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Caring for the Teenager in an Adult Unit

Overview of Transition/Transfer to Adult Care Adolescence is known as a period of transition toward adulthood that is characterized by significant developmental changes in cognitive, emotional, and social domains. For adolescent/young adult dialysis patients, this process also involves the acquisition of self-managed medical care. For many patients, this time is also marked by treatment nonadherence, lapses in medical care, and poor outcomes. As this transition progresses,…

Infectious Complications in Children Undergoing Dialysis

Introduction Infectious complications are a major cause of morbidity and mortality in children on peritoneal dialysis (PD) and hemodialysis (HD). This chapter reviews the major infectious risks of each modality, proposed preventive strategies, treatment guidelines, and areas for further development. Peritoneal Dialysis The infectious complications associated with PD consist of peritonitis, exit-site infections (ESIs), and catheter tunnel infections (TIs). These complications can occur individually or concurrently.…

Prevention and Treatment of Cardiovascular Complications in Children Undergoing Dialysis

Cardiovascular Mortality in Children on Maintenance Dialysis Reports from international registries since 2000 have confirmed, that like in adults, cardiovascular disease (CVD) is the leading cause of death in children with end-stage renal disease (ESRD) and young adults with childhood onset of CKD. There has been some improvement in mortality rates; however, it still remains about 30 times higher than in the general pediatric population. Not…

Management of Anemia in Children Undergoing Dialysis

Introduction Anemia is common and associated with adverse outcomes in children with chronic kidney disease. The management of anemia was dramatically changed due to the development of erythropoiesis-stimulating agents (ESAs) and new understandings of iron metabolism. As the adverse effects of anemia have become more apparent and concerning, there has been a push to optimize ESA and iron therapy. This chapter will review the basic management…

Prevention and Treatment of Bone Disease in Pediatric Dialysis Patients

Childhood and adolescence are crucial times for developing a healthy skeletal system; alterations in bone modeling/remodeling in youth carry consequences that severely impact quality of life even into adulthood. In childhood, chronic kidney disease (CKD) causes disordered regulation of mineral metabolism, with subsequent alterations in bone modeling, remodeling, and growth. Additionally, uremia itself, independent of altered mineral metabolism, impairs bone cell function in a manner that…

Continuous Renal Replacement Therapy in Pediatric Patients

Introduction Continuous renal replacement therapy (CRRT) is the preferred modality for the optimal management of fluid and electrolytes as well as nutritional support for children developing acute kidney injury (AKI) in the pediatric intensive care unit (PICU). Recent awareness about the association between fluid overload (FO) and adverse outcomes in patients with AKI has led to a practice change resulting in the earlier use of CRRT…

Adequacy of Peritoneal Dialysis/Assessing Peritoneal Function in Pediatric Patients

End-stage kidney disease (ESKD) is a debilitating disease, and its consequences are particularly detrimental in children who face a lifelong treatment burden. In the absence of the availability of a preemptive kidney transplant, dialysis initiation in children is recommended at an estimated glomerular filtration rate (eGFR) of < 10 mL m 2 or at a greater eGFR level when the patient’s clinical course is complicated by…

Growth in Children With End-Stage Kidney Disease

Introduction Growth is a complex biologic process dependent on adequate nutrition as well as the integrated homeostasis of metabolic and endocrine pathways. Growth failure has long been recognized as one of the most common and profound complications seen in children with chronic kidney disease (CKD) and advances in our understanding of the crucial role of nutrition and benefits of treatment directed to the growth hormone-insulin-like growth…

Neurocognitive Function in Pediatric Dialysis

Introduction Children with chronic kidney disease (CKD) present unique clinical challenges to practitioners when compared to adults in two very important aspects. First, they differ with respect to physical growth. Linear growth occurs through childhood and continues into puberty. Second, the human brain undergoes a remarkable physical and functional transformation from the moment of birth until early adulthood, with about 50% of brain growth noted in…

Dialysis for Inborn Errors of Metabolism

Inherited dysfunction of amino and organic acid metabolism usually manifests in the early neonatal period by neurologic abnormalities such as irritability, somnolence, and, eventually, coma. In urea cycle defects or organic acidemias, these symptoms are mainly due to excessive hyperammonemia, which may cause irreversible neuronal damage. In disorders of branched-chain amino acid metabolism such as maple syrup urine disease (MSUD), prolonged accumulation of leucine and/or its…

