Over the past 16 years, 18 children under 2 years of age received chronic hemodialysis (HD) at our center. Five children were anuric at the start of HD and 6 had significant co-morbidity. The most common underlying diagnosis was posterior urethral valves. The median age at the start of HD was 12.2 months. A total of 39 episodes (defined as a discrete time period during which HD was the principle form of renal replacement therapy) of HD were performed, with a median duration of 7 months and 91.3 dialysis sessions per episode. Problems with vascular access were very common, with a revision ratio of 40%. Twenty-two line revisions were required for 36 episodes of line infection, with a median rate of line infection of 2.7 infections/patient years. The most commonly encountered organism was coagulase-negative Staphylococcus (69%). Twenty-three lines needed revision due to poor line function, despite the routine use of heparin. The effectiveness of HD was assessed in 11 patients who received HD for a continuous period of 3 or more months. The median urea reduction rate was 72%, while the parathyroid hormone levels improved to within twice the upper limit of the reference range in 69%. While there was no significant change in the median weight and height standard deviation score (SDS), the median SDS for head circumference showed significant improvement ( P=0.04). Both growth and developmental outcomes were strongly influenced by existing co-morbidity. Sixteen (89%) children were transplanted. Four (22%) children died, 3 after successful transplants. None of the deaths occurred on HD or resulted from its complications. In conclusion, HD in infants and small children is an effective and safe form of renal replacement therapy, but problems with vascular access limit its long-term use.

Chronic hemodialysis in infants and children under 2 years of age

Aims: To determine the outcome of children who reach end stage renal failure before the age of 2 years. 

Methods: Using a retrospective questionnaire, 10 years' data were collected from the paediatric nephrology units in Britain and Ireland (1988 to 1997, follow up 1.3–11.5 years). 

Results: A total of 192 children were identified; 0.31/million/year. Most had congenital or inherited conditions, and there were more boys. Latterly, half were diagnosed antenatally. Ninety per cent were dialysed initially, most using home peritoneal cyclers, some by haemodialysis through central lines. Five per cent recovered sufficient function to come off dialysis. Most required tube feeding (often gastrostomy) and erythropoietin; some needed growth hormone. A total of 56% received a transplant (2% without prior dialysis) at (medians) 2.6 years and 12.3 kg. The 2 and 10 year survival of first kidneys was 78%. Growth improved following transplantation. Fourteen per cent died because treatment was not started or was withdrawn. Most had particularly complex renal conditions, or additional major non-renal diagnoses. Typically, decisions not to treat were made mutually between clinicians and families. When treatment was continued, 71% survived, and few had serious non-renal conditions. Most attended normal schools, and by 6 years of age, less than 10% still required dialysis. Infants starting treatment under and over 1 month of age fared equally well. 

Conclusions: By school age, most infants treated for end stage renal failure will have a functioning transplant, reasonable growth, and will attend a normal class, regardless of the age at which they commence treatment. Treatment is seldom sustained in children who have serious additional medical conditions. It is reasonable to treat infants with uncomplicated renal failure.

https://adc.bmj.com/content/archdischild/87/6/511.full.pdf

Outcome of reaching end stage renal failure in children under 2 years of age

Survival and causes of death in children dialyzed in a single center were analyzed. During the last 12 years a chronic dialysis program was introduced in 146 children in our center and 125 of them, eligible for observation, were included in this analysis; 58 patients were on hemodialysis (HD) and 67 on peritoneal dialysis [continuous ambulatory peritoneal dialysis/automated peritoneal dialysis (CAPD/APD)]. Mean age at the start of dialysis was 13.1 years in HD and 9.8 years in CAPD/APD patients. Overall, 16 patients died (12.5%); 6 (10.3%) on HD and 10 (14.9%) on CAPD/APD; 4 HD patients died of hemorrhagic stroke and 2 were killed in road traffic accidents. Of 10 CAPD/APD patients, 7 died of heart failure, ischemic stroke, and/or disseminated thromboembolic disease. Another was killed in a road traffic accident and 2 died during the course of severe infections. The 1-year patient survival rate was 96.6% in HD patients and 95% in CAPD/APD patients, 2-year survival 94% and 93% and 5-year survival 91% and 78%, respectively (P=0.2, NS). In conclusion, the survival rate for HD and CAPD patients is similar, although after 2 years of therapy, it is lower in CAPD patients. The main causes of death are cardiovascular. However, in CAPD/APD patients, heart failure with low cardiac output and thromboembolic complications are major causes of death, and in HD patients the main cause is hemorrhagic stroke.

Patient survival and causes of death on hemodialysis and peritoneal dialysis--single-center study.

Peritoneal dialysis is the preferred chronic dialysis modality for most children owing to its almost universal applicability and superior compatibility with lifestyle over other modalities. Although technological advances and increasing clinical experience have impacted favorably on patient and technique survival, clinical research in pediatric peritoneal dialysis has been hampered by the low incidence of end-stage renal disease (ESRD) in the pediatric population. To overcome this limitation, several international registries have emerged in the past few years to complement other long-standing registries, which together have provided useful information regarding technique-specific complications and comorbidities associated with ESRD in children undergoing chronic peritoneal dialysis. In this Review, we summarize the most relevant findings from these studies, highlighting the substantial variation in patient conditions, peritoneal dialysis practices and management of comorbidities encountered in different parts of the world.

Peritoneal dialysis in children with end-stage renal disease

Management of the infant with end-stage renal failure: editorial, child-adult interface

Hemodialysis (HD) of infants with end-stage renal disease (ESRD) is technically difficult and labor intensive, although there are few data in the literature to document the outcomes of this treatment. We retrospectively reviewed all patients with ESRD who received HD between 1983 and 1997 who weighed <10 kg at the beginning of HD. A total of ten patients aged 2–27 months, weighing 3.5–9.5 kg, were identified. All patients were dialyzed through a central venous line; three had a failed sapheno-femoral loop and one a failed brachial shunt. Line clot was observed in nine and line sepsis in six patinets. Subclavian vein stenosis was documented in one patient following removal of a clotted subclavian line. The mean urea reduction ratios calculated during the 1st and 3rd month of HD were only 54% and 49%, respectively. Anemia was a frequent problem, despite the use of erythropoietin in seven of the infants. Outcomes included: successful renal transplant in four, switch back to peritoneal dialysis in two, improved renal function and dialysis discontinuation in one, and death after withdrawal of treatment in three patients. All three patients who died were <5 months of age, weighed <5 kg, and were anuric; two of the three had congenital nephrotic syndrome. In conclusion, successful HD is possible in small children with ESRD, but morbidity is substantial and mortality is high.

Hemodialysis for end-stage renal disease in children weighing less than 10 kg.

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Hemodialysis for end-stage renal disease in children weighing less than 10 kg.