Skip to main content
Log in

Barriers for implementation of intensified hemodialysis: survey results from the International Pediatric Dialysis Network

  • Original Article
  • Published:
Pediatric Nephrology Aims and scope Submit manuscript

Abstract

Background

In patients on conventional hemodialysis (HD), morbidity is high and quality of life is poor. Intensified HD programs have been developed to help overcome these shortcomings, , but very few pediatric dialysis centers have reported the implementation of such a HD program.

Methods

An online survey was sent to all 221 pediatric dialysis centers which participate in the International Pediatric Dialysis Network (IPDN). The aim of the survey was to assess the attitude of pediatric nephrologists towards intensified HD, the penetrance of intensified HD into their clinical practice and barriers to implementation.

Results

Of the 221 pediatric dialysis centers sent the survey, respondents from 61% (134) replied. Among these respondents, 69% acknowledged being aware of the evidence in support of the use of intensified HD, independent of whether intensified HD was offered at their own center, and 50% associated the use of daily nocturnal HD with the best overall patient outcome. In contrast, only 2% of respondents were in favor of conventional HD. Overall, 38% of the respondents stated that at their center intensified HD is prescribed to a subgroup of patients, most commonly in the form of short daily HD sessions. The most important barriers to expansion of intensified HD programs were lack of adequate funding (66%) and shortage of staff (63%), whereas lack of expertise and of motivation were reported infrequently as obstacles (21 and 14%, respectively).

Conclusion

Intensified HD is considered by many pediatric nephrologists to be the dialysis modality most likely associated with the best patient outcome. The limited use of this treatment approach highlights the importance of defining and successfully addressing the barriers to implementation.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Chavers BM, Molony JT, Solid CA, Rheault MN, Collins AJ (2015) One-year mortality rates in US children with end-stage renal disease. Am J Nephrol 41:121–128

    Article  PubMed  PubMed Central  Google Scholar 

  2. Parekh RS, Carroll CE, Wolfe RA, Port FK (2002) Cardiovascular mortality in children and young adults with end-stage kidney disease. J Pediatr 141:191–197

    Article  CAS  PubMed  Google Scholar 

  3. Shroff R (2011) Dysregulated mineral metabolism in children with chronic kidney disease. Curr Opin Nephrol Hypertens 20:233–240

    Article  CAS  PubMed  Google Scholar 

  4. Mitsnefes MM (2012) Cardiovascular disease in children with chronic kidney disease. J Am Soc Nephrol 23:578–585

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Oh J, Wunsch R, Turzer M, Bahner M, Raggi P, Querfeld U, Mehls O, Schaefer F (2002) Advanced coronary and carotid arteriopathy in young adults with childhood-onset chronic renal failure. Circulation 106:100–105

    Article  PubMed  Google Scholar 

  6. Warady BA, Neu AM, Schaefer F (2014) Optimal care of the infant, child, and adolescent on dialysis: 2014 update. Am J Kidney 64:128–142

    Article  Google Scholar 

  7. Ikizler TA (2013) Optimal nutrition in hemodialysis patients. Adv Chronic Kidney Dis 20:181–189

    Article  PubMed  PubMed Central  Google Scholar 

  8. Nistor I, Palmer SC, Craig JC, Saglimbene V, Vecchio M, Covic A, Strippoli GF (2015) Haemodiafiltration, haemofiltration and haemodialysis for end-stage kidney disease. Cochrane Database Syst Rev 5:CD006258

    Google Scholar 

  9. Slinin Y, Greer N, Ishani A, MacDonald R, Olson C, Rutks I, Wilt TJ (2015) Timing of dialysis initiation, duration and frequency of hemodialysis sessions, and membrane flux: a systematic review for a KDOQI clinical practice guideline. Am J Kidney Dis 66:823–836

    Article  PubMed  Google Scholar 

  10. Chertow GM, Levin NW, Beck GJ, Daugirdas JT, Eggers PW, Kliger AS, Larive B, Rocco MV, Greene T, Frequent Hemodialysis Network (FHN) Trials Group (2016) Long-term effects of frequent in-center hemodialysis. J Am Soc Nephrol 27:1830–1836

    Article  CAS  PubMed  Google Scholar 

  11. Susantitaphong P, Koulouridis I, Balk EM, Madias NE, Jaber BL (2012) Effect of frequent or extended hemodialysis on cardiovascular parameters: a meta-analysis. Am J Kidney Dis 59:689–699

    Article  PubMed  PubMed Central  Google Scholar 

  12. Unruh ML, Larive B, Chertow GM, Eggers PW, Garg AX, Gassman J, Tarallo M, Finkelstein FO, Kimmel PL, FHN Trials Group (2013) Effects of 6-times-weekly versus 3-times-weekly hemodialysis on depressive symptoms and self-reported mental health: frequent hemodialysis network (FHN) trials. Am J Kidney Dis 61:748–758

