Recent advances in pediatric dialysis: a review of selected articles

Attention-deficit/hyperactivity disorder in children undergoing peritoneal dialysis

Background:

Attention-deficit/hyperactivity disorder (ADHD) is the most common childhood psychiatric disorder. This disorder is more prevalent in some chronic disease.

Objectives:

The aim of this study was to investigate ADHD in children with end-stage renal disease (ESRD) undergoing continuous ambulatory peritoneal dialysis (CAPD) and to compare the results with those of healthy children.

Patients and Methods:

This case-control study was conducted for six months (December 22, 2013 to June 21, 2014) on five to 16-year-old children, visiting the Pediatric Dialysis Unit of Amirkabir Hospital, Arak, Iran, and Taleghani Hospital, Kermanshah, Iran. A total of 100 children with ESRD who had undergone CAPD for at least six months and 100 healthy children were included in this study as case and control groups, respectively. ADHD was diagnosed by Conner's Parent Rating Scale-48 (CPRS-48) and DSM-IV-TR criteria, and was confirmed through consultation by psychologist. Data were analyzed by Binomial test in SPSS 18.

Results:

The ADHD inattentive type was observed in 16 cases (16%) with CAPD and five controls (5%) (P = 0.01). Moreover, ADHD hyperactive-impulsive type was observed in 27 cases (27%) with CAPD and seven controls (9%) (P = 0.002). Despite these significant differences, no children were diagnosed with ADHD combined type among all subjects.

Conclusions:

Inattentive type and hyperactive-impulsive type of ADHD are more prevalent in children with ESRD undergoing CAPD. Therefore screening methods for ADHD is necessary in these patients.

Optimal hemodialysis prescription: do children need more than a urea dialysis dose?

When prescribing hemodialysis in children, the clinician should first establish an adequate regimen, before seeking to optimize the treatment (Fischbach et al. 2005). A complete dialysis dose should consist of a urea dialysis dose and a determined convective volume. Intensified and more frequent dialysis regimens should not be considered exclusively as rescue therapy. Interestingly, a recent single-center study demonstrated that frequent on-line HDF provides an optimal dialysis prescription, both in terms of blood pressure control (and therefore avoidance of left ventricular hypertrophy), and catch-up growth, that is, no malnutrition or cachexia and less resistance to growth hormone. Nevertheless, this one-center experience would benefit from a prospective randomized study.

Application of Individualized Bayesian Urea Kinetic Modeling to pediatric hemodialysis

Incorporating urea rebound using equilibrated urea concentration (Ceq) after hemodialysis (HD) is essential for accurate assessment of HD efficiency. It is impractical to measure Ceq in clinical settings, and there are no recommended methodologies to predict Ceq in children. The objective of this work is to assess the ability of an Individualized Bayesian Urea Kinetic Model (IBKM) for predicting Ceq in children receiving HD. Developed based on adult HD data, the IBKM is a two-pool urea kinetic model that calculates Bayesian estimates of individual Ceq. Blood urea nitrogen (BUN) samples from 30 HD sessions in 13 children (age 12-18 years) were taken at pre-HD, immediately post-HD, and 60 minutes post-HD (Ceq). The IBKM and estimated population parameters from adult data were fitted to the observed data from children to predict individual Ceq using NONMEM VI software in comparison with observed Ceq (9.5 +/- 3.8 mmol/L), the average individual predicted Ceq was 9.4 +/- 3.8 mmol/L, with absolute individual prediction error of 6.2% +/- 4.4%. For a given dialysis goal and desired dialysis duration, the required blood flow rate and dialyzer size are predicted by IBKM and confirmed by the analysis data. This study suggests that the IBKM can be used in a pediatric HD setting and accurately predict Ceq in children using only pre-HD and immediately post-HD BUN.