title: Safety and efficacy of tandem hemodialysis and plasma exchange in children.
abstract: OBJECTIVE
  Patients with immune-mediated kidney disease and liver failure often require plasma exