1
|
Ranchin B, Schmitt CP, Warady BA, Hataya H, Jones J, Lalji R, Licht C, Mosca M, Stronach L, Vidal E, Walle JV, Shroff R. Technical requirements and devices available for long-term hemodialysis in children-mind the gap! Pediatr Nephrol 2024; 39:2579-2591. [PMID: 38141144 DOI: 10.1007/s00467-023-06233-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/10/2023] [Accepted: 11/13/2023] [Indexed: 12/24/2023]
Abstract
Children requiring long-term kidney replacement therapy are a "rare disease" cohort. While the basic technical requirements for hemodialysis (HD) are similar in children and adults, key aspects of the child's cardiovascular anatomy and hemodynamic specifications must be considered. In this article, we describe the technical requirements for long-term HD therapy for children and the devices that are currently available around the world. We highlight the characteristics and major technical shortcomings of permanent central venous catheters, dialyzers, dialysis machines, and software available to clinicians who care for children. We show that currently available HD machines are not equipped with appropriately small circuits and sensitive control mechanisms to perform safe and effective HD in the youngest patients. Manufacturers limit their liability, and health regulatory agencies permit the use of devices, only in children according to the manufacturers' pre-specified weight limitations. Although registries show that 6-23% of children starting long-term HD weigh less than 15 kg, currently, there is only one long-term HD device that is cleared for use in children weighing 10 to 15 kg and none is available and labelled for use in children weighing less than 10 kg anywhere in the world. Thus, many children are being treated "off-label" and are subject to interventions delivered by medical devices that lack pediatric safety and efficacy data. Moreover, recent improvements in dialysis technology offered to adult patients are denied to most children. We, in turn, advocate for concerted action by pediatric nephrologists, industry, and health regulatory agencies to increase the development of dedicated HD machines and equipment for children.
Collapse
Affiliation(s)
- Bruno Ranchin
- Pediatric Nephrology Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Université de Lyon, Lyon, France.
- Centre de référence des maladies rénales rares, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 59 boulevard Pinel, 69677, Bron Cedex, France.
| | - Claus Peter Schmitt
- Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Bradley A Warady
- Division of Nephrology, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Hiroshi Hataya
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Fuchu, Japan
- Department of Pediatrics, School of Medicine, Keio University, Shinjuku-ku, Tokyo, Japan
| | - Joanne Jones
- Queensland Children's Hospital, University of Queensland, Brisbane, Australia
| | - Rowena Lalji
- Centre for Kidney Disease Research, University of Queensland, Brisbane, Australia
- Department of Nephrology, Queensland Children's Hospital, Brisbane, Australia
- Metro South and Integrated Nephrology and Transplant Services, Princess Alexandra Hospital, Brisbane, Australia
| | - Christoph Licht
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
- Division of Nephrology and Research Institute, Cell Biology Program, The Hospital for Sick Children, Toronto, ON, Canada
| | - Melodie Mosca
- Pediatric Nephrology Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Université de Lyon, Lyon, France
| | - Lynsey Stronach
- University College London Great Ormond Street Hospital and Institute of Child Health, London, UK
| | - Enrico Vidal
- Pediatric Nephrology Unit, Department for Woman and Child's Health, University-Hospital of Padua, Padua, Italy
| | - Johan Vande Walle
- Department of Pediatric Nephrology, Ghent University Hospital, Ghent, Belgium
| | - Rukshana Shroff
- University College London Great Ormond Street Hospital and Institute of Child Health, London, UK
| |
Collapse
|
2
|
