DIALYSIS

BY:MERON
MODORATOR: DR.YEMISIRACH ,PED.NEPHROLOGIST

MARCH 31,2023
 Outlines
• Introduction
• Indications
• Types of modalities
• Peritoneal dialysis
• Hemodialysis
• Continuous renal replacement therapy
• References
 Introduction
• Dialysis is derived from Greek words
“dia”meaning through and “lysis” loosening or
splitting
• Is a process of removing body waste and
toxins and fluid from the blood as renal
replacement
• The first successful dialysis performed in 1944
Indications for Dialysis
• Severe fluid overload in presence of oligoanuria
• Severe electrolyte derangement severe metabolic acidosis
that fail to respond adequately to conservative measures
• Symptomatic uremia
• Stage 5 CKD
For patients who undergo dialysis as the initial RRT, earlier
indications for intervention prior to CKD stage 5 may include:
• Children with congenital nephrotic syndrome or bilateral
ARPKD requiring bilateral nephrectomies pretransplant.
• Correction of metabolic abnormalities that fail medical
management including hyperkalemia, hyperphosphatemia,
and metabolic acidosis.
• Inadequate nutrition because of fluid limitations. This is
especially an issue with infants who are maintained on a
completely liquid diet (ie, formula or breast milk). In these
patients, dialysis is instituted to allow the required volume of
feeds to maintain adequate growth
• Hypertension that is refractory to dietary sodium restriction
and medications
• Intoxication (salicylates, ethylene glycol, methanol,
isopropanol, metformin, valproic acid, lithium)
• Severe hyperammonemia >400ìmol/l
– infants with inborn errors of metabolism should be rapidly
hemodialyzed, once NH4 + exceeds 170 ìmol/l, as seen
with urea cycle disorders, maple syrup urine disease and
organic acidemias
• To enable nutritional support
• NB;There are no absolute blood values of blood urea or
serum creatinine that define the need for dialysis
The renal replacement therapeutic interventions are based on the
following mechanisms:
• Diffusion
– solute exchange is driven by concentration gradient
– Rate is determined by solute size , charge,and the permeability
of the membrane
• Filtration
– driven by either differences in hydrostatic pressure (eg,
hemodialysis [HD] and hemofiltration) or
– osmotic pressure (eg, HD and peritoneal dialysis [PD])
• Convection
– solute movement (also referred to as solute drag) with filtration
across the membrane independent of concentration gradient
Choice of Various Modalities of RRT
• Peritoneal dialysis (PD)
• Intermittent hemodialysis (HD)
• Continuous renal replacement therapy (CRRT)
Factors Influencing the Choice of RRT Modality
• Goal of dialysis: ultra filtration versus solute clearance versus
toxin removal
• Clinical status of the child and hemodynamic stability
• Feasibility of peritoneal or large vascular access
• Training of medical personnel, institutional preference
• Need for anticoagulation
• Cost of treatment and supplies
•PD may achieve less efficient solute removal than CRRT or HD, but
advantages are
–relative simplicity of the setup, reduced training time and costs, and no
need for anticoagulation
•PD permits other supportive measures to proceed with few limitations
(e.g. enteral and parenteral nutrition) until renal function resumes
•The disequilibrium syndrome observed with HD does not occur in
children on PD
• It is less effective than HD in
–extreme catabolic states or
–to rapidly improve pulmonary edema or
–clear toxic drug levels, low molecular weight poisons or toxins
• HD requires
– central vascular access
– specialized equipment and technical personnel
– anticoagulation (except in patients with coagulopathy)
– the ability to tolerate a large extracorporeal volume
• Useful in patients with a relatively stable hemodynamic status
• The advantage of hemodialysis in the setting of AKI lies in its
ability to rapidly correct imbalances in fluid, electrolyte, and
acid-base status.
• CRRT is especially useful in patients with hemodynamic
instability and multiorgan dysfunction
– it allows continuous management of fluid overload
without significant fluid shifts that may occur with HD
 Peritoneal dialysis
• It is most commonly employed in neonates and infants with
AKI
• Hyperosmolar dialysate is infused into the peritoneal cavity
via a surgically or percutaneously placed peritoneal dialysis
catheter.
• The fluid is allowed to dwell for certain duration and is then
drained from the patient by gravity (manually or with the use
of machine-driven cycling)
• CPD, cycles are repeated for 8-24 hr/day based on the
patient's fluid and electrolyte balance
 PD Components
– Peritoneal Membrane
– Peritoneal Microcirculation
• Peritoneal capillary blood flow has been reported to
vary between 50 and 100 ml/min
– Dialysis Fluid Compartment
During PD, fluid is lost from the peritoneal cavity both directly
into the surrounding tissues and via lymphatic vessels and
capillaries
– Lymphatic absorption was estimated to account for about
20 % of fluid absorption
Several factors affect the solute diffusion rate:
• The concentration gradient between blood and dialysate
• The molecular weight (MW)
• Effective peritoneal surface area
• Permeability of the peritoneal membrane
• In Acute PD temporary rigid catheter with a metal stylet can
be inserted
• A “permanent soft catheter” may be used when it is
anticipated that the need for PD will be longer than a few
days. Insertion of this catheter (percutaneously with the help
of a guide wire and a peel-away sheath) may be done at the
bedside.
• Children who are to initiate chronic PD need to undergo
abdominal surgery for placement of a PD catheter
– double cuff catheter be used
– perioperative antibiotic prophylaxis within 60 minutes
prior to the incision
– the minimum timeframe for wound healing is
approximately two weeks
Peritoneal Dialysis Prescription
• Optimal PD prescription
should be tailored to the
– child’s age, body size, residual
renal function (RRF),
nutritional intake, and
peritoneal membrane
transporter status
 Peritoneal Dialysis Solutions

