Home hemodialysis in children

International equity in access to home dialysis

PURPOSE OF REVIEW

Discussion of inequalities and inequities in global distribution of and access to home dialysis.

RECENT FINDINGS

The majority of patients receiving home dialysis receive peritoneal dialysis, but these are concentrated in few countries across the globe. Peritoneal dialysis as the most common form of home dialysis has many advantages in terms of individual freedoms, similar outcomes to haemodialysis, being less costly in some countries, and more scalable than in-centre haemodialysis. Despite this there are many inequities in access at the patient, clinician, health system and geopolitical levels. Poverty, discrimination and lack of support at home are important drivers of inequities at the patient level. At the clinician and health systems level lack of experience in home dialysis, lack of resources and lack of time drive patients towards in-centre dialysis. At the geopolitical level, high costs associated with procurement and distribution of peritoneal dialysis solutions exacerbate inequities in access.

SUMMARY

The challenge of reducing global inequities in access to home dialysis in low- and middle-income countries are vast and would require training of the doctors, nurses, families, patients, leaders and community partners. Once this is achieved, dealing with costs and logistics of supplies is crucial to improve and sustain equitable access.

Chronic Kidney Disease in Children

Chronic kidney disease (CKD) in children occurs mostly due to congenital anomalies of kidney and urinary tract and hereditary diseases. For advanced cases, a multidisciplinary team is needed to manage nutritional requirements and complications such as hypertension, hyperphosphatemia, proteinuria, and anemia. Neurocognitive assessment and psychosocial support are essential. Maintenance dialysis in children with end-stage renal failure has become the standard of care in many parts of the world. Children younger than 12 years have 95% survival after 3 years of dialysis initiation, whereas the survival rate for children aged 4 years or younger is about 82% at one year."

Reducing the burden of cardiovascular disease in children with chronic kidney disease: prevention vs. damage limitation

Cardiovascular disease (CVD) is a life-limiting condition in patients with chronic kidney disease (CKD) and is rapidly progressive, especially in those with stage 5 CKD and on dialysis. Cardiovascular mortality, although reducing, remains at least 30 times higher than in the general pediatric population. The American Heart Association guidelines for cardiovascular risk reduction in high-risk pediatric patients has stratified pediatric CKD patients in the "high risk" category for the development of CVD, with associated pathological and/or clinical evidence for manifest coronary disease before 30 years of age. While improving patient survival is a key priority, other patient-related outcomes, such as psychosocial development, quality of life and growth are of major importance to children and their caregivers. Once vascular damage or calcification has developed, there are no data to suggest that they can be reversed. Treatments such as intensified dialysis and transplantation may attenuate the progression of subclinical cardiovascular disease, but no treatment to date has shown that the inexorable progression of CVD in CKD can be reversed. Thus, our management must focus on early diagnosis and robust preventative strategies to give our patients the best chance of optimal cardiovascular health and survival. In this review, the pathophysiology and importance of preventing the development of CVD in CKD is discussed.

Nocturnal home hemodialysis in children: Advantages, implementation, and barriers

Chronic kidney disease and end-stage renal disease (ESRD) in children are major health concerns worldwide with increasing incidence and prevalence. Renal replacement therapies and kidney transplants have remarkably improved the management of patients with ESRD in both adult and pediatric populations. Kidney transplant has the best patient outcomes, but many a time it has a considerable waiting period. In the meantime, the majority of patients with pediatric ESRD are dependent on dialysis. The conventionally utilized hemodialysis regimen is the three times weekly, in-center hemodialysis. Many studies have demonstrated the unfavorable long-term morbidity associated with the conventional regimen. Intensified dialysis programs, which include extended nocturnal hemodialysis or short daily hemodialysis, are being increasingly advocated over the past two decades. In addition to having much better clinical outcomes as compared with the conventional regimen, the flexibility to provide dialysis at home serves as a great incentive. PubMed/Medline, Embase and Cochrane databases for literature on nocturnal home hemodialysis in children with ESRD were extensively searched. Contrary to the noticeable literature available on adult home hemodialysis, a small number of studies exist in the pediatric population. In this review, the benefits, implementation and associated barriers of nocturnal home hemodialysis in children were addressed.

Dalteparin anticoagulation in paediatric home haemodialysis

BACKGROUND

The aim of this study was to investigate whether dalteparin is a safe and effective anticoagulant for paediatric home haemodialysis (HD) and to assess the determinants of dosing.

METHODS

Data were collected for all children (< 18 years) undergoing home HD from 2011 to 2017 at one large paediatric nephrology centre in the UK. All children had anticoagulation with dalteparin sodium according to a standardised protocol. Dalteparin safety was assessed by monitoring for accumulation, adequate clearance of dalteparin and adverse events. Dalteparin efficacy was assessed through monitoring for clot formation in dialysis circuits. Potential determinants of dalteparin dosing were assessed.

RESULTS

Eighteen children were included, their median age at start was 12 years, and 50% were male. Eighty-three percent of children had four home HD sessions each week, with a median total dialysis hours of 20 h/week. Thirty-three percent of children had nocturnal home HD. Median dalteparin dose at 12-month follow-up was 40 IU/kg (range 8-142 IU/kg). Factors associated with higher dalteparin dosing requirements included a younger age of the child (p < 0.01), a lower blood flow rate (p < 0.01) and the use of a central venous line for dialysis access (p = 0.038). No children had evidence of bioaccumulation of dalteparin or inadequate clearance. No significant bleeding or adverse events were reported.

CONCLUSIONS

Dalteparin is a safe and effective anticoagulant when used for paediatric home HD. In this study, there was no evidence of bioaccumulation or significant adverse events. Further research is required to directly compare dalteparin with unfractionated heparin (UFH) and evaluate anticoagulant choice for paediatric home HD.

Survival in children requiring chronic renal replacement therapy

Survival in the pediatric end-stage renal disease (ESRD) population has improved substantially over recent decades. Nonetheless, mortality remains at least 30 times higher than that of healthy peers. Patient survival is multifactorial and dependent on various patient and treatment characteristics and degree of economic welfare of the country in which a patient is treated. In this educational review, we aim to delineate current evidence regarding mortality risk in the pediatric ESRD population and provide pediatric nephrologists with up-to-date information required to counsel affected families.

There's no place like home: 35-year patient survival on home hemodialysis

The vast majority of maintenance dialysis patients suffer from poor long-term survival rates and lower levels of health-related quality of life. However, home hemodialysis is a historically significant dialysis modality that has been associated with favorable outcomes as well as greater patient autonomy and control, yet only represents a small minority of the total dialysis performed in the United States. Some potential disadvantages of home hemodialysis include vascular access complications, infection-related hospitalizations, patient fatigue, and attrition. In addition, current barriers and challenges in expanding the utilization of this modality include limited patient and provider education and technical expertise. Here we report a 65-year old male with end-stage renal disease due to Alport's syndrome who has undergone 35 years of uninterrupted thrice-weekly home hemodialysis (ie, every Sunday, Tuesday, and Thursday evening, each session lasting 3 to 3¼ hours in length) using a conventional hemodialysis machine who has maintained a high functional status allowing him to work 6-8 hours per day. The patient has been able to liberalize his dietary and fluid intake while only requiring 3-4 liters of ultrafiltration per treatment, despite having absence of residual kidney function. Through this case of extraordinary longevity and outcomes after 35 years of dialysis and a review of the literature, we illustrate the history of home hemodialysis, its significant clinical and psychosocial advantages, as well as the barriers that hinder its widespread adaptation.