Paglialonga F, Shroff R, Zagozdzon I, Bakkaloglu SA, Zaloszyc A, Jankauskiene A, Gual AC, Consolo S, Grassi MR, McAlister L, Skibiak A, Yazicioglu B, Puccio G, Edefonti A, Ariceta G, Aufricht C, Holtta T, Klaus G, Ranchin B, Schmitt CP, Snauwaert E, Stefanidis C, Walle JV, Stabouli S, Verrina E, Vidal E, Vondrak K, Zurowska A. Sodium intake and urinary losses in children on dialysis: a European multicenter prospective study. Pediatr Nephrol 2023; 38:3389-3399. [PMID: 36988689 DOI: 10.1007/s00467-023-05932-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 02/06/2023] [Accepted: 02/26/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND Sodium (Na) balance is unexplored in dialyzed children. We assessed a simplified sodium balance (sNaB) and its correlates in pediatric patients receiving maintenance dialysis. METHODS Patients < 18 years old on hemodialysis (HD) or peritoneal dialysis (PD) in six European Pediatric Dialysis Working Group centers were recruited. sNaB was calculated from enteral Na, obtained by a 3-day diet diary, Na intake from medications, and 24-h urinary Na (uNa). Primary outcomes were systolic blood pressure and diastolic blood pressure standard deviation scores (SBP and DBP SDS), obtained by 24-h ambulatory blood pressure monitoring or office BP according to age, and interdialytic weight gain (IDWG). RESULTS Forty-one patients (31 HD), with a median age of 13.3 (IQR 5.2) years, were enrolled. Twelve patients (29.3%) received Na-containing drugs, accounting for 0.6 (0.7) mEq/kg/day. Median total Na intake was 1.5 (1.1) mEq/kg/day, corresponding to 60.6% of the maximum recommended daily intake for healthy children. Median uNa and sNaB were 0.6 (1.8) mEq/kg/day and 0.9 (1.7) mEq/kg/day, respectively. The strongest independent predictor of sNaB in the cohort was urine output. In patients receiving HD, sNaB correlated with IDWG, pre-HD DBP, and first-hour refill index, a volume index based on blood volume monitoring. sNaB was the strongest predictor of IDWG in multiple regression analysis (β = 0.63; p = 0.005). Neither SBP SDS nor DBP SDS correlated with sNaB. CONCLUSIONS Na intake is higher than uNa in children on dialysis, and medications may be an important source of Na. sNaB is best predicted by urine output in the population, and it is a significant independent predictor of IDWG in children on HD. A higher resolution version of the Graphical abstract is available as Supplementary information.
Collapse
Affiliation(s)
- Fabio Paglialonga
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 9, 20122, Milan, Italy.
| | - Rukshana Shroff
- University College London Great Ormond Street Hospital for Children and Institute of Child Health, London, UK
| | - Ilona Zagozdzon
- Department of Pediatrics Nephrology & Hypertension, Medical University of Gdansk, Gdansk, Poland
| | | | - Ariane Zaloszyc
- Department of Pediatric Nephrology, Hopital de Hautepierre, Strasbourg, France
| | - Augustina Jankauskiene
- Pediatric Center, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
| | - Alejandro Cruz Gual
- Department of Pediatric Nephrology, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Silvia Consolo
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 9, 20122, Milan, Italy
| | - Maria Rosa Grassi
- Department of Clinical Sciences and Community Health, University of Milano, Milan, Italy
| | - Louise McAlister
- University College London Great Ormond Street Hospital for Children and Institute of Child Health, London, UK
| | - Aleksandra Skibiak
- Department of Pediatrics Nephrology & Hypertension, Medical University of Gdansk, Gdansk, Poland
| | - Burcu Yazicioglu
- Department of Pediatric Nephrology, Gazi University, Ankara, Turkey
| | - Giuseppe Puccio
- Department of Sciences for Health Promotion, University of Palermo, Palermo, Italy
| | - Alberto Edefonti
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 9, 20122, Milan, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
3
|
