Hemodialysis in children: safety, efficiency and adequacy

Assessment of dialysis adequacy is a complex issue that remains controversial. Urea kinetic modeling are the most common parameters used, however they are less well studied in pediatric hemodialysis than in adult. This study aimed to evaluate different strategies to obtain optimum dialysis therapy by using different filters and by changing the time of dialysis session. 200 dialysis sessions were performed in patients with ESRD to test adequacy and evaluate patient's safety. Urea kinetic modeling [Kt/V] was used to assess adequacy of dialysis in addition to R [R=Postdialysis urea level/predialysis urea level] and URR [urea reduction ratio= 1 -R]. Monitoring dialysis efficiency by comparing delivered and predicted Kt/V was also done using different filters [polysulfone 0.7m 2, cellulose 0.7m 2, polysulfone 0.4m 2]. The dialysis time was reassessed for patients with frequent complications where smaller filters for longer time were used. Retrospectively, the two sessions per week dialysis program were compared to three sessions per week in relation to adequacy and ultrafiltration. In this study, the relationship between delivered and predicted Kt/V [QE] was close to ideal value of 1. The smaller filters [F3] showed lower dialysis adequacy than accepted [0.85] but the larger filters [F4, CA70] showed accepted dialysis adequacy [1.14 and 1.19] thus smaller filters for longer time were used in patients with frequent complications. The frequency of dialysis sessions 3 times weekly was better than twice weekly because of volume overload complications. Delivered Kt/V were significantly correlated with QE, URR, filter surface area, and dialysis session time. The study concluded that the dialysis should be adjusted to the individual needs of a child as determined not only by the size of the patients or the specifications of the used prescription alone but also by individual variations in dialysis tolerance

Psychosocial problems and EEG findings in children with end stage renal failure

Psychosocial disturbances are most commonly encountered problems in children with chronic renal failure and end stage renal disease but little is known about the prevalence in Egypt. The present study aimed to assess the psychosocial functioning level and EEG findings in children with chronic renal failure whether on conservative therapy or undergoing chronic dialysis. Fifty four patients with end-stage renal disease were divided into three groups: Group I: twelve patients on regular hemodialysis three times weekly. Group II: twelve patients on continuous intermittent peritoneal dialysis [CIPD]. Group III: thirty patients with CRF on conservative treatment [CTr]. The patients and controls [13 children] were assessed for psychosocial problems including depression [Children's Depression Inventory], anxiety [Children Manifest Anxiety Scale], phobia [Phobic scale for children], behavioral disturbances, and intelligence [IQ]. Also EEG was done for patients with CNS manifestations. Psychiatric diagnosis on axis I according to DSM-IV showed that HD group had more prevalent major depression compared to other CRF groups. As regard social difficulties, no significant differences were detected statistically between CRF group and control group but HD group was more significantly complaining from social difficulties than CTr and control groups. The depression was more common in HD and PD groups than CTr group with no statistically significant difference. Severe anxiety symptoms were more common among HD patients with high significant difference than CTr and control. Differences between the studied groups as regard phobic scale revealed that phobia was significantly more common among HD, CTr and CRF groups in relation to control group. The patients on HD had more fear of illness than those on PD or CTr with no statistically significant difference but a highly significant difference was found between CRF groups and control. Behavioral disturbances were more common in HD and PD groups than controls with statistically significant difference in between [p=0.05]. Nocturnal enuresis [NE] of primary type was more prevalent in HD and PD groups than CTr group with significant difference in between. Also NE was more prevalent in CRF groups than control with significant difference between HD and PD groups and controls. Statistically significant correlation [border line] was detected between NE and age of onset with higher rate of primary NE among children with early age at onset of the illness [<6y]. The highest mean of IQ was found in the control group with significant difference between it and CRF group [p<0.001]. The IQ was negatively correlated with duration of the disease [p<0.01], and age of onset of CRF [p<0.001]. The school leavers and failure were more common among RD and PD groups than conservative group [p<0.01] and control [p<0.001]. Differences between studied groups as regard global assessment score showed that HD group had lower score than other CRF groups with no significant difference but a significant difference was found between CRF groups and controls [p<0.001]. EEG findings revealed generalized slow wave activity in EEG [generalized low voltage] in all patients whether on hemodialysis [11 patients] or on conservative treatment [14 patients]. Activity of Beta and Alpha waves are mostly poor with generalized Theta and Delta waves. Psychosocial disturbances are commonly encountered problems in children with end stage renal disease. Depression was more common among HD and PD patients. High rates of phobia on phobic scales, phobia of illness, severe anxiety and behavioral disturbances were found among CRF groups. Multiaxial assessment showed significant differences in psychiatric diagnosis, educational difficulties and global function with higher rate in CRF children. Nocturnal enuresis was significantly higher among CRF children and correlated with the age at onset of illness and social difficulties. Thus proper medical support and rehabilitation programs to guard against psychiatric troubles, their causes, and their sequalae are recommended including transporting vehicles, hospital based educational programs, summer camps, peer socialization, and others