Monitoring dialysis adequacy: history and current practice

Continuous renal replacement therapy is a safe and effective modality for the initial management of dogs with acute kidney injury

OBJECTIVE

To describe the management of dogs with acute kidney injury (AKI) by continuous renal replacement therapy (CRRT), and to investigate the relationship between a prescribed CRRT dose, the hourly urea reduction ratio (URR), and the overall efficacy.

ANIMALS

45 client-owned dogs diagnosed with severe AKI, receiving 48 CRRT treatments at a veterinary teaching hospital.

PROCEDURES

Retrospective study. Search of medical records of dogs with AKI managed by CRRT.

RESULTS

Median serum urea and creatinine at CRRT initiation were 252 mg/dL [Inter quartile range (IQR), 148 mg/dL; range, 64 to 603 mg/dL] and 9.0 mg/dL (IQR, 7 mg/dL; range, 4.3 to 42.2 mg/dL), respectively. Median treatment duration was 21 hours (IQR, 8.8 hours; range, 3 to 32 hours). Systemic heparinization and regional citrate anticoagulation were used in 24 treatments each (50%). The prescribed median CRRT dose for the entire treatment was 1 mL/kg/min (IQR, 0.4 mL/kg/min; range, 0.3 to 2.5 mL/kg/min). The median hourly URR was 4% (IQR, 1%; range, 2% to 12%), overall URR was 76% (IQR, 30%; range, 11% to 92%) and median Kt/V was 2.34 (IQR, 1.9; range, 0.24 to 7.02). The CRRT dose was increased gradually from 0.9 mL/kg/min to 1.4 mL/kg/min (P < .001) and the hourly URR decreased from 6.5% to 5.5% (P = .05). The main complication was clotting of the extra-corporeal circuit, occurring in 6/48 treatments (13%). Twenty-four dogs (53%) survived to discharge.

CLINICAL RELEVANCE

CRRT is safe when the prescription is based on the current veterinary guidelines for gradual urea reduction. Treatment efficacy can be maximized by gradually increasing the dose according to the actual URR.

Chronic haemodialysis in infants and children less than 15 kg

BACKGROUND

Peritoneal dialysis (PD) is the most commonly used kidney replacement therapy in infants and young children with chronic kidney disease (CKD) stage 5. Chronic haemodialysis (cHD) is the alternative treatment when PD is not possible for technical reasons; however, the difficulties that may be encountered are challenging and require clinicians with specialist training and experience. This study aims to describe the clinical history, complications and outcomes in children < 15 kg on cHD.

METHODS

A retrospective, descriptive study of the clinical records of patients weighing < 15 kg on cHD for more than 3 months. The reasons for CKD stage 5, age at start of treatment, duration of haemodialysis, anthropometric and metabolic variables, as well as vascular access, complications and clinical outcome were recorded.

RESULTS

Fifteen patients were included between 2006 and 2018 with a median age at start of cHD of 30 (interquartile range (IQR) 13, 39) months and median duration of 15 (IQR 7.5, 25.3) months. Five patients were younger than 2 years. The median weight at start of treatment was 11.2 (IQR 6.4, 12.8) kg. Forty-five tunneled catheters with a median survival of 106 days were used. The main cause of loss of vascular access was obstruction or displacement dysfunction (39%). The catheter-associated infection rate was 0.76 per 1000 catheter days. Ten patients received a successful kidney transplant, 4 were transferred to PD and one died from complications during abdominal surgery.

CONCLUSIONS

cHD can be successfully performed in children < 15 kg by addressing specific clinical and technical issues.

Chronic Kidney Disease-Associated Itch (CKD-aI) in Children-A Narrative Review

Chronic kidney disease (CKD) is a condition of widespread epidemiology and serious consequences affecting all organs of the organism and associated with significant mortality. The knowledge on CKD is rapidly evolving, especially concerning adults. Recently, more data is also appearing regarding CKD in children. Chronic itch (CI) is a common symptom appearing due to various underlying dermatological and systemic conditions. CI may also appear in association with CKD and is termed chronic kidney disease-associated itch (CKD-aI). CKD-aI is relatively well-described in the literature concerning adults, yet it also affects children. Unfortunately, the data on paediatric CKD-aI is particularly scarce. This narrative review aims to describe various aspects of CKD-aI with an emphasis on children, based on the available data in this population and the data extrapolated from adults. Its pathogenesis is described in details, focusing on the growing role of uraemic toxins (UTs), as well as immune dysfunction, altered opioid transmission, infectious agents, xerosis, neuropathy and dialysis-associated aspects. Moreover, epidemiological and clinical aspects are reviewed based on the few data on CKD-aI in children, whereas treatment recommendations are proposed as well, based on the literature on CKD-aI in adults and own experience in managing CI in children.