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Pediatric intradialytic hypotension: recommendations from the Pediatric Continuous Renal Replacement Therapy (PCRRT) Workgroup

  • Rupesh RainaEmail author
  • Stephanie Lam
  • Hershita Raheja
  • Vinod Krishnappa
  • Daljit Hothi
  • Andrew Davenport
  • Deepa Chand
  • Gaurav Kapur
  • Franz Schaefer
  • Sidharth Kumar Sethi
  • Mignon McCulloch
  • Arvind Bagga
  • Timothy Bunchman
  • Bradley A. Warady
Consensus Conference
Part of the following topical collections:
  1. What's New in Dialysis

Abstract

Intradialytic hypotension (IDH) is a common adverse event resulting in premature interruption of hemodialysis, and consequently, inadequate fluid and solute removal. IDH occurs in response to the reduction in blood volume during ultrafiltration and subsequent poor compensatory mechanisms due to abnormal cardiac function or autonomic or baroreceptor failure. Pediatric patients are inherently at risk for IDH due to the added difficulty of determining and attaining an accurate dry weight. While frequent blood pressure monitoring, dialysate sodium profiling, ultrafiltration-guided blood volume monitoring, dialysate cooling, hemodiafiltration, and intradialytic mannitol and midodrine have been used to prevent IDH, they have not been extensively studied in pediatric population. Lack of large-scale studies on IDH in children makes it difficult to develop evidence-based management guidelines. Here, we aim to review IDH preventative strategies in the pediatric population and outlay recommendations from the Pediatric Continuous Renal Replacement Therapy (PCRRT) Workgroup. Without strong evidence in the literature, our recommendations from the expert panel reflect expert opinion and serve as a valuable guide.

Keywords

Intradialytic hypotension Children Blood pressure monitoring Sodium profiling Blood volume monitoring Dialysate cooling Mannitol Midodrine 

Notes

Acknowledgments

We thank Ms. Jennifer Clark, Medical Writer, Akron Children’s Hospital for her assistance in language editing.

Funding information

None.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest.

Supplementary material

467_2018_4190_MOESM1_ESM.docx (14 kb)
Appendix A (DOCX 14 kb)
467_2018_4190_MOESM2_ESM.docx (14 kb)
Appendix B (DOCX 13 kb)
467_2018_4190_MOESM3_ESM.docx (14 kb)
Appendix C (DOCX 13 kb)
467_2018_4190_MOESM4_ESM.docx (15 kb)
Appendix D (DOCX 14 kb)

