in the name of godtreat.bpums.ac.ir/uploadedfiles/xfiles/file/darman/22.pdf · pediatric...
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In the name ofIn the name of
GODGODGODGOD
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DialysisDialysisDialysis Dialysis in:in:
ChildrenChildren
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RRisk groupAcute kidney Acute kidney
diseasedisease g pdisease disease (AKD)(AKD)
IInjury group
FFailure group
LLoss of Lkidney function
EEESRD
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Indications for Acute dialysis:Indications for Acute dialysis:AKD Th RIFLE it iAKD- The RIFLE criteria
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CKDCKDP lPrevalence:18/million population18/million population2% of total ESRD population2% of total ESRD population
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Chronic Renal Failure
Etiology< 5 years: Congenital anomalies
HypoplasiaDysplasiaObstructions (PUV)Malformations (RN)Malformations (RN)
> 5 years: GlomerulopathiesFSGS (more common)SGS ( o e co o )GlomerulonephritisHUSFamilial nephritis (Alport)Familial nephritis (Alport)Cystic kidney diseases
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Pediatric Dialysisy
Old classification of CRF:GFR:
> 80% Normal80 -50% ERF50- 25% CRI25- 10% CRF
< 10% ESRF RRT
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CKDNKFNKF--K/DOQI Classification of CKDK/DOQI Classification of CKD
CKD StageCKD Stage GFRGFR DescriptionDescription Action planAction planNormalNormal >>9090%% screeningscreening
11 >>9090%% known kidney damageknown kidney damage diagnose and treat diagnose and treat
with normal or increased GFRwith normal or increased GFR primary renal diseaseprimary renal disease
22 6060 8989%%22 6060--8989%% mild reduction of GFRmild reduction of GFR evaluate rate decline GFRevaluate rate decline GFR
33 3030--5959 moderate reduction of GFRmoderate reduction of GFR evaluate, treat CKD complicationevaluate, treat CKD complication
44 1515 2929 i Gi G44 1515--2929 severe reduction GFR prepare RRTsevere reduction GFR prepare RRT
55 < < 1515% % kidney failurekidney failure RRTRRT
66 Di l iDi l i66 DialysisDialysis
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CRF- Lack of pubertal growth spurt
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• ESRF due to• ESRF due to Cystinosisy
• Short stature
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CKD-Renal Osteodystrophy
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Pediatric Dialysis
A-Fluid overload:Indications of acute Dialysis
Pediatric Dialysis
A Fluid overload:1-Pulmonary edema2-CHF due to fluid overload3-Refractory hypertension3-Refractory hypertension 4-Hindrance to nutrition5-Oliguria after open heart surgery, ECMOB-Symptomatic electrolyte/acid base imbalance:B Symptomatic electrolyte/acid base imbalance:1-Hyperkalemia K>7 ,with ECG abnormalities2-Hypo-hypernatremia3-Hyperphosphatemiayp p p4-Severe acidosis with fluid overload(PH<7.2)
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Indications for dialysis
Indications of acute Dialysis-cont
C-Toxins:1- Uremia(Pruritus, pleuritis pericarditis,encephalop.
Indications of acute Dialysis cont.
