Dialyzing Children in the Adult World

Angel Krueger, RN, CNN, is a Renal Outpatient Clinic Nurse, Texas Children’s Hospital, Houston, TX. She is a member of ANNA’s Pediatric Special Interest Group and of the Gulf Coast Chapter.
Amelia Allsteadt, BSN, RN, CNN, is a Nurse Educator, Texas Children’s Hospital, Houston, TX. She is a member of ANNA’s Pediatric Special Interest Group and of the Gulf Coast Chapter.

Due to increasing numbers of children requiring maintenance hemodialysis, lack of pediatric nephrologists and distance from pediatric dialysis facilities, some children are receiving dialysis therapy in adult programs. According to the United States Renal Data System (USRDS, 2007), there were 7,288 children with chronic kidney disease (CKD) Stage 5 in 2005. Of those, 1292 were on hemodialysis, 892 on peritoneal dialysis, and 5104 were transplanted. Currently, in the U.S., there are 354 adult and pediatric dialysis units providing incenter hemodialysis to pediatric patients.

We currently provide maintenance dialysis to 68 patients at Texas Children’s Hospital in Houston, Texas. Thirty-three children receive hemodialysis and 35 children receive peritoneal dialysis. While our center cares for children from as far away as 541 miles, many patients cannot be cared for effectively at great distances due to family constraints. In the event that a family does not have the resources for long, frequent commutes or relocation, these children must be followed in an adult program. This article is focused at assisting nurses in adult facilities with the care required for a child or adolescent receiving hemodialysis. Included are some of the fundamental differences encountered when providing care to children.

Assessment
The pre/post-treatment assessment of a child or adolescent resembles that of the adult with some modifications. Details on comprehensive physical assessment for children with CKD are available in the ANNA Core Curriculum for Nephrology Nurses (Currier, McCarley, & Brewer, 2001; McAfee, Richards & Smith, 2008). Pre/posttreatment weight is supervised by staff at the scale to ensure accurate measurement. Height is measured at least quarterly and plotted on a growth chart. Temperature is taken pre/posttreatment and during treatment if an infection is suspected. Children weighing less than 20 kg are placed on an electrocardiogram (EKG) monitor prior to initiation of hemodialysis treatment. Ranges for heart and respiratory rates are shown in Table 1.

Blood pressures (BP) should be measured with an appropriately sized cuff. The cuff bladder should cover 80%-100% of the arm circumference and length should cover approximately two-thirds of the upper arm. Pediatric blood pressure standards based on gender and height can be found at: http://www.nhlbi.nih.gov/guidelines/hypertension/child_tbl.pdf (National Heart Lung and Blood Institute [NHLBI], 2004).

The dialysis facility should ensure that children are current on their childhood immunizations. These immunizations are in addition to the dialysis specific hepatitis B and pneumococcal pneumonia and influenza vaccines. A complete vaccination schedule can be found at http:// www.cdc.gov/vaccines/recs/schedules/default.htm (Centers for Disease Control and Prevention [CDC], 2007).

Target Dry Weight
Assessment of target dry weight in pediatric patients on hemodialysis is difficult. Small fluid shifts may result in symptoms associated with ultrafiltration, such as cramping and nausea, but children may not verbalize complaints. Achieving dry weight is critical since chronic fluid overload can result in hypertension and left ventricular hypertrophy (Jain, Smith, Brewer, & Goldstein, 2001).

Accurate determination involves clinical assessment as well as the use of new technologies. Assessment should include: pre/postreplacement treatment weight, pre/intradialytic/post BP measurements as well as noninvasive volumetric measurements (NIVM), and bioimpedance.
 
NIVM measures hematocrit, blood volume change, and oxygen saturation during each hemodialysis treatment. These values allow the clinician to observe real time intravascular volume changes and proactively intervene during the treatment. (HemaMetrics, 2004). Bioimpedance can also be useful in determining body hydration in patients requiring hemodialysis. (Schneditz 2006). Bioelectrical impedance analysis (BIA) measures the resistance met by the flow of a low electrical current as it passed through the body. Fluid in lean tissue contains intracellular fluid and electrolytes and will have low impedance. In contrast, impedance is high in fat tissue; thus, impedance is proportional to total body water (TBW). (Biodynamics Corporation, 2007).

In our patient population, bioimpedance is performed by our renal dietician at least monthly and more often in those children with difficult to manage BP and fluid volumes. It is our practice to reassess dry weight on a monthly basis or in the event of any change in health status such as recent hospitalization.

