Hemodialysis in children: General Practical Guidelines

IntroductionIntroduction

Hemodialysis in children progress over the last 20 years Hemodialysis in children progress over the last 20 years

The morbidity of the sessions has decreased The morbidity of the sessions has decreased

Technological progress, the availability of erythropoietin and of Technological progress, the availability of erythropoietin and of

growth hormone enhanced dialysis dose increased quality of lifegrowth hormone enhanced dialysis dose increased quality of life Technically all children can underwent HD even infantsTechnically all children can underwent HD even infants

Primary renal diseases leading to chronic renal failurePrimary renal diseases leading to chronic renal failure

France%France% North America%North America% Iran%Iran%

Primary DiagnosisPrimary Diagnosis

GNGN 25.625.6 24.824.8 10.210.2

Malformation Malformation 25.625.6 34.134.1 4747

Inherited Renal Inherited Renal DiseaseDisease

16.716.7 13.513.5 21.121.1

CINCIN 18.818.8 77 9.69.6

Vascular DiseaseVascular Disease 2.22.2 4.44.4 3.63.6

UnknownUnknown 11.111.1 16.216.2 8.58.5

Comprehensive pediatric Nephrology 2008Pediatric Nephrology Journal 2001

Indication of RRT and DialysisIndication of RRT and DialysisRenal Function, GFR?, before uremic symptomsRenal Function, GFR?, before uremic symptoms

Fluid statusFluid status

Biochemical abnormalitiesBiochemical abnormalities

No well being: physical and psychologicalNo well being: physical and psychological

Growth retardationGrowth retardation

Acute Renal FailureAcute Renal Failure

Oligoanuria, resistant volume overload, hyperkalemia, Oligoanuria, resistant volume overload, hyperkalemia, mAc, uremic encephalopathy, uremic pericarditis, TLS mAc, uremic encephalopathy, uremic pericarditis, TLS with uric acid ≥10, Inborn metabolic syndromes, with uric acid ≥10, Inborn metabolic syndromes,

Intoxication, BUNIntoxication, BUN

Guideline 1: the dialysis unitGuideline 1: the dialysis unitGuideline 1: The Dialysis Unit

Taking care of a child with ESRF Taking care of a child with ESRF necessitates an engaged team consisting of necessitates an engaged team consisting of doctors, nurses, dietician, psychologist, doctors, nurses, dietician, psychologist, school teacher, play therapist, and social school teacher, play therapist, and social worker worker (second family or support team)(second family or support team)

Nutrition, growth, and educational support Nutrition, growth, and educational support are of major importanceare of major importanceHemodialysis: a frequency of three times per Hemodialysis: a frequency of three times per week for most patients. This frequency may be week for most patients. This frequency may be increased in babies and/or adolescents increased in babies and/or adolescents requiring requiring “more dialysis”  “more dialysis” 

Guideline 1: the dialysis unitGuideline 1: the dialysis unitGuideline 2: Water Quality

Blood contact with 120 cc water during Blood contact with 120 cc water during a dialysis sessionsa dialysis sessions

adequate in terms of biochemical adequate in terms of biochemical composition composition

Free from microbiological Free from microbiological contamination contamination (germs and endotoxins)(germs and endotoxins)

Pure versus ultra pure water (High Flux, High Pure versus ultra pure water (High Flux, High flow hemofiltration, conventional HD?)flow hemofiltration, conventional HD?)

