乱.40例患儿上尿路梗阻完全解除,肾功能均恢复正常;结石成分主要为尿酸盐结石,结石多能自行排出.结论 三聚氰胺诱发尿酸盐结石可能是近期小儿梗阻性肾衰的主要原因.治疗手段包括膀胱镜输尿管插管、腹膜透析等.     

Long-term outcome of peritoneal dialysis in infants

Debate continues concerning the treatment of infants with end-stage renal disease. We evaluated progress and outcome of 20 infants with a mean age of 0.34 year (range, 0.02-1 year) in a long-term peritoneal dialysis program at a single center. Mean weight at the start of dialysis was 4.8 kg (range, 1.7-11.4 kg), and the duration of dialysis was 17.3 months (range, 1-59 months). Eleven infants received renal transplants, 4 were switched to hemodialysis and then received transplants, 4 died, and 1 continues to receive peritoneal dialysis. There was significant co-morbidity in 6 infants who died or required hemodialysis. Catheter interventions were frequent, with 12 infants requiring at least one replacement. There were 1.1 episodes of peritonitis per patient-year; 70% of infants had 0 to 1 episode. Mean weight standard deviation score (SDS) was -1.6 at the start, -0.3 at 1 year (P =.0008), and 0.3 at 2 years (P =.0008). Height SDSs were -1.8 at the start, -1.1 at 1 year (P =.046), and -0. 8 at 2 years (P =.06). Head circumference SDSs were -1.9 at the start, -1.3 at 6 months (P =.003), and -0.9 at 1 year (P =.015). Fourteen of 16 survivors are achieving normal developmental milestones or attend mainstream school. Peritoneal dialysis in infancy is a demanding treatment, but outcome for growth, development, and transplantation justifies this intensive approach. When parents are counseled, the importance of non-renal co-morbidity must be emphasized.     

An overview of pediatric peritoneal dialysis and renal replacement therapy in infants: A review for the general pediatric surgeon

Currently, there are about 10,000 pediatric patients in the United States who rely on dialysis for renal replacement therapy. Dialysis allows children with chronic kidney disease a means of support until renal transplant is feasible. All forms of renal replacement therapy require a surgical intervention, whether the modality is hemodialysis or peritoneal dialysis. Despite peritoneal dialysis being the most common modality of dialysis in children, there is not prospectively collected much evidence in the literature which can guide the pediatric surgeon about best practices on access placement, management of complications, and timing of removal. Most available studies are small, single-center retrospective reviews. This limits the power of the data collected to help guide decision-making in the management of peritoneal dialysis catheters.The purpose of this review is to provide a consolidated source of best available evidence and identify important areas for future study. Furthermore, this is an area of pediatric surgical care that lacks up to date outcomes research with robust surgeon participation. Lack of coordinated, evidence-based best practices likely results in heterogenous surgical practices and uneven strategies for managing complications. Furthermore, with improvements in neonatal critical care and fetal interventions available for obstructive uropathies and other congenital kidney disorders, there is increased likelihood of the need for dialysis access in more infants, who represent a particularly vulnerable patient population. Importantly, peritoneal dialysis access should be instituted into the national PEDScore curriculum for pediatric surgical fellows, as this procedure is common enough that any pediatric surgeon could be consulted for catheter placement and management. Surgeon awareness of, and participation in the formulation, of guidelines and prospective studies is of paramount importance to ensure optimal care of this vulnerable population of children.     

Pediatric renal transplantation: the Bangalore experience

A retrospective analysis was done on 47 pediatric renal transplants performed over last 16 years at Bangalore, Karnataka. The median age and weight of the recipients at transplantation were 120 months and 21 kg respectively; male to female ratio was 30 to 17. Twenty two children had underlying glomerular disease and 23 had tubulointerstitial disease. Preemptive transplantation was done in 33.3% of patients, 57.2% received hemodialysis and 9.5% received peritoneal dialysis prior to transplantation. The mean duration of dialysis was 2.6 months.The most common source of donor organ was the mother. Immunosuppression medications included cyclosporine, azathioprine, and corticosteroids. Graft survival at 1 year, 5 years, and 10 years was 80%, 45.8% and 37.5% respectively. Renal transplantation is the most optimal way to manage children with ESRD with satisfactory long term results.     