References

  1. 1.
    Hayes W, Hothi DK (2011) Intradialytic hypotension. Pediatr Nephrol 26(6):867–879CrossRefGoogle Scholar
  2. 2.
    Blumenthal S, Epps RP, Heavenrich R, Lauer RM, Lieberman E, Mirkin B, Mitchell SC, Boyar Naito V, O'Hare D, McFate Smith W, Tarazi RC, Upson D (1977) Report of the task force on blood pressure control in children. Pediatrics 59(5 2 suppl):I-ii):797–820Google Scholar
  3. 3.
    Hothi DK (2009) An investigation into the mechanisms, consequences and moderators of intradialytic hypotension in paediatric haemodialysis. University College London, London discovery.ucl.ac.uk/17442/1/17442.pdf. Accessed 3 Apr 2018
  4. 4.
    Arieff AI (1994) Dialysis disequilibrium syndrome: current concepts on pathogenesis and prevention. Kidney Intl 45(3):629–635CrossRefGoogle Scholar
  5. 5.
    Merouani A, Kechaou W, Litalien C, Ducruet T, Jouvet P (2011) Impact of blood volume monitoring on fluid removal during intermittent hemodialysis of critically ill children with acute kidney injury. Nephrol Dial Transplant 26(10):3315–3319CrossRefGoogle Scholar
  6. 6.
    Lavergne V, Nolin TD, Hoffman RS, Roberts D, Gosselin S, Goldfarb DS, Kielstein JT, Mactier R, Maclaren R, Mowry JB, Bunchman TE, Juurlink D, Megarbane B, Anseeuw K, Winchester JF, Dargan PI, Liu KD, Hoegberg LC, Li Y, Calello DP, Burdmann EA, Yates C, Laliberte M, Decker BS, Mello-Da-Silva CA, Lavonas E, Ghannoum M (2012) The EXTRIP (EXtracorporeal TReatments In Poisoning) workgroup: guideline methodology. Clin Toxicol (Phila) 50(5):403–413CrossRefGoogle Scholar
  7. 7.
    Fitch K, Bernstein SJ, Aguilar MD, Burnand B, LaCalle JR, Lázaro P, Mvh L, McDonnell J, Vader JP, Kahan JP (2001) The RAND/UCLA appropriateness method user’s manual. Rand Publication https://www.rand.org/content/dam/rand/pubs/monograph_reports/2011/MR1269.pdf. Accessed 10 Apr 2018
  8. 8.
    Thornton J, Alderson P, Tan T, Turner C, Latchem S, Shaw E, Ruiz F, Reken S, Mugglestone MA, Hill J, Neilson J, Westby M, Francis K, Whittington C, Siddiqui F, Sharma T, Kelly V, Ayiku L, Chamberlain K (2013) Introducing GRADE across the NICE clinical guideline program. J Clin Epidemiol 66(2):124–131CrossRefGoogle Scholar
  9. 9.
    Hothi DK, Harvey E, Goia CM, Geary DF (2008) Evaluating methods for improving ultrafiltration in pediatric hemodialysis. Pediatr Nephrol 23(4):631–638CrossRefGoogle Scholar
  10. 10.
    Fadel FI, Makar SH, Eskander AE, Aon AH (2014) Decreasing intra-dialytic morbid events and assessment of dry weight in children on chronic hemodialysis using non-invasive changes in hematocrit. Saudi J Kidney Dis Transpl 25(5):1030–1037CrossRefGoogle Scholar
  11. 11.
    Hothi DK, Harvey E, Goia CM, Geary D (2008) Blood-volume monitoring in paediatric haemodialysis. Pediatr Nephrol 23(5):813–820CrossRefGoogle Scholar
  12. 12.
    Blowey DL, Balfe JW, Gupta I, Gajaria MM, Koren G (1996) Midodrine efficacy and pharmacokinetics in a patient with recurrent intradialytic hypotension. Am J Kidney Dis 28(1):132–136CrossRefGoogle Scholar
  13. 13.
    Hothi DK, Harvey E, Goia CM, Geary D (2009) The value of sequential dialysis, mannitol and midodrine in managing children prone to dialysis failure. Pediatr Nephrol 24(8):1587–1591CrossRefGoogle Scholar
  14. 14.
    Brooks ER, Fatallah-Shaykh SA, Langman CB, Wolf KM, Price HE (2008) Bioelectric impedance predicts total body water, blood pressure, and heart rate during hemodialysis in children and adolescents. J Ren Nutr 18(3):304–311CrossRefGoogle Scholar
  15. 15.
    Hegazy RA, Sharaf IA, Fadel F, Bazaraa H, Esam R (2011) Heart rate variability in pediatric patients on regular hemodialysis. Europace Conference: EHRA. Europace 13 https://insights.ovid.com/europ/201106003/00127069-201106003-00638. Accessed 5 Apr 2018
  16. 16.
    Levtchenko E, Creemers D, Schaijk DV, Rijbroek I, Schroder C (2003) Use of NIMH for determination of dry weight and prevention of dialysis associated morbidity in children. Hemodial Int 7(1):104CrossRefGoogle Scholar
  17. 17.
    Goldstein SL, Silverstein DM, Leung JC, Feig DI, Soletsky B, Knight C, Warady BA (2008) Frequent hemodialysis with NxStage system in pediatric patients receiving maintenance hemodialysis. Pediatr Nephrol 23(1):129–135CrossRefGoogle Scholar
  18. 18.
    Jain SR, Smith L, Brewer ED, Goldstein SL (2001) Non-invasive intravascular monitoring in the pediatric hemodialysis population. Pediatr Nephrol 16(1):15–18CrossRefGoogle Scholar
