Contents

Introduction Indications of dialysis Choice of dialysis Pediatric hemodialysis Vascular access Extracorporeal circuit

Dialysate Dialysis machine Anticoagulation Complication Conclusions References

Why a infant needs dialysis?

Development of kidney

The new born kidney is immature and contains only 17% of cells found in an adult kidney The remainder of the cells develop by six months of age The glomerular filtration rate (GFR) at birth averages only about 20ml/min/1.73m2. It increases to 80ml/min/1.73m2,by six months At age and reaches the normal adult rate in the 2nd year of life

Acute dialysis indications

Oliguria(06ml/kg/hr) Hypo perfusion Glomerulornephritis Nephrotoxic poisons Uremic pericarditis Hyperkalemia

Chronic renal failure

Glomerular disease Malformation of urinary track Hereditary (transmitted from parents)

= 34% = 22% = 16% Dysplasia (abnormal development of renal tissue )11% Uncertain = 5% Others = 12%

Choice of dialysis

PERITONEAL DIALYSIS
peritoneal dialysis is the first treatment of choice in infants Because its have many advantages than others No need for vascular access, blood priming, anticoagulation, ext.. Neonatal has a peritoneal surface area almost twice that of the adult when ... peritoneal dialysis should be twice as efficient in the neonatal'

continuous renal replacement therapy

CRRT is used almost exclusively in the intensive care setting only So its not convenient for chronic OP patients In Acute Patients it may be ok

Haemodialysis

Hemodialysis is performed when peritoneal dialysis is contraindicated because of an intraabdominal process (including recent abdominal surgery, diaphragmatic hernia, or respiratory limitation)

AGAINST Technically difficult in the very small Need for anticoagulation Not a continuous modality fluids and nutrition need to be restricted Not suitable for haemodynamicall unstable

Vascular access

Vascular access remains a major limitation to successful hemodialysis in small children. Placing and maintaining permanent accesses in small vessels requires experienced and dedicated surgeons and radiologists. Vascular catheters can be placed by interventional radiologists or surgeons depending on the best experience available in an institution.

Catheters

Available double-lumen hemodialysis catheters range from 3 F to 12 F in lengths appropriate for small children temporary and permanent catheters are available, and. The catheter tip should be radiologically positioned in the junction of the superior vena cava and right atrium. In small infants and neonates, single-lumen catheters may be more appropriate considering vessel size.

How to decide catheter size

Patient size (kg) < 10
10-20 20-40 > 40

Catheter size
3 TO 8 Fr dual lumen 8 Fr dual lumen 10 Fr dual lumen 11.5 or 12.5 Fr dual lumen

Fistulas and grafts

In older children, creation of an arteriovenous fistula between the radial artery and cephalic vein in the end-to-side anastomosis is a common mode of vascular access. When blood vessel size is too small for constructing an adequate fistula, a polytetrafluoroethylene (GoreTex or Impra) graft can be placed between an extremity artery and vein.

Cannulation is very difficult because of very small vein so we need patients cooperation To avoid pain use Anesthetic spray avoid small needling also,,,,,

Blood flow and dialysate flow

Desired

blood flow rate is targeted to urea clearance specifications for a chosen dialyzer. an initial urea clearance of 3 mL per minute per kg is prudent to avoid symptomatic disequilibrium Typically in the range of 50ml to 150 mL per minute in small children and 200ml to 350 mL per minute in older children. Small catheters often limit flow to 25ml to 100 mL per minute because of limited arterial inflow. Dialysate flow to be kept at 400-500 ml/min. Does not depend on size of child.

Extra corporal circuit

A generally accepted rule for infant dialysis is that the extra corporal blood volume should not exceed 10% of total blood volume This is calculated using this formula (blood volume=80ml/kg)

For example 20kg child * 80ml =1600ml 10%of 1600 = 160ml Therefore 160ml is the total blood volume that should be in the Extra corporal circuit during hemodialysis If the volume is exceeded dialyzer & bloodline primed with blood or albumin solution

Planning UF
Goal to promote fluid removal while maintaining hemodynamic stability throughout treatment Absolutely essential estimate of dry weight + accurate measurement of current weight UF removal in a single session should not exceed 5% of body weight or 0.2 ml/kg/min to avoid circulatory collapse

Dialyzer

Dialyzer characteristics - surface area should not exceed childs BSA - small priming volume - urea clearance 3-5 ml/kg/min - synthetic over cellulose based membranes

