The value of sequential dialysis, mannitol and midodrine in managing children prone to dialysis failure

Abstract

The uremic state impairs compensatory responses to ultrafiltration (UF). Intradialytic symptoms and hypotension can result and lead to premature discontinuation of treatment and sub-optimal dialysis. We report the benefits of mannitol, sequential dialysis and midodrine in reducing dialysis failures in those children prone to intradialytic hypotension. Prophylactic mannitol halved the odds of intradialytic symptoms and hypotension and increased UF volumes. Sequential dialysis halved the odds of symptoms but hypotension persisted. In one patient with refractory hypotension, only intradialytic midodrine consistently maintained acceptable intradialytic blood pressures, reduced intradialytic symptoms and increased the UF potential.

Osmolality and blood pressure stability during hemodialysis

“…In another study of six pediatric patients prone to IDH (mean age 12 years), Hothi et al. reported that the use of mannitol vs not was associated with a 56% reduction in the frequency of intra‐dialytic symptoms (abdominal pain, cramps, headaches, loss of consciousness or change in behavior), with similar findings from a prospective review of 506 treatments from 10 patients . Furthermore, Battaglia et al.…”

Intradialytic hypotension

“…A cut-off of 7.5 mg of the total dose was applied for a 3 h treatment and no midodrine was given in the final 30 min irrespective of BP. Used within this context, we observed a 10-to 15 mmHg increase in the systolic BP within 30 min of administering midodrine in the absence of adverse effects in the intradialytic or interdialytic period [72]. Despite the success, owing to the limited paediatric experience we can only recommend midodrine for resistant cases.…”

“…Adult data-variable results [82] Paediatric data-positive effect [72] Quotidian haemodialysis Paediatric data-improved haemodynamic stability [83] move from the interstitial space to the vascular compartment. In addition, owing to a concentration gradient, sodium diffuses across the dialyser membrane, transferring a sodium load to the patient and thus with it the risk of causing interdialytic thirst, increased interdialytic weight gain and hypertension.…”

“…Adult data [9]-positive effect, but risk of chronic sodium loading and resultant volume expansion and hypertension Sequential dialysis Adult data-reduced intradialytic hypotension [70,71] Paediatric data-improved ultrafiltration potential, not a reduction in intradialytic hypotension episodes [72] Haemodiafiltration…”

“…We investigated the benefits of 30 min of sequential dialysis during 3-h treatments or 1-h sequential dialysis during 4-h treatments in children prone to IDH and demonstrated a 50% reduction in intradialytic symptoms. The incidence of IDH episodes did not significantly improve; nevertheless, the number of treatments that were prematurely discontinued fell and more than 50% of treatments achieved UF goals greater than individual patient averages [72].…”