Guideline 1: the dialysis unitGuideline 1: the dialysis unitGuideline 3: The Dialysis Machine

Specific Feature that are necessary in a Specific Feature that are necessary in a pediatric hemodialysis machinepediatric hemodialysis machine

Precise control of ultrafiltration volumetric assessmentPrecise control of ultrafiltration volumetric assessment

Capable of low blood flow speedsCapable of low blood flow speeds

Ability to use lines of varying blood volumsAbility to use lines of varying blood volums

Measure and remove very small amounts of fluidsMeasure and remove very small amounts of fluids

Continuous blood volume monitoringContinuous blood volume monitoring during the sessionduring the session

Buffered bicarbonateBuffered bicarbonate Specific material available for babies/infantsSpecific material available for babies/infants

Guideline 1: the dialysis unitGuideline 1: the dialysis unitGuideline 4: blood lines

Available in infants/babies size Available in infants/babies size

High biocompatible materialHigh biocompatible material

Guideline 1: the dialysis unitGuideline 1: the dialysis unitGuideline 5: principles of blood purification

Guideline 1: the dialysis unitGuideline 1: the dialysis unitGuideline 6: extracorporeal blood access and circulation

Extracorporeal blood flow rate and volumeExtracorporeal blood flow rate and volume150–200 mL min−1 m−2 150–200 mL min−1 m−2

5–7 mL/min/kg up to 8 cc/kg/min5–7 mL/min/kg up to 8 cc/kg/min

(BW+10)×2.5=(BW+10)×2.5=QQB (mL min−1) in small infantsB (mL min−1) in small infants

Arterial blood aspiration pressure : 150–200 mmHg to Arterial blood aspiration pressure : 150–200 mmHg to limit endothelial traumalimit endothelial trauma

The venous return pressure should not be more than The venous return pressure should not be more than +200 mmHg to prevent endothelial vascular trauma+200 mmHg to prevent endothelial vascular trauma

The total extracorporeal blood volume : 7- 10 % of The total extracorporeal blood volume : 7- 10 % of patient total blood volume (<8cc/kg)patient total blood volume (<8cc/kg)

System priming with saline, albumin, and blood System priming with saline, albumin, and blood

Double-needle technique: standard, single needle with Double-needle technique: standard, single needle with double pump system: alternativedouble pump system: alternative

Anticoagulation in the extracorporeal circuitAnticoagulation in the extracorporeal circuitInfants and small children are sensitive to Infants and small children are sensitive to anticoagulation because of cerebral hemorrhage anticoagulation because of cerebral hemorrhage Conventional, heparin: continuous infusion of 20 to Conventional, heparin: continuous infusion of 20 to 30 IU kg/ h through arterial line, or 25-50 u/kg loading 30 IU kg/ h through arterial line, or 25-50 u/kg loading dose and 10u/kg/hr. dose and 10u/kg/hr. Clotting time is the best monitor for heparin dose in first Clotting time is the best monitor for heparin dose in first dialysis (1.25-1.5 Nl range, PTT: 120-160) dialysis (1.25-1.5 Nl range, PTT: 120-160) Low-molecular-weight heparin at 1 mg/kg as a bolus at Low-molecular-weight heparin at 1 mg/kg as a bolus at the beginning of the dialysis session, bleedingthe beginning of the dialysis session, bleeding, improved , improved lipid metabolism, half lifelipid metabolism, half life, cost, costCitrate anticoagulation especially with acute dialysis, IV Citrate anticoagulation especially with acute dialysis, IV calcium at venous line 0.3-0.5 mmol/lcalcium at venous line 0.3-0.5 mmol/lHeparin free dialysis, minimal heparinizationHeparin free dialysis, minimal heparinization

TPA 1mg/ml for one hour preferably overnightTPA 1mg/ml for one hour preferably overnight

Vascular AccessVascular Access

Catheters (cuffed, uncuffed), AV Fistula, AV Catheters (cuffed, uncuffed), AV Fistula, AV GraftGraftThe type of access depending on : The type of access depending on :

Factors in different units and countries, surgical Factors in different units and countries, surgical experience, experience, patient age and sizepatient age and size, the time , the time available before dialysis, the waiting time before available before dialysis, the waiting time before transplantation, and patient choicetransplantation, and patient choiceTunneled cuffed catheter for short term HDTunneled cuffed catheter for short term HDFistula vascular access is preferred for long-term Fistula vascular access is preferred for long-term chronic hemodialysis chronic hemodialysis

