By Ken Kolnacki, RN, BSN, CNN

Successful renal transplantation is the treatment of choice for children with end-stage renal disease (ESRD). Ideally, children with ESRD should be transplanted before becoming ill and requiring dialysis. However, this is not always possible. Children with severe proteinuria, reflux disease and hypertension may require removal of their kidneys before transplant. In other situations, living related transplants are not possible and the child is placed on the deceased donor list. Therefore, many children require dialysis treatments before transplant. For children, dialysis should be viewed as a complement to transplantation, which may be needed before and between transplants. Children, like many adults, may need more than one transplant during their life.

If possible, a dialysis orientation should be scheduled for families of children with chronic kidney disease (CKD) who are approaching ESRD. Options, such as peritoneal or hemodialysis, should be discussed with the child and family. Age appropriate teaching materials such as posters, pamphlets, coloring books, dolls/puppets/stuffed animals, videos or actual equipment can be used. It is helpful for the patient to meet the pediatric dialysis nurses, social worker and dietitian. Other patients and parents can provide information and support. This orientation helps relieve some of the stress on the family and child if dialysis becomes necessary. Knowledge is power to deal with a chronic disease that many times makes families feel powerless. Education is essential to successful outcomes during all phases of treatment.

Both dialysis modalities have their advantages and disadvantages. Peritoneal dialysis (PD) is the preferred treatment for children, particularly small and young patients. PD can be done at home during the day or with the aid of a cycler machine at night. This causes less disruption to the child’s daily routine and facilitates regular school attendance. It minimizes dietary and fluid restrictions, but does place a high level of responsibility on the caregiver, which can increase family stress. Hemodialysis can reduce family stress and responsibility, but requires three to four hour sessions, three to four times weekly depending on patient size. Hemodialysis requires greater fluid and dietary restrictions and may only be available in specialized hospital-based settings.

Crucial to pediatric dialysis is tailoring treatments to size. Children less than 40 kg need smaller size dialyzers, bloodlines, lower doses of medications, smaller increments of intravenous fluids and gentler dialysis treatments. The golden rule of pediatric hemodialysis is that not more than 10 percent of the child’s blood can be outside their body in the dialysis circuit. Peritoneal dialysis volumes are calculated in milliliters per kilogram (mL/kg) of body weight. Since, children are not small adults, medical management using adult protocols and procedures are not acceptable.

Fundamental to successful interventions in pediatrics is medication and equipment safety that must be appropriate to the child’s size. Furthermore, even though the effects of CKD are similar in adults and children, there are distinct differences. Growth and development are unique to childhood. Growth is one of the most sensitive indicators of adequacy of CKD treatment. The goals in treating children and adolescents with ESRD are to foster growth and development while maintaining the highest quality of life. Therefore, besides providing safe and effective dialysis, there must be special attention to nutrition, fluid/electrolyte balance, acid-base status, as well as control of anemia, renal bone disease and hypertension. Small children frequently need tube feedings. Blood pressure (BP) should be monitored using the correct sized BP cuffs. X-rays to evaluate bone age and renal osteodystrophy should be done twice yearly. Growth hormone may be necessary if height velocity declines. There are also age specific educational, social and psychological concerns and considerations. The goal of pediatric dialysis is to keep the child healthy, in mind and body, while awaiting a new kidney.

Ken Kolnacki, RN, BSN, CNN, is a pediatric dialysis nurse in Albany Medical Center Hospital, Albany, New York. He has cared for children with ESRD since 1986. He is a member of the American Nephrology Nurses’ Association and is on their Pediatric Special Interest Group.

This article originally appeared in the March 2004 issue of aakpRENALIFE, Vol. 19, No. 5.

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