Home nocturnal hemodialysis in children

doi:10.1016/j.jpeds.2005.04.034

The Journal of Pediatrics

Volume 147, Issue 3, September 2005, Pages 383-387

https://doi.org/10.1016/j.jpeds.2005.04.034 Get rights and content

Objective

To describe the effect of home nocturnal hemodialysis (NHD) in North American children.

Study design

Four teenagers underwent NHD for 8 hours, 6 to 7 nights/week, using either central venous lines or fistulae for periods of 6 to 12 months. Blood flow approximated 200 mL/min, and dialysate flow was 300 mL/min; the dialysate contained potassium and phosphate. The procedure was remotely monitored.

Results

The children had unrestricted diets and fluid allowance and did not require phosphate binders. Persistent relative hypotension developed in 2 of 4 children. Weekly Kt/V urea values were consistently >10; other biochemical measures varied. Quality of life and school attendance improved in 3 of 4 children. The workload and reported emotional burden of NHD was substantial. No significant complications occurred. Dialysate losses of calcium, phosphate and carnitine required supplementation. The annual cost per patient was $64,000 Canadian, which represented a 27% savings compared with thrice weekly in-center hemodialysis.

Conclusions

NHD is feasible in selected children, allows free dietary and fluid intake, and improves patient wellbeing. The burden on the family is substantial, and NHD requires support of a dedicated multidisciplinary team.

Section snippets

Patient 1

Patient 1 was a 13-year-old male with end-stage renal disease caused by focal segmental glomerulosclerosis who started PD at age 4 years, and subsequently underwent bilateral nephrectomy and renal transplantation at age 8. At age 11, because of recurrent disease in the graft and chronic allograft nephropathy, he underwent graft nephrectomy and restarted PD. He had recurrent peritonitis and 2 episodes of pancreatitis, which necessitated a switch to HD. On HD, he remained malnourished, had

Methods

The technical considerations, including home renovations, dialysis machines and water purification units, the possible need for water softeners, and the remote monitoring process, were previously reported for our program and for adults.13, 14

Vascular access was provided initially with central venous lines (CVL) in all 4 patients and, subsequently, arteriovenous (AV) fistulae in 2 patients. During NHD, central venous lines are held in place with a locking device described by Pierratos.⁷ Access

Patient Selection

The 4 families who met eligibility criteria agreed to participate in the program and completed the training requirements. No families have been denied access to this program. Clinical and biochemical outcomes are reported at 3 and 6 months for all patients; 12-month data are available for patients 1 and 2. Patient 1 received NHD for 1 year before switching to a hybrid form of dialysis of NHD Sunday to Wednesday nights inclusive, with an in-center HD on Friday for respite purposes. There have

Discussion

This report describes the successful implementation of NHD for children. Although introduced approximately 10 years ago for adults, the only previous pediatric experience with NHD, published in abstract form from Sweden,¹² described 4 children with ages similar to our own patients. They used CVL as blood access, whereas we have also successfully used AV fistulas. Overall, their brief report suggests that outcomes are comparable to our own, and that NHD provides an improvement in patient

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Conventionally, HD has been provided 3 times a week; however, intensified HD for children and adolescents, including short daily HD, intermittent nocturnal HD, and daily nocturnal HD, increasingly is recognized as an important strategy to optimize care.28,43-48 Compared to conventional thrice-weekly HD, intensified programs have demonstrated improved control of phosphate levels, anemia, blood pressure, and fluid status and have provided unique benefits for children and adolescents in terms of improved growth and nutrition.28,47-56 As with PD, the efficiency of HD typically is measured in terms of urea clearance.
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Original ArticleHome nocturnal hemodialysis in children

Objective

Study design

Results

Conclusions

Section snippets

Patient 1

Methods

Patient Selection

Discussion

J Pediatr

Kidney Int

Adv Ren Replace Ther

Adv Ren Replace Ther

Kidney Int

Kidney Int

Kidney Int

J Pediatr

Am J Kidney Dis

Am J Kidney Dis

Continuous ambulatory peritoneal dialysis in pediatrics

J Am Assoc Nephrol Nurses Tech

Original Article
Home nocturnal hemodialysis in children