--

** The types of vascular access: The types of vascular access:

- Catheter: - Catheter:

*Rt/Lt Int jugular> femoral>subclavian, 8-12 F *Rt/Lt Int jugular> femoral>subclavian, 8-12 F

*Double lumen cuffed/uncuffed catheter, 8 French*Double lumen cuffed/uncuffed catheter, 8 French

*In small infants a single lumen catheter with the *In small infants a single lumen catheter with the

alternative clamps techniquealternative clamps technique

**Complications is more common in children thanComplications is more common in children than adultsadults

*Real time Ultrasound*Real time Ultrasound

*Cathetr malfunction: kinking versus intraluminal *Cathetr malfunction: kinking versus intraluminal

thrombosisthrombosis

-AV Fistula-AV Fistula>25 kg in some centers and >10 kg in centers with microsurgery>25 kg in some centers and >10 kg in centers with microsurgeryPreoperative evaluation and protection of the vessels, upper limb Preoperative evaluation and protection of the vessels, upper limb venography, hydrated and above dry weight and adjustment of venography, hydrated and above dry weight and adjustment of antihypertensive drugs, prophylactic ASA (1-5mg/kg/day) antihypertensive drugs, prophylactic ASA (1-5mg/kg/day) Selection of vein: 4 mm diameter with 40 mmHg cuffSelection of vein: 4 mm diameter with 40 mmHg cuffThe time for venous development depends on the age and the The time for venous development depends on the age and the place of the AVF (distal or proximal).place of the AVF (distal or proximal).Usually 4-6 wk for maturation, in young children, less than 15 kg, Usually 4-6 wk for maturation, in young children, less than 15 kg, the time needed to develop a fistula before it can be used could be the time needed to develop a fistula before it can be used could be some months (up to 4 mo)some months (up to 4 mo)Complications: Thrombosis, Infection, Stenosis Complications: Thrombosis, Infection, Stenosis (recirculation>10%), Aneurysm, neuropathy, CHF(recirculation>10%), Aneurysm, neuropathy, CHFRecirculation% = S-A/S-V ÷100Recirculation% = S-A/S-V ÷1002/3 is functional after 4 years2/3 is functional after 4 yearsDistal fistuals more complicated in childrenDistal fistuals more complicated in children

AV GraftAV Graft

Rarely used in childrenRarely used in children

Complication: stenosis and thrill, clotting, Complication: stenosis and thrill, clotting, Infection with difficulty in eradicationInfection with difficulty in eradication

Straight Graft in small children and loop Graft Straight Graft in small children and loop Graft in larger patientsin larger patients

Long term complications is high in childrenLong term complications is high in children

Guideline 1: the dialysis unitGuideline 1: the dialysis unitGuideline 7: which dialyzer membrane to “choose”

The choice of a dialyzer membrane should take into The choice of a dialyzer membrane should take into account the followingaccount the following

Type of membrane: biocompatibility toward complement systemType of membrane: biocompatibility toward complement system Initial blood volume needed, i.e. area-related Initial blood volume needed, i.e. area-related Molecular permeability: Molecular permeability: Highly permeable membranes give the Highly permeable membranes give the theoretical potential for middle-molecular-weight theoretical potential for middle-molecular-weight Hydraulic permeability Hydraulic permeability ((CCUF) UF) : High flux vs low flux: High flux vs low fluxhigh flux membranes need ultrapure dialysatehigh flux membranes need ultrapure dialysateSurface area (0.25-1.7): no more infant surface area Surface area (0.25-1.7): no more infant surface area CostCost

improved removal of middle molecules by high flux, large pore, improved removal of middle molecules by high flux, large pore, biocompatible membranes : reduction of uremia related biocompatible membranes : reduction of uremia related

amyloidosis, amyloidosis, inflammation, malnutrition, anemia, dyslipidemia, and mortality. inflammation, malnutrition, anemia, dyslipidemia, and mortality.

