HD modality in children

1. dr. Zakky Hazami
DEPARTMENT OF PEDIATRICS
HARAPAN KITA WOMEN AND CHILDREN HOSPITAL
JULY 2018

2. • No controlled trials in children with ESRD have assessed the
benefits of more frequently administered HD
• In FHN (frequent hemodialysis network) RCT frequent
HD treatments improved survival and left ventricular
hypertrophy condition
INTRODUCTION

3. • To conduct a multicenter pilot trial ( 2 extra days per week of
in-center HD feasible and associated improvements in
systolic blood pressure and multiple additional outcomes
OBJECTIVE

4. SUBJECT AND METHOD
• Children and young adults aged 3–21 years receiving HD for
ESKD at Cincinnati Children’s Hospital , Hospital of
Philadelphia (CHOP, June 2012–September 2013), and The
Hospital for Sick Children (September 2012–May 2014) were
screened
• Screening inclusion criteria
• were a diagnosis of hypertension defined as the prescription
of
• antihypertensive medication or a systolic blood pressure
• ≥95th percentile for age, gender, and height

5. SUBJECT AND METHOD
Inclusion criteria:
Children 3-18 years old with hypertension (defined as the
prescription of antihypertensive medication or a systolic blood
pressure ≥95th percentile for age, gender, and height)
Exclusion Criteria:
• receiving maintenance HD for <2 months
• a living kidney transplant
• switch to peritoneal dialysis within the subsequent 6 months,
• already receiving >3 days or >12 h per week of HD
• receiving concomitant peritoneal dialysis
• use of a temporary or femoral dialysis catheter

6. DESIGN
Patients were randomized
conventional HD treatment of
3 days per week for 4 h (12 h
per week)
5 days per week for 2 h
25 minutes ( 12 hour per
week)

7. STUDY DESIGN
Measure Blood
Pressure
Measure Blood
Pressure
Any adverse event monitored everytime
Pre HD electrolyte and Post HD
complete blood count every 2 weeks
Every 4 weeks recorded antihypertensive prescription, dry weight, concomitant
drugs, post dialysis albumin, blood urea nitrogen, PTH, and iron serum
3 times echocardiography before study, after the first period, and the end of study

8. END POINT
Blood Pressure Inter dialytic
fluid overload
(Predialytic-dry weight)/dry weight x100 %

9. END POINT

10. ADVERSE EVENT
Others: feeling hot, dizziness, lightheaded, tachycardia, malaise,
back pain, flank pain

11. ANALYSIS

12. PATIENT DEMOGRAPHIC

13. ENROLLEMENT OF STUDY

14. RESULT
• Patient during 5 not 3 times a week
HD had decrease systolic blood
pressure 10%
• 5 times duration reduces day that
patient fluid overload
• In echocardiography 5 times a week
reduces LV mass

15. DISSCUSSION
• Even the small size study, there was statistically significant
improvement in blood pressure and shorter fluid overload controle
• The study was limited by :
• its small size,
• relatively short follow-up period
• enrollment of only adolescents
• Lack of 24-h ambulatory blood pressure monitoring
• antihypertensive medication administration that was not
standardized,
• recording changes in dry weight once a month only
• crossover design that had the potential for unequal carryover
effects across study periods.

16. CONCLUSION
• Frequent HD with shorter period shows
significant effect controling BP and Fluid
overload but had more adverse event

17. TAKE HOME MESSAGE
• This study shows a new paradigm about
frequent HD with shorter HD duration
• More RCT with larger sample is needed to
prove the concept
• The RCT with sub group analysis should had
be done after RCT with large sample size
exist

18. CRITICAL APPRAISAL

19. VALIDITAS INTERNAL
• Cause and effect causality?
• Design: RCT cross over
• Similiar characteristic
• No similiar concomitant intervention (anti hypertensive)
• Biological Plausibility and consistency?
• FHN RCT study in adult
• Asociation ? P<0,05
• FHN RCT study in adult

20. IMPORTANCE
• HD 5 times a week with shorter duration reduces blood
pressure and fluid overload

21. APLICABILTY
• Not cost effective and difficult to be aplicable