Infant dialysis: The future is now
2000; Elsevier BV; Volume: 136; Issue: 1 Linguagem: Inglês
10.1016/s0022-3476(00)90037-4
ISSN1097-6833
Autores Tópico(s)Central Venous Catheters and Hemodialysis
ResumoSee related article, p. 24 .The study by Ledermann et al1Ledermann SE Scanes ME Fernando ON Duffy PG Madden SJ Trompeter RS Long-term outcome of peritoneal dialysis in infants.J Pediatr. 2000; 136: 24-29Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar signals an era of change in infant end-stage renal disease therapy. From the mid 1980s to the latter part of the 1990s, this group has successfully followed up a large group of infants with ESRD. They have shown that focused care, in consort with adaptions and implementation of new techniques and technology, both improves survival and enhances the quality of life for these infants.The group observed that the outcome of 20 infants with ESRD, followed up over 12 years, was linked with extrarenal organ dysfunction such as pulmonary or cardiac diseases. This observation is consistent with recent work by Ellis et al,2Ellis EN Pearson D Champion B Wood EG Outcomes of infants on chronic peritoneal dialysis.Adv Perit Dial. 1995; 11: 266-269PubMed Google Scholar who reported that survival is related to urine output, as well as to non-renal organ dysfunction.Ledermann et al1Ledermann SE Scanes ME Fernando ON Duffy PG Madden SJ Trompeter RS Long-term outcome of peritoneal dialysis in infants.J Pediatr. 2000; 136: 24-29Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar demonstrate that with the transition from continuous ambulatory peritoneal dialysis to continuous cycling PD, these infants were treated in a home environment with better-quality dialysis and the opportunity for improved nutrition. Others have similarly shown that continuous cycling PD allows for improved dialysis efficiency and improved solute and free water clearance.3Warady BA Alexander SR Watkins S Kohaut E Harmon WE Optimal care of the pediatric end-stage renal disease patient on dialysis (review).Am J Kidney Dis. 1999; 33: 567-583Abstract Full Text Full Text PDF PubMed Scopus (62) Google ScholarThis work further addresses an area that many have identified as the most important issue for infants with ESRD: attention to nutrition. Data to date have suggested that these infants require 130% to 140% of the recommended daily allowance for calories. During PD, 3 to 4 g of protein per kilogram of body weight is needed for adequate growth, as well as to compensate for protein losses across the peritoneal membrane.4Geary DF Ikse KH Coulter P Secker D The role of nutrition in neurologic health and development of infants with chronic renal failure (review).Adv Perit Dial. 1990; 6: 252-254PubMed Google Scholar In order to deliver this added amount of nutrition, Ledermann et al1Ledermann SE Scanes ME Fernando ON Duffy PG Madden SJ Trompeter RS Long-term outcome of peritoneal dialysis in infants.J Pediatr. 2000; 136: 24-29Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar have struggled with and addressed the transition from oral to enteral feeding tubes with detail of risk and benefit of both nasogastric tubes and gastrostomy tubes.5Coleman JE Watson AR Rance CH Moore E Gastrostomy buttons for nutritional support on chronic dialysis.Nephrol Dial Transplant. 1998; 13: 2041-2046Crossref PubMed Scopus (45) Google Scholar, 6Warady BA Weis L Johnson L Nasogastric tube feeding in infants on peritoneal dialysis.Perit Dial Int. 1996; 1: S521-S525Google Scholar They point out that both of these methods have complications and demand extra work by parents. The complications of percutaneous endoscopic gastrostomy (PEG) tubes, which are not as well recognized, are well addressed and bring to light protocols that should be in place for children requiring enteral feeding tubes with PD catheters.Careful attention to the details of phosphorus binders, nutrition, and vitamin D should eliminate renal osteodystrophy in this population. This therapy is also important in maximizing growth.7Salusky IB Goodman WG The management of renal osteodystrophy.Pediatr Nephrol. 1996; 10: 651Crossref PubMed Scopus (19) Google Scholar Anemia is also preventable and should no longer be a problem in these children with the use of recombinant erythropoietin and iron supplementation.8Jabs K Harmon WE Recombinant human erythropoietin therapy in children on dialysis.Adv Ren Replace Ther. 1996; 3: 24-36PubMed Google ScholarThis group also examined the role of the combination of adequate dialysis, enhanced nutrition, prevention of renal osteodystrophy, and prevention of anemia. As determined by behavioral and psychologic testing, most children receiving dialysis seem to be able to be mainstreamed into school.9Fennell RS Fennell EB Carter RL Mings EL Klausner AB Hurst JR Correlations between performance on neuropsychological tests in children with chronic renal failure.Child Nephrol. 