Hemodialysis in Children: how is it

different from adults?

Eka Laksmi Hidayati
Divisi Nefrologi
Departemen Ilmu Kesehatan Anak FKUI- RSCM
ESKD in children is rare
But they are vulnerable!
Chronic disease affects all aspects of maturation
Requires a comprehensive and specialized medical care

Chand DH. et al. Am J Kidney Dis. 2016

Children is not miniature of adult
Pediatric Dialysis Problem

Proper
Members of the understanding of
interdisciplinary both disease
More children are
dialyzed in adult dialysis team prosses and
facilities than in may have management are
pediatric facilities minimal or no needed to
training/ effectively treat
experience in patients
pediatric patients

Chand DH. et al. Am J Kidney Dis. 2016

Special aspects should be considered in
pediatric hemodialysis

Procedure – related aspect

• Fluid management
• (Broad range of) Body weight
• Dialysate rate consideration
• Vascular access patency
• Dialysis adequacy

Ashby et al. BMC Nephrology. 2019

Special aspects should be considered in
pediatric hemodialysis

Other health – related aspect

• Growth and development aspect
• School and other activity aspect
• Psychological aspect and quality of life

Ashby et al. BMC Nephrology. 2019

Fluid status and target weight

• Regular assessment of fluid status and target weight are important

with validated objective measurement (such as bio-impedance)
• Overestimation of target weight chronic overload hypertension
• Underestimation of target weight affect residual kidney function
and hypotension
• Regular assessment of UF tolerance is essential!

Ashby et al. BMC Nephrology. 2019

Fluid removal
• Consider body fluid composition (<10 kg: 80 mL/kg - >10 kg: 70 mL/kg)
• Maximum volume of fluid removed should not exceed 5% of the child’s
ideal weight.
• Extended times to avoid excessive ultra-filtration rates
• Hypoalbuminemic and nephrotic child may need priming with 20%
human albumin solutions - allow adequate fluid removal, maintaining
vascular stability, minimizing the risk of intra-dialytic hypotension, but
can risk precipitating pulmonary edema
Vascular access patency
• Ideal modality: AVF
• Recommended choice: cuffed tunneled double lumen central venous catheter (CVC)
• Catheter size is chosen according to the child’s weight and estimated vessel diameter

Weight (kg) Double Lumen Catheter Max blood flow (mL/min)

3-15 7 Fr – 10 cm/12 cm 75-100
16-30 9 Fr – 12 cm/16 cm 100-250
>30 11 Fr/11.5 Fr/13 Fr – Up to 350
13.5 cm/16 cm/21 cm
• Preferred site: internal jugular vein
• Children require sedation or anesthesia
Dialysate rate consideration
Dialysate flow rate is usually 2x blood flow rate
- with an average of 300 mL/min for the smaller child,
- 500 mL/min for larger child
- range 300 – 800mL/min

Ashby et al. BMC Nephrology. 2019

 (Broad range of) Body Weight
• Extracorporeal blood volume is
important aspect for safety!
 related to body weight
• Dialyzer and blood line should be
tailored to BSA in children
• Blood flow rate 5-7 ml/kg/min
• Extracorporeal volume less than
10% of Pt’s blood volume

Ashby et al. BMC Nephrology. 2019

Dialysis adequacy in children:
more than a urea dialysis dose

Therapeutic goals include:

normal growth, bone
health, cardiac function,
and quality of life

Chand DH. et al. Am J Kidney Dis. 2016

Ashby et al. BMC Nephrology. 2019
Hemodialysis adequacy:
more than a urea dialysis dose

• Optimal care, including nutrition, growth, education

• High convective volume  removal of middle-sized uremic molecules
• High-flux membranes
• Blood pressure controlled – prevention of cardiac problems
• Intensified hemodialysis regimen – longer and or more frequent HD
• Highest standard of dialysis, i.e., biocompatibility of the material used,
purity of the dialysis fluids, and controlled determined convective flow
 Dialysis adequacy in children

Special condition for HD in children (higher risk of overload):

1. Liquid nutrition intake
2. Ventricular systolic dysfunction

 Increase frequency or duration of HD

Ashby et al. BMC Nephrology. 2019

What is adequate parameter?

Kaur A, et al. Hemodialysis International. 2014.

 Other “special” issues in children
• Risk of malnutrition:
-Routine monitoring of nutrition status
-Parenteral nutrition intra HD

• Risk of cardiac compromised:

-Routine heart evaluation
-Prevent cardiomyopathy insult: anemia, overload, electrolyte imbalance,
hypertension, uremia, etc.
Growth and development aspect
• Optimizing nutritional status support is a fundamental element of care
- adequate calorie intake and protein requirements
• Recommend measuring the following on a monthly basis:
•Serum albumin levels.
•Height with height Z scores.
•Dry weight (best assessed weight).
•Mid-arm circumference and skin fold thickness.
•Head-circumference, for children aged 3 years or less

Ashby et al. BMC Nephrology. 2019

School and other activity aspect
• A variety of feelings toward school: some feel ashamed while others
were empowered to do better
• Adolescent should participating in the decision-making process as the
child matures allows proactive involvement in their health
• Supporting groups were important (parents/family members/friend)

Chand DH. et al. Am J Kidney Dis. 2016

Psychological aspect and quality of life
• Feeling different because of abnormal physical appearances
• Feeling of guilt as being a burden to their families
• Disruption to normal family life
• Parents need to understand diagnosis and management  the
consequences of long-life disease
• Medical team also provide support and friendship to both the child
and their family

Chand DH. et al. Am J Kidney Dis. 2016

ESKD and dialysis in children in RSCM
2014-2017: 61 children had RRT in RSCM
World Kidney Day Celebration
 Thank you
Special thanks to our patient and our
dialysis team