Chronic Hemodialysis in Children

Abstract

Conventional hemodialysis (HD) is a widely used kidney replacement therapy for children with end-stage kidney disease. HD is based on diffusive transport of solutes across a semipermeable membrane and is effective in removing small uremic retention solutes such as urea, correcting electrolyte abnormalities and restoring fluid balance. The addition of convective therapies with hemodiafiltration (HDF) allows the removal of larger uremic retention solutes, such as Β2-microglobulin and inflammatory cytokines. Extended hours of hemodialysis, best achieved through home hemodialysis programs, achieves optimal clearances without the hemodynamic strain of conventional HD. Despite technical advances, children on dialysis continue to experience high rates of morbidity and mortality compared to the general pediatric population. In this chapter we discuss the principles, technique and practical aspects of performing conventional HD and intensified dialysis techniques, including HDF and home hemodialysis, in children, and relevant pediatric and adult studies to support these practices. We outline commonly encountered complications of HD and strategies for their prevention and treatment. Vascular access, often called the “Achilles’ heel” of dialysis, is discussed at length, comparing the relative merits of central venous lines and arteriovenous fistulas. Finally, we suggest future directions for children treated with HD including the benefits of intensified hemodialysis options.