1 Uremia(Pruritus, pleuritis pericarditis,encephalop.2- Hyperuricemia (TLS)3- Progressive rise in BUN to 150mg/dl
(Recovery not anticipated) 4- Poisoning: ASA, Promethazine, Chlorpromazine, Aminoglycosides, Ethanol, Methanol, Ethylen glycol D- Inborn errors of metabolism(Hyperammonemia, Severe organic acidemia)
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Pediatric DialysisPediatric DialysisIndications for Acute dialysis:Indications for Acute dialysis:
1.1.Oliguric ARF and need for nutritionOliguric ARF and need for nutritiongg2.2.Volume overloadVolume overload3.3.HyperkalemiaHyperkalemiaypyp4.4.Met. AcidosisMet. Acidosis5.5.Uremic EncephalopathyUremic Encephalopathyp p yp p y6.6.Uremic pericarditisUremic pericarditis7.7.TLSTLS8.8.Progressive rise BUN (Infant: Progressive rise BUN (Infant: 3535--5050))9.9.Inborn error of metabolismInborn error of metabolism10.10.IntoxicationIntoxication
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Pediatric Dialysisy
Indication for chronic Indication for chronic di l idi l idialysisdialysis
GFR < 10ml/min/1.73m2G 0 / / 73Reduced growth velocityDecreased head circumferenceDecreased head circumferenceLack of developmental milestonesE li t i i thEarlier to maximize growth
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GFRPediatric Dialysis
• Chromium EDTAI li Cl
GFR• Inulin Clearance• Cystatin-C• Creatinine Clearance = U V X 1 73• Creatinine Clearance = U(mg/ml).V(ml/min) X 1.73
P(mg/ml) SA• Schwarts F: GFR = (k) (H) (ml/min/1 73m2)Schwarts F: GFR (k).(H) (ml/min/1.73m2)
Scr• K = 0.33 In preterm infants up to 1 year p p y• K = 0.45 In term infants up to 1 year• K = 0.55 In children 1 - 18 years• K = 0.7 In adults
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Pediatric DialysisPediatric Dialysis
Acute: Chronic:
Acute Peritoneal Dialysis CAPDHemodialysis APDyCAVH(SCUF) IPDCVVH CCPDCAVHD HemodialysisCVVHDCVVHD
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Pediatric Dialysisy
A t di l iChoice of dialysis modality
Acute dialysis: Choice= PD because of:Ease of peritoneal accessRapidity (In life threatening HYPERKALEMIA)Patients with hemodynamic instabilityIn patients with hypotension(CAVH, CVVH, CAVHD, CVVHD)CCRF: Choice = APD (CCPD, NIPD)Infants:APD ( Vascular access)Preschool (2-5y), School(6-11y):APD, CAPD - HD( y), ( y) ,Adolescent: CAPD, APD( Compliance?) , - HD.
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Pediatric DialysisPediatric DialysisType of Dialysis
In candidates for kidney transplantation:Old belief: PD increases the risk of infectionNow: In StudiesMorbidity and mortality related to TP Didn't differDesirability of TP isn't a factor in h h i f di l i d lithe choice of dialytic modality.
In 142 TP patients at GOS:Only 7(5%) HemodialysedOnly 7(5%) Hemodialysed103(72%) Exclusively on PD (23%) Pre-emptive TP.
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Pediatric DialysisPediatric Dialysis
1 Cl t f th di l
Hemodialysis- Principles 1- Clearance rate of the dialyzer Adults: Most dializers have UREA clearance of: 60- 80%of Blood flow rate( in range 200-300ml/min) 60 80%of Blood flow rate( in range 200 300ml/min)Children: Relationship betweem UREA clearance and blood flow= CurvilinearWith small dialyzers: Urea clearance curve = plateauWith larger dialyzers: Dialyzer Urea cl. = 90% BFR(<150)2- Ultrafiltration rate: Adults:UF ~ TMPIn small infants: BFR(<100) important determinant of UF
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Relation between BFR and dialyzer clearance in pediatric dialysisclearance in pediatric dialysis
CA110250
Dialyzer Dialyzer clearanceclearance
Minor
Mini minor100
Minor
BFR 300200BFR
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Pediatric DialysisPediatric Dialysis Dialysis Machines
Children <20 kg: Gambro AK10 and AK100Gambro AK10 and AK100 * BFR = 10- 200ml/min 10- 500ml/min * Suitable for Bicarbonate dialysisChildren >20 kg: Other MachinesSingle needle adaptors with reservoir(30-50ml) should not be used in small childrenshould not be used in small children
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Pediatric DialysisPediatric Dialysis
DialyzersDialyzer priming + Blood tubing volume < 10% of blood volume =8ml/kgParallel plates:Parallel plates:slightly higher priming volume/ unit membrane SAContained blood volume increases when TMP is applied for UFapplied for UF.Compliance well suited for single-needle dialysisfor Neonates and<10kg:Gambro Mini-Minor, Minor >15k B t CA 50>15kg: Baxter CA-50Adult hollow-fibers (P.V=75ml): children >20kg
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Pediatric DialysisPediatric Dialysis
Blood lines
Priming volume of:adult blood lines: 75-150ml adult blood lines: 75 150ml
Neonatal and pediatric blood lines: 25-75mlSmaller blood lineswith diameter of 3mm: Restrict BFR to 75ml/minFor higher BFR:Short blood lines with larger inner diameter is gavailable
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Pediatric DialysisPediatric Dialysis
Vascular accessT Temporary access:
Single or double lumen percutaneouly to Vena cavaSubclavian, Internal jugular or femoral approachI t ll i f t th t ti h ld bIn neonates, small infants: catheter tip should be radiologically positioned in upper right atriumIn neonates: Catheter in vena cava via UMBILICAL V.Th h b l f i l f l kThese catheters can be left in place for several weeksPermanent Access: <15kg: short 7F.catheter in Fem. VOr subclavian or internal jugular, Arteriovenous shuntOlder children: AV fistula:radial artery ~cephalic veinIn small vessle: Gore-Tex or Impra graft between A-V.
