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Pediatric intradialytic hypotension: recommendations from the Pediatric Continuous Renal Replacement Therapy (PCRRT) Workgroup

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Abstract

Intradialytic hypotension (IDH) is a common adverse event resulting in premature interruption of hemodialysis, and consequently, inadequate fluid and solute removal. IDH occurs in response to the reduction in blood volume during ultrafiltration and subsequent poor compensatory mechanisms due to abnormal cardiac function or autonomic or baroreceptor failure. Pediatric patients are inherently at risk for IDH due to the added difficulty of determining and attaining an accurate dry weight. While frequent blood pressure monitoring, dialysate sodium profiling, ultrafiltration-guided blood volume monitoring, dialysate cooling, hemodiafiltration, and intradialytic mannitol and midodrine have been used to prevent IDH, they have not been extensively studied in pediatric population. Lack of large-scale studies on IDH in children makes it difficult to develop evidence-based management guidelines. Here, we aim to review IDH preventative strategies in the pediatric population and outlay recommendations from the Pediatric Continuous Renal Replacement Therapy (PCRRT) Workgroup. Without strong evidence in the literature, our recommendations from the expert panel reflect expert opinion and serve as a valuable guide.

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References

  1. Hayes W, Hothi DK (2011) Intradialytic hypotension. Pediatr Nephrol 26(6):867–879

    Article  PubMed  Google Scholar 

  2. Blumenthal S, Epps RP, Heavenrich R, Lauer RM, Lieberman E, Mirkin B, Mitchell SC, Boyar Naito V, O'Hare D, McFate Smith W, Tarazi RC, Upson D (1977) Report of the task force on blood pressure control in children. Pediatrics 59(5 2 suppl):I-ii):797–820

    Google Scholar 

  3. Hothi DK (2009) An investigation into the mechanisms, consequences and moderators of intradialytic hypotension in paediatric haemodialysis. University College London, London discovery.ucl.ac.uk/17442/1/17442.pdf. Accessed 3 Apr 2018

  4. Arieff AI (1994) Dialysis disequilibrium syndrome: current concepts on pathogenesis and prevention. Kidney Intl 45(3):629–635

    Article  CAS  Google Scholar 

  5. Merouani A, Kechaou W, Litalien C, Ducruet T, Jouvet P (2011) Impact of blood volume monitoring on fluid removal during intermittent hemodialysis of critically ill children with acute kidney injury. Nephrol Dial Transplant 26(10):3315–3319

    Article  PubMed  Google Scholar 

  6. Lavergne V, Nolin TD, Hoffman RS, Roberts D, Gosselin S, Goldfarb DS, Kielstein JT, Mactier R, Maclaren R, Mowry JB, Bunchman TE, Juurlink D, Megarbane B, Anseeuw K, Winchester JF, Dargan PI, Liu KD, Hoegberg LC, Li Y, Calello DP, Burdmann EA, Yates C, Laliberte M, Decker BS, Mello-Da-Silva CA, Lavonas E, Ghannoum M (2012) The EXTRIP (EXtracorporeal TReatments In Poisoning) workgroup: guideline methodology. Clin Toxicol (Phila) 50(5):403–413

    Article  Google Scholar 

  7. Fitch K, Bernstein SJ, Aguilar MD, Burnand B, LaCalle JR, Lázaro P, Mvh L, McDonnell J, Vader JP, Kahan JP (2001) The RAND/UCLA appropriateness method user’s manual. Rand Publication https://www.rand.org/content/dam/rand/pubs/monograph_reports/2011/MR1269.pdf. Accessed 10 Apr 2018

  8. Thornton J, Alderson P, Tan T, Turner C, Latchem S, Shaw E, Ruiz F, Reken S, Mugglestone MA, Hill J, Neilson J, Westby M, Francis K, Whittington C, Siddiqui F, Sharma T, Kelly V, Ayiku L, Chamberlain K (2013) Introducing GRADE across the NICE clinical guideline program. J Clin Epidemiol 66(2):124–131

    Article  PubMed  Google Scholar 

  9. Hothi DK, Harvey E, Goia CM, Geary DF (2008) Evaluating methods for improving ultrafiltration in pediatric hemodialysis. Pediatr Nephrol 23(4):631–638

    Article  PubMed  Google Scholar 

  10. Fadel FI, Makar SH, Eskander AE, Aon AH (2014) Decreasing intra-dialytic morbid events and assessment of dry weight in children on chronic hemodialysis using non-invasive changes in hematocrit. Saudi J Kidney Dis Transpl 25(5):1030–1037

    Article  PubMed  Google Scholar 

  11. Hothi DK, Harvey E, Goia CM, Geary D (2008) Blood-volume monitoring in paediatric haemodialysis. Pediatr Nephrol 23(5):813–820

