Dr ahmed alnakib hd in children

1. Dr. Ahmed Al-Nakeeb
Nephrology department
NMGH

2. When should dialysis start ?
 Severity of renal dysfunction
 Clinical factors……….”most important”
 Biochemical facrtors

3. Severity of renal dysfunction
eGFR < 15ml/min/1.73m2 with symptoms
or signs of uremia, fluid overload or
malnutrition in spite of medical therapy
or
Before an asymptomatic patient has an
eGFR <6ml/min/1.73m2.

4. BEDSIDE SCHWARTZ EQUATION
For use in children 1 – 18 years old.
eGFR =0.413 x (height/Scr)
Height is expressed in centimeters

5. Clinical factors
Clinical wellbeing of patient is more
important than GFR in dialysis decision.
 Poor growth/ severe GIT symptoms
 Poor development
 Neurological complications of uremia
 Worsening school performance
 Deteriorating nutrition/ anorexia

6. Biochemical facrtors
Hyperkalemia
(failed diet control& medical ttt)
GFR less than 30
Hyperphosphatemia
(failed diet control& medical ttt)
GFR less than 30
Metabolic acidosis
(failed medical ttt)
GFR less than 20

7. Early Dialysis ???

8. Dialysis modality selection
Hemodialysis (HD)
Peritoneal dialysis (PD)

9. Factors Contributing to the Choice
of Dialysis Modality in Children:
- Age (All below 2y and 80% below 5y……PD)
- Geographic location
- Medical conditions………..prevent PD
- Family composition
- Social support
- Compliance
- Native kidney function

10. Hemodialysis fasilities
 Dialysis unit
 Water management unit

11. Dialysis unit
Kids are not little adults , they need
pediatric expertise!!!
New family

12. Dialysis unit

13. Dialysis unit
 Infection control strategies in HD units for
children should consider:
*the special needs of children.
*not affecting their psychological status.
*not disturbing the joyful appearance of
unit.
* sometimes the need for attendance of
family members through sessions.

14. Water management unit

15. Vascular access

16. Vascular access
TemporaryVascularAccess
The preferred mode: Double-lumen central
venous catheters.
The preferred site:Internal jugular vein not the
same side as a planned or maturing upper limb
fistula.

17. Vascular access
PermanentAccess
 According to the KDOQI guidelines, the percentage
of catheters in a dialysis unit for adults should be less
than 10%.
 many pediatric centers do not meet this standard,
because of the Difficulty of creating fistulas in
smaller children, especially in children less than 2
years of age

18. Vascular access
PermanentAccess
The preferred mode: A native arteriovenous fistula.
Fistula creation:
6-12 months before hemodialysis is expected to start.
Should be undertaken by appropriately trained and
skilled surgeon.
Psychological preparation is needed for the child and
family before a fistula is created.
Local anesthetic creams must be applied before
needling to avoid pain.

19. Hemodialysis Prescriptions
* Estimation of Dry Weight
* Dialyzer
* Blood Lines
* Blood Pump Rate
* Anticoagulants

20. Estimation of Dry Weight
Defined as the post-HD weight at which the
patient is as close to euvolemia without
experiencing symptoms indicative of over-
hydration or underhydration at or after the
end of HD .

21. Estimation of Dry Weight
It is difficult ..!!
 The hypotensive tendency during a dialysis session
is multifactorial and not only related to the
ultrafiltration rate.
 Body mass is variable with age especially during
infancy and puberty.
 No “unique” optimum method.

22. Dialyzer
Dialyzer surface area/body surface area ratio = 0.8–1.0

23. Dialyzer

24. Blood Lines
 Available in infants/babies size
size Priming volume Weight of patient
Medisystem neonatal
Medisystem pediatric
Adult
29 mL
58 mL
125 mL
<7kg
7-20kg
>20kg

25. Blood Pump Rate
 150-200 mL/min/m2
 5-8 mL/min/kg
 In small children (mL/min): (BW+10) x 2.5
 The total extracorporeal blood volume (needles,
tubing, and dialyser) should preferably be less than
10% of patient total blood volume.
The TBV is approximately equal to
100 ml/kg body weight in neonates (less than 1 month of age)
80 ml/kg body weight for infants and children up to 16 years of age.

26. Anticoagulants
Unfractionated Heparin
Dose:
15-20 IU/kg bolus at start of session
With continuous infusion of 20 to 30 IU/kg/h.
stopped 30 minutes before the end of dialysis

27. Anticoagulants
Low Molecular Weight Heparins
 LMWH can achieve a sustained intradialytic anticoagula-
tion following a single bolus at the start of dialysis so
represents an extremely simple method of
anticoagulation.
 In addition, the negative charge of the LMWH complexes
make them impermeable across dialysis membranes and
therefore in spite of their low molecular weight clearance
by HD or hemofiltration is insignificant.

28. Comparison of currently available LMWHs
LMWH Half-life(h) Adult dose Pediatric dose
Enoxaparin 4.2 0.5-0.7 mg/kg 24-36mg/m2
0.5-1mg/kg

29. First dialysis session special aspects:
 Blood flow rate is maintained at a low level to prevent
the dysequilibrium syndrome secondary to too efficient
solute removal during this first session.Therefore, the
blood flow rate should be approximately 3-4ml/kg
 Choose dialyzer smaller than the ideal for patient SA.
 The duration of the first dialysis session should be short
1-1.5 hours unless more ultrfiltration is required.
 First dialysis should not reduce blood urea by more
than 30 %
 First dialysis should be heparin free or just
extracorporeal lines priming by heparinated saline.

30. .