Hemodialysis in Small Children

Hemodialysis in Small Children
Dr Md Abdul Qader
MBBS; MD (Pediatric Nephrology)
Clinical Fellow (NUH, Singapore)
Associate Consultant, Pediatric Nephrology, SQUARE Hospitals Ltd.
# Co- editor ‫ ׀‬Little Bean community blog, Kidney International Reports (KIReports)
# SoMe। #Communication, International Pediatric Nephrology Association (IPNA)

# Member, Junior council, Asian Pediatric Nephrology Association (AsPNA)
Hemodialysis in Infants and small children
History
• 1957 Kolff et al report 5 children (2-
14y) undergoing HD for ARF using
venous cannula (IVC and cephalic): But
has not proven safe in small children
• 1962 Hickman and Scribner report 6

children, including a 7 month old,
receiving HD for ARF, using Scribner
shunt [https://nephrology.uw.edu/about/history]
• By 1965 reports of 7 infants under 2

years of age and 30 children under 15
years of age receiving HD for ARF
2years old boy presented to Chittagong Medical

College Hospital with
Fever and vomiting for 7days
Oligouria for 6 days
Acute kidney injury secondary to

septicemia and advised for
Renal replacement therapy.
Diagnosis of AKI in small children

Urinary output and duration
GFR criteria RIFLE pRIFLE nRIFLE
Risk (R) Increased creatinine x 1.5 ≤0.5ml/Kg/H <0.5ml/Kg/H <1.5ml/Kg/H

or GFR decreases >25% (6H) (8H) (24H)
Injury (I) Increased creatinine x 2 ≤0.5ml/Kg/H <0.5ml/Kg/H <1.0ml/Kg/H
or GFR decreases >50% (12H) (16H) (24H)
Failure (F) Increased creatinine x 3 ≤0.3ml/Kg/H <0.3ml/Kg/H <0.7ml/Kg/H

or GFR decreases >75% or (24H) or Anuric (24H) or (24H) or Anuric
creatinine ≥4mg/dL (acute (12H) Anuric (12H) (12H)
rise ≥0.5mg/dL)
Loss Loss of kidney function for 4 weeks
End stage Loss of kidney function for >3months

2years old boy (10Kg) presented to Chittagong Medical

College Hospital with
Fever and vomiting for 7days
Oligouria for 6 days
Acute kidney injury

Renal replacement therapy
Peritoneal Dialysis
Acute kidney injury

Renal replacement therapy
Peritoneal Dialysis
72 H
• His serum creatinine improved minimally but

he remain oligouric.
• So he was then referred for hemodialysis and
got admitted to SHL on 3/06/2021
He was then initiated on

Hemodialysis
With
6.5Fr double lumen

dialysis catheter
Catheter size
Weight Catheter Maximum blood
flow (ml/min)
<3Kg 5Fr 2 Single 15cm 50-75
lumen 17cm
6.5Fr Double lumen 10cm 75-100
3-15Kg 7Fr Double lumen 10cm 75-100
12cm
16-30Kg 8Fr Double lumen 12cm 100-250
9Fr 16cm
>30Kg 11Fr Double lumen 13.5cm Up to 350
12Fr 16cm
Blood
lines
https://www.niddk.nih.gov/health-information/kidney-
disease/kidney-failure/hemodialysis
Patient size Internal diameter Filling volume

Adult 172ml
Paed 6.4mm 126ml
Paed/Baby 6.4mm 56ml
https://www.freseniusmedicalcare.se/fileadmin/data/sv/pdf/Product_Info/HD-produkter/Blodslangar.pdf
Dialyzer
Dialyzer F40 Fx50 Fx60 Fx80 Fx100

Effective surface area 0.7 1.0 1.4 1.8 2.2
(m2)
Priming volume 42ml 53ml 74ml 95ml 116ml
https://www.freseniusmedicalcare.se/fileadmin/data/sv/pdf/Product_Info/HD-produkter/Blodslangar.pdf
He was then initiated on

Hemodialysis
With
6.5Fr double lumen

dialysis catheter
0.9 (m2)
NIPRO 9H dialyzer
Extracorporeal circuit:
The lines and hemodialyzer are selected on the

basis that
child can tolerate 8-10 % of their blood volume
Examp
Weight 10 le
kg
Total blood volume= 80ml/kg Total blood volume
TBV= 80x 10=800 ml. (TBV)
Blood volume
So, extracorporeal circuit can be neonate :100ml/kg.
64-80mls < 10kg blood volume
80ml/kg.
Extracorporeal circuit:
The lines and hemodialyzer are selected on the

basis that
child can tolerate 8-10 % of their blood volume
In infants,
Examppriming of the circuit
ICON with
Weight 10 le
blood kg or 5% albumin is required
Total blood volume= 80ml/kg Total blood volume
TBV= 80x 10=800 ml. (TBV)
Careful attention Blood during blood volume
return.
So, extracorporeal
64-80mls
Discard
circuit can be blood if needed
neonate :100ml/kg.
< 10kg blood volume
80ml/kg.
Blood
lines
Blood flow:
Children: 150-200ml/m2/min or 5-7ml/kg/min
BW <10Kg: Blood flow ≤100ml/min
BW 10-40Kg: Blood flow= [2.5x BW (kg)+100]ml/min
BW >40Kg: Blood flow up to 250ml/min
** Blood flow rate should not exceed the maximum
extracorporeal volume per min [BW(Kg)x8 ml/min]
Dialysate flow:
Dialysate flow rate is usually 2x blood flow rate
(300-800ml/min)
Ultrafiltration:
keep UF rate about 10-12 ml/kg /min.
Total UF should not exceed 5% of BW in a dialysis session.
Anticoagulation:
Heparin Loading dose (U/Kg) Maintenance dose Monitoring
(U/kg/hr)
Regular 50 10-50 ACT 200-250sec
Heparin (Adults: 1500U) (Adults: 750U/hr) APTT 60-80sec
Low dose >15Kg: 10-20 5-10 ACT 200-250sec

Heparin ≤15Kg: 5-10 (Adults: 500U/hr) APTT 60-80sec
(Adults: 1000U)
1) Infants and small children are sensitive to anticoagulation because of cerebral

hemorrhage
2) Citrate anticoagulation especially with acute dialysis, IV calcium at venous
line 0.3-0.5 mmol/l
3) Heparin free dialysis, minimal heparinization
4) TPA 1mg/ml for one hour preferably overnight
Small size catheter Large extracorporeal

Not available in all the centre circuit
Usual extracorporeal circuit is 200-
Difficult insertion because of 300ml (Dialyzer & adult blood lines)
small caliber of vein.
So need to prime
the circuit with blood
Difficulties ICON
Blood loss during Increase total cost

blood return of the therapy
Join us for the next IPNA Journal Club @ipnajc
֎ April 24, 2024 11am ET/ 5pm CEST/9pm IST
Zoom Registration: http://tinyurl.com/mr3fhwsf
Thank You

Hemodialysis in Small Children

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Hemodialysis in Small Children

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Hemodialysis in Small Children

# SoMe। #Communication, International Pediatric Nephrology Association (IPNA)

• 1962 Hickman and Scribner report 6

• By 1965 reports of 7 infants under 2

2years old boy presented to Chittagong Medical

Acute kidney injury secondary to

Diagnosis of AKI in small children

GFR criteria RIFLE pRIFLE nRIFLE

Risk (R) Increased creatinine x 1.5 ≤0.5ml/Kg/H <0.5ml/Kg/H <1.5ml/Kg/H

Failure (F) Increased creatinine x 3 ≤0.3ml/Kg/H <0.3ml/Kg/H <0.7ml/Kg/H

End stage Loss of kidney function for >3months

2years old boy (10Kg) presented to Chittagong Medical

Acute kidney injury

Acute kidney injury

• His serum creatinine improved minimally but

He was then initiated on

6.5Fr double lumen

Patient size Internal diameter Filling volume

Dialyzer F40 Fx50 Fx60 Fx80 Fx100

He was then initiated on

6.5Fr double lumen

The lines and hemodialyzer are selected on the

The lines and hemodialyzer are selected on the

Low dose >15Kg: 10-20 5-10 ACT 200-250sec

1) Infants and small children are sensitive to anticoagulation because of cerebral

Small size catheter Large extracorporeal

Blood loss during Increase total cost

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