Guideline 1: the dialysis unitGuideline 1: the dialysis unitGuideline 8: the dialysate

Bicarbonate buffered (35 meq/l)Bicarbonate buffered (35 meq/l)low calcium level (1.25-1.5 mmol L−1)low calcium level (1.25-1.5 mmol L−1)glucose concentration at physiological level: 1 gr/l glucose concentration at physiological level: 1 gr/l (prevent cellular potassium shift) (prevent cellular potassium shift)

““Zero”, “low” Zero”, “low” (1–1.5 mmol/l),(1–1.5 mmol/l), “normal” “normal” (2–2.5 mmol/l),(2–2.5 mmol/l), and “high” and “high” (3–3.5 mmol/l)(3–3.5 mmol/l) potassium dialysate potassium dialysate Sodium concentrations:138 to 144 mmol/l Sodium concentrations:138 to 144 mmol/l (difference: (difference: 10-15 mmol/l)10-15 mmol/l), hypernatremia, , hypernatremia, change during a change during a dialysis (sodium modeling)dialysis (sodium modeling) The dialysate FR 300 to 800 mL min−1 (1.5 BFR).The dialysate FR 300 to 800 mL min−1 (1.5 BFR). Thermal degree: Thermal degree: 34.5-3734.5-37, Dialytic thermal exchanges, , Dialytic thermal exchanges, for babies and/or high-flow dialysate usefor babies and/or high-flow dialysate use Dialysate quality control (germs and endotoxins) is Dialysate quality control (germs and endotoxins) is requiredrequired

Guideline 1: the dialysis unitGuideline 1: the dialysis unitGuideline 9: post-dialytic dry weight assessment and adjustment

Difficult to define in growing children especially infantsDifficult to define in growing children especially infants

-Hypotensive tendency during a dialysis (plasma refilling -Hypotensive tendency during a dialysis (plasma refilling rate capacity)  rate capacity) 

-Total body water ratio to total body mass, is variable -Total body water ratio to total body mass, is variable with age, especially during infancy and pubertywith age, especially during infancy and puberty

need for regular assessment in a growing child need for regular assessment in a growing child

Monthly in infants, Monthly in infants, anabolic conditions (GH), anabolic conditions (GH), Catabolic Catabolic

conditions (low intake, illness)conditions (low intake, illness) close collaboration with pediatric renal dieticianclose collaboration with pediatric renal dietician

no “unique” optimum method, importance of a clinical no “unique” optimum method, importance of a clinical “pediatric” experience“pediatric” experience

-assessment of TBW by bioelectrical impedance analysis, -assessment of TBW by bioelectrical impedance analysis, continuous measurement of hematocrit by non-invasive continuous measurement of hematocrit by non-invasive methods during dialysis, plasma ANP or cyclic methods during dialysis, plasma ANP or cyclic guanosine monophosphate determination, by guanosine monophosphate determination, by echography of the inferior vena cava (IVC) diameter of echography of the inferior vena cava (IVC) diameter of the IVC (IVCD)the IVC (IVCD), , An IVCD between 8.0 and An IVCD between 8.0 and 11.5 mm m−2 and a collapse index between 40 and 75 % 11.5 mm m−2 and a collapse index between 40 and 75 % is considered as representing normovolemiais considered as representing normovolemia

    -crash hematocrite, Flat HCT curve, more precise-crash hematocrite, Flat HCT curve, more precise

Guideline 1: the dialysis unitGuideline 1: the dialysis unitGuideline 10: urea dialytic kinetic, dialysis dose, and protein intake

assessment (nutrition)

In children the criteria of adequate hemodialysis In children the criteria of adequate hemodialysis is not clear as adultsis not clear as adults

Growth and development is the most important Growth and development is the most important indicator of adequate dialysisindicator of adequate dialysis

