Chronic dialysis in the infant less than 1 year of age

Abstract

Dialysis in the infant carries a mortality rate of 16%. Institution of dialysis may be the result of adequate nutritional intake, but avoidance of nutritional intake should never be seen as a way to prevent dialysis. Increased caloric intake, usually via enteral feeding tubes, is needed for optimal growth in the infant with end-stage renal disease (ESRD) in order to attain adequate nutrition with resulting good growth. “Renal” formulae may be constituted as dilute (as in thepolyuric infant) or concentrated (as in theanuric infant) to fit the infants needs. Peritoneal dialysis (PD) is the usual mode of renal replacement therapy (97%), with access via a surgically placed cuffed catheter with attention to the placement of the exit site in order to avoid fecal or urinary contamination. PD volumes of 30–40 ml/kg per pass or 800–1,200 ml/m² per pass usually result in dialysis adequacy. Additional dietary sodium (3–5 mEq/kg per day) and protein (3–4 g/kg per day) are needed, due to sodium and protein losses in the dialysate. Protein losses are associated with significant infectious morbidity and nonresponsiveness to routine immunizations. Hemodialysis (HD) can be performed either as single- or dual-needle access that have minimal dead space (less then 2 ml) and recirculation rate (less then 5%). Attnetion to extracorporeal blood volume (<10% of intravascular volume), blood flow rates (3–5 ml/kg per min), heparinization (activated clotting times), ultrafiltration (ultrafiltration monitor), and temperature control is imperative during each treatment. Because infants' nutrition is mostly fluid, HD may be needed 4–6 days/week (especially in the oligoanuric infant) to avoid excessive volume overload between treatments. At the end of the treatment a slow blood return with minimal saline rinse is needed to avoid hemodynamic compromise. Infant dialysis, although technically challenging with a significant morbidity and mortality rate, can be safely carried out in the infant with ESRD but requires infant-specific equipment and trained personnel.