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Pediatric Dialysis
Vascular accessPatient sizePatient size Catheter choiceCatheter choicePatient sizePatient size Catheter choiceCatheter choiceNeonateNeonate 55F single lumenF single lumen
77F Double lumenF Double lumen77F Double lumenF Double lumen33--6 6 kgkg 77F Double lumenF Double lumen66--3030kgkg 88 Double lumenDouble lumen66 3030kgkg 88 Double lumenDouble lumen1515--3030kgkg 99F Double lumenF Double lumen>>3030kgkg 1010F Double lumenF Double lumen
1212..55F Double lumenF Double lumen
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Pediatric DialysisPediatric Dialysis
S l ti f di li d bl d li b d
TECHNIQUE OF DIALYSISSelection of dializer and blood lines based on:
Priming volumeClearance efficiencyUlt filt ti h t i tiUltrafiltration characteristics
> 8ml/kg primed with BLOODCalculate BFR from BF-Clearance graph to obtain:
U l 3 l/k /MiUrea clearance =3ml/kg/MinExample: 20kg BFR # 60 ml/MinSession length = usualy 3- 4 hrFi t di l U l 1 5 2 l/k / i i 2hFirst dialys: Urea cl.=1.5- 2ml/kg/min or session =2hr
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Pediatric DialysisPediatric DialysisTECHNIQUE OF DIALYSIS
Dialysis solution Flow rate= 500ml/minHemodynamically unstable: Bicarb dialysisHemodynamically unstable: Bicarb. dialysisMaximum fluid removal/session: not exceed 5% BWVolumetric(Ultrafiltration) controller machine O TMPOr TMP* Urea clearance(# BFR):
should not exceed 3ml/kg/ming
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Flow RatesPediatric Dialysis
Blood Flow Rate (BFR):Flow Rates
Blood Flow Rate (BFR):• 4 cc /kg/min• < 10 kg = <100cc/min• 10 - 40 = 2.5*W+100
40 k 250 / i• >40 kg = 250cc/min
• Dialysis fluid Flow RateDialysis fluid Flow Rate• 1.5* BFR in small children• Then up to 500cc/min
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Pediatric DialysisPediatric DialysisHeparinization
S d ltSame as adultsACT # 150- 200%% of normals or predialysisLoading dose: 40 - 50 u/kg then monitorM i t 0 3 0 5 /k / iMaintenance: 0.3- 0.5 u/kg/min
50 u/kg/hr 25u/kg bolus 2nd hr
ACT # 125% i l d h i i ti (hi h i k )ACT # 125% in low dose heparinization(high risks)Surgery past 5 days- next 24hr :25u/kg ACT kept 12- 15min P t i d f di l (1 /100 h i l t 2 h )Protamine end of dialys(1mg/100u heparin last 2 hr)
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Pediatric Dialysis- OldOldPediatric Dialysis OldOldAdequacy of dialysis
KT/V 1 3KT/V = 1.3K= urea clearance litre/hrT= session lengthT= session lengthV= Urea space= total body water= 0.6WAdequate if:
BUN < 30 35%postdialysis BUN < 30- 35% of predialysisPredialysis BUN < 100- 120 (higher than adults due to protein intake >1.5g/kg/d)( g p g g )
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Pediatric DialysisAdequacy of dialysis
Pediatric Dialysis
In children:In children:
KT/V=KT/V= 11 44-- 11 55KT/VKT/V 11..44-- 11..55URR>URR> 6060 6565%%URR> URR> 6060--6565%%
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Pediatric DialysisPediatric DialysisComplications of Dialysis
DDSHypotensionHypothermiaH iHypoxiaMuscle crampAir embolismHemolysisHemolysisIN small children:
Yawing, Restlessness, Nausea, Staring, Changes in skin color: often p recede : DDSChanges in skin color: often p recede : DDS
Hypotension and vomiting
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Pediatric DialysisPediatric DialysisDialysis Disequilibrium syndrome (DDS)