Dialysis Prescription
The selection of a dialyzer and appropriate bloodlines is dependent on the size of the child. A safe extra-corporeal volume (ECV) should be less than 10% of the child’s estimated blood volume (EBV). The EBV for a child or adolescent is determined by multiplying 70 mL times the child’s dry weight in kg. The formula for ECV% is (Currier et al., 2001):

ECV% =  Dialyzer volume + blood line volume
                _____________________________
EBV

Blood pump flow rates can be maximized to 400 mL/min/1.73 m2. Dialysate flow should be set at 1fi times the ordered blood pump flow to maximize clearance.

A dialysis treatment in our facility is complete when the liters processed have met the original goal as outlined in the renal replacement therapy (RRT) prescription. This prevents inadequate RRT in the event of poor access flows or excessive machine alarms. In order to determine needed liters processed, the ordered blood flow is multiplied by the treatment hours in minutes and divided by 1000. For example: QB (400 ml) x 3 hour (180 min)/1000 = 72 liters processed. The liters processed goal can be programmed into the treatment parameters on some dialysis machines.

Ultrafiltration
NIVM during hemodialysis for ultrafiltration (UF) is especially useful in children. A study by Jain and colleagues  (2001) concluded that NIVM with blood volume change less than 8% is safe in the first hour of RRT. The study also showed that blood volume change less than 4% in each subsequent hour of dialysis reduces ultrafiltration-associated symptoms in children. Further studies from Patel and colleagues (2007) demonstrated the effectiveness of targeting 50% of total UF in the first hour of treatment guided by a maximum blood volume change of 8%-12%. The remaining 50% of UF is the goal for the remainder of the treatment with a blood volume change less than 5% per hour. This can lead to better BP control and decreased need for anti-hypertensive medications. Our staff utilizes these guidelines to optimize fluid removal and assessment of overall fluid status. Children who are nonadherent to fluid restriction may require an additional 30 minutes of sequential ultrafiltration at the beginning of the treatment for fluid weight gain greater than 10% above dry weight. In some cases, an additional treatment during the week may be necessary.

Anticoagulation
Heparin dosing is based on activated clotting time (ACT) profiling and can be adjusted to achieve ACTs in the prescribed range as follows: tight or controlled anticoagulation ACT range - 120 to 160 seconds and regular systemic anticoagulation ACT range - 180 to 220 seconds (Daschner & Schaefer, 2004).

Children/adolescents with fistulas or grafts receive 50 units/kg of heparin at initiation of hemodialysis. They also receive 25 units of heparin/kg during each subsequent hour. The heparin infusion is terminated 30 minutes prior to completion of treatment in patients with an arteriovenous fistula/arteriovenous graft (AVF/AVG) in order to minimize posttreatment bleeding from the venipuncture sites. Children with indwelling catheters receive heparin infusion until RRT is complete to maintain patency of the indwelling catheter.

Vascular Access
A fistula or graft is the ideal vascular access for children greater than 20 kg on hemodialysis. Those children expecting to wait more than 1 year for renal transplantation should also be considered for fistula or graft placement. In children less than 20 kg, a central venous catheter (CVC) placed in the internal jugular vein is acceptable for long-term vascular access. Other considerations in choosing a CVC rather than a fistula or graft include lack of surgical expertise, child size unable to support vascular access, and bridging from one modality to another (National Kidney Foundation [NKF], 2006).

The goal of vascular access is to deliver blood pump flow rates through the extracorporeal circuit at a range of 3 to 5 mL/kg/min to achieve desired urea clearance. To ensure adequate blood pump flow rates, vascular accesses should be monitored monthly for stenosis and other complications. At our facility, we have identified a staff member as an access coordinator. This individual monitors AV fistulas and grafts with ultrasound dilution (UD) monthly, and documents findings. Numerous studies from our center show that UD is a dependable method for monitoring access flow and detecting venous stenosis. Patients with access flow of less than 650 ml/min/1.73m2 and more than 50% luminal stenosis should be referred for venography and angioplasty within 48 hours (NKF, 2006).

Cannulation
It is helpful to designate a core group of experienced staff members for initial cannulation of newly formed fistulas and grafts. If using the buttonhole technique, the same staff member should cannulate the fistula until the buttonhole is established. Our center has been very successful in training children/adolescents to perform self-cannulation with the buttonhole technique. This technique fosters independence and decreases pain associated with cannulation. Guidelines, tools used in creating and working with buttonholes, and patient information on buttonholes can be found at www.fistulafirst.org/professionals/literature.php (Centers for Medicare and Medicaid Services, 2007).

Pain Management
Our goal for pain management is to strive for atraumatic care. This involves minimizing physical stressors that are encountered in the dialysis facility. Utilizing topical or subcutaneous anesthetic for cannulation, buttonhole technique, distraction or play therapy, and minimizing child/parental separation support the goals of atraumatic care.