  19. 19.
    Thumfart J, Puttkamer CV, Wagner S, Querfeld U, Muller D (2014) Hemodiafiltration in a pediatric nocturnal dialysis program. Pediatr Nephrol 29(8):1411–1416CrossRefGoogle Scholar
  20. 20.
    Zarauza-Santovena A, Alonso-Melgar A, Gonzalez-Perez P, Lopez-Font M, Hernandez-Zuniga L, Ruiz-Hernandez F, Fernandez-Camblor C, Melgosa-Hijosa M, Espinosa-Roman L (2015) Safety and efficacy of online-hemodiafiltration in pediatric population. Pediatr Nephrol 30(9):1639–1640Google Scholar
  21. 21.
    Fischbach M, Terzic J, Laugel V, Dheu C, Menouer S, Helms P, Livolsi A (2004) Daily on-line haemodiafiltration: a pilot trial in children. Nephrol Dial Transplant 19(9):2360–2367CrossRefGoogle Scholar
  22. 22.
    Baldamus CA, Schoeppe W, Koch KM (1978) Comparison of haemodialysis (HD) and post dilution haemofiltration (HF) on an unselected dialysis population. Proc Eur Dial Transplant Assoc 15:228–235PubMedGoogle Scholar
  23. 23.
    Davenport A (2011) Using dialysis machine technology to reduce intradialytic hypotension. Hemodial Int 15(Suppl 1):S37–S42CrossRefGoogle Scholar
  24. 24.
    Reddan DN, Szczech LA, Hasselblad V, Lowrie EG, Lindsay RM, Himmelfarb J, Toto RD, Stivelman J, Winchester JF, Zillman LA, Califf RM, Owen WF Jr (2005) Intradialytic blood volume monitoring in ambulatory hemodialysis patients: a randomized trial. J Am Soc Nephrol 16(7):2162–2169CrossRefGoogle Scholar
  25. 25.
    Fresenius Medical Care Crit-Line III user manual. https://fmcna.com/wp-content/uploads/documents/CL80020031_Rev_H.pdf. Accessed 20 Apr 2018
  26. 26.
    Davenport A (2009) Can advances in hemodialysis machine technology prevent intradialytic hypotension? Semin Dial 22(3):231–236CrossRefGoogle Scholar
  27. 27.
    Mitra S, Chamney P, Greenwood R, Farrington K (2004) The relationship between systemic and whole-body hematocrit is not constant during ultrafiltration on hemodialysis. J Am Soc Nephrol 15(2):463–469CrossRefGoogle Scholar
  28. 28.
    Fischbach M, Edefonti A, Schröder C, Watson A (2005) Hemodialysis in children: general practical guidelines. Pediatr Nephrol 20(8):1054–1066CrossRefGoogle Scholar
  29. 29.
    Petitclerc T, Trombert JC, Coevoet B, Jacobs C (1996) Electrolyte modelling: sodium. Is dialysate sodium profiling actually useful? Nephrol Dial Transplant 11(Suppl 2):35–38CrossRefGoogle Scholar
  30. 30.
    Advanced renal education program: sodium modelling (2015) Fresenius Medical Care. http://advancedrenaleducation.com/content/sodium-modeling. Accessed 15 Apr 2018
  31. 31.
    Mann H, Stiller S (2000) Sodium modeling. Kidney Int Suppl 76:S79–S88CrossRefGoogle Scholar
  32. 32.
    Sadowski RH, Allred EN, Jabs K (1993) Sodium modeling ameliorates intradialytic and interdialytic symptoms in young hemodialysis patients. J Am Soc Nephrol 4(5):1192–1198PubMedGoogle Scholar
  33. 33.
    Tangvoraphonkchai K, Davenport A (2018) Why does the choice of dialysate sodium concentration remain controversial? Hemodial Int.  https://doi.org/10.1111/hdi.12645
  34. 34.
    Kidney Disease Outcomes Quality Initiative (2015) KDOQI clinical practice guideline for hemodialysis adequacy: 2015 update. Am J Kidney Dis 66(5):884–930CrossRefGoogle Scholar
  35. 35.
    Hecking M, Wong MMY, Port FK, Robinson BM, McCullough KP (2017) Regional differences in the associations between prescribed dialysate sodium concentration and Interdialytic weight gain in the dialysis outcomes and practice patterns study. Am J Kidney Dis 70(3):450–451CrossRefGoogle Scholar
  36. 36.
    Hecking M, Kainz A, Horl WH, Herkner H, Sunder-Plassmann G (2011) Sodium setpoint and sodium gradient: influence on plasma sodium change and weight gain. Am J Nephrol 33(1):39–48CrossRefGoogle Scholar
  37. 37.
    Dheu C, Terzic J, Menouer S, Fischbach M (2009) Importance of the curve shape for interpretation of blood volume monitor changes during haemodiafiltration. Pediatr Nephrol 24(7):1419–1423CrossRefGoogle Scholar
  38. 38.
    Daugirdas JT, Schneditz D (2017) Hemodialysis ultrafiltration rate targets should be scaled to body surface area rather than to body weight. Semin Dial 30(1):15–19CrossRefGoogle Scholar
  39. 39.
    Quellhorst E (1983) Long-term follow up in chronic hemofiltration. Int J Artif Organs 6(3):115–120CrossRefGoogle Scholar

