Intensified hemodialysis regimens: neglected treatment options for children and adolescents

Abstract

During recent years, the importance of intensified dialysis regimens has gathered increasing interest, especially after the Hemodialysis (HEMO) Study Group reported that a higher dose of thrice-weekly hemodialysis failed to improve clinical outcomes. Long nocturnal hemodialysis (three to six times per week) or short daily hemodialysis are the currently used forms of intensified dialysis. There is substantial evidence for cardiovascular and quality-of-life improvements as well as financial benefits with intensified hemodialysis. Preliminary experience with daily hemodialysis and hemodiafiltration in children has been reported. Given the continuing shortage of donor organs for kidney transplantation, the increasing incidence of end-stage renal disease (ESRD) and recognition of the deleterious effects of long-lasting ESRD, growth retardation, and poor social rehabilitation, more intensified dialysis regimens are a much-needed therapeutical option in both adults and children.

A Review of Pediatric Chronic Kidney Disease

“…According to NAPRTCS data, the use of PD has declined over the last 30 years and in 2010, the use of HD surpassed the use of PD for the first time [4] . Recently, there has been attention in the literature on frequent HD or long-duration HD, both home and in-center, as a means to improve clearance and outcomes [38,39] . Although distance from home to hospital dialysis center has previously precluded the use of HD, the option of home HD and telemedicine may change dialysis demographics in the near future.…”

Hemodialysis in Children

“…One study in children demonstrated an improvement in the risk for hospitalization up to a Kt/V of Pediatric Nephrology DOI 10.1007/978-3-642-27843-3_63-1 # Springer-Verlag Berlin Heidelberg 2015 that level, but above 1.4, no further improvement occurred [48]. However, the improvement in all aspects of patient well-being with daily or frequent short hemodialysis suggests that a higher Kt/V must be better [12,[16][17][18][19][20][21][22][23].…”

“…Intensified dialysis is particularly indicated in those with chronic fluid overload or hyperphosphatemia, because of poor growth, or for infants, whose predominantly liquid diet requires removal of relatively large fluid volumes, although it is likely to benefit all children. Reports demonstrate better phosphate and BP control, with many patients being able to come off all their medications, improved appetite and growth, and, despite increased time spent dialyzing, improved quality of life [12,[17][18][19][20][21][22][23].…”

Hemodiafiltration: the addition of convective flow to hemodialysis

“…This growth impact is multifactorial, due to an improvement in both the adequacy of the dialysis [17] (urea, uremic toxins, inflammation, acidosis, fluid overload) and nutrition [18,19]. At present, it is not yet known if the different forms of daily hemodialysis available are equivalent in terms of the catch-up growth obtained [19,24].…”