Osmotic Agents Constituents of a standard PD solution

• Glucose and icodextrin are;
• Amino acids (AA) • dextrose 1.7 g/dl (0.094
Buffer Substance mmol/l)
• Lactate • sodium 130 mmol/l
• Bicarbonate • chloride 100 mmol/l
• Sodium • acetate/lactate 3.88 mmol/l
• Calcium • magnesium 1.23 mmol/l
• calcium 1.5 mmol/l and
osmolality 355 mOsm/kg
Fill Volume Prescription
• Dwell volume is prescribed according to BSA, with target
volumes adjusted to intraperitoneal pressure
– Dwell volumes of 1,000–1,200 ml/m2 in patients older
than 2 years and of 600–800 ml/m2 for patients younger
than 2 years are usually prescribed
– The daytime fill volume is generally 50 percent of the
nighttime volume
• Maximization of functional peritoneal surface area and thus
of transport capacity can been obtained by
– raising dwell volume to 1,400-ml/m2 BSA
• Very high dwell volumes may
– cause patient discomfort, abdominal pain, dyspnea,
hydrothorax, hernia, and gastroesophageal reflux
– increase the risk of enteric peritonitis and loss of UF due
to increased absorption into the tissue and drainage
• IPP in children above 2 years of age on nocturnal PD should
therefore be limited to 14-cm H2O and to 8–10-cm H2O in
infants,
– which corresponds to a fill volume of about 1,400- and
800-ml/m2 BSA
Dwell Time Prescription
• Dwell duration should always be adjusted to the
– individual transport status, to the required small and middle-sized molecule
removal, and to the UF needs
• Short dwells are more efficient for small solute clearance and UF
• UF can further be enhanced by increasing dialysate glucose
concentration
• Long dwells
– favor middle sized molecule removal (cr,phosphate)
– may result in insufficient UF
• Patients with a high transporter status need short exchanges for
adequate UF and achieve high small solute clearance rates
– but are at risk of increasing glucose needs, peritoneal protein losses, and
– inadequate UF due to rapid dissipation of the osmotic gradient and ultimately
PD failure
Peritoneal Dialysis Prescription and Monitoring for Acute PD

