Studies in adults show superior serum phosphate and parathyroid hormone (PTH) control on slow nocturnal haemodialysis (NHD) compared with conventional haemodialysis. We studied the progress of four children aged 12, 13, 14 and 16 years after they had been initiated on NHD. The follow-up period ranged from 6 months to 20 months. Biochemical indices of bone metabolism were collected prospectively. All four children were initially dialysed against a 1.5 mmol/l calcium bath. In two patients, owing to biochemical hypocalcaemic episodes, the dialysate calcium concentration was increased to 1.75 mmol/l. One patient became hypercalcaemic and received calcitonin for bone pain secondary to osteoporosis and was dialysed against a 1.0 mmol/l calcium bath. Including an evaluation of dietary intake, all four patients had a net positive calcium balance, ranging from 5.1 mmol/m2 body surface area (BSA) per day to 24.3 mmol/m2 BSA per day. A significant reduction in the pre-dialysis phosphate level was observed in all four patients, such that none required dietary restrictions or phosphate binders, and dialysate phosphate supplements of 0.8-2.03 mmol/l were employed to prevent hypophosphataemia. The (CaxPO4) dropped below 4.4 mmol(2) l(-2) in all four patients. Concurrently, significant reductions in intact PTH levels were seen in all four patients, but the level dropped to below normal range in two. In our cohort of patients, NHD rapidly lowered plasma phosphate and PTH levels, and additional dialysate phosphate and possibly calcium may be necessary to prevent bone demineralisation due to chronic losses and to prevent oversuppression of PTH.
Whereas the success of nocturnal home hemodialysis (NHHD) as a treatment modality for adults has been clearly demonstrated, there is very little experience with NHHD in children. There are genuine concerns related to patient safety, as well as a potentially overwhelming burden on the parents of children, while supervising NHHD. Each of these issues has been considered in the development of the NHHD program for children in Toronto. The steps involved in the development of this program are outlined. The experience of Simonsen (4), that NHHD is feasible and provides excellent dialysis for children, is confirmed.
Our observations reveal that the larger the fill volume the higher the likelihood of achieving ultrafiltration with icodextrin and suggest that a minimum day dwell volume of 550 ml/m(2) BSA seems to facilitate ultrafiltration in children. To our knowledge this is the largest study addressing ultrafiltration with icodextrin in children.
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