in the name of godtreat.bpums.ac.ir/uploadedfiles/xfiles/file/darman/22.pdf · pediatric...

In the name ofIn the name of

GODGODGODGOD

DialysisDialysisDialysis Dialysis in:in:

ChildrenChildren

RRisk groupAcute kidney Acute kidney

diseasedisease g pdisease disease (AKD)(AKD)

IInjury group

FFailure group

LLoss of Lkidney function

EEESRD

Indications for Acute dialysis:Indications for Acute dialysis:AKD Th RIFLE it iAKD- The RIFLE criteria

CKDCKDP lPrevalence:18/million population18/million population2% of total ESRD population2% of total ESRD population

Chronic Renal Failure

Etiology< 5 years: Congenital anomalies

HypoplasiaDysplasiaObstructions (PUV)Malformations (RN)Malformations (RN)

> 5 years: GlomerulopathiesFSGS (more common)SGS ( o e co o )GlomerulonephritisHUSFamilial nephritis (Alport)Familial nephritis (Alport)Cystic kidney diseases

Pediatric Dialysisy

Old classification of CRF:GFR:

> 80% Normal80 -50% ERF50- 25% CRI25- 10% CRF

< 10% ESRF RRT

CKDNKFNKF--K/DOQI Classification of CKDK/DOQI Classification of CKD

CKD StageCKD Stage GFRGFR DescriptionDescription Action planAction planNormalNormal >>9090%% screeningscreening

11 >>9090%% known kidney damageknown kidney damage diagnose and treat diagnose and treat

with normal or increased GFRwith normal or increased GFR primary renal diseaseprimary renal disease

22 6060 8989%%22 6060--8989%% mild reduction of GFRmild reduction of GFR evaluate rate decline GFRevaluate rate decline GFR

33 3030--5959 moderate reduction of GFRmoderate reduction of GFR evaluate, treat CKD complicationevaluate, treat CKD complication

44 1515 2929 i Gi G44 1515--2929 severe reduction GFR prepare RRTsevere reduction GFR prepare RRT

55 < < 1515% % kidney failurekidney failure RRTRRT

66 Di l iDi l i66 DialysisDialysis

CRF- Lack of pubertal growth spurt

• ESRF due to• ESRF due to Cystinosisy

• Short stature

CKD-Renal Osteodystrophy

Pediatric Dialysis

A-Fluid overload:Indications of acute Dialysis

Pediatric Dialysis

A Fluid overload:1-Pulmonary edema2-CHF due to fluid overload3-Refractory hypertension3-Refractory hypertension 4-Hindrance to nutrition5-Oliguria after open heart surgery, ECMOB-Symptomatic electrolyte/acid base imbalance:B Symptomatic electrolyte/acid base imbalance:1-Hyperkalemia K>7 ,with ECG abnormalities2-Hypo-hypernatremia3-Hyperphosphatemiayp p p4-Severe acidosis with fluid overload(PH<7.2)

Indications for dialysis

Indications of acute Dialysis-cont

C-Toxins:1- Uremia(Pruritus, pleuritis pericarditis,encephalop.

Indications of acute Dialysis cont.

1 Uremia(Pruritus, pleuritis pericarditis,encephalop.2- Hyperuricemia (TLS)3- Progressive rise in BUN to 150mg/dl

(Recovery not anticipated) 4- Poisoning: ASA, Promethazine, Chlorpromazine, Aminoglycosides, Ethanol, Methanol, Ethylen glycol D- Inborn errors of metabolism(Hyperammonemia, Severe organic acidemia)

Pediatric DialysisPediatric DialysisIndications for Acute dialysis:Indications for Acute dialysis:

1.1.Oliguric ARF and need for nutritionOliguric ARF and need for nutritiongg2.2.Volume overloadVolume overload3.3.HyperkalemiaHyperkalemiaypyp4.4.Met. AcidosisMet. Acidosis5.5.Uremic EncephalopathyUremic Encephalopathyp p yp p y6.6.Uremic pericarditisUremic pericarditis7.7.TLSTLS8.8.Progressive rise BUN (Infant: Progressive rise BUN (Infant: 3535--5050))9.9.Inborn error of metabolismInborn error of metabolism10.10.IntoxicationIntoxication

