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Hemodialysis in Children

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)

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Hemodialysis in Children

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  1. Hemodialysis in Children Dr. Khalid Al-alsheikh MD Director of Nephrology & Dialysis Center Consultant Pediatric Nephrologist Afhsr, Khamis Mushayt, ksa

  2. 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

  3. 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

  4. 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)

  5. 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

  6. Epidemiology of chronic kidney disease in children Pediatr Nephrol (2012) 27:363–373وJérôme Harambat & Karlijn J. van Stralen &Jon Jin Kim & E. Jane Tizard

  7. 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

  8. 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

  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. Principle of Vascular Access • Deliver adequate flow rate • Has long use life • Has low rate of complications • - Infection • - Stenosis • - Thrombosis • - Aneurysm • - Limb ischemia

  12. 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%

  13. AV Fistula con’t. • PREFERRED SITE FOR AVF IN CHILDREN • Radiocephalic • Brachiocephalic • Brachiobasilic with or without transposition • Alternative: • Ulnar artery to basilic vein • Femoral artery to saphenous vein • Nondominant forearm

  14. 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

  15. AVG AVGShould be considered an option for HD access in children especially who require replacement of native vessels to perform an adequate anastamosis Alternative materials: • Saphenous vein • Bovine • Umbilical • Darcon • Polyurethane, cryopreserved femoral vein • Polytetrafluorethylene (PTFE) is most commonly used

  16. 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

  17. Advantage of AVG • Shorter time to use • High primary potency rate • 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 • Thrombosis • Stenosis • Infection Sheath et al permanent vascular access survival in children and adolescent with end stage renal disease 2002 Kidney Int 62:1864-1869

  18. 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

  19. COMPARISON BETWEEN AVF & AVG

  20. 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

  21. 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

  22. 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

  23. Two questions to be answered: • What size of catheter to use? • Where to put it?

  24. “Size matters!”

  25. Pousielle’s law- • 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) Q = ∆Pπr4 8l

  26. Catheter Specifications

  27. Catheter Specifications

  28. Vascular Access • Central Venous catheter • Cuffed catheter • Uncuffed catheter

  29. 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

  30. PROS AND CONS OF CENTRAL VENOUS CATHETER FOR HD IN CHILDREN

  31. 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.

  32. 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.

  33. 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.

  34. Hemodialysis Prescription • Hemodialysis Equipment: • Tubing • Dialyzer • Dialysis Machine • Tubing:

  35. Types of Dialyzer • Dialyzer: • Types of Membrane • Blood volume capacity • Service area • UF coefficient • Clearance of various substances • Sterilization

  36. 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

  37. Selection of Dialyzer that can be used in children

  38. 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

  39. 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

  40. 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 BW (10-20 kg) • 2500 U/ml BW>20 kg

  41. Hemodialysis Prescription Components

  42. 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

  43. 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

  44. 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

  45. 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

  46. 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)

  47. 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?

  48. Practical example of hemodialysis adequacy

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