More common in childrenEspecially: during initial dialysis treatment
in high BUN > 150 in high BUN > 150High efficiency & rapid dialysis
Manifestations: Irritability, headache, disorientation muscle cramp nauseadisorientation, muscle cramp, nausea
Drowsiness, seizure, comaResult of brain swellingP ti S ll i di l R d i BFRPrevention: Small size dialyzer, Reducing BFR
Manitol: 0.5- 1g/kg
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DialysisDialysis in ARFyyCompared with every other day Compared with every other day Compared with every other day Compared with every other day dialysis: dialysis:
D il th i t d ithdialysis: dialysis:
D il th i t d ithDaily therapy was associated with a significant reduction in mortality
Daily therapy was associated with a significant reduction in mortalitysignificant reduction in mortality
P l k PM S i Di lP l k PM S i Di l 20062006 1919 165165
significant reduction in mortality
P l k PM S i Di lP l k PM S i Di l 20062006 1919 165165Palevsky, PM. Semin Dial Palevsky, PM. Semin Dial 20062006; ; 1919::165165Palevsky, PM. Semin Dial Palevsky, PM. Semin Dial 20062006; ; 1919::165165
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Advantages of CRRT over IHDAdvantages of CRRT over IHDAdvantages of CRRT over IHDAdvantages of CRRT over IHD
• Improved cardiovascular stability I d l l fil i
• Improved cardiovascular stability I d l l fil i• Improved tolerance to ultrafiltration
• Removal of large obligatory fluid loads• Improved tolerance to ultrafiltration• Removal of large obligatory fluid loadsRemoval of large obligatory fluid loads• Ability to maintain excellent azotemia
Removal of large obligatory fluid loads• Ability to maintain excellent azotemia
and solute control even in severely catabolic patientsand solute control even in severely catabolic patientscatabolic patients catabolic patients
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H b id hH b id hHybrid therapyHybrid therapy• Sustained low efficiency daily dialysis (SLEDD)• Sustained low efficiency (daily) diafiltration
(SLEDD f)
• Sustained low efficiency daily dialysis (SLEDD)• Sustained low efficiency (daily) diafiltration
(SLEDD f)(SLEDD-f)• Extended daily dialysis (EDD)
(SLEDD-f)• Extended daily dialysis (EDD)• Slow continuous dialysis (SCD)• Slow continuous ultra filtration (SCUF) • Slow continuous dialysis (SCD)• Slow continuous ultra filtration (SCUF) Go slow dialysis
Marshall, MR, Contrib Nephrol 2001; :252 Go slow dialysis
Marshall, MR, Contrib Nephrol 2001; :252
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Hybrid therapy ( ti )Hybrid therapy ( ti )Hybrid therapy (continue)Hybrid therapy (continue)
•• Treatments are deliberately:Treatments are deliberately:•• Treatments are deliberately:Treatments are deliberately:Treatments are deliberately: Treatments are deliberately: intermittent rather than continuousintermittent rather than continuous
Treatments are deliberately: Treatments are deliberately: intermittent rather than continuousintermittent rather than continuouswith longer session durations thanwith longer session durations thanconventional iHDconventional iHDwith longer session durations thanwith longer session durations thanconventional iHDconventional iHDconventional iHD. conventional iHD.
•• Solute and fluid removal are slower Solute and fluid removal are slower conventional iHD. conventional iHD.
