385 gets in infants on chronic HD, but levels of intact PTH between 100 and 200 pg/ml are usually sug gested Treatment with native vitamin D if defi cient or activated vitamin D analogue such as calci[.]
22 Maintenance Hemodialysis During Infancy Chronic HD in infancy is associated with significant psychological stress for the child and the family due to frequent in-center treatments, multiple hospitalizations, invasive procedures, and various medical problems resulting in significant care complexity Moreover, infants with ESKD often experience significant development delays associated with chronic illness and have an increased risk of neurologic deficit compared to their healthy peers Each dialysis treatment can be difficult and stressful as the infant is unable to understand the procedure and requires a continuous presence of a caregiver Frequently not only is a parent required for distraction but additional members of the interdisciplinary team including the child life specialist or music therapist In addition a 1:1 nurse to patient ratio is usually needed to ensure the infant’s safety especially as they become more mobile A psychologist and social worker are also instrumental in aiding the family in the adjustment process for caring for an infant with complex medical needs Hence, the provision of psychosocial support is an integral part of the care of these patients Outcomes Infants maintained on chronic HD have a mortality rate 14–30% with those with comorbidities having the greatest risk according to available reports [1–5, 7–14] Cardiovascular complications and infections remain the leading causes of death for this age Lack of vascular access is a a 1.0 Cumulative incidence Psychosocial Impact huge problem in the long term [14] HD however can provide a successful bridge to transplant for those infants that are unable to be maintained on peritoneal dialysis Successful transplantation is reported in a variable percentage ranging from 28% to 82% of patients according to different studies [1–5, 7–14] In a study of the ERA/ESPN registry, Vidal recently compared the outcome of 917 infants who initiated dialysis with PD to 146 infants who initiated dialysis with HD; the 5-year cumulative incidence of death and of transplantation in HD cohort was 16.3% and 69%, respectively [5] Interestingly, the mortality risk and the likelihood of transplantation were not different between the modalities Notably, however infants on HD had a higher risk for changing dialysis modality (at 5 years 30.9 vs 24.6%) (Fig. 22.1) HD PD 0.8 0.6 0.4 0.2 0.0 Time since dialysis start (years) b 1.0 Cumulative incidence gets in infants on chronic HD, but levels of intact PTH between 100 and 200 pg/ml are usually suggested Treatment with native vitamin D if deficient or activated vitamin D analogue such as calcitriol or paricalcitol if high PTH should be initiated Frequently infants require supplements with both Activated vitamin D analogues can be administered enterally or intravenously; if given enterally however, medication should be administered by mouth as it frequently will adhere to plastic resulting in ineffective administration 385 HD PD 0.8 0.6 0.4 0.2 0.0 Time since dialysis start (years) Fig 22.1 Cumulative incidence curves for (a) death (with transplantation as a competing risk); (b) modality switching (with both death and transplation as competing risks); and (c) transplantation (with death as competing risk) (Modified from Ref [5]) 386 S J Swartz and F Paglialonga c which must include pediatric nephrologists, nurses, psychologists, dieticians, child life specialists, play therapists, and social workers as well as other pediatric subspecialists Cumulative incidence 1.0 HD PD 0.8 0.6 References 0.4 0.2 0.0 Time since dialysis start (years) Fig 22.1 (continued) Developmental delay is a major issue in infants undergoing chronic dialysis irrespective of dialysis modality Infants require early physical and occupational therapy to help promote appropriate development Infants on hemodialysis however are at increased risk for brain injury associated with alterations in blood pressure with repeated episodes of both hypotension and hypertension as well as potential hypoxemia, hypoperfusion, and temperature dysregulation during HD sessions Conclusions Although PD is the most appropriate renal replacement therapy modality for infants requiring dialysis, maintenance hemodialysis can provide an alternative management strategy to bridge an infant to the ultimate goal of renal transplantation for management of ESKD. Hemodialysis is feasible in infants with ESKD. Notwithstanding significant advances in the last decades, the provision of hemodialysis for infants is still hampered by technical challenges including the limitation of the available equipment and need for a CVC with its short- and long-term complications and clinical challenges including poor growth, anemia, and blood pressure variability Infants with ESKD should be treated in very specialized centers with a skilled multidisciplinary team, 2017 Annual data report: atlas of pediatric end-stage renal disease in the United States United States Renal Data System (USRDS) 2017 Available from: https:// www.usrds.org/2017/view/v2_07.aspx North American Pediatric Renal Trials and Collaborative Studies NAPRTCS 2011 annual dialysis report The EMMES Corporation 2012 Available at: http://www.emmes.com/study/ped/annlrept/annualrept2011.pdf Carey WA, Talley LI, Sehring SA, Jaskula JM, Mathias RS. 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