Small tunneled central venous catheters as an alternative to a standard hemodialysis catheter in neonatal patients

Recent Advances in Kidney Replacement Therapy in Infants: A Review

Kidney replacement therapy (KRT) is used to treat children and adults with acute kidney injury (AKI), fluid overload, kidney failure, inborn errors of metabolism, and severe electrolyte abnormalities. Peritoneal dialysis and extracorporeal hemodialysis/filtration can be performed for different durations (intermittent, prolonged intermittent, and continuous) through either adaptation of adult devices or use of infant-specific devices. Each of these modalities have advantages and disadvantages, and often multiple modalities are used depending on the scenario and patient-specific needs. Traditionally, these therapies have been challenging to deliver in infants due the lack of infant-specific devices, small patient size, required extracorporeal volumes, and the risk of hemodynamic stability during the initiation of KRT. In this review, we discuss challenges, recent advancements, and optimal approaches to provide KRT in hospitalized infants, including a discussion of peritoneal dialysis and extracorporeal therapies. We discuss each specific KRT modality, review newer infant-specific devices, and highlight the benefits and limitations of each modality. We also discuss the ethical implications for the care of infants who need KRT and areas for future research.

Programs and processes for advancing pediatric acute kidney support therapy in hospitalized and critically ill children: a report from the 26th Acute Disease Quality Initiative (ADQI) consensus conference

Pediatric acute kidney support therapy (paKST) programs aim to reliably provide safe, effective, and timely extracorporeal supportive care for acutely and critically ill pediatric patients with acute kidney injury (AKI), fluid and electrolyte derangements, and/or toxin accumulation with a goal of improving both hospital-based and lifelong outcomes. Little is known about optimal ways to configure paKST teams and programs, pediatric-specific aspects of delivering high-quality paKST, strategies for transitioning from acute continuous modes of paKST to facilitate rehabilitation, or providing effective short- and long-term follow-up. As part of the 26th Acute Disease Quality Initiative Conference, the first to focus on a pediatric population, we summarize here the current state of knowledge in paKST programs and technology, identify key knowledge gaps in the field, and propose a framework for current best practices and future research in paKST.

Kidney support for babies: building a comprehensive and integrated neonatal kidney support therapy program

Kidney support therapy (KST), previously referred to as Renal Replacement Therapy, is utilized to treat children and adults with severe acute kidney injury (AKI), fluid overload, inborn errors of metabolism, and kidney failure. Several forms of KST are available including peritoneal dialysis (PD), intermittent hemodialysis (iHD), and continuous kidney support therapy (CKST). Traditionally, extracorporeal KST (CKST and iHD) in neonates has had unique challenges related to small patient size, lack of neonatal-specific devices, and risk of hemodynamic instability due to large extracorporeal circuit volume relative to patient total blood volume. Thus, PD has been the most commonly used modality in infants, followed by CKST and iHD. In recent years, CKST machines designed for small children and novel filters with smaller extracorporeal circuit volumes have emerged and are being used in many centers to provide neonatal KST for toxin removal and to achieve fluid and electrolyte homeostasis, increasing the options available for this unique and vulnerable group. These new treatment options create a dramatic paradigm shift with recalibration of the benefit: risk equation. Renewed focus on the infrastructure required to deliver neonatal KST safely and effectively is essential, especially in programs/units that do not traditionally provide KST to neonates. Building and implementing a neonatal KST program requires an expert multidisciplinary team with strong institutional support. In this review, we first describe the available neonatal KST modalities including newer neonatal and infant-specific platforms. Then, we describe the steps needed to develop and sustain a neonatal KST team, including recommendations for provider and nursing staff training. Finally, we describe how quality improvement initiatives can be integrated into programs.

Kidney Replacement Therapy in Low Birth Weight Preterm Newborns

Managing newborns with kidney failure is a complex undertaking; even under ideal circumstances, dialysis is technically challenging and available therapies are designed for adults. These issues are exacerbated in smaller newborns, and intervention has traditionally not been offered in those below a certain weight threshold. Ethical concerns abound and patients deemed too small for dialysis are typically transitioned to comfort or palliative care. However, many of these neonates are otherwise healthy and would be considered survivable if kidney replacement therapy were available. To challenge the existing paradigm, we present 7 preterm, low birth weight neonates with end-stage kidney disease who were successfully managed using an innovative approach to kidney replacement therapy. These newborns had a median gestational age of 32 weeks (interquartile range [IQR], 32-35) and a median birth weight of 1.58 kg (IQR, 1.41-2.01). Kidney replacement therapy was initiated at a median age of 16 days (IQR, 1.5-40) and a weight of 1.85 kg (IQR, 1.57-2.1). Five of the 7 newborns (71%) survived to hospital discharge. Kidney replacement therapy was provided using 3F and 4F single lumen catheters and a modified ultrafiltration device. Patients experienced excellent metabolic control, and fluid homeostasis was achieved in the first week of life. Furthermore, survivors experienced physiologic weight gain and linear growth throughout their hospitalization. These findings, although preliminary, are encouraging for our smallest patients with kidney failure and suggest that survivability thresholds should be reexamined. At a minimum, neonatologists should be aware that novel approaches exist and may be considered for these challenging patients.