Low dialysate sodium in children and young adults on maintenance hemodialysis: a prospective, randomized, crossover study. Pediatr Nephrol 2022; 38:1599-1607. [PMID: 36315274 DOI: 10.1007/s00467-022-05792-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/29/2022] [Accepted: 10/12/2022] [Indexed: 03/01/2023]
Abstract
BACKGROUND The optimal dialysate sodium concentration (dNa) in children on hemodialysis (HD) is unknown. The aim of this study was to compare the effect on interdialytic weight gain (IDWG) and blood pressure (BP) of a low (135 mmol/l) and standard dNa (138 mmol/l) in children and young adults on maintenance HD. METHODS This prospective single-blind randomized crossover study consisted of a randomized sequence of two phases: "standard dNa" of 138 mmol/L and "low dNa" of 135 mmol/L. Each phase lasted 4 weeks. Inclusion criteria were age < 25 years, hypertension, pre-HD serum Na (sNa) ≥ 130 mmol/L, and occurrence of symptoms in less than 25% of sessions. Primary outcomes were pre-HD systolic and diastolic BP and IDWG. RESULTS Fifteen patients were recruited, mean age 17.8 ± 4.4 years. Pre-HD SBP and DBP were not different between the two treatments. Mean IDWG was significantly lower with low dNa than with standard dNa: 2.12 ± 1.39% vs. 2.77 ± 1.53%, respectively (p = 0.008). The first-hour refill index (a volume index based on blood-volume monitoring) was significantly lower with dNa 135 mmol/L (p = 0.018). The mean Na gradient (dNa-sNa) was - 2.53 ± 2.4 mmol/L with dNa 135 mmol/L and 0.17 ± 2.8 mmol/L with dNa 138 mmol/L (p = 0.0001). The incidence of symptomatic sessions was similar (1.0% vs. 1.0%). CONCLUSIONS In a selected population of hypertensive pediatric and young adult HD patients, a dNa of 135 mmol/L was associated with a significant reduction of IDWG compared with a dNa of 138 mmol/L. Furthermore, long-term studies are needed to investigate the effect of lowering dNa on BP. A higher resolution version of the Graphical abstract is available as Supplementary information.
Collapse
|
4
|
Nutritional status and volume control in adolescents on chronic hemodialysis. Pediatr Nephrol 2021; 36:3733-3740. [PMID: 33988730 DOI: 10.1007/s00467-021-05089-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 03/31/2021] [Accepted: 04/20/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Pediatric patients on maintenance hemodialysis (HD) are at risk of both malnutrition and fluid overload. This pilot study aimed to assess correlates of normalized protein catabolic rate (nPCR) in adolescents on chronic HD, in particular fluid status markers. METHODS All patients aged 10-18 years on chronic HD in our center between 2017 and 2019 were enrolled. For each patient, mean nPCR was calculated and correlations with the following parameters investigated: dry body weight change in subsequent 3 months in kg (∆BW) and percentage of BW (∆BW%), change in body mass index (∆BMI), preHD systolic and diastolic blood pressure (SBP, DBP), residual urine output, biochemistry, and blood volume monitoring-derived first hour refill index (RI), calculated as ratio between ultrafiltration rate and reduction in relative blood volume in first hour of dialysis. RESULTS Seventy-nine nPCR determinations were collected in 23 patients, median age 14.8 years. nPCR significantly correlated with ∆BW, ∆BW%, ∆BMI, spKT/V, and preHD serum creatinine, and negatively correlated with age, DBP SDS (r=-0.466, p=0.025) and RI (r=-0.435, p=0.043). RI was significantly higher in patients with nPCR <1 than those with nPCR above this threshold: 3.2 (1.9-4.7) vs. 1.4 (0.7-1.8) ml/kg/h/% (p=0.021). At multivariable analysis, nPCR remained positively correlated with creatinine and spKt/V, and inversely correlated with RI. CONCLUSIONS nPCR is a significant predictor of weight change in adolescents on maintenance HD, and seems associated with creatinine and dialysis adequacy. Inverse correlation with RI suggests possible associations between malnutrition and fluid overload, but larger prospective studies are needed to confirm this. A higher resolution version of the Graphical abstract is available as Supplementary information.
Collapse
|