1990; 10: 199-204PubMed Google ScholarThe sticky issue of the ethics of dialysis in this population has been well addressed during this decade of care.10Bunchman TE The ethics of infant dialysis.Perit Dial Int. 1996; 16: S505-S508PubMed Google Scholar This population is truly “high maintenance” and requires a lot of attention to detail by both family and the health care team. It takes a very devoted and very focused family to care for these children, for whom morbidity and mortality rates are very high. Ledermann et al1Ledermann SE Scanes ME Fernando ON Duffy PG Madden SJ Trompeter RS Long-term outcome of peritoneal dialysis in infants.J Pediatr. 2000; 136: 24-29Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar express what many of us feel: that the outcome of these children is somewhat related to the health care team but is mostly related to the quality of care by the family. Partnership between the family and the health care team is paramount for a good outcome.In those infants with peritoneal membrane failure, the authors also address the issue of hemodialysis. Twenty percent of their patients required hemodialysis because of peritoneal membrane complications. Hemodialysis therapy in infants continues to be somewhat behind PD for long-term care, despite advancements in vascular access, infant-specific equipment, and expertise in infants.11Donckerwolcke R Bunchman TE Hemodialysis—modalities and management in infants and small children.Pediatr Nephrol. 1994; 8: 103-106Crossref PubMed Scopus (41) Google Scholar These authors have used hemodialysis, as do most programs, as a backup for PD. They also allude to the fact that if one is going to have a balanced program, one needs to have the ability to include an infant or a child receiving both PD and hemodialysis.Ledermann et al1Ledermann SE Scanes ME Fernando ON Duffy PG Madden SJ Trompeter RS Long-term outcome of peritoneal dialysis in infants.J Pediatr. 2000; 136: 24-29Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar also point out that if one is going to begin treating an infant with dialysis, one also needs to have a plan for transplantation. Infant transplantation has grown up along with renal replacement therapy. A partnership between dialysis and transplantation needs to occur for infants to have a quality outcome.12Valentini RP Bunchman TE Pre-emptive renal transplantation in infancy.in: 3rd ed. Clinical dialysis. : Appleton and Lang, Norwalk (CT)1995: 944-965Google ScholarWith newer technology, the support of a good family, attention to nutrition, and appropriate use of vitamin D and erythropoietin, the end result can be a very functional child. In essence, no longer is renal replacement therapy in infants considered experimental, but should be and is the standard of care. See related article, p. 24 . The study by Ledermann et al1Ledermann SE Scanes ME Fernando ON Duffy PG Madden SJ Trompeter RS Long-term outcome of peritoneal dialysis in infants.J Pediatr. 2000; 136: 24-29Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar signals an era of change in infant end-stage renal disease therapy. From the mid 1980s to the latter part of the 1990s, this group has successfully followed up a large group of infants with ESRD. They have shown that focused care, in consort with adaptions and implementation of new techniques and technology, both improves survival and enhances the quality of life for these infants. The group observed that the outcome of 20 infants with ESRD, followed up over 12 years, was linked with extrarenal organ dysfunction such as pulmonary or cardiac diseases. This observation is consistent with recent work by Ellis et al,2Ellis EN Pearson D Champion B Wood EG Outcomes of infants on chronic peritoneal dialysis.Adv Perit Dial. 1995; 11: 266-269PubMed Google Scholar who reported that survival is related to urine output, as well as to non-renal organ dysfunction. Ledermann et al1Ledermann SE Scanes ME Fernando ON Duffy PG Madden SJ Trompeter RS Long-term outcome of peritoneal dialysis in infants.J Pediatr. 2000; 136: 24-29Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar demonstrate that with the transition from continuous ambulatory peritoneal dialysis to continuous cycling PD, these infants were treated in a home environment with better-quality dialysis and the opportunity for improved nutrition. Others have similarly shown that continuous cycling PD allows for improved dialysis efficiency and improved solute and free water clearance.3Warady BA Alexander SR Watkins S Kohaut E Harmon WE Optimal care of the pediatric end-stage renal disease patient on dialysis (review).Am J Kidney Dis. 1999; 33: 567-583Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar This work further addresses an area that many have identified as the most important issue for infants with ESRD: attention to nutrition. Data to date have suggested that these infants require 130% to 140% of the recommended daily allowance for calories. During PD, 3 to 4 g of protein per kilogram of body weight is needed for adequate growth, as well as to compensate for protein losses across the peritoneal membrane.4Geary DF Ikse KH Coulter P Secker D The role of nutrition in neurologic health and development of infants with chronic renal failure (review).Adv Perit Dial. 1990; 6: 252-254PubMed Google Scholar In order to deliver this added amount of nutrition, Ledermann et al1Ledermann SE Scanes ME Fernando ON Duffy PG Madden SJ Trompeter RS Long-term outcome of peritoneal dialysis in infants.J Pediatr. 