Low-volume peritoneal dialysis in 116 neonatal and paediatric critical care patients

Acute renal insufficiency accounts for high mortality in paediatric intensive care patients, particularly in infants. Peritoneal dialysis, usually carried out with dialysate volumes of >20 ml/kg body weight, increases pulmonary artery pressure, which may compromise myocardial function in critical illness. In this paper we report our experiences with the use of lower dialysate volumes in the treatment of critically ill children with renal impairments. We suggest that low-volume peritoneal dialysis is able to achieve adequate ultrafiltration, which relieves overhydration in ventilated and haemodynamically compromised children. A total of 116 paediatric intensive care patients treated between 1992 and 2000 was the subject of this investigation. Diagnosis, indication for dialysis, arterial and central venous pressure, blood gases, creatinine, blood urea nitrogen, urinary output at installation, ultrafiltration, fluid balance, duration and complications during dialysis as well as survival were investigated. The overall mortality was 53%. The respective diagnoses and mortality rates were as follows: 65% of the patients suffered from cardiac diseases (54% mortality), 7% from renal diseases (13%) and 28% from multi-organ system failure (62%). Low-volume peritoneal dialysis was started at evidence of total body fluid overload with inadequate urinary output and resulted in a mean ultrafiltration of 2.8 ml/kg body weight per h. A negative fluid balance was achieved in 53% of patients, mainly in those suffering from hypervolaemia and minor oliguria. None of the complications resulted in death. CONCLUSION: early installation of low-volume peritoneal dialysis offers a safe and adequate ultrafiltration procedure for paediatric critical care patients suffering from minor oliguria and fluid overload.     

Causes, prognostic factors and treatment results of acute renal failure in children treated in a tertiary hospital in South Africa

The aim of this study was to determine the causes, prognostic factors and treatment results of acute renal failure (ARF) in children admitted to the Pretoria Academic Hospital from 1986 to 2002. A retrospective chart review of 102 children (mean age 37 months) was done. Various factors were analysed including age, sex, causes of ARF, morbidity, mortality, dialysis requirement and outcome. Peritoneal dialysis was the only form of dialysis available. Patients were categorized as those who survived without dialysis or in whom renal function recovered without the need for continuing dialysis (Group I, termed 'survivors'), and those who died or remained dialysis dependent (Group II, termed 'non-survivors'). The most common causes of ARF were haemolytic uraemic syndrome (35.3%), acute tubular necrosis (31.4%) and acute glomerulonephritis (15.7%). There were 77 patients in Group I of whom 38 required dialysis, and 25 in Group II of whom 16 were dialysed. Fifteen patients in Group II died and 10 remained dialysis dependent ('renal deaths'). Only four patients with 'renal death' received long-term dialysis. Coma (P < 0.001), liver dysfunction (P < 0.009), a clotting deficiency (P < 0.001), respiratory failure (P < 0.001) and multi-organ failure (P < 0.001) were significantly associated with poor outcome. These factors should be taken into account before initiating dialysis in children in countries where available resources for long-term dialysis are limited.     

Evidence of hypothalamic-pituitary thyroid abnormalities in children with end-stage renal disease

