Paediatric Dialysis at the UHWI: the first five years

Dr Rebecca Thomas-Chen

Disclosures

• Talk made possible by IPNA sponsored fellowship grant

• Also received scholarship funds from ISN, JKKF

Origin of Hemodialysis

• HD first described by Thomas Graham (Glasgow Univ) in 1854

• First human HD performed by Haas (Univ Gliegen, Germany) in 1924

• Paediatric HD first reported

1968-72 (Germany, France)

• Cumulative effort of many physicians

Origin of Peritoneal Dialysis

• First documented therapeutic peritoneal infusion Warrick (red wine used to treat ascites) in 1774

• By 1920 intraperitoneal infusions used to rehydrate NPO infants

• PD first used to treat ESRD from obstructive uropathy by Ganther in 1923

• Segar + Etteldorf first described use of PD as RRT in infants

Local origin of dialysis

• HD first performed at KPH in 1970, first started at UHWI in 1987 • 12 HD trained nurses

• Training once per year

• PD • ? Started 1970s, initially performed at KPH

• Less than 5 active PD nurses now at UHWI, though many HDU nurses have been trained there is loss of skills due to underuse

• Training 1-2 times per year

Paediatric Dialysis

• Multiple patients managed by adult nephrology (incomplete data) since 1990

• Paediatric programme formally started 2012

• 32 patients reported to have received some form of dialysis since 2012

• Two full time paed nephrologists

• Still no paediatric dialysis nurses

• Two dedicated paediatric HD machines, 4 PD cyclers

• Protocols inspired by those of HSC (Toronto)

Handing over of donated PD and HD machines

Logistics

• Should be patient funded, however multiple financial constraints • Many parents unemployed, most single parent households

• As a result hospital foots cost of dialysis sessions at present • With prior arrangement many patients owe hospital million

• Dialysis supplies initially provided by hospital but supplies were inconsistent, not necessarily paediatric size- appropriate

Logistics

• Non-profit founded in 2012 by Dr Maolynne Miller

• Dependent on fundraisers, charitable donations (eg CHASE fund)

• Sponsor dialysis supplies, hemodialysis machines, PD cyclers

• Also provide CRF support group, information sessions to general population

Kidney Kids and their family members at the most recent JKKF treat, where they were gifted back to school supplies

Gender Distribution

8

7

0 0

n=15

Male Female

Age at start of dialysis

1

3

9

2

< 1 year 1 - 5 years 6-10 years >10 years

Youngest child started on PD since formal programme begun

Parish of origin

4

5

2

2

KSA Manchester St Catherine St Ann

• Some families forced to move to Kingston

• Others send children away from family to live with guardians

• Some travel long distances to come for each session

• 3 parents taught home PD

• All this impacts their treatment efficacy

Modalities

0 2 4 6 8 10 12

Peritoneal Dialysis

Hemodialysis

Both modalities

Chart Title

Male Females

• Switched from PD to HD due to: • Failure of membrane

• Loculated intra-abdominal collection

• Large abdominal hematoma

• Switched from HD to PD due to: • Recurrent line infections,

prohibitive replacement costs

Dwarfed by the chair in adult HDU, one of our dear babies who has been on PD->HD!

Total new patients started on dialysis per year

0

1

2

3

4

5

6

7

8

2012 2014 2015 2017

Male Female

Dialysis Access

• PD • All used permanent swan neck

Tenchkoff catheters

• Historical reports of straight acute catheter use

• HD • All used permanent HD catheters

(right IJ)

• All except two had fistula placement of which three failed

Etiologies

• CAKUT (5) • Posterior urethral valves, anterior urethral valves, vesicoureteric reflux, solitary

hypodysplastic kidney

• Congenital nephrotic syndrome (2) • No genetic testing, Denys Drash

• Glomerulonephritis (2) • Dengue, Parvovirus, Unclear etiology

• Focal segmental glomerulosclerosis (2) • Likely primary

• Sarcoidosis (1)

• Trauma (1)

• Lupus (2) • Class IV, the other too scarred for assessment

Complications-PD

• Bacterial peritonitis (though some culture negative) • All patients

• Eosinophilic peritonitis (recurrent) • Recurrence noted more in patients with atopy

• Blocked catheters (omentum, fibrin)

• Catheter migration/ extrusion-> malfunction

• Exit site/ tunnel infection

• Fungal peritonitis • One necessitating discontinuation of PD

• Membrane failure

• Loculated collections

• Post procedure hematoma

Complications-HD

• Recurrent catheter sepsis

• Thrombophlebitis

• Line migration and extrusion

• Infective endocarditis

• Exit site infections

• Fistula pseudoaneurysm

• Fistula thrombosis

Duration on dialysis

0

1

2

3

4

5

6

7

8

9

< 1year 1-5years >5years

Male Female

Outcomes

• 4 deaths • 2 were on home PD, 2 received in-centre treatment

• No post mortems, however likely from peritonitis (1), hyperkalemia (1), fluid overload with cardiac failure (2)

• 2 transferred to adult nephrology • One at UHWI, one to MRH

• 2 recovered enough function to discontinue dialysis • 1 of these now needs to restart, but parent reluctant

• 1 migrated

Current patient load

• 3 hemodialysis patients

• 3 peritoneal dialysis patients

• At least 2 others who need to be on RRT at present, however parent refusal is a barrier

Challenges

• Financial • All in low/ no income households so costs of treatment, medication, transportation

almost prohibitive

• Social • Poor family support with single parent households->depression in parents and

children

• Hospital related • Writing off of treatment costs affects ability of hospital to stay financially viable • Inadequate staff, post training migration • No dedicated paediatric renal trained nurses, dieticians, social workers etc • Nephrologists are employed primarily as general paediatricians for clinical and

student training purposes so less nephrology dedicated time

But not all is doom and gloom…

The future is bright…

• Goals include growing program • Finding sustainable funding in association with hospital team and charitable

groups like JKKF

• Continue/ expand training programmes • With emphasis on paeds specific training for physicians, nurses, renal

dieticians/social workers

• CRRT??, other extracorporeal therapies

• Transplant • Active workup of 2 patients at present

• New programme at the UHWI ( and already ongoing in adults at CRH)

Thank you!