    Article  PubMed  PubMed Central  Google Scholar 

  13. Daugirdas JT, Greene T, Rocco MV, Kaysen GA, Depner TA, Levin NW, Chertow GM, Ornt DB, Raimann JG, Larive B, Kliger AS, FHN Trial Group (2013) Effect of frequent hemodialysis on residual kidney function. Kidney Int 83:949–958

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Suri RS, Larive B, Sherer S, Eggers P, Gassman J, James SH, Lindsay RM, Lockridge RS, Ornt DB, Rocco MV, Ting GO, Kliger AS, Frequent Hemodialysis Network Trial Group (2013) Risk of vascular access complications with frequent hemodialysis. J Am Soc Nephrol 24:498–505

    Article  PubMed  PubMed Central  Google Scholar 

  15. Jin HM, Guo LL, Zhan XL, Pan Y (2013) Effect of prolonged weekly hemodialysis on survival of maintenance hemodialysis patients: a meta-analysis of studies. Nephron Clin Pract 123:220–228

    Article  CAS  PubMed  Google Scholar 

  16. Movilli E, Gaggia P, Zubani R, Camerini C, Vizzardi V, Parrinello G, Savoldi S, Fischer MS, Londrino F, Cancarini G (2007) Association between high ultrafiltration rates and mortality in uraemic patients on regular haemodialysis. A 5-year prospective observational multicentre study. Nephrol Dial Transplant 22:3547–3552

    Article  PubMed  Google Scholar 

  17. Flythe JE, Kimmel SE, Brunelli SM (2011) Rapid fluid removal during dialysis is associated with cardiovascular morbidity and mortality. Kidney Int 79:250–257

    Article  PubMed  Google Scholar 

  18. Assimon MM, Wenger JB, Wang L, Flythe JE (2016) Ultrafiltration rate and mortality in maintenance hemodialysis patients. Am J Kidney Dis 8:911–922

    Article  Google Scholar 

  19. FHN Trial Group, Chertow GM, Levin NW, Beck GJ, Depner TA, Eggers PW, Gassman JJ, Gorodetskaya I, Greene T, James S, Larive B, Lindsay RM, Mehta RL, Miller B, Ornt DB, Rajagopalan S, Rastogi A, Rocco MV, Schiller B, Sergeyeva O, Schulman G, Ting GO, Unruh ML, Star RA, Kliger AS (2010) In-center hemodialysis six times per week versus three times per week. N Engl J Med 363:2287–2300

  20. Culleton BF, Walsh M, Klarenbach SW, Mortis G, Scott-Douglas N, Quinn RR, Tonelli M, Donnelly S, Friedrich MG, Kumar A, Mahallati H, Hemmelgarn BR, Manns BJ (2007) Effect of frequent nocturnal hemodialysis vs conventional hemodialysis on left ventricular mass and quality of life: a randomized controlled trial. JAMA 298:1291–1299

    Article  CAS  PubMed  Google Scholar 

  21. Rocco MV, Lockridge RS Jr, Beck GJ et al (2011) The effects of frequent nocturnal home hemodialysis: the frequent hemodialysis network nocturnal trial. Kidney Int 80:1080–1091

    Article  PubMed  PubMed Central  Google Scholar 

  22. Daugirdas JT, Depner TA, Inrig J, Mehrotra R, Rocco MV, Suri RS, Weiner DE, Greer N, Ishani A, MacDonald R, Olson C, Rutks I, Slinin Y, Wilt TJ, Rocco M, Kramer H, Choi MJ, Samaniego-Picota M, Scheel PJ, Willis K, Joseph J, Brereton L (2015) KDOQI clinical practice guideline for hemodialysis adequacy: 2015 update. Am J Kidney Dis 66:884–930

    Article  Google Scholar 

  23. Hoppe A, von Puttkamer C, Linke U, Kahler C, Booss M, Braunauer-Kolberg R, Hofmann K, Joachimsky P, Hirte I, Schley S, Utsch B, Thumfart J, Briese S, Gellermann J, Zimmering M, Querfeld U, Müller D (2011) A hospital-based intermittent nocturnal hemodialysis program for children and adolescents. J Pediatr 158:95–99 99.e1

    Article  PubMed  Google Scholar 

  24. Thumfart J, von Puttkamer C, Wagner S, Querfeld U, Müller D (2014) Hemodiafiltration in a pediatric nocturnal dialysis program. Pediatr Nephrol 29:1411–1416

    Article  PubMed  Google Scholar 

  25. Thumfart J, Hilliger T, Stiny C, Wagner S, Querfeld U, Müller D (2015) Is peritoneal dialysis still an equal option? Results of the Berlin pediatric nocturnal dialysis program. Pediatr Nephrol 30:1181–1187