• Fill volume 30–50 ml/kg, run-in time 5–10 min, dwell time 20–30 min,
and out flow time 10–20 min constitute the usual dialysis prescription
•In patients with pulmonary edema, dwell time can be shortened to 15–
20 min and 2.5 % dextrose containing PD fluid can be used to remove
fluid rapidly.
•Each cycle usually lasts for 1 h
•Avoid excessive abdominal distention and respiratory compromise
 Acute PD…
• Addition of potassium to the dialysis fluid may be withheld for
initial 8–10 cycles.
• Subsequently 2–4 mmol/l of KCl can be added depending on the
serum potassium level.
• Heparin (500 IU/l) may be added to prevent clot formation
particularly to the first liter of fluid and when out fl ow contains
blood and fibrinous material
• Dialysis can be continued for 48–72 h (total treatment time).
• It is preferable to remove the acute PD catheter after 72 h (risk of
infection if the catheter is left in place for a longer period) and
reinsert later if required
• Before removing the catheter, drain out dialysate fluid completely
• Monitoring:
– Maintain pulse, blood pressure, and intake/output hourly charts;
serum electrolytes and blood sugar every 8 h and blood urea and
creatinin every 24 h.
– Watch changes in appearance of returning peritoneal fluid
(infection, blood, fibrin threads)
– Send PD fluid for analysis: cell count, gram stain, culture, and
antibiotic sensitivity if patient is febrile or drained PD fluid color
transparency is altered
• Almost all children receiving PD may be encouraged to eat an
appropriate diet
– relatively high in protein, considering protein loss into the dialysate
Disadvantages of CPD include:
• Mechanical Complications
– Pericatheter leaks
– Positional blockage
– Catheter dislocation
• Infectious Complication
• Limitations in hypercatabolic states such as sepsis, burns, heat
stroke, or crush Injuries
• Increased caregiver burden, which may lead to psychological
and social stress
• Possible patient/caregiver nonadherence to prescribed therapy
 HEMODIALYSIS
• Hemodialysis (HD) is an extracorporeal, intermittent form of
renal replacement therapy (RRT).
• Technical advances have substantially improved the safety of
the procedure.
• HD is now technically possible in a child of any age, even in
infants
• Solute Clearance
– occurs by diffusion and convection
Vascular Access
• Stable, large-bore vascular access is essential for effective
dialysis
• Three forms of vascular access in children are:
– Native arteriovenous (AV) fistulas
– Subcutaneously tunneled central venous catheters (CVCs)
– Synthetic AV grafts
HD EQUIPMENT 
• Tubing
• Dialyzer
• Dialysis machine
Extracorporeal circuit 
• The arterial (inflow) and venous (outflow) lines, and the
dialyzer
• The volume of this circuit is restricted by the upper safe limit
for extracorporeal blood volume that is dependent on the total
blood volume of the patient
• A child can tolerate 8 percent (up to a maximum of 10 percent)
of his or her total blood volume (80 mL/kg estimated optimum
weight) in the extracorporeal circuit
• The volume of the lines and dialyzer should not exceed this
volume
Dialyzer 
•  The type of dialyzer generally used in children is a hollow fiber
design that minimizes blood volume, and provides reliable and
predictable solute clearance and ultrafiltration coefficients
• dialyzer is selected on the basis of the size of the child (ie, surface
area of the child) and the type of hemodialysis (eg, standard or
hemodiafiltration [HDF])
• The size of the dialyzer is calculated by its surface area. The surface
area should be as large as possible to optimize clearances but
should not exceed that of the child
• At present, dialyzer surface areas range from 0.25 m2 up to 1.7
m2 and above
• Dialyzer surface area/body surface area ratio = 0.8–1.0
• Dialyzer material may be
– cellulose based (can cause complement activation, activation of
coagulation cascade) or
– synthetic (more biocompatible) – Polysulphone, polyamix,
polycarbonate, polyamide, or polyacryl-polyamide acrylate.
HD machine 
• Components of the HD machine include a blood pump to
move blood between patient and the dialyzer, a delivery
system to transport dialysis solution, and monitoring devices.
• Pressure monitors located proximal to the blood pump and
distal to the dialyzer guard against excessive suction of blood
from and excessive resistance to blood return to the
patient's vascular access site
• Modern machines are able to combine diffusive and
convective transport (HDF) and generate ultrapure dialysis
and infusion fluids online
Predialysis
• Monitor wt,input/output
• Hold
– Antihypertensives
– Sedatives
– Vasodilators diuretics
• Other medications be given after the session
• Drug adjustment, needed if clearance is >25%
 Dialysis Prescription
• If the predialysis blood urea levels are high, HD session should not
last more than 1–2 h
• The standard duration of HD sessions is 4 h, three times a week.
Hypercatabolic and very young children may require more frequent
dialysis
• To prevent DES, urea clearance should be limited during the first few
dialysis sessions, aiming at a blood urea reduction of not more than
30 %.
• Consider using mannitol if serum urea >30 mmol/l (>84 mg/l BUN).
– Give 0.5–1 g/kg IV (½ dose in first hour, remainder over next 2–3 h
as needed)
• Blood flow rate 5–8 ml/kg/min.
• Dialysate flow rates should be at least 1.5–2 times the blood flow
rates
Fluid removal  
• The amount of fluid removal per session is dependent on the
difference between the predialytic weight and the optimal
weight of the patient
– should be less than 5 % body weight or not more than 0.2
ml/kg/min, a generally safe starting point is about
10 mL/kg per hour
• In children who weigh more than 40 kg, typically
600 mL/hr can be removed without significant symptoms in
patients who are consistently volume overloaded as they
become tolerant of larger fluid shifts
Dialysate composition