Urea kinetic modeling (UKM) , A marker of Urea kinetic modeling (UKM) , A marker of middle molecules?, increasing urea clearance middle molecules?, increasing urea clearance above accepted target,above accepted target, underdialyzed patients underdialyzed patients and dietary complianceand dietary compliance

normalized protein catabolic rate (nPCR)normalized protein catabolic rate (nPCR)

Urea dialytic reduction rate (URR)Urea dialytic reduction rate (URR) +URR is proportional to dialysis efficiency, and thus to +URR is proportional to dialysis efficiency, and thus to

urea dialytic clearance. urea dialytic clearance. +The ratio post/pre ≤ 0.35 and the difference between +The ratio post/pre ≤ 0.35 and the difference between

pre and post-urea, divided by the pre dialysis value≥ pre and post-urea, divided by the pre dialysis value≥ 0.60 0.60

KtKt//VV : :dialyzer urea clearance (dialyzer urea clearance (KK) multiplied by ) multiplied by duration (duration (tt) of the dialysis session and divided by ) of the dialysis session and divided by urea volume (urea volume (VV) of distribution) of distribution

+A minimum+A minimum single pool Kt single pool Kt//VV level of 1.2–1.4 : desirable level of 1.2–1.4 : desirable

+ in small children + in small children single pool Ktsingle pool Kt//VV more than 1.4 more than 1.4

Formulas enabling calculation of the volume of Formulas enabling calculation of the volume of distribution of urea in liters (total body water) using distribution of urea in liters (total body water) using height, weight, sex and age height, weight, sex and age

Boys:Boys:

Ht<132.7 cm, Ht<132.7 cm, VV=1.927+0.465/BW (kg)+0.0045/ht (cm) =1.927+0.465/BW (kg)+0.0045/ht (cm) Ht>132.7 cm, Ht>132.7 cm, VV=−21.1933+0.406/BW (kg)+0.209/ht (cm) =−21.1933+0.406/BW (kg)+0.209/ht (cm)

Girls:Girls:

Ht<110.8 cm, Ht<110.8 cm, VV=0.076+0.507/BW (kg)+0.013/ht (cm) =0.076+0.507/BW (kg)+0.013/ht (cm) Ht>110.8 cm, Ht>110.8 cm, VV=-10.313+0.252/BW (kg)+0.154/ht (cm)=-10.313+0.252/BW (kg)+0.154/ht (cm)

Guideline 1: the dialysis unitGuideline 1: the dialysis unitGuideline 11: dialysis dose and outcome

Hemodialysis prescription for children: adequate, Hemodialysis prescription for children: adequate, before optimumbefore optimum

Blood pressure control, normal myocardial morphology Blood pressure control, normal myocardial morphology and functionand functionurea dialysis dose, removal middle molecules and overall urea dialysis dose, removal middle molecules and overall phosphate, a minimumphosphate, a minimum Kt Kt//VV level of 1.2–1.4 : desirable, level of 1.2–1.4 : desirable, urea clearance 3-4cc/kg/minurea clearance 3-4cc/kg/min Dialysis frequency and duration : adjusted to the Dialysis frequency and duration : adjusted to the tolerance of ultrafiltration to reach the dry weight. tolerance of ultrafiltration to reach the dry weight. UFR=W-Wd+I/T, UFR=TMP×KUFUFR=W-Wd+I/T, UFR=TMP×KUFUltrafiltration rate should not exceed 1.5±0.5% of body Ultrafiltration rate should not exceed 1.5±0.5% of body weight per hour (in theory no more than 5% BW loss weight per hour (in theory no more than 5% BW loss per whole session). 10cc/kg/hr as safe starting point for per whole session). 10cc/kg/hr as safe starting point for water removal. No more than 0.2 cc/kg/min water removal. No more than 0.2 cc/kg/min

Hemodialysis prescription for children: adequate, Hemodialysis prescription for children: adequate, before optimumbefore optimum