•• Solute and fluid removal are slower Solute and fluid removal are slower than conventional iHD, but faster than than conventional iHD, but faster than conventional CRRT conventional CRRT than conventional iHD, but faster than than conventional iHD, but faster than conventional CRRT conventional CRRT
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Preferred machines for Preferred machines for hybrid therapyhybrid therapy
•• Gambro AKGambro AK200200S Ultra® machine S Ultra® machine •• GambroGambro 200200S Ultra®S Ultra®•• Gambro AKGambro AK200200S Ultra® machine S Ultra® machine •• GambroGambro 200200S Ultra®S Ultra®Gambro Gambro 200200S Ultra® S Ultra® •• Fresenius Fresenius 20082008HH
F iF i 20082008KK
Gambro Gambro 200200S Ultra® S Ultra® •• Fresenius Fresenius 20082008HH
F iF i 20082008KK•• Fresenius Fresenius 20082008K K •• Fresenius Fresenius 40084008SS•• Fresenius Fresenius 20082008K K •• Fresenius Fresenius 40084008SS•• Fresenius Fresenius 40084008E or E or 40084008H machines H machines •• Fresenius Genius® machineFresenius Genius® machine•• Fresenius Fresenius 40084008E or E or 40084008H machines H machines •• Fresenius Genius® machineFresenius Genius® machineFresenius Genius® machine Fresenius Genius® machine Fresenius Genius® machine Fresenius Genius® machine
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P i lPeritoneal Dialysisy
In ChildrenIn ChildrenM f Sh ifiMostafa Sharifian Pediatric Nephrologistp g
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Peritoneal Dialysis In Children
Use of peritoneal cavity for treatment f i ill i hild 9090of serious illnesses in children= 9090 yrsyrs
19181918: Blackfan , Maxy: Injection of saline IP: Blackfan , Maxy: Injection of saline IP19481948: Bloxum, Powel: PD for ARF: Bloxum, Powel: PD for ARF19491949: Swan, Gordon: Short term treatments: Swan, Gordon: Short term treatments,,19761976: Popovich: Novel portable equilibrium : Popovich: Novel portable equilibrium
dialysis technique (Now: CAPD)dialysis technique (Now: CAPD)y q ( )y q ( )19781978: Oreopoulos, Balfe: CAPD in CHILDREN: Oreopoulos, Balfe: CAPD in CHILDREN19781978: EDTA:: EDTA: 3030% OF <% OF < 1515yr andyr and 6262%<%<22yr PDyr PD19781978: EDTA: : EDTA: 3030% OF % OF 1515yr and yr and 6262%% 22yr PDyr PDNow: CAPD is most commonly used for ESRF
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Peritoneal Dialysis In ChildrenPeritoneal Dialysis In Children
Advantages:No need for Vascular AccessNo need for Vascular AccessTechnical simplicityRapid trainingRapid trainingGreater mobilityMinimal dietary restrictionyImproved growth rateSteady state chemistriesBetter control of HypertensionFewer transfusionI t i b diImprovement in bone disease hemodynamically stable
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Peritoneal Dialysis In ChildrenPeritoneal Dialysis In Children
Peritoneal surface area:(Putiloff)( )In infant( 2.9kg) = 0.15 m2In adults = 2.08 m2
383- 522 cm2/kg in In infant177- 285 cm2/kg In adultsg=> 2/1
Equilibration: Urea in 4 hr Cr: 8 hrEquilibration: Urea in 4 hr Cr: 8 hrPD twice as efficient in infants
(Esperanca in dogs)
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PD - ContraindicationsPD - ContraindicationsAbsolute: Lack of adequate peritoneal cavity
Neonates: Diaphragmatic herniaGastroschisis, Omphalocele
i i iNo contraindication:Recent abdominal surgery if no draining wound,g y gVesicostomies,Ureterostomy, Polycystic kidneys, Colostomy, Gastrostomies, Prune belly, RecentColostomy, Gastrostomies, Prune belly, Recent bowel surgery, V-P shunt, Wilms tumor, Concurrent Immunosuppressive therapyConcurrent Immunosuppressive therapyAllograft dysfunction in and extraperitoneal Tx.