• Dialysate sodium should be equal to or more than serum sodium.

• Dialysate K+ concentration is adjusted according to pre-dialysis serum K
levels
• Many children, particularly those with CAKUT, may continue to pass urine
and can have ongoing large urinary losses of bicarbonate
– need to be replaced using a high concentration of dialysate bicarbonate.
• The normal range for calcium is higher in the first 12 months of life, and
particularly in the first 6 months
– dialysate calcium concentration needs to be selected depending on the plasma
calcium level and whether calcium influx or removal is required
• Standard dialysate Ca concentration is 2.5 mEq/l (1.25 mmol/l); it can be
adjusted if there is hypo or hypercalcemia
Anticoagulation 
•  Unfractionated heparin is the standard anticoagulant used
during hemodialysis
• It is administered at a rate of 5 to 50 units/kg per hour
through the arterial side of the circuit.
• If heparin is contraindicated, frequent saline flushes or
regional citrate anticoagulation may be tried
 Hemodialysis Adequacy

• Urea reduction rate (URR) = (1 − urea post HD/urea pre HD)

× 100.
• Adequate dialysis should yield a URR >65 %.
• Dialyzer clearance of urea (Kt/V), where K is the clearance
coefficient for urea of the dialyzer measured as mL/min, t is
duration of the of dialysis treatment measured in minutes,
and V is the distribution of urea in the body measure in mL
– Target Kt/V >1.2
• Measuring urea 1 h postdialysis would hence truly reflect the
delivered Kt/ V , referred to as “equilibrated Kt/ V .”
Calculation of n PCR (normalized protein catabolic rate) –
• This is representative of urea generation between dialysis sessions and
protein catabolism and is a valuable indicator of recent protein intake
• It is equal to 5.43 × G /Vd + 0.17, where G = urea generation rate
mg/minute and Vd = post HD total body water = 0.58 × post HD weight
in kg.
• Target it to >1 g/kg/day. The value <1 g/kg/ day is predictive of weight
and BMI decrease.
 Other indicators of adequacy of ultra filtration,
good control of blood pressure, anemia, acidosis, bone disease, and patient
well-being
Optimal growth parameters and pubertal stage
Hospitalizations and school attendance
PRE- AND POST-HEMODIALYSIS LABORATORY VALUE
MONITORING 
• A basic metabolic profile (electrolytes, glucose, urea,
creatinine, phosphate, calcium, and magnesium) should be
reviewed prior to acute hemodialysis sessions
• Post-dialysis chemistry studies, if indicated, should generally
be done after the first one to two hours of the session
 Complications of HD
Intradialytic hypotension
• Causes are
–overzealous or (too) rapid fluid removal (UF)
–pre-dialysis antihypertensive medication
–bradykinin release
–use of hypotonic (low sodium) dialysate relative to the plasma.
•Treat with cessation of ultra filtration, reduce blood flow, head low position,
bolus of saline 5–10 ml/kg.
–Dry weight of the patient should be reassessed; avoid antihypertensives
