Abstract
Background
Hemodialysis (HD) in infants is usually used when peritoneal dialysis (PD) has failed. We describe our experience with HD, outlining the morbidity, complications, and outcomes for infants weighing less than 10 kg managed with HD for more than 6 months over a 10-year period.
Methods
A retrospective review of the clinical notes was conducted to collect demographic information, anthropometric data, dietary history, site and form of vascular access, details of HD prescription, complications, and outcomes.
Results
Nine patients weighing less than 10 kg were hemodialyzed for more than 6 months. Median age at commencement was 9 months. Median weight and height standard deviation score (SDS) at commencement of HD were −2.14 and −0.61, respectively, and at the end they were −1.56 and −1.61. Median energy intake was 96.6 kcal/kg/day and protein intake was 1.66 g/kg/day. Median number of line revisions was 0.32 line changes/patient year. Median central venous catheter (CVC) longevity was 13 months. Mean rate of line infection was 0.14/patient year. Median time on HD was 27 months. Median age at transplantation was 3.4 years.
Conclusions
This case series shows that chronic HD is a viable management option in children <10 kg. Access issues can be minimized with good line care to maximize line longevity and minimize line infection rates.
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Appendix 1
Appendix 1
CVC care
All our CVCs are placed by experienced pediatric surgeons and we have a small team of trained specialized nurses who perform CVC care within a strict protocol as outlined below.
Prophylactic antibiotics are given immediately prior to CVC placement (vancomycin 10 mg/kg). The dressing is left untouched for 5 days and then changed three times a week by the HD nursing team, when skin is cleaned with 0.5 % chlorhexidine and the dressing is changed with strict adherence to a sterile non-touch technique. Sterile gloves are worn and the child is positioned as necessary to avoid any accidental contact with the line. Neither staff nor patient wears a mask.
If the exit site appears erythematous at any stage, a skin swab is taken and the site is treated with a topical antibiotic cream. Treatment is discontinued if the swab is negative. If positive, then treatment is continued according to sensitivities until a subsequent swab is negative. Each child is given a full body screen (swabs from nose, throat, axilla, groin, CVC site, and any other devices in situ) 3-monthly including culture for MRSA, ESBL, and VRE. Only trained HD nurses from our unit are allowed to access the CVCs. Parents are advised to wash children in shallow baths only, no showers, and lines are secured far from the nappy area where applicable.
Bacteremia is suspected if the child becomes pyrexic or unwell at any stage. Blood is sent for culture, full blood count and CRP prior to the commencement of IV vancomycin. The antibiotics are discontinued if the culture is negative after 48 h, and if it is positive, then treatment is continued according to sensitivities and in discussion with the consultant microbiologist and nephrologist.
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Quinlan, C., Bates, M., Sheils, A. et al. Chronic hemodialysis in children weighing less than 10 kg. Pediatr Nephrol 28, 803–809 (2013). https://doi.org/10.1007/s00467-012-2373-8
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DOI: https://doi.org/10.1007/s00467-012-2373-8