Chronic haemodialysis in children

Elisabeth Hodson

Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW 2145, Australia

The treatment of choice for a child with end stage renal failure is a transplant, preferably from a living donor and before dialysis is necessary. Continuous cycling peritoneal dialysis (CCPD) is the preferred option for paediatric dialysis since it can be performed at home and provides 7-day per week dialysis. However haemodialysis can be used in children of all ages if CCPD is not feasible because of membrane failure associated with peritonitis and, rarely, if the home environment does not allow CCPD. The type of access is determined by the size of the child. Small children will require tunnelled cuffed catheters placed in the internal jugular veins. Their use is complicated by infection and obstruction. Where possible an arterio-venous (A-V) graft or A-V fistula should be used. An A-V fistula should be created at least 3 months before dialysis is started. A-V grafts can be used immediately. Peripheral and central veins should be preserved because of the need for later haemodialysis access. Needling of fistulae or grafts is easier if local anaesthetic cream is placed over the access 1-2 hours before needling and if the child is carefully prepared for the procedure by nursed and play therapists. Children receive haemodialysis for 4-5 hours three times per week. The dialyser and lines are chosen to ensure that the total extracorporeal volume does not exceed 10% of the child's blood volume and to ensure that the urea clearance initially does not exceed 3 ml/kg/minute. A bicarbonate-containing dialysate and a machine with ultrafiltration volume control should be used especially in small children. Ideally ultrafiltration volumes should not exceed 10% of the child's blood volume; additional fluid should be removed in additional dialyses. Dialysis adequacy is assessed every 6 months with the aim of maintaining it at or above the acceptable adult levels although the optimal dialysis dose in relation to growth, nutrition and other parameters in children is not known. Haemodialysis in children is very resource intensive, requires a highly experienced nursing staff and considerable input from play therapists, occupational therapists, school teachers, psychologists and social workers to ensure maximum rehabilitation.

Invited lecture at the 6th annual convention of Pediatric Nephrology of the Philippines, Manila, July 2001

Correspondence
Elisabeth Hodson
ElisaH@chw.edu.au