Pediatric Maintenance Dialysis

Indications and modality selection: 1) Etiology of pediatric ESKD - CAKUT (congenital anomalies of kidney and urinary tract: posterior urethral valves, renal hypoplasia/dysplasia, vesicoureteral reflux nephropathy) 30-50%; glomerulonephritis (FSGS, MPGN, IgA, lupus nephritis, ANCA vasculitis) 20-30%; hereditary kidney disease (Alport, polycystic kidney disease, juvenile nephronophthisis, NPHS1/NPHS2 nephrotic syndrome) 15-25%; HUS, thrombotic microangiopathy 5-10%; tubular disorders, ischemic injury, others 5-10%; 2) Indications for dialysis - eGFR <8-15 mL/min/1.73m² with symptoms of uremia, fluid overload, electrolyte imbalances; preemptive dialysis if transplant not imminent; severe failure to thrive related to uremia; 3) Modality selection - peritoneal dialysis preferred in children <5 years and infants (no vascular access needed, more flexible, school attendance, less dietary restriction, less hemodynamic instability), hemodialysis for older children when PD contraindicated (severe abdominal pathology, repeated peritonitis), failed PD, family preference; 4) Patient evaluation - severity of CKD progression, growth, neurodevelopment, electrolyte status, anemia (Hgb usually <10 g/dL), bone disease (vitamin D, calcium, PTH), hypertension control, family education and support; 5) Pre-dialysis preparation - vascular access planning (HD: AV fistula 6 months before need, central venous catheter as bridge; PD: catheter placement 2-4 weeks before initiation), psychological support, family education, school coordination; 6) Pediatric-specific considerations - growth velocity, school performance, social development, age-appropriate education, transition to adult care, transplant planning early.

Peritoneal dialysis: 1) PD principles - peritoneum acts as semipermeable membrane; dialysate dwells in peritoneal cavity, removing solutes by diffusion and water by ultrafiltration; PD catheter (Tenckhoff) placed surgically; 2) PD modalities - automated PD (APD) most common in children: cycler performs 4-6 exchanges nightly with last fill; CAPD: manual exchanges 4-5 times daily; tidal PD; 3) Prescription - dialysate volume 1000-1400 mL/m² body surface area; glucose 1.5%, 2.5%, or 4.25% based on ultrafiltration needs; icodextrin for long dwells; calcium 1.25 or 1.75 mmol/L; bicarbonate-based; cycle time 30-60 minutes; weekly Kt/V target >2.0; 4) Adequacy assessment - weekly Kt/V, residual kidney function, peritoneal equilibration test (PET) for transport characterization, growth velocity, well-being; 5) Complications - peritonitis (most serious; presentation cloudy fluid, fever, abdominal pain; treatment with intraperitoneal antibiotics; recurrent peritonitis may necessitate catheter removal or HD switch); exit site/tunnel infections; mechanical (catheter migration, leak, hernia); ultrafiltration failure; metabolic (hypoalbuminemia, hyperglycemia, glucose-induced obesity in adolescents); peritoneal membrane failure with prolonged duration; 6) Pediatric advantages - dialysis at home, school attendance, family-centered care, more dietary flexibility, less dietary potassium and phosphate restriction (continuous), less hemodynamic instability.

Hemodialysis and outcomes: 1) HD prescription - blood flow 3-8 mL/kg/min initially, increasing as tolerated; 3-5 hours per session, 3-6 days per week (often 4-5 days for adolescents); pediatric-sized dialyzer (membrane area appropriate for child size, prevent disequilibrium syndrome); single-needle access for some children; 2) Vascular access - AV fistula best for long-term (forearm radiocephalic ideal, brachiocephalic alternative; maturation 6-12 weeks); AV graft second-line; tunneled central venous catheter for short-term, infants, before fistula maturation, salvage; complications include thrombosis, infection (especially CVC: 1-3 events per 1000 catheter-days), stenosis; 3) Adequacy - weekly Kt/V >1.8 for prepubertal, >2.0 for postpubertal; URR (urea reduction ratio) >70%; dialysis frequency reflects toxin removal; daily/nocturnal HD considered for cardiac stability and growth; 4) Complications - intradialytic hypotension, muscle cramps, headache, disequilibrium syndrome (especially first dialysis - prevented by gradual increase in efficiency), hypocalcemia, transient blood pressure issues; 5) Outcomes - mortality 30-100x higher than age-matched general population; 5-year survival 85-90%; cardiovascular events leading cause of death; growth retardation despite dialysis; neurocognitive impairment; school attendance reduced; 6) Multidisciplinary care - pediatric nephrologist, nutritionist (calorie/protein optimization), social worker, child life specialist, school liaison, psychologist; growth hormone for stunted growth; 7) Renal transplantation - preferred long-term option in 95-99% of children; preemptive transplant ideal (reduces dialysis morbidity); 5-year graft survival 80-90%; living donor preferred (better outcomes than deceased donor in pediatric); 8) Long-term issues - CV disease (premature atherosclerosis), bone disease, growth failure, neurocognitive impairment, school performance, transition to adult care 18-22 years; 9) Newer technologies - wearable dialysis emerging, home HD, robotic exchange systems, tissue engineering on horizon.