Daily on-line haemodiafiltration: a pilot trial in children.
BACKGROUND
Despite major improvements in paediatric dialysis over the last two decades, cardiovascular outcome is often poor. As France gives priority to kidney transplantation over dialysis, children in chronic haemodialysis are generally pre-adolescents or adolescents with long medical histories and low compliance. In them, the usual weekly schedule of dialysis is often unsuitable. We conducted a study of conversion to daily dialysis, which allowed an enhanced dialysis dose, a gentle ultrafiltration rate and achievement of dry body weight.


METHODS
In this single-centre, observational, prospective, non-randomized study, five oligoanuric dialysis patients (mean age: 13.8 +/- 3.2 years) were converted from standard on-line haemodiafiltration (S-OL-HDF) (4 h, three times/week) to daily on-line haemodiafiltration (D-OL-HDF) (3 h, six times/week). Patient selection was based on both the presence of uraemic cardiomyopathy (left ventricular hypertrophy and reduced fractional shortening) and their reduced therapeutic compliance. The D-OL-HDF parameters were the same as for the S-OL-HDF.


RESULTS
Increasing the number of sessions from three to six weekly positively impacted the weekly dialysis dose. On D-OL-HDF, mean arterial blood pressure decreased significantly (from 95 +/- 15 to 82 +/- 13 and 87 +/- 9 mmHg at 6 and 12 months, respectively). Left ventricular hypertrophy decreased and its fractional shortening improved markedly (from 26.6 +/- 17% to 31 +/- 14% and 46.6 +/- 15% at 6 and 12 months, respectively). Pre-dialytic plasma phosphorus also decreased markedly (from 1.87 +/- 0.23 to 1.43 +/- 0.22 and 1.28 +/- 0.29 mmol/l at 6 and 12 months, respectively), as did the calcium-phosphorus product. The post-dialytic recovery time disappeared and so did perception of fatigue. Fasting the day before dialysis to avoid excess weight gain (necessitating longer dialysis) disappeared. Combined with an improved appetite, these changes resulted in higher caloric and protein intake (nPCR), from 1.28 +/- 0.23 to 1.43 +/- 0.24 g/kg at 6 months, and school attendance became regular. The only pre-pubertal child included showed catch-up growth.


CONCLUSIONS
Increasing dialysis frequency to daily sessions without shortening the durations of sessions excessively allowed us to overcome the "free diet" imposed on these paediatric, very uncompliant patients. This strategy led to a reduction in blood pressure and an improvement of left ventricular size and function, normalization of pre-dialytic plasma phosphorus and improvements in general well-being and dialysis acceptance. Long-term, however, this protocol is only acceptable for the children if associated with the potential of clinical recovery allowing inscription on the kidney transplantation waiting list.
Fischbach
Michel
M
Nephrology Dialysis Transplantation Children's Unit, Hospital de Hautepierre, Avenue Moliere, 67098 Strasbourg, France. Michel.Fischbach@chru-strasbourg.fr
Terzic
Joëlle
J
Laugel
Vincent
V
Dheu
Céline
C
Menouer
Soraya
S
Helms
Pauline
P
Livolsi
Angelo
A
D000293:Adolescent; D002648:Child; D005260:Female; D017583:Hemodiafiltration / Q000379:methods*; D006801:Humans; D007676:Kidney Failure, Chronic / Q000628:therapy*; D008297:Male; D010349:Patient Compliance; D018579:Patient Selection; D010865:Pilot Projects; D011446:Prospective Studies; D013997:Time Factors; D016896:Treatment Outcome