Pediatric Dialysisy

Indication for chronic Indication for chronic di l idi l idialysisdialysis

GFR < 10ml/min/1.73m2G 0 / / 73Reduced growth velocityDecreased head circumferenceDecreased head circumferenceLack of developmental milestonesE li t i i thEarlier to maximize growth

GFRPediatric Dialysis

• Chromium EDTAI li Cl

GFR• Inulin Clearance• Cystatin-C• Creatinine Clearance = U V X 1 73• Creatinine Clearance = U(mg/ml).V(ml/min) X 1.73

P(mg/ml) SA• Schwarts F: GFR = (k) (H) (ml/min/1 73m2)Schwarts F: GFR (k).(H) (ml/min/1.73m2)

Scr• K = 0.33 In preterm infants up to 1 year p p y• K = 0.45 In term infants up to 1 year• K = 0.55 In children 1 - 18 years• K = 0.7 In adults

Pediatric DialysisPediatric Dialysis

Acute: Chronic:

Acute Peritoneal Dialysis CAPDHemodialysis APDyCAVH(SCUF) IPDCVVH CCPDCAVHD HemodialysisCVVHDCVVHD

Pediatric Dialysisy

A t di l iChoice of dialysis modality

Acute dialysis: Choice= PD because of:Ease of peritoneal accessRapidity (In life threatening HYPERKALEMIA)Patients with hemodynamic instabilityIn patients with hypotension(CAVH, CVVH, CAVHD, CVVHD)CCRF: Choice = APD (CCPD, NIPD)Infants:APD ( Vascular access)Preschool (2-5y), School(6-11y):APD, CAPD - HD( y), ( y) ,Adolescent: CAPD, APD( Compliance?) , - HD.

Pediatric DialysisPediatric DialysisType of Dialysis

In candidates for kidney transplantation:Old belief: PD increases the risk of infectionNow: In StudiesMorbidity and mortality related to TP Didn't differDesirability of TP isn't a factor in h h i f di l i d lithe choice of dialytic modality.

In 142 TP patients at GOS:Only 7(5%) HemodialysedOnly 7(5%) Hemodialysed103(72%) Exclusively on PD (23%) Pre-emptive TP.


1 Cl t f th di l

Hemodialysis- Principles 1- Clearance rate of the dialyzer Adults: Most dializers have UREA clearance of: 60- 80%of Blood flow rate( in range 200-300ml/min) 60 80%of Blood flow rate( in range 200 300ml/min)Children: Relationship betweem UREA clearance and blood flow= CurvilinearWith small dialyzers: Urea clearance curve = plateauWith larger dialyzers: Dialyzer Urea cl. = 90% BFR(<150)2- Ultrafiltration rate: Adults:UF ~ TMPIn small infants: BFR(<100) important determinant of UF

Relation between BFR and dialyzer clearance in pediatric dialysisclearance in pediatric dialysis

CA110250

Dialyzer Dialyzer clearanceclearance

Minor

Mini minor100

Minor

BFR 300200BFR

Pediatric DialysisPediatric Dialysis Dialysis Machines

Children <20 kg: Gambro AK10 and AK100Gambro AK10 and AK100 * BFR = 10- 200ml/min 10- 500ml/min * Suitable for Bicarbonate dialysisChildren >20 kg: Other MachinesSingle needle adaptors with reservoir(30-50ml) should not be used in small childrenshould not be used in small children


DialyzersDialyzer priming + Blood tubing volume < 10% of blood volume =8ml/kgParallel plates:Parallel plates:slightly higher priming volume/ unit membrane SAContained blood volume increases when TMP is applied for UFapplied for UF.Compliance well suited for single-needle dialysisfor Neonates and<10kg:Gambro Mini-Minor, Minor >15k B t CA 50>15kg: Baxter CA-50Adult hollow-fibers (P.V=75ml): children >20kg


Blood lines

Priming volume of:adult blood lines: 75-150ml adult blood lines: 75 150ml

Neonatal and pediatric blood lines: 25-75mlSmaller blood lineswith diameter of 3mm: Restrict BFR to 75ml/minFor higher BFR:Short blood lines with larger inner diameter is gavailable


Vascular accessT Temporary access:

Single or double lumen percutaneouly to Vena cavaSubclavian, Internal jugular or femoral approachI t ll i f t th t ti h ld bIn neonates, small infants: catheter tip should be radiologically positioned in upper right atriumIn neonates: Catheter in vena cava via UMBILICAL V.Th h b l f i l f l kThese catheters can be left in place for several weeksPermanent Access: <15kg: short 7F.catheter in Fem. VOr subclavian or internal jugular, Arteriovenous shuntOlder children: AV fistula:radial artery ~cephalic veinIn small vessle: Gore-Tex or Impra graft between A-V.