A regular diet A regular diet

Too fast ultrafiltration (Too fast ultrafiltration (more than 5% BW)more than 5% BW) hypotension and cramps during the second half time hypotension and cramps during the second half time session, and fatigue and/or hang over after dialysissession, and fatigue and/or hang over after dialysis

A small solute, e.g. urea, clearance which is too high is a A small solute, e.g. urea, clearance which is too high is a factor of disequilibrium syndrome usually after the first factor of disequilibrium syndrome usually after the first half/or one hour session time with headache, even half/or one hour session time with headache, even seizures, nausea, vomiting, sleepiness or a hypertensive seizures, nausea, vomiting, sleepiness or a hypertensive tendency with a narrow range between systolic and tendency with a narrow range between systolic and diastolic pressure values. Symptoms usually disappear a diastolic pressure values. Symptoms usually disappear a few hours after the end of the dialysisfew hours after the end of the dialysis

Guideline 1: the dialysis unitGuideline 1: the dialysis unitGuideline 12: the dialysis session, prescription, and monitoring

Importance of first session:Importance of first session:Pain relief, Emotional support Pain relief, Emotional support Prevention of recirculation Prevention of recirculation First contact with the “extracorporeal” material, dyspnea, First contact with the “extracorporeal” material, dyspnea, burning heat throughout the body or access site, angioedema, burning heat throughout the body or access site, angioedema, flushing or vascular collapse, or with minor symptoms such as flushing or vascular collapse, or with minor symptoms such as itching, rhinorrhea, lacrymation, urticaria, or abdominal itching, rhinorrhea, lacrymation, urticaria, or abdominal cramping). cramping). Prevention:Prevention: Biocompatible membranes, steam- Biocompatible membranes, steam-sterilized material, adequate flushing of the circuitsterilized material, adequate flushing of the circuit Prevention of disequilibrium syndrome Prevention of disequilibrium syndrome

-The BFR should be ≤ 3 mL kg−1 BW (or 90 mL m−2)-The BFR should be ≤ 3 mL kg−1 BW (or 90 mL m−2) -Short dialysis time (less than 2 hr)-Short dialysis time (less than 2 hr) -Mannitol infusion (0.5- 1 g kg/ BW/ 1 to 2 h during dialysis)-Mannitol infusion (0.5- 1 g kg/ BW/ 1 to 2 h during dialysis) - Urea clearance: 1.5-2 cc/kg/min- Urea clearance: 1.5-2 cc/kg/min - Sodium modeling- Sodium modeling -selection of dialyzer-selection of dialyzer

Hemodynamic assess Hemodynamic assess (asymptomatic and without (asymptomatic and without compensation)compensation)

- Movement of fluid from extracellular to the Movement of fluid from extracellular to the Intracellular spaceIntracellular space

- Impaired sympathetic activityImpaired sympathetic activity- Vasodilation due to warm dialysateVasodilation due to warm dialysate- Splanchnic pooling of blood while eating during dialysisSplanchnic pooling of blood while eating during dialysis- Excessive UFExcessive UF- Antihypertensive agentsAntihypertensive agents- Low Diasylate sodiumLow Diasylate sodium Symptoms of hypotension: pallor, cyanosis, vomiting, irritability, Symptoms of hypotension: pallor, cyanosis, vomiting, irritability,

drowsiness, sudden cry, sweating, headache, Seizure, check BP at 1 drowsiness, sudden cry, sweating, headache, Seizure, check BP at 1

hr +monitoring + pulse oximetry: children <20 kghr +monitoring + pulse oximetry: children <20 kg

Next sessionsNext sessions

Usually Usually a blood flow rate of 150 to 200 mL/ min/a blood flow rate of 150 to 200 mL/ min/ and and threethree sessions per week for sessions per week for 3 to 4 h3 to 4 h per session achieve per session achieve

the minimum target prescription of the minimum target prescription of 1.2 to 1.41.2 to 1.4 Kt Kt//VV   The duration of a dialysis session is often prescribed to The duration of a dialysis session is often prescribed to reach the anticipated dry weight at the end of the reach the anticipated dry weight at the end of the session, DSA/BSA × Dialysis Index (13-18)session, DSA/BSA × Dialysis Index (13-18)