Peritoneal Dialysis in Neonates and Infants

Introduction Peritoneal dialysis (PD) has long been considered an effective treatment modality for neonates and infants with severe acute kidney injury (AKI) and is the dialysis modality of choice for patients in this age group with end-stage kidney disease (ESKD). Its popularity and success largely derive from its simplicity and effectiveness as a means of removing solute and fluid in even the smallest patients and because…

Nutritional Management of Children Undergoing Peritoneal Dialysis

Nutritional management is a key component of the care of children treated with peritoneal dialysis (PD). This includes regular assessment of nutritional status as well as development and implementation of a dietary prescription. Optimal nutritional management requires collaboration among the child, the caregivers, a renal dietitian, and other members of the multidisciplinary pediatric nephrology team. The goals are to achieve normal growth, development, and body composition…

Prescribing Peritoneal Dialysis in Children

Peritoneal dialysis (PD) became a more available therapy for children in the 1960s, such that it was no longer considered “experimental” by the early 1970s. Further advances have been made in the size of catheters and tubing and the technology of automated cyclers, which has made PD more adaptable to a variety of patient needs. This would seem to make PD a potentially optimal modality for…

Anticoagulation in Children Undergoing Hemodialysis, Continuous Renal Replacement Therapy, or Apheresis Therapy

Introduction Extracorporeal blood purification techniques are associated with clotting of the extracorporeal circuit; therefore, with the exception of some coagulation disorders, anticoagulation is mandatory. In pediatric practice, the relative surface area of the extracorporeal circuit is increased in relation to its blood volume. The use of smaller lumen diameter lines provides greater surface contact. Passage of blood through the extracorporeal circuit results in activation of leukocytes,…

Alternate Hemodialysis Prescriptions in Children

The life span of a child on dialysis is 40 to 60 years less than that of the general population, but that of a pediatric transplant recipient is 20 to 30 years less than the general population. There is no doubt that dialysis is a significant risk factor for mortality and morbidity in children and adults alike. However, over the past decade, there has been a…

Urea Kinetic Modeling for Hemodialysis Prescription in Children

Chronic Hemodialysis in Children Although renal transplantation is the optimal treatment for end-stage kidney disease in children and adolescents, many pediatric patients nonetheless must spend some time on chronic dialysis. Historically, a much larger proportion of children than adults undergo peritoneal dialysis, but registry data from the U.S. Renal Data System (USRDS) and the North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) suggest that the…

Infant Hemodialysis

Vascular Access Hemodialysis requires a central venous catheter, and in infants, this poses technical challenges because of their smaller vessel size and the likelihood that they may require vascular access throughout their lifetime if end-stage renal disease is present. Dialysis catheters are stiff, allow for high rates of blood flow, and are relatively larger than other central lines. Thus, use of central lines other than those…

Vascular Access and Peritoneal Dialysis Catheter Placement in Children

Dialysis Access in the Pediatric ESRD Patient Vascular Access in Children Introduction Renal transplantation is the most common renal replacement modality for prevalent children with end-stage renal disease (ESRD). However, hemodialysis (HD) continues to be the most common initial treatment. Of 1319 incident children with ESRD in 2017, 51.3% began treatment with HD. Because of their young age, children with ESRD will require decades of renal…

Treatment of Poisoning with Extracorporeal Methods

More than 2 million poisonings were reported to the American Association of Poison Control Centers in 2021. Outcomes are generally favorable, and supportive measures alone are sufficient to manage the majority of poisonings. In selected situations, gastrointestinal decontamination, timely administration of antidotes, and elimination enhancement treatments may be administered to prevent or reverse toxicity. Urine alkalinization was reported in 0.6% of cases, and multiple-dose activated charcoal…

Anticoagulation for Continuous Renal Replacement Therapy

Continuous renal replacement therapy (CRRT) has evolved as the preferred form of dialysis in hemodynamically unstable critically ill patients with acute kidney injury (AKI). It is applied continuously and achieves solute clearance and fluid removal by convection, as in continuous venovenous hemofiltration (CVVH), diffusion, as in continuous venovenous hemodialysis (CVVHD), or a combination of both, as in continuous venovenous hemodiafiltration (CVVHDF). CRRT requires anticoagulation for the…