Pediatric Dialysis

Vascular accessPatient sizePatient size Catheter choiceCatheter choicePatient sizePatient size Catheter choiceCatheter choiceNeonateNeonate 55F single lumenF single lumen

77F Double lumenF Double lumen77F Double lumenF Double lumen33--6 6 kgkg 77F Double lumenF Double lumen66--3030kgkg 88 Double lumenDouble lumen66 3030kgkg 88 Double lumenDouble lumen1515--3030kgkg 99F Double lumenF Double lumen>>3030kgkg 1010F Double lumenF Double lumen

1212..55F Double lumenF Double lumen


S l ti f di li d bl d li b d

TECHNIQUE OF DIALYSISSelection of dializer and blood lines based on:

Priming volumeClearance efficiencyUlt filt ti h t i tiUltrafiltration characteristics

> 8ml/kg primed with BLOODCalculate BFR from BF-Clearance graph to obtain:

U l 3 l/k /MiUrea clearance =3ml/kg/MinExample: 20kg BFR # 60 ml/MinSession length = usualy 3- 4 hrFi t di l U l 1 5 2 l/k / i i 2hFirst dialys: Urea cl.=1.5- 2ml/kg/min or session =2hr

Pediatric DialysisPediatric DialysisTECHNIQUE OF DIALYSIS

Dialysis solution Flow rate= 500ml/minHemodynamically unstable: Bicarb dialysisHemodynamically unstable: Bicarb. dialysisMaximum fluid removal/session: not exceed 5% BWVolumetric(Ultrafiltration) controller machine O TMPOr TMP* Urea clearance(# BFR):

should not exceed 3ml/kg/ming

Flow RatesPediatric Dialysis

Blood Flow Rate (BFR):Flow Rates

Blood Flow Rate (BFR):• 4 cc /kg/min• < 10 kg = <100cc/min• 10 - 40 = 2.5*W+100

40 k 250 / i• >40 kg = 250cc/min

• Dialysis fluid Flow RateDialysis fluid Flow Rate• 1.5* BFR in small children• Then up to 500cc/min

Pediatric DialysisPediatric DialysisHeparinization

S d ltSame as adultsACT # 150- 200%% of normals or predialysisLoading dose: 40 - 50 u/kg then monitorM i t 0 3 0 5 /k / iMaintenance: 0.3- 0.5 u/kg/min

50 u/kg/hr 25u/kg bolus 2nd hr

ACT # 125% i l d h i i ti (hi h i k )ACT # 125% in low dose heparinization(high risks)Surgery past 5 days- next 24hr :25u/kg ACT kept 12- 15min P t i d f di l (1 /100 h i l t 2 h )Protamine end of dialys(1mg/100u heparin last 2 hr)

Pediatric Dialysis- OldOldPediatric Dialysis OldOldAdequacy of dialysis

KT/V 1 3KT/V = 1.3K= urea clearance litre/hrT= session lengthT= session lengthV= Urea space= total body water= 0.6WAdequate if:

BUN < 30 35%postdialysis BUN < 30- 35% of predialysisPredialysis BUN < 100- 120 (higher than adults due to protein intake >1.5g/kg/d)( g p g g )

Pediatric DialysisAdequacy of dialysis

Pediatric Dialysis

In children:In children:

KT/V=KT/V= 11 44-- 11 55KT/VKT/V 11..44-- 11..55URR>URR> 6060 6565%%URR> URR> 6060--6565%%

Pediatric DialysisPediatric DialysisComplications of Dialysis

DDSHypotensionHypothermiaH iHypoxiaMuscle crampAir embolismHemolysisHemolysisIN small children:

Yawing, Restlessness, Nausea, Staring, Changes in skin color: often p recede : DDSChanges in skin color: often p recede : DDS

