Pediatric Hemodialysis Prescription, Complications, and Future Directions

Hemodialysis (HD) is a common method of renal replacement therapy for children with end-stage renal disease (ESRD). Over the last few decades, there have been advancements in dialysis equipment, medications, and treatment standards, leading to improved patient outcomes. However, children on dialysis continue to experience very high rates of morbidity and mortality compared to the general pediatric population. Dialysis related symptoms including hypotension, nausea, and cramps continue to be prominent causes of morbidity among children with ESRD. Furthermore, cardiovascular morbidity and mortality remain common in children treated with maintenance dialysis. In this chapter we describe current methods to calculate adequate clearance, estimate dry weight, and prescribe HD in children with ESRD. We also outline commonly encountered complications of HD including dialysis disequilibrium syndrome, intra-dialytic hypotension, myocardial stunning, hypertension, inflammation, and malnutrition. Finally, we suggest future directions for children treated with HD including the potential benefits of convective modalities (hemodiafiltration) and intensified hemodialysis options.