    Article  PubMed  Google Scholar 

  12. Blowey DL, Balfe JW, Gupta I, Gajaria MM, Koren G (1996) Midodrine efficacy and pharmacokinetics in a patient with recurrent intradialytic hypotension. Am J Kidney Dis 28(1):132–136

    Article  CAS  PubMed  Google Scholar 

  13. Hothi DK, Harvey E, Goia CM, Geary D (2009) The value of sequential dialysis, mannitol and midodrine in managing children prone to dialysis failure. Pediatr Nephrol 24(8):1587–1591

    Article  PubMed  Google Scholar 

  14. Brooks ER, Fatallah-Shaykh SA, Langman CB, Wolf KM, Price HE (2008) Bioelectric impedance predicts total body water, blood pressure, and heart rate during hemodialysis in children and adolescents. J Ren Nutr 18(3):304–311

    Article  PubMed  Google Scholar 

  15. Hegazy RA, Sharaf IA, Fadel F, Bazaraa H, Esam R (2011) Heart rate variability in pediatric patients on regular hemodialysis. Europace Conference: EHRA. Europace 13 https://insights.ovid.com/europ/201106003/00127069-201106003-00638. Accessed 5 Apr 2018

  16. Levtchenko E, Creemers D, Schaijk DV, Rijbroek I, Schroder C (2003) Use of NIMH for determination of dry weight and prevention of dialysis associated morbidity in children. Hemodial Int 7(1):104

    Article  Google Scholar 

  17. 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(1):129–135

    Article  PubMed  Google Scholar 

  18. Jain SR, Smith L, Brewer ED, Goldstein SL (2001) Non-invasive intravascular monitoring in the pediatric hemodialysis population. Pediatr Nephrol 16(1):15–18

    Article  CAS  PubMed  Google Scholar 

  19. Thumfart J, Puttkamer CV, Wagner S, Querfeld U, Muller D (2014) Hemodiafiltration in a pediatric nocturnal dialysis program. Pediatr Nephrol 29(8):1411–1416

    Article  PubMed  Google Scholar 

  20. Zarauza-Santovena A, Alonso-Melgar A, Gonzalez-Perez P, Lopez-Font M, Hernandez-Zuniga L, Ruiz-Hernandez F, Fernandez-Camblor C, Melgosa-Hijosa M, Espinosa-Roman L (2015) Safety and efficacy of online-hemodiafiltration in pediatric population. Pediatr Nephrol 30(9):1639–1640

    Google Scholar 

  21. 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(9):2360–2367

    Article  PubMed  Google Scholar 

  22. Baldamus CA, Schoeppe W, Koch KM (1978) Comparison of haemodialysis (HD) and post dilution haemofiltration (HF) on an unselected dialysis population. Proc Eur Dial Transplant Assoc 15:228–235

    CAS  PubMed  Google Scholar 

  23. Davenport A (2011) Using dialysis machine technology to reduce intradialytic hypotension. Hemodial Int 15(Suppl 1):S37–S42

    Article  PubMed  Google Scholar 

  24. Reddan DN, Szczech LA, Hasselblad V, Lowrie EG, Lindsay RM, Himmelfarb J, Toto RD, Stivelman J, Winchester JF, Zillman LA, Califf RM, Owen WF Jr (2005) Intradialytic blood volume monitoring in ambulatory hemodialysis patients: a randomized trial. J Am Soc Nephrol 16(7):2162–2169

    Article  PubMed  Google Scholar 

  25. Fresenius Medical Care Crit-Line III user manual. https://fmcna.com/wp-content/uploads/documents/CL80020031_Rev_H.pdf. Accessed 20 Apr 2018

  26. Davenport A (2009) Can advances in hemodialysis machine technology prevent intradialytic hypotension? Semin Dial 22(3):231–236

    Article  PubMed  Google Scholar 

  27. Mitra S, Chamney P, Greenwood R, Farrington K (2004) The relationship between systemic and whole-body hematocrit is not constant during ultrafiltration on hemodialysis. J Am Soc Nephrol 15(2):463–469

    Article  PubMed  Google Scholar 

  28. Fischbach M, Edefonti A, Schröder C, Watson A (2005) Hemodialysis in children: general practical guidelines. Pediatr Nephrol 20(8):1054–1066

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Petitclerc T, Trombert JC, Coevoet B, Jacobs C (1996) Electrolyte modelling: sodium. Is dialysate sodium profiling actually useful? Nephrol Dial Transplant 11(Suppl 2):35–38