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Peritoneal Dialysis In Children
Catheters:y
One cuff: 1 peritonitis in 12.6 patient/ month
Two cuff: 1 peritonitis in 15.1 patient/ monthOmentectomyOmentectomy:: 53% of centersyyDownward Exit site: 69% of centersIn 18 centers:In 18 centers:
88% prefer Curled Tenckhoff69% Straight tunnel, single cuff
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C th tPeritoneal Dialysis In Children
Catheters:>3 days Use Tenckhoff>3 days Use Tenckhoff> 30 kg Adult size10 30 k P di t i10 - 30 kg Pediatric< 10 kg Infantile< 3 kg NeonatalFirst dialysis postponed until fibrosisFirst dialysis postponed until fibrosis around catheter Partial or Total omentectomyPartial or Total omentectomy No more infection rate
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Peritoneal Dialysis In Children
Dialysis fluidLactate 40 mEq/litre preferredAcute dialysis with 2.5% dextroseyCritically ill Infants with:
(Hypoxia Hypotension Lactic acidosis)(Hypoxia, Hypotension, Lactic acidosis) Don`t tolerate lactate ==> BicarbonateBicarbonateWarmed to body temperature:
Cold =>Infants: Sudden fall in BPCold >Infants: Sudden fall in BPAdults: Discomfort
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Peritoneal Dialysis In Children
CPD prescription:Dialysis started when:
Cr Cl = 9 - 14 ml/min/ 1 73m2Cr Cl 9 - 14 ml/min/ 1.73m2Weekly renal KT/Vurea < 2
NAPRTCS report: 2/3 APDFirst First 24 24 hr: hr: 2020 cc/kg (cc/kg (500500ml/mml/m22))g (g ( ))
Maximum: Maximum: 4545ml/kg (ml/kg (11001100ml/mml/m22))33 2020 exchanges/ dayexchanges/ day3 3 -- 20 20 exchanges/ dayexchanges/ day
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Peritoneal Dialysis In ChildrenPeritoneal Dialysis In Children
Problems in achieving adequate ultrafiltration in Children
Large residual peritoneal volume inLarge residual peritoneal volume in children:Li i Fl id fl d S lLimit Fluid flux and Solute transportHigher rate of lymphatic absorption g y p pthan adultsRepeated peritonitis (more commonRepeated peritonitis (more common than adults)
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Peritoneal Dialysis In Children
PD adequacyCAPD CCPD NIPD
(Residual renal+ PD)weekly KT/V urea >2 2.1 2.2Total weekly Cr Cl (L/1.73m2) >60 63 66weekly urea Clearance 1.4 Litre4040-- 5050% more than adults =>Higher protein intake% more than adults =>Higher protein intake
3 3 times / yrtimes / yryyWhen changes in clinical status influence PDSevere or repeated Peritonitis
(Pseudomonas, Fungal)
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Peritoneal Dialysis In Children
Acute PD prescription:Peritocath
Di l i fl id itiDialysis fluid compositionExchange volumegInflow, dwell, drain timesFirst 24 hr: 20 cc/kg (500ml/m2)First 24 hr: 20 cc/kg (500ml/m2)
Maximum: 45ml/kg (1100ml/m2)30 -60 min exchanges
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C li tiPeritoneal Dialysis In Children
Complications:InfectionInfectionCatheter obstruction;
Clot: HeparinClot: HeparinOmentum: Omentectomyy
Catheter dislocationHernias:Hernias: 75% require surgical repairBloody effluent in menstruation: HeparinBloody effluent in menstruation: HeparinGlucose toxicity
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Peritoneal Dialysis In Children
Complications: InfectionExit site Peritonitis or bothExit site, Peritonitis or bothPeritonitis:During the first year:
95% Experience one or more episodes95% Experience one or more episodesBacterial entry:
Luminal, PeriluminalAcross intestinal wall Hematogenous: Rare
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P it itiPeritoneal Dialysis In Children
Peritonitis:Cli i l if t tiClinical manifestations:Subtle:Subtle:Cloudy peritoneal fluidy pLow grade feverMild abdominal pain TendernessMild abdominal pain, TendernessCell count > 100/ ulSmear: 40% positive
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Peritoneal Dialysis In Children
Peritonitis-Organisms:G 50% G 30% C l 10 20%G+ :50% G- :30% Culture neg: 10- 20%Staph epidermidis 30- 40%Staph aureus 10- 20%Streptococci 10- 15%pE-Coli 5- 10%Enterococci 3- 6%Enterococci 3 6%Fungi 2- 10%Exit or Tunnel infection 42% Staph au.Exit or Tunnel infection 42% Staph au.
Pseudomona
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Peritoneal Dialysis In Children
Peritonitis: Treatment:E i i l id d b G t iEmpirical guided by Gram stainNo organism on smear: IP:Vanco+ Aminoglycoside or Third generation
(Antipseudomonas)Staph aureus: Oral Rifampin addedFungal: IP Fluconazole+ Oral Flucytosine- AmphoDuration: 14 – 21 days
In S. aureus, Pseudomonas, Fungal: 21- 28daysFungal or Pseudomona Peritonitis:: Remove catheter.Remove catheter.
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CAPD Connectology: R d d i kReduced risk
The short distance between the Y-Junction and the patientThe short distance between the Y Junction and the patient connection ensures effective removal of bacterial contamination from the patient line should connection failure occur.
Kubey W., et al., Blood Purification; 2000, 19(1).