Hypotension and vomiting

Pediatric DialysisPediatric DialysisDialysis Disequilibrium syndrome (DDS)

More common in childrenEspecially: during initial dialysis treatment

in high BUN > 150 in high BUN > 150High efficiency & rapid dialysis

Manifestations: Irritability, headache, disorientation muscle cramp nauseadisorientation, muscle cramp, nausea

Drowsiness, seizure, comaResult of brain swellingP ti S ll i di l R d i BFRPrevention: Small size dialyzer, Reducing BFR

Manitol: 0.5- 1g/kg

DialysisDialysis in ARFyyCompared with every other day Compared with every other day Compared with every other day Compared with every other day dialysis: dialysis:

D il th i t d ithdialysis: dialysis:

D il th i t d ithDaily therapy was associated with a significant reduction in mortality

Daily therapy was associated with a significant reduction in mortalitysignificant reduction in mortality

P l k PM S i Di lP l k PM S i Di l 20062006 1919 165165

significant reduction in mortality

P l k PM S i Di lP l k PM S i Di l 20062006 1919 165165Palevsky, PM. Semin Dial Palevsky, PM. Semin Dial 20062006; ; 1919::165165Palevsky, PM. Semin Dial Palevsky, PM. Semin Dial 20062006; ; 1919::165165

Advantages of CRRT over IHDAdvantages of CRRT over IHDAdvantages of CRRT over IHDAdvantages of CRRT over IHD

• Improved cardiovascular stability I d l l fil i

• Improved cardiovascular stability I d l l fil i• Improved tolerance to ultrafiltration

• Removal of large obligatory fluid loads• Improved tolerance to ultrafiltration• Removal of large obligatory fluid loadsRemoval of large obligatory fluid loads• Ability to maintain excellent azotemia

Removal of large obligatory fluid loads• Ability to maintain excellent azotemia

and solute control even in severely catabolic patientsand solute control even in severely catabolic patientscatabolic patients catabolic patients

H b id hH b id hHybrid therapyHybrid therapy• Sustained low efficiency daily dialysis (SLEDD)• Sustained low efficiency (daily) diafiltration

(SLEDD f)

• Sustained low efficiency daily dialysis (SLEDD)• Sustained low efficiency (daily) diafiltration

(SLEDD f)(SLEDD-f)• Extended daily dialysis (EDD)

(SLEDD-f)• Extended daily dialysis (EDD)• Slow continuous dialysis (SCD)• Slow continuous ultra filtration (SCUF) • Slow continuous dialysis (SCD)• Slow continuous ultra filtration (SCUF) Go slow dialysis

Marshall, MR, Contrib Nephrol 2001; :252 Go slow dialysis

Marshall, MR, Contrib Nephrol 2001; :252

Hybrid therapy ( ti )Hybrid therapy ( ti )Hybrid therapy (continue)Hybrid therapy (continue)

•• Treatments are deliberately:Treatments are deliberately:•• Treatments are deliberately:Treatments are deliberately:Treatments are deliberately: Treatments are deliberately: intermittent rather than continuousintermittent rather than continuous

Treatments are deliberately: Treatments are deliberately: intermittent rather than continuousintermittent rather than continuouswith longer session durations thanwith longer session durations thanconventional iHDconventional iHDwith longer session durations thanwith longer session durations thanconventional iHDconventional iHDconventional iHD. conventional iHD.

•• Solute and fluid removal are slower Solute and fluid removal are slower conventional iHD. conventional iHD.

•• Solute and fluid removal are slower Solute and fluid removal are slower than conventional iHD, but faster than than conventional iHD, but faster than conventional CRRT conventional CRRT than conventional iHD, but faster than than conventional iHD, but faster than conventional CRRT conventional CRRT

Preferred machines for Preferred machines for hybrid therapyhybrid therapy

•• Gambro AKGambro AK200200S Ultra® machine S Ultra® machine •• GambroGambro 200200S Ultra®S Ultra®•• Gambro AKGambro AK200200S Ultra® machine S Ultra® machine •• GambroGambro 200200S Ultra®S Ultra®Gambro Gambro 200200S Ultra® S Ultra® •• Fresenius Fresenius 20082008HH