Continuous blood volume monitoring during the session Continuous blood volume monitoring during the session

for ultrafiltration tolerancefor ultrafiltration tolerance (with crash HCT)(with crash HCT)

Intensified HD: 6-8 HR/3-7/WK, 2-3 HR/5-7/WK: Intensified HD: 6-8 HR/3-7/WK, 2-3 HR/5-7/WK: chronic fluid overload, phchronic fluid overload, ph, poor growth, infancy, poor growth, infancy

A weight gain over 10% dry BW during the interval of A weight gain over 10% dry BW during the interval of two sessions: Non compliancetwo sessions: Non compliance

optimum dialysis obtained with longer (4 and optimum dialysis obtained with longer (4 and more hours) and/or more frequent (daily: 5 to 6) more hours) and/or more frequent (daily: 5 to 6) sessions to achieve phosphate purification and sessions to achieve phosphate purification and maintain the calcium×phosphorus product in the maintain the calcium×phosphorus product in the optimum range of 3.3 to 4.4 mmol/mL and in optimum range of 3.3 to 4.4 mmol/mL and in following patients:following patients:

Infants, Malnutrition, Growth retardation, chronic Infants, Malnutrition, Growth retardation, chronic overhydration, Intractable HTN, LVH, Primary overhydration, Intractable HTN, LVH, Primary hyperoxaluria  hyperoxaluria 

Injections during DialysisInjections during Dialysis

Albumin: small boluses through arterial line at the Albumin: small boluses through arterial line at the beginning of dialysisbeginning of dialysis

Blood: small boluses at the beginning of dialysis Blood: small boluses at the beginning of dialysis blood required (ml): weight (kg) × 3 × grams of Hb is to be raisedblood required (ml): weight (kg) × 3 × grams of Hb is to be raised

EPO: More dose in infants and children and IVEPO: More dose in infants and children and IV

ComplicationsComplications• Intradialytic HypotensionIntradialytic Hypotension• DisequilibriumDisequilibrium• HemolysisHemolysis

--Overheating, contamination, Hypotonicity, Kinking of lines, Overheating, contamination, Hypotonicity, Kinking of lines, pump malfunctionpump malfunction

- Dialysis should be stopped and potassium checked immediately- Dialysis should be stopped and potassium checked immediately

-pains, nausea, dark appearance of venous blood -pains, nausea, dark appearance of venous blood

• Air EmbolismAir Embolism

Rare, one ml/kg is fatal, fitting and coma in upright Rare, one ml/kg is fatal, fitting and coma in upright patient and chest symptoms in recombinant patientpatient and chest symptoms in recombinant patient

Head Down, left lateral position and 100% oxygen, Head Down, left lateral position and 100% oxygen, Aspiration from the ventricleAspiration from the ventricle

• AnaphylaxisAnaphylaxis

+First use syndrome, prevention by dialyzer +First use syndrome, prevention by dialyzer

reuse and predialysis rinsing or dialyzer change reuse and predialysis rinsing or dialyzer change

in severe reactionsin severe reactions

+Stop dialysis and blood should not be retained +Stop dialysis and blood should not be retained

to patientto patient

+Normal saline, Epinephrine (SC, IM), +Normal saline, Epinephrine (SC, IM),

HydrocoprtisoneHydrocoprtisone• AmyloidosisAmyloidosis

Unusual in children, 7-10 yr after HD clinicallyUnusual in children, 7-10 yr after HD clinically

جهان يادگار است و ما رفتني به گيتي نماند مگر مردمي

كسي كو گذشت از ره مردمي زديوان شمر، مشمرش زآدمي

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