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O tPeritoneal Dialysis In Children
OutcomeMembrane failure: (Andreoli)Membrane failure: (Andreoli)Peritonitis with Pseudomona, Alpha Strep.Change modality:Change modality:Excessive infection in 42%Inadequate Ultrafiltration 15%Inadequate Ultrafiltration 15%Inadequate solute removal 4%Overall mortality: 5 7%Overall mortality: 5.7%0 - 1 yr age 13.8% 6 - 12yr 3.72 5 yr 8 1% 13 17 yr 2 5%2 - 5 yr 8.1% 13 - 17 yr 2.5%Cause: Cardiopulmonary - Infection
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Peritoneal Dialysis In Children
VaccinationRoutine immunization + >Routine immunization + =>Influenza yearly before fallPne mococcal at 2 and 3 5 r later<10Pneumococcal at 2 and 3 - 5 yr later<10yVaricella in 2 doseP t ti d tPoor protection due to:Loss of immunoglobulin into dialysate:Hib MMR P HBV d bl th dHib, MMR, Pneumo. HBV: double the doseResponse to vaccination:h ld b it d thshould be monitored every other yr
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CKD- TreatmentVaccinationVaccination
our protocol:our protocol:•Routine +Routine • Influvac yearlyy y
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Peritoneal Dialysis In Children
Nutrition in CPDAt least 100% of RDAAt least 100% of RDAAlthough Receive 8 - 20 cal/day from dextroseDiminished weight-High- Triceps skinfold thickness- Mid-arm circumference
H lb i iHypoalbuminemiaHypertriglyceridemiaHypercholstrolemia
Protein loss esp. in Peritonitis <=> 2.5 g/kg/dIntraperitoneal amino acids: SuggestedIntraperitoneal amino acids: Suggested
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CKD- TreatmentAnorexia, Low energy intake:gy
PEG +PEG overnight feedingg g
Vomiting:Fundoplication
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G th t d tiPeritoneal Dialysis In Children
Growth retardationMetabolic acidosisMetabolic acidosisMalnutritionOsteodystrophyOsteodyst op yGH: Normal or elevatedAbnormalities in GH- IGF1 axisGH insensitivity:
Reduced Hepatic GH expressionDecreased production of IGF 1Decreased production of IGF-1Inhibition of IGF bioactivity by increased binding to specific proteins
T GH C id iTreatment: GH+ Correct acidosis,...
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Chronic Renal Failure
Treatment- Osteodystrophy1- Low Phosphate diet1 Low Phosphate diet2- Phosphate binder
CaCO3 - Aluminium Hydroxide - Ca Acetate (with Meal)3- Active Vit D if Ca is low - Alchaline Ph. high
No Ca infusion except TETANYCareful acidosis correctionCareful acidosis correctionAvoid Ca X P > 70
* Calcitriol= Rocaltrol pearl( f ) (1 , 25 Dihydroxy cholecalciferol) l = 0.25 ug
Dose = 15 - 60 nanog /kg / d * DHT Not in liver disease * AT10 ( 1 cc = 1 mg = 30 drops 1 drops = 0.03mg)
Starting Dose = 0.01 - 0.02 ng/kg/d
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CKD- Treatment•Anemia
D fi i f• Deficiency of: – Iron, Folic acid, B12, Erythropoetin
• Target Hb: 11- 12g/dl• Transferrin saturation (TSAT): > 20% (20 -50 %)( ) ( )
• Ferritin: > 100 ng/ml (100 -800)
• Eprex : Start 300 U/Kg/ week• Eprex : Start 300 U/Kg/ week50- 150 U/Kg 3 X week
S• Rout: Sc, IV, IP
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Chronic Renal FailureNutrition
Protein: LProtein: Low1.5 g/kg Essential aminoacidsIn CAPD: 2 - 2.5 g/kg (Protein loss in PD Fluid)Egg, Milk, Fish, fowlLow phosphate DietZinc & Iron Supplementspp
Vitamines:Water soluble VitaminesA E K N t i dA, E, K: Not required
Water & Electrolytes:Edema: Restriction + FrusemideEdema: Restriction FrusemidePolyuria: Water + Salt
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CKDCKD-- Team ApproachTeam Approachpppp• Nurse : Team Coordinator• Dietician• Social worker• Social worker• Surgeon (Vascular surgery: PD g ( g y
catheter- Permcath)• Pediatric UrologistPediatric Urologist• Pediatric Nephrologist• School counselor
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Thank you for your y yattention