    Article  PubMed  Google Scholar 

  26. Geary DF, Piva E, Tyrrell J, Gajaria MJ, Picone G, Keating LE, Harvey EA (2005) Home nocturnal hemodialysis in children. J Pediatr 147:383–387

    Article  PubMed  Google Scholar 

  27. Goldstein SL, Silverstein DM, Leung JC, Feig DI, Soletsky B, Knight C, Warady BA (2008) Frequent hemodialysis with NxStage system in pediatric patients receiving maintenance hemodialysis. Pediatr Nephrol 23:129–135

    Article  PubMed  Google Scholar 

  28. Fischbach M, Terzic J, Laugel V, Dheu C, Menouer S, Helms P, Livolsi A (2004) Daily on-line haemodiafiltration: a pilot trial in children. Nephrol Dial Transplant 19:2360–2367

    Article  PubMed  Google Scholar 

  29. Fischbach M, Terzic J, Menouer S (2010) Daily on line haemodiafiltration promotes catch-up growth in children on chronic dialysis. Nephrol Dial Transplant 25:867–873

    Article  CAS  PubMed  Google Scholar 

  30. Jayanti A, Morris J, Stenvinkel P, Mitra S (2014) Home hemodialysis: beliefs, attitudes, and practice patterns. Hemodial Int 18:767–776

    Article  PubMed  Google Scholar 

  31. Lime Survey Project Team (2015) LimeSurvey: an open source survey tool. LimeSurvey Project Team, LimeSurvey GmbH, Hamburg. http://www.limesurvey.org

  32. R Core Team (2013) R: a language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. URL http://www.R-project.org

  33. Bargman JM, Thorpe KE, Churchill DN, CANUSA Peritoneal Dialysis Study Group (2001) Relative contribution of residual renal function and peritoneal clearance to adequacy of dialysis: a reanalysis of the CANUSA study. J Am Soc Nephrol 12:2158–2162

    CAS  PubMed  Google Scholar 

  34. Shafi T, Jaar BG, Plantinga LC, Fink NE, Sadler JH, Parekh RS, Powe NR, Coresh J (2010) Association of residual urine output with mortality, quality of life, and inflammation in incident hemodialysis patients: the choices for healthy outcomes in caring for end-stage renal disease (CHOICE) study. Am J Kidney Dis 56:348–358

    Article  PubMed  PubMed Central  Google Scholar 

  35. Schaefer F, Borzych-Duzalka D, Azocar M, Munarriz RL, Sever L, Aksu N, Barbosa LS, Galan YS, Xu H, Coccia PA, Szabo A, Wong W, Salim R, Vidal E, Pottoore S, Warady BA, IPPN investigators (2012) Impact of global economic disparities on practices and outcomes of chronic peritoneal dialysis in children: insights from the International Pediatric Peritoneal Dialysis Network registry. Perit Dial Int 32:399–409

    Article  PubMed  PubMed Central  Google Scholar 

  36. Patzer RE, McClellan WM (2012) Influence of race, ethnicity and socioeconomic status on kidney disease. Nat Rev Nephrol 8:533–541

    Article  PubMed  PubMed Central  Google Scholar 

  37. Hasegawa T, Nakai S, Masakane I, Watanabe Y, Iseki K, Tsubakihara Y, Akizawa T (2015) Dialysis fluid endotoxin level and mortality in maintenance hemodialysis: a nationwide cohort study. Am J Kidney Dis 65:899–904

    Article  CAS  PubMed  Google Scholar 

  38. Penne EL, Sergeyeva O (2011) Sodium gradient: a tool to individualize dialysate sodium prescription in chronic hemodialysis patients? Blood Purif 31:86–91

    Article  CAS  PubMed  Google Scholar 

  39. McIntyre CW (2014) Cardiovascular benefits of daily haemodialysis: peeling the onion. Nephrol Dial Transplant 29:1–4

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

We are grateful to Dr. Sandip Mitra for providing help with the survey.

Funding

This survey was financially supported by the German Society of Pediatric Nephrology GPN. IPDN is financially supported by Fresenius and Baxter Healthcare.

Author information

Authors and Affiliations

Authors

Contributions

All listed authors contributed to this article.

Corresponding author

Correspondence to Julia Thumfart.

Ethics declarations

Conflict of interest

CP Schmitt received travel grants and lecturing honoraria from Fresenius and Baxter and consulting honoraria from Baxter. All other authors have no conflicts of interest to declare.

Electronic supplementary material

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Thumfart, J., Müller, D., Wagner, S. et al. Barriers for implementation of intensified hemodialysis: survey results from the International Pediatric Dialysis Network. Pediatr Nephrol 33, 705–712 (2018). https://doi.org/10.1007/s00467-017-3831-0

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00467-017-3831-0

Keywords

Navigation