Patients with end-stage renal disease may have abnormalities of growth and of gonadal and thyroid hormones, so we attempted to determine the mechanisms that may be involved in the altered thyroid function. We evaluated serum thyroid hormone levels, their changes immediately after hemodialysis, the serum thyrotropin (thyroid-stimulating hormone (TSH) response to thyrotropin releasing hormone, and the circadian pattern of serum TSH in nine children with end-stage renal disease who were between 7 1/2 years and 17 years 1 month of age. Seven patients had been receiving hemodialysis for a median of 3.3 years; the other two were receiving continuous ambulatory peritoneal dialysis. Four patients had low serum total thyroxine (T4) values, and all nine had low free T4 values. Mean concentrations of total T4, free T4, and total triiodothyronine (T3), which were significantly less than normal before hemodialysis, returned to normal levels immediately after dialysis. Postdialysis thyroid hormone increases did not correlate with the decrease in weight or the increase in hematocrit observed immediately after dialysis. All but one patient had basal TSH levels within the normal range. Three patients had a deficient TSH response to thyrotropin releasing hormone, and the TSH response was prolonged in all of them. The mean (+/- SD) nocturnal TSH surge was 50 +/- 68%. Five of the eight patients studied had a nocturnal TSH surge below the normal range (95% confidence limits 47% to 300%). Serum free T4 values correlated with the TSH nocturnal surge (r, 0.73; p less than 0.05). Our findings support the hypothesis that some patients with end-stage renal disease have central hypothyroidism.     

三聚氰胺泌尿系结石并急性肾衰竭婴幼儿的预后与转归

目的探讨三聚氰胺泌尿系结石(MUS)并急性肾衰竭(ARF)婴幼儿的预后与转归。方法对2008年7-10月在本院住院治疗的21例MUS并ARF婴幼儿[ARF组,年龄(10.5±5.7)个月]进行20个月随访。随访内容包括泌尿系超声、尿常规、肾功能检查,并记录其身高、体质量、临床症状及并发症情况。选取同期住院治疗的30例单纯MUS无ARF患儿(MUS组)及50例无三聚氰胺污染奶粉喂养史的健康儿童(健康对照组)作为对照。比较三组间相关参数异同。结果成功随访17例MUS并ARF患儿;经过保守治疗(其中12例患儿行血液透析),患儿恢复顺利,无临床症状及相关并发症,尿常规和肾功能检查未见明显异常。12例带结石出院患儿中结石消失7例、变小4例、无明显变化1例。8例出院时仍有肾积水的患儿中,5例消失;2例减轻,1例无明显变化。ARF组患儿出院带石率、结石消失率、出院积水率及积水消失率与MUS组比较差异均无统计学意义(Pa>0.05);AFR组和MUS组患儿及健康对照组儿童身高及体质量比较差异均无统计学意义(Pa>0.05)。结论 MUS并AFR患儿经过住院保守治疗(包括血液透析),ARF得以纠正,症状缓解,20个月随访显示预后与转归较好,生长发育无明显影响,未见泌尿系肿瘤形成。     

Nonrenal indications for continuous renal replacement therapy: A report from the Prospective Pediatric Continuous Renal Replacement Therapy Registry Group

OBJECTIVE:: Continuous renal replacement therapy is the most often implemented dialysis modality in the pediatric intensive care unit setting for patients with acute kidney injury. However, it also has a role in the management of patients with nonrenal indications such as clearance of drugs and intermediates of disordered cellular metabolism. MEASUREMENTS AND METHODS:: Using data from the multicenter Prospective Pediatric Continuous Renal Replacement Therapy Registry, we report a cohort of pediatric patients receiving continuous renal replacement therapy for nonrenal indications. Nonrenal indications were obtained from the combination of "other" category for continuous renal replacement therapy initiation and patient diagnosis (both primary and secondary). This cohort was further divided into three subgroups: inborn errors of metabolism, drug toxicity, and tumor lysis syndrome. RESULTS:: From 2000 to 2005, a total of 50 continuous renal replacement therapy events with nonrenal indications for therapy were included in the Prospective Pediatric Continuous Renal Replacement Therapy Registry. Indication-specific survival of the subgroups was 62% (inborn errors of metabolism), 82% (tumor lysis syndrome), and 95% (drug toxicity). The median small solute dose delivered among the subgroups ranged from 2125 to 8213 mL/1.73 m/hr, with 54%-59% receiving solely diffusion-based clearance as continuous venovenous hemodialysis. No association was established between survival and dose delivered, modality of continuous renal replacement therapy, or use of intermittent hemodialysis prior to continuous renal replacement therapy. CONCLUSIONS:: Pediatric patients requiring continuous renal replacement therapy for nonrenal indications are a distinct cohort within the population receiving renal replacement therapy with little published experience of outcomes for this group. Survival within this cohort varies by indication for continuous renal replacement therapy and is not associated with continuous renal replacement therapy modality. Additionally, survival is not associated with small solute doses delivered within a cohort receiving >2000 mL/1.73 m/hr. Our data suggest metabolic control is established rapidly in pediatric patients and that acute detoxification may be provided with continuous renal replacement therapy for both the initial and maintenance phases of treatment using either convection or diffusion at appropriate doses.     