F iF i 20082008KK

Gambro Gambro 200200S Ultra® S Ultra® •• Fresenius Fresenius 20082008HH

F iF i 20082008KK•• Fresenius Fresenius 20082008K K •• Fresenius Fresenius 40084008SS•• Fresenius Fresenius 20082008K K •• Fresenius Fresenius 40084008SS•• Fresenius Fresenius 40084008E or E or 40084008H machines H machines •• Fresenius Genius® machineFresenius Genius® machine•• Fresenius Fresenius 40084008E or E or 40084008H machines H machines •• Fresenius Genius® machineFresenius Genius® machineFresenius Genius® machine Fresenius Genius® machine Fresenius Genius® machine Fresenius Genius® machine

P i lPeritoneal Dialysisy

In ChildrenIn ChildrenM f Sh ifiMostafa Sharifian Pediatric Nephrologistp g

Peritoneal Dialysis In Children

Use of peritoneal cavity for treatment f i ill i hild 9090of serious illnesses in children= 9090 yrsyrs

19181918: Blackfan , Maxy: Injection of saline IP: Blackfan , Maxy: Injection of saline IP19481948: Bloxum, Powel: PD for ARF: Bloxum, Powel: PD for ARF19491949: Swan, Gordon: Short term treatments: Swan, Gordon: Short term treatments,,19761976: Popovich: Novel portable equilibrium : Popovich: Novel portable equilibrium

dialysis technique (Now: CAPD)dialysis technique (Now: CAPD)y q ( )y q ( )19781978: Oreopoulos, Balfe: CAPD in CHILDREN: Oreopoulos, Balfe: CAPD in CHILDREN19781978: EDTA:: EDTA: 3030% OF <% OF < 1515yr andyr and 6262%<%<22yr PDyr PD19781978: EDTA: : EDTA: 3030% OF % OF 1515yr and yr and 6262%% 22yr PDyr PDNow: CAPD is most commonly used for ESRF

Peritoneal Dialysis In ChildrenPeritoneal Dialysis In Children

Advantages:No need for Vascular AccessNo need for Vascular AccessTechnical simplicityRapid trainingRapid trainingGreater mobilityMinimal dietary restrictionyImproved growth rateSteady state chemistriesBetter control of HypertensionFewer transfusionI t i b diImprovement in bone disease hemodynamically stable


Peritoneal surface area:(Putiloff)( )In infant( 2.9kg) = 0.15 m2In adults = 2.08 m2

383- 522 cm2/kg in In infant177- 285 cm2/kg In adultsg=> 2/1

Equilibration: Urea in 4 hr Cr: 8 hrEquilibration: Urea in 4 hr Cr: 8 hrPD twice as efficient in infants

(Esperanca in dogs)

PD - ContraindicationsPD - ContraindicationsAbsolute: Lack of adequate peritoneal cavity

Neonates: Diaphragmatic herniaGastroschisis, Omphalocele

i i iNo contraindication:Recent abdominal surgery if no draining wound,g y gVesicostomies,Ureterostomy, Polycystic kidneys, Colostomy, Gastrostomies, Prune belly, RecentColostomy, Gastrostomies, Prune belly, Recent bowel surgery, V-P shunt, Wilms tumor, Concurrent Immunosuppressive therapyConcurrent Immunosuppressive therapyAllograft dysfunction in and extraperitoneal Tx.


Catheters:y

One cuff: 1 peritonitis in 12.6 patient/ month

Two cuff: 1 peritonitis in 15.1 patient/ monthOmentectomyOmentectomy:: 53% of centersyyDownward Exit site: 69% of centersIn 18 centers:In 18 centers:

88% prefer Curled Tenckhoff69% Straight tunnel, single cuff

C th tPeritoneal Dialysis In Children

Catheters:>3 days Use Tenckhoff>3 days Use Tenckhoff> 30 kg Adult size10 30 k P di t i10 - 30 kg Pediatric< 10 kg Infantile< 3 kg NeonatalFirst dialysis postponed until fibrosisFirst dialysis postponed until fibrosis around catheter Partial or Total omentectomyPartial or Total omentectomy No more infection rate


Dialysis fluidLactate 40 mEq/litre preferredAcute dialysis with 2.5% dextroseyCritically ill Infants with:

(Hypoxia Hypotension Lactic acidosis)(Hypoxia, Hypotension, Lactic acidosis) Don`t tolerate lactate ==> BicarbonateBicarbonateWarmed to body temperature:

Cold =>Infants: Sudden fall in BPCold >Infants: Sudden fall in BPAdults: Discomfort


CPD prescription:Dialysis started when:

Cr Cl = 9 - 14 ml/min/ 1 73m2Cr Cl 9 - 14 ml/min/ 1.73m2Weekly renal KT/Vurea < 2

NAPRTCS report: 2/3 APDFirst First 24 24 hr: hr: 2020 cc/kg (cc/kg (500500ml/mml/m22))g (g ( ))

Maximum: Maximum: 4545ml/kg (ml/kg (11001100ml/mml/m22))33 2020 exchanges/ dayexchanges/ day3 3 -- 20 20 exchanges/ dayexchanges/ day


Problems in achieving adequate ultrafiltration in Children

Large residual peritoneal volume inLarge residual peritoneal volume in children:Li i Fl id fl d S lLimit Fluid flux and Solute transportHigher rate of lymphatic absorption g y p pthan adultsRepeated peritonitis (more commonRepeated peritonitis (more common than adults)


PD adequacyCAPD CCPD NIPD

(Residual renal+ PD)weekly KT/V urea >2 2.1 2.2Total weekly Cr Cl (L/1.73m2) >60 63 66weekly urea Clearance 1.4 Litre4040-- 5050% more than adults =>Higher protein intake% more than adults =>Higher protein intake

3 3 times / yrtimes / yryyWhen changes in clinical status influence PDSevere or repeated Peritonitis

(Pseudomonas, Fungal)


Acute PD prescription:Peritocath

Di l i fl id itiDialysis fluid compositionExchange volumegInflow, dwell, drain timesFirst 24 hr: 20 cc/kg (500ml/m2)First 24 hr: 20 cc/kg (500ml/m2)

Maximum: 45ml/kg (1100ml/m2)30 -60 min exchanges

C li tiPeritoneal Dialysis In Children

Complications:InfectionInfectionCatheter obstruction;

Clot: HeparinClot: HeparinOmentum: Omentectomyy

Catheter dislocationHernias:Hernias: 75% require surgical repairBloody effluent in menstruation: HeparinBloody effluent in menstruation: HeparinGlucose toxicity


Complications: InfectionExit site Peritonitis or bothExit site, Peritonitis or bothPeritonitis:During the first year:

95% Experience one or more episodes95% Experience one or more episodesBacterial entry:

Luminal, PeriluminalAcross intestinal wall Hematogenous: Rare

P it itiPeritoneal Dialysis In Children

Peritonitis:Cli i l if t tiClinical manifestations:Subtle:Subtle:Cloudy peritoneal fluidy pLow grade feverMild abdominal pain TendernessMild abdominal pain, TendernessCell count > 100/ ulSmear: 40% positive


Peritonitis-Organisms:G 50% G 30% C l 10 20%G+ :50% G- :30% Culture neg: 10- 20%Staph epidermidis 30- 40%Staph aureus 10- 20%Streptococci 10- 15%pE-Coli 5- 10%Enterococci 3- 6%Enterococci 3 6%Fungi 2- 10%Exit or Tunnel infection 42% Staph au.Exit or Tunnel infection 42% Staph au.

Pseudomona


Peritonitis: Treatment:E i i l id d b G t iEmpirical guided by Gram stainNo organism on smear: IP:Vanco+ Aminoglycoside or Third generation

(Antipseudomonas)Staph aureus: Oral Rifampin addedFungal: IP Fluconazole+ Oral Flucytosine- AmphoDuration: 14 – 21 days

In S. aureus, Pseudomonas, Fungal: 21- 28daysFungal or Pseudomona Peritonitis:: Remove catheter.Remove catheter.

CAPD Connectology: R d d i kReduced risk

The short distance between the Y-Junction and the patientThe short distance between the Y Junction and the patient connection ensures effective removal of bacterial contamination from the patient line should connection failure occur.

Kubey W., et al., Blood Purification; 2000, 19(1).