    Article  PubMed  Google Scholar 

  30. Advanced renal education program: sodium modelling (2015) Fresenius Medical Care. http://advancedrenaleducation.com/content/sodium-modeling. Accessed 15 Apr 2018

  31. Mann H, Stiller S (2000) Sodium modeling. Kidney Int Suppl 76:S79–S88

    Article  CAS  PubMed  Google Scholar 

  32. Sadowski RH, Allred EN, Jabs K (1993) Sodium modeling ameliorates intradialytic and interdialytic symptoms in young hemodialysis patients. J Am Soc Nephrol 4(5):1192–1198

    CAS  PubMed  Google Scholar 

  33. Tangvoraphonkchai K, Davenport A (2018) Why does the choice of dialysate sodium concentration remain controversial? Hemodial Int. https://doi.org/10.1111/hdi.12645

  34. Kidney Disease Outcomes Quality Initiative (2015) KDOQI clinical practice guideline for hemodialysis adequacy: 2015 update. Am J Kidney Dis 66(5):884–930

    Article  Google Scholar 

  35. Hecking M, Wong MMY, Port FK, Robinson BM, McCullough KP (2017) Regional differences in the associations between prescribed dialysate sodium concentration and Interdialytic weight gain in the dialysis outcomes and practice patterns study. Am J Kidney Dis 70(3):450–451

    Article  PubMed  Google Scholar 

  36. Hecking M, Kainz A, Horl WH, Herkner H, Sunder-Plassmann G (2011) Sodium setpoint and sodium gradient: influence on plasma sodium change and weight gain. Am J Nephrol 33(1):39–48

    Article  CAS  PubMed  Google Scholar 

  37. Dheu C, Terzic J, Menouer S, Fischbach M (2009) Importance of the curve shape for interpretation of blood volume monitor changes during haemodiafiltration. Pediatr Nephrol 24(7):1419–1423

    Article  PubMed  Google Scholar 

  38. Daugirdas JT, Schneditz D (2017) Hemodialysis ultrafiltration rate targets should be scaled to body surface area rather than to body weight. Semin Dial 30(1):15–19

    Article  PubMed  Google Scholar 

  39. Quellhorst E (1983) Long-term follow up in chronic hemofiltration. Int J Artif Organs 6(3):115–120

    Article  CAS  PubMed  Google Scholar 

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Acknowledgments

We thank Ms. Jennifer Clark, Medical Writer, Akron Children’s Hospital for her assistance in language editing.

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Authors and Affiliations

  1. Department of Nephrology, Cleveland Clinic Akron General and Akron Children’s Hospital, Akron, OH, USA

    Rupesh Raina

  2. Akron Nephrology Associates/Cleveland Clinic Akron General, Akron, OH, USA

    Rupesh Raina & Vinod Krishnappa

  3. Department of Pediatrics, Akron Children’s Hospital, Akron, OH, USA

    Stephanie Lam

  4. The Children’s Hospital of New Jersey, Newark Beth Israel Medical Center, Newark, NJ, USA

    Hershita Raheja

  5. Northeast Ohio Medical University, Rootstown, OH, USA

    Vinod Krishnappa

  6. Department of Paediatric Nephrology, Great Ormond Street Hospital, Great Ormond Street, London, UK

    Daljit Hothi

  7. UCL Centre for Nephrology, Royal Free Hospital, University College London, London, UK

    Andrew Davenport

  8. Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA

    Deepa Chand

  9. Pediatric Nephrology and Hypertension, Children’s Hospital of Michigan, Detroit, MI, USA

    Gaurav Kapur

  10. Pediatric Nephrology Division, Center for Pediatrics and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany

    Franz Schaefer

  11. Pediatric Nephrology & Pediatric Kidney Transplantation, Kidney and Urology Institute, Medanta, The Medicity Hospital, Gurgaon, India

    Sidharth Kumar Sethi

  12. Red Cross War Memorial Children’s Hospital, University of Cape Town, Cape Town, South Africa

    Mignon McCulloch

  13. Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India

    Arvind Bagga

  14. Pediatric Nephrology & Transplantation, Children’s Hospital of Richmond, Virginia Commonwealth University, Richmond, VA, USA

    Timothy Bunchman

  15. Division of Nephrology, Children’s Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA

    Bradley A. Warady

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  1. Rupesh Raina
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  14. Bradley A. Warady
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Correspondence to Rupesh Raina.

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Raina, R., Lam, S., Raheja, H. et al. Pediatric intradialytic hypotension: recommendations from the Pediatric Continuous Renal Replacement Therapy (PCRRT) Workgroup. Pediatr Nephrol 34, 925–941 (2019). https://doi.org/10.1007/s00467-018-4190-1

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  • DOI: https://doi.org/10.1007/s00467-018-4190-1

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