腹膜透析治疗小儿肾功能衰竭临床分析

目的 探讨腹膜透析对儿童肾功能衰竭治疗的效果.方法 对2003年6月至2008年4月应用腹膜透析治疗的11例急慢性肾功能衰竭患儿临床资料及随访结果 进行分析.结果 11例患儿无一例死亡,急性肾功能衰竭平均在院透析时间15.5 d,慢性肾功能衰竭平均在院透析时间22.8 d.治疗前后血尿素氮、肌酐分别由(34.03±8.44) mmol/L和(710.09±167.54) μmol/L降至(15.94±4.93) mmol/L和(233.87±92.71) μmol/L,差异有非常显著性(P＜0.01).血钠由(130.91±9.15) mmol/L升至(139.46±3.98) mmol/L,差异有显著性(P＜0.05).血碳酸氢根由(14.56±2.07) mmol/L升至(22.47±3.29) mmol/L,差异有非常显著性(P＜0.01).随访时间1个月至5年不等.5例急性肾功能衰竭患儿肾功能和尿常规均正常.1例慢性肾功能衰竭患儿规律透析后行肾移植,3例仍于院外透析中.结论 经济、实用、有效的腹膜透析辅以综合治疗可成为儿童急慢性肾功能衰竭较好替代治疗方法 .     

Effect of dialysis on all trans retinoic acid levels in a child with acute promyelocytic leukemia and renal failure

All trans retinoic acid (ATRA) combined with chemotherapy has become the mainstay of treatment for patients with acute promyelocytic leukemia (APL). Renal dysfunction (RD) is commonly seen in patients with APL. We describe a patient with APL and multi-organ failure, who was on chronic veno-venous hemofiltration followed by hemodialysis (HD) and later peritoneal dialysis (PD), who received ATRA. ATRA levels were assessed as the body clearance of ATRA in children on HD and/or PD was unknown. Neither HD nor PD significantly affected ATRA levels, suggesting that dose modifications of ATRA may not be necessary for children with these forms of renal replacement therapy.     

Management of Acute Renal Failure in the Pediatric Intensive Care Unit

Pediatric acute renal failure (ARF) is a dynamic entity that has many causes. ARF is frequently seen in the pediatric population and is associated with increased mortality and long-term morbidity rates. Of importance is its early detection so as to allow interventions to either prevent or treat the disease timely during its course. Recent developments in the definitions and classification schemes and the identification of new biomarkers shall allow better predictive interventions for childhood ARF. ARF management in children requires special considerations. Optimal care for the pediatric patient requiring renal replacement therapy requires an understanding of the causes and patterns of pediatric ARF and recognition of the local expertise with respect to the personnel and equipment resources. The aim of this article is to review pediatric ARF management with an emphasis on emerging practice patterns and the modalities for renal replacement therapy.     

Continuous renal prosthetic therapy in acute renal failure: an overview

The technology surrounding the treatment of acute renal failure has been traditionally left in the realm of dialysis. The use of peritoneal dialysis for the neonate or small infant and the often difficult use of hemodialysis in larger children and adolescents have been the mainstay of support. Not infrequently, however, the multisystem nature of the failure demonstrated by these patients made either form of therapy at best inadequate. The morbidity of the procedure would add to the already high morbidity of the disease and the patient would either be unable to receive the needed medications because of necessary fluid restrictions, or be subjected to severe hemodynamic or respiratory embarrassment due to the treatment methods themselves. It is precisely toward this patient population that the continuous forms of renal replacement therapy, reviewed herein, are directed.