Staffing Ratios
Staff to patient ratio is dependent on child size, acuity, and state requirements. In our facility, children weighing less than 10 kg are cared for at a 1:1 ratio. Children weighing 10-20 kg are 1:2, and those weighing more than 20 kg and who are stable can be 1:3. Facilities utilizing patient care technicians (PCTs), should refer to state-specific ESRD facilities licensing regulations. In certain states, PCTs are prohibited from providing hemodialysis treatment to pediatric patients under 14 years of age or under 35 kilograms. Otherwise pediatric patients can be cared for by PCTs under the supervision of a registered nurse. (Texas Department of State Health Services, 2004).

Nutrition
Children receiving dialysis are at risk for protein-energy malnutrition (PEM). In order to support adequate growth, protein and caloric intake should be optimized. Our dieticians and nephrologists monitor the normalized protein catabolic rate (nPCR) as well as serum albumin levels to assess nutritional status. Children with nPCR less than 1 g/kg/d may be at risk for weight loss. Those children with poor nutritional status may require oral supplementation such as Nepro® or Suplena®. When oral supplementation is inadequate, the nasogastric or gastrostomy button (GB) route may be necessary. In severe cases of PEM (patients less than 90% of ideal body weight), intradialytic parenteral nutrition (IDPN) may be warranted (Goldstein, Baronette, Gambrell, Currier, & Brewer, 2002).

Although nutritional status is a concern, we have found that children in our facility tolerate hemodialysis better if they avoid eating or drinking during their treatments. Daily dietary recommendations based on age and dialysis modality are found in Table 2.

Growth and Development
Growth failure is a significant complication experienced by children with CKD. The correction of malnutrition, acidosis, anemia, and bone disease in conjunction with growth hormone therapy can increase height for children with CKD. Data from the USRDS (2007) shows that 65% of children with CKD Stage 5 have a growth rate in the lowest one-fifth of the general population.

Growth hormone (GH) therapy should be considered when a child’s height plateaus or for children who are at less than the third percentile of height for age. Prior to initiation of growth hormone therapy, thyroid function tests, wrist bone age, and hip x-rays are necessary. Children with rickets or slipped capital femoral epiphysis should not begin GH therapy until these problems have been resolved. Height should be measured at least quarterly and documented on a standardized growth chart (NKF, 2004). For those children who are nonadherent to GH therapy, the dose can be adjusted and administered at the dialysis facility.

It is important to remember that children with CKD also experience a delay in pubertal development. Bi-annual physical assessment should include Tanner staging. The Tanner stages for both males and females are described in Table 3.

Child Life Specialists
Child life specialists can provide much needed support to children/adolescents in the dialysis setting. These trained professionals use age-appropriate play and distraction techniques to assist children through uncomfortable procedures. In the event that a child life specialist is not available in your facility, you can collaborate with a child life specialist at another facility for support.

Psychosocial    
Children and adolescents with kidney disease have unique emotional and social needs. It is important for caregivers to assist children and families to cope with CKD. Social development and self-esteem are closely tied to relationships with peers; therefore, those relationships should be encouraged. In an effort to facilitate socialization, children in our facility have many opportunities to meet and interact outside of the dialysis setting. They may choose to attend summer camp, museum outings, professional sports engagements, and teen lock-ins. In adult facilities caring for more than one child/adolescent patient, social activities should be introduced. Collaboration with the nearest pediatric center may provide opportunities such as summer camp for child/adolescent patients on dialysis.

School
Children receiving dialysis experience many interruptions during the school year due to dialysis treatments, hospital admissions, and illness. Children should be encouraged to continue attending school as much as possible in order not to fall behind their peers. It is often necessary to adjust dialysis schedules to allow them to attend as much of the school day as possible. In our facility, the first hour of dialysis is dedicated to homework. Children are encouraged not to watch television or play video games during this time.

Other Considerations
Any facility caring for a child/adolescent must have the resources and equipment to meet the safety needs of this population. The emergency cart in your facility should be equipped with pediatric-specific equipment. All medication doses are based on a child’s weight. Dosages for emergency medications should be calculated and documented in the child’s chart. This eliminates need for calculations during an emergency situation. These doses should be updated with any significant weight change.

Conclusion
When a child or adolescent arrives in an adult facility, both the patient and the caregivers may experience anxiety. It may be helpful to identify staff members who enjoy caring for a younger population and partnering with a pediatric facility for support and collaboration. The ANNA Pediatric Special Interest Group is another available resource for education and support.

By sharing our knowledge and work experience with those suddenly faced with providing care for this unique population, we as pediatric nephrology nurses hope to assuage some of the anxiety while providing support and education to ultimately improve care.


References
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Patel, H.P., Goldstein, S.L., Mahan, J.D., Smith, B., Fried, C.B., Currier, H., et al., (2007). A standard, noninvasive monitoring of hematocrit algorithm improves blood pressure control in pediatric hemodialysis patients. Clinical Journal of American Society of Nephrology, 2(2), 252-257.

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