2000; 136: 24-29Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar have struggled with and addressed the transition from oral to enteral feeding tubes with detail of risk and benefit of both nasogastric tubes and gastrostomy tubes.5Coleman JE Watson AR Rance CH Moore E Gastrostomy buttons for nutritional support on chronic dialysis.Nephrol Dial Transplant. 1998; 13: 2041-2046Crossref PubMed Scopus (45) Google Scholar, 6Warady BA Weis L Johnson L Nasogastric tube feeding in infants on peritoneal dialysis.Perit Dial Int. 1996; 1: S521-S525Google Scholar They point out that both of these methods have complications and demand extra work by parents. The complications of percutaneous endoscopic gastrostomy (PEG) tubes, which are not as well recognized, are well addressed and bring to light protocols that should be in place for children requiring enteral feeding tubes with PD catheters. Careful attention to the details of phosphorus binders, nutrition, and vitamin D should eliminate renal osteodystrophy in this population. This therapy is also important in maximizing growth.7Salusky IB Goodman WG The management of renal osteodystrophy.Pediatr Nephrol. 1996; 10: 651Crossref PubMed Scopus (19) Google Scholar Anemia is also preventable and should no longer be a problem in these children with the use of recombinant erythropoietin and iron supplementation.8Jabs K Harmon WE Recombinant human erythropoietin therapy in children on dialysis.Adv Ren Replace Ther. 1996; 3: 24-36PubMed Google Scholar This group also examined the role of the combination of adequate dialysis, enhanced nutrition, prevention of renal osteodystrophy, and prevention of anemia. As determined by behavioral and psychologic testing, most children receiving dialysis seem to be able to be mainstreamed into school.9Fennell RS Fennell EB Carter RL Mings EL Klausner AB Hurst JR Correlations between performance on neuropsychological tests in children with chronic renal failure.Child Nephrol. 1990; 10: 199-204PubMed Google Scholar The sticky issue of the ethics of dialysis in this population has been well addressed during this decade of care.10Bunchman TE The ethics of infant dialysis.Perit Dial Int. 1996; 16: S505-S508PubMed Google Scholar This population is truly “high maintenance” and requires a lot of attention to detail by both family and the health care team. It takes a very devoted and very focused family to care for these children, for whom morbidity and mortality rates are very high. Ledermann et al1Ledermann SE Scanes ME Fernando ON Duffy PG Madden SJ Trompeter RS Long-term outcome of peritoneal dialysis in infants.J Pediatr. 2000; 136: 24-29Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar express what many of us feel: that the outcome of these children is somewhat related to the health care team but is mostly related to the quality of care by the family. Partnership between the family and the health care team is paramount for a good outcome. In those infants with peritoneal membrane failure, the authors also address the issue of hemodialysis. Twenty percent of their patients required hemodialysis because of peritoneal membrane complications. Hemodialysis therapy in infants continues to be somewhat behind PD for long-term care, despite advancements in vascular access, infant-specific equipment, and expertise in infants.11Donckerwolcke R Bunchman TE Hemodialysis—modalities and management in infants and small children.Pediatr Nephrol. 1994; 8: 103-106Crossref PubMed Scopus (41) Google Scholar These authors have used hemodialysis, as do most programs, as a backup for PD. They also allude to the fact that if one is going to have a balanced program, one needs to have the ability to include an infant or a child receiving both PD and hemodialysis. Ledermann et al1Ledermann SE Scanes ME Fernando ON Duffy PG Madden SJ Trompeter RS Long-term outcome of peritoneal dialysis in infants.J Pediatr. 2000; 136: 24-29Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar also point out that if one is going to begin treating an infant with dialysis, one also needs to have a plan for transplantation. Infant transplantation has grown up along with renal replacement therapy. A partnership between dialysis and transplantation needs to occur for infants to have a quality outcome.12Valentini RP Bunchman TE Pre-emptive renal transplantation in infancy.in: 3rd ed. Clinical dialysis. : Appleton and Lang, Norwalk (CT)1995: 944-965Google Scholar With newer technology, the support of a good family, attention to nutrition, and appropriate use of vitamin D and erythropoietin, the end result can be a very functional child. In essence, no longer is renal replacement therapy in infants considered experimental, but should be and is the standard of care.
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