O tPeritoneal Dialysis In Children

OutcomeMembrane failure: (Andreoli)Membrane failure: (Andreoli)Peritonitis with Pseudomona, Alpha Strep.Change modality:Change modality:Excessive infection in 42%Inadequate Ultrafiltration 15%Inadequate Ultrafiltration 15%Inadequate solute removal 4%Overall mortality: 5 7%Overall mortality: 5.7%0 - 1 yr age 13.8% 6 - 12yr 3.72 5 yr 8 1% 13 17 yr 2 5%2 - 5 yr 8.1% 13 - 17 yr 2.5%Cause: Cardiopulmonary - Infection


VaccinationRoutine immunization + >Routine immunization + =>Influenza yearly before fallPne mococcal at 2 and 3 5 r later<10Pneumococcal at 2 and 3 - 5 yr later<10yVaricella in 2 doseP t ti d tPoor protection due to:Loss of immunoglobulin into dialysate:Hib MMR P HBV d bl th dHib, MMR, Pneumo. HBV: double the doseResponse to vaccination:h ld b it d thshould be monitored every other yr

CKD- TreatmentVaccinationVaccination

our protocol:our protocol:•Routine +Routine • Influvac yearlyy y


Nutrition in CPDAt least 100% of RDAAt least 100% of RDAAlthough Receive 8 - 20 cal/day from dextroseDiminished weight-High- Triceps skinfold thickness- Mid-arm circumference

H lb i iHypoalbuminemiaHypertriglyceridemiaHypercholstrolemia

Protein loss esp. in Peritonitis <=> 2.5 g/kg/dIntraperitoneal amino acids: SuggestedIntraperitoneal amino acids: Suggested

CKD- TreatmentAnorexia, Low energy intake:gy

PEG +PEG overnight feedingg g

Vomiting:Fundoplication

G th t d tiPeritoneal Dialysis In Children

Growth retardationMetabolic acidosisMetabolic acidosisMalnutritionOsteodystrophyOsteodyst op yGH: Normal or elevatedAbnormalities in GH- IGF1 axisGH insensitivity:

Reduced Hepatic GH expressionDecreased production of IGF 1Decreased production of IGF-1Inhibition of IGF bioactivity by increased binding to specific proteins

T GH C id iTreatment: GH+ Correct acidosis,...

Chronic Renal Failure

Treatment- Osteodystrophy1- Low Phosphate diet1 Low Phosphate diet2- Phosphate binder

CaCO3 - Aluminium Hydroxide - Ca Acetate (with Meal)3- Active Vit D if Ca is low - Alchaline Ph. high

No Ca infusion except TETANYCareful acidosis correctionCareful acidosis correctionAvoid Ca X P > 70

* Calcitriol= Rocaltrol pearl( f ) (1 , 25 Dihydroxy cholecalciferol) l = 0.25 ug

Dose = 15 - 60 nanog /kg / d * DHT Not in liver disease * AT10 ( 1 cc = 1 mg = 30 drops 1 drops = 0.03mg)

Starting Dose = 0.01 - 0.02 ng/kg/d

CKD- Treatment•Anemia

D fi i f• Deficiency of: – Iron, Folic acid, B12, Erythropoetin

• Target Hb: 11- 12g/dl• Transferrin saturation (TSAT): > 20% (20 -50 %)( ) ( )

• Ferritin: > 100 ng/ml (100 -800)

• Eprex : Start 300 U/Kg/ week• Eprex : Start 300 U/Kg/ week50- 150 U/Kg 3 X week

S• Rout: Sc, IV, IP

Chronic Renal FailureNutrition

Protein: LProtein: Low1.5 g/kg Essential aminoacidsIn CAPD: 2 - 2.5 g/kg (Protein loss in PD Fluid)Egg, Milk, Fish, fowlLow phosphate DietZinc & Iron Supplementspp

Vitamines:Water soluble VitaminesA E K N t i dA, E, K: Not required

Water & Electrolytes:Edema: Restriction + FrusemideEdema: Restriction FrusemidePolyuria: Water + Salt

CKDCKD-- Team ApproachTeam Approachpppp• Nurse : Team Coordinator• Dietician• Social worker• Social worker• Surgeon (Vascular surgery: PD g ( g y

catheter- Permcath)• Pediatric UrologistPediatric Urologist• Pediatric Nephrologist• School counselor

Thank you for your y yattention

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