Available Dialyzers
Dialyzer

100HG Sureflux30l (50l)(70l)

FB50T(70T) (90T) F3F4F40 CA50(70)

Priming volume( ml)

Surface area (m2)

membrane manufactu re

18

0.2

Hemophan Triacetate

Gambro Nipro

25(35)(45 0.3(0.5)(0.7) ) 35(45)(55 0.5(0.7)(0.9) ) 28(42)(42 0.4(0.7)(0.7) ) 35(45) 0.5(0.7) Diacetate Nipro

polysolfone Fresenius Cellulose acetate Baxter

Clearance
Depends on - Blood flow - Dialysate flow - Dialyzer surface area - Dialyzer permeability Aim for urea clearance of 1ml/kg/min in initial dialysis sessions and gradually increase upto 4 ml/kg/min

Blood Tubing
Appropriately sized blood lines allow control of circuit volume. If the volume of the entire extracorporeal circuit exceeds 10% of the patient's blood volume (>8 mL/kg), a warmed blood (or albumin) prime is usually given to ensure hemodynamic stability. Blood lines are available in a range of sizes: Neonatal (~20 mL), infant (~40 mL), and pediatric (~70 mL). It is important that the blood pump be properly calibrated for the chosen blood lines.

Available tubing
Name of the blood lines
A-367a3 V-414ax S-53088 V-3089 Bsm2 A36p-pv7 manufactur Artery Venus Totalvolume er volume volum (ml) (ml)

e (ml)
21 22 30.5

12 28 37.5

33 50 68

Gambro cardiovision hospal

Dialysate

Bicarbonate dialysis solution is standard for pediatric hemodialysis; it provides better hemodynamic stability and fewer intradialytic symptoms. Patients with small muscle mass will be unable to metabolize a large acetate load quickly.

Dialysis machines
Dialysis machines that provide volumetric ultrafiltration control are required. Small errors in ultrafiltration volume (of a few hundred milliliters) may cause symptomatic hypotension or chronic volume overload. Blood flows must be accurate within the range of 30 to 300 mL per minute and the blood pump calibrated to different size lines.

Anticoagulation Standard heparinisation

Patients weight (kg) Initial bolus (Units of heparin/kg)

5-15 15-25 25-35 35-55 > 55

10-16 16-20 18-20 18-20 20

Infusion during dialysis = 15-20 Units/kg/hr

For all weights commonly

we are using standard heparin doses for pediatric patients that is Systemic = 750iu bolus 500iu/hr maintenance Rigid= 500iu bolus 250iu/hr maintenance

Heparin free dialysis

Avoiding clotting of the circuit ; flush with normal saline every 30 minutes - Weight < 20 kg 25 ml of normal saline - Weight > 20 kg 50 ml of normal saline Add this volume to net ultrafiltration target

Blood sampling

The slow-flow technique for blood sampling is important for accurate measurement Pediatric blood lines can be adequately cleared by a slow-flow rate (60 mL per minute) for 17 seconds; we predict infant lines will require 12 seconds at a slow-flow rate of 20 mL per minute. The greater reliance on catheters in pediatric dialysis raises concern that recirculation will diminish treatment efficiency.

complication
Our small mistakes will give a big complication for infants All adult complications (like air embolism & machine errors) are same but other important complications need discussion

Disequilibrium syndrome

Same like adults but hear happen more Small brain tissues urea transfers more slowly to the blood so fluid is drawn in to the brain easily it causes swelling So urea clearance should be 3ml/min

Hypotension

Intradialytic hypotension and cramping with fluid removal >5% of body weight are common Volume removal must be closely monitored because blood pressure is normally lower in children than in adults Use separate pediatric BP apparatus for infants for accurate measurement of BP blood (or albumin) prime is usually given to ensure hemodynamic stability.

Support therapies

Give Erythropoietin Therapy for Anemia

Give Recombinant Human Growth Hormone (rhGH) Therapy for growth Vitamin D Therapy for Renal Osteodystropathy Play Therapy for rRehabilitation

Reference

Hand book of dialysis - John T. Daugirdas MD -2007 ; 606-625 Renal Nursing Robert Uldall MD FRCP 1988; 320-327 Children with kidney diseases Semin nephrol -2006;653-658 web reference: www.hdcn.com www.kidney.org www.pcrrt.com