Copyright information

© IPNA 2019

Authors and Affiliations

  • Rupesh Raina
    • 1
    • 2
    Email author
  • Stephanie Lam
    • 3
  • Hershita Raheja
    • 4
  • Vinod Krishnappa
    • 2
    • 5
  • Daljit Hothi
    • 6
  • Andrew Davenport
    • 7
  • Deepa Chand
    • 8
  • Gaurav Kapur
    • 9
  • Franz Schaefer
    • 10
  • Sidharth Kumar Sethi
    • 11
  • Mignon McCulloch
    • 12
  • Arvind Bagga
    • 13
  • Timothy Bunchman
    • 14
  • Bradley A. Warady
    • 15
  1. 1.Department of NephrologyCleveland Clinic Akron General and Akron Children’s HospitalAkronUSA
  2. 2.Akron Nephrology Associates/Cleveland Clinic Akron GeneralAkronUSA
  3. 3.Department of PediatricsAkron Children’s HospitalAkronUSA
  4. 4.The Children’s Hospital of New JerseyNewark Beth Israel Medical CenterNewarkUSA
  5. 5.Northeast Ohio Medical UniversityRootstownUSA
  6. 6.Department of Paediatric NephrologyGreat Ormond Street HospitalLondonUK
  7. 7.UCL Centre for Nephrology, Royal Free HospitalUniversity College LondonLondonUK
  8. 8.Department of PediatricsWashington University School of MedicineSt. LouisUSA
  9. 9.Pediatric Nephrology and HypertensionChildren’s Hospital of MichiganDetroitUSA
  10. 10.Pediatric Nephrology Division, Center for Pediatrics and Adolescent MedicineHeidelberg University HospitalHeidelbergGermany
  11. 11.Pediatric Nephrology & Pediatric Kidney Transplantation, Kidney and Urology InstituteMedanta, The Medicity HospitalGurgaonIndia
  12. 12.Red Cross War Memorial Children’s HospitalUniversity of Cape TownCape TownSouth Africa
  13. 13.Division of Nephrology, Department of PediatricsAll India Institute of Medical SciencesNew DelhiIndia
  14. 14.Pediatric Nephrology & Transplantation, Children’s Hospital of RichmondVirginia Commonwealth UniversityRichmondUSA
  15. 15.Division of NephrologyChildren’s Mercy Kansas City, University of Missouri-Kansas City School of MedicineKansas CityUSA

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