before dialysis session.
–Sodium remodeling, online blood volume monitoring, sequential
ultrafiltration, and use of intradialytic dobutamine (in patients with poor
cardiac reserve) may be beneficial
–Discontinue dialysis if hypotension is severe
Disequilibrium syndrome
• Risk factors for DDS include the following
– First dialysis treatment
– Markedly elevated blood urea concentration predialysis (ie,
>175 mg/dL or 60 mmol/L)
– Chronic kidney disease (CKD, as compared with acute kidney injury
[AKI])
– Severe metabolic acidosis
– Older age
– Pediatric patients
– Pre-existing neurologic disease (head trauma, stroke, seizure disorder)
– Other conditions characterized by cerebral edema (hyponatremia,
hepatic encephalopathy, malignant hypertension)
– Any condition that increases permeability of the blood-brain barrier
(such as sepsis, vasculitis, thrombotic thrombocytopenic purpura-
hemolytic uremic syndrome [TTP/HUS], encephalitis, or meningitis)
 Air embolism due to technical problem, e.g., at the negative
pressure part of the circuit.
Treatment is
– to clamp the lines
– Stop the pump
– put the patient head down in left lateral position
– give 100 % oxygen,
– aspirate air from right ventricle if required, and other
resuscitative measures.
 Hemolysis –
– presents with nausea, pains, and dark venous blood
– It may be due to contamination, overheating, hypotonicity of
dialysate, defective pump, or kinked blood lines.
– Dialysis should be stopped.
– Hyperkalemia should be looked for.
• Blood leak – This is due to entry of blood into the dialysate circuit
Dialyzer reactions/bioincompatibility – anaphylaxis or fi rst use
syndrome, back pain, chest pain, pruritus.
• Fever – pyrogens, presence of contaminants, infection.
• Bleeding – check anticoagulation.
• Related to the access – thrombosis, stenosis, recirculation,
infection.
Complications of chronic HD
• Malnutrition and poor growth
• abnormalities of mineral metabolism
• bone and cardiovascular disease
• Anemia
• neuropsychological impairment
 Continuous renal replacement therapy
(CRRT)
• CRRT mimics native renal function with its continual
ultrafiltration and solute clearance
• Is useful in patients with an unstable hemodynamic status,
concomitant sepsis, or multiorgan failure in the intensive care
setting
• CRRT is an extracorporeal therapy in which fluid, electrolytes,
and small- and medium-size solutes are continuously removed
from the blood (24 hr/day) using a specialized pump-driven
machine
 CRRT
• Usually, a double-lumen catheter is placed into the internal
jugular or femoral vein
• The patient is then connected to the pump-driven CRRT
circuit, which continuously passes the patient's blood across a
highly permeable filter
•  there is usually no need for fluid restriction
• allows for administration of all necessary blood products,
large volumes of medications, and adequate nutrition
• More complex and costly
 References
• Manual of Ped.Nephrology
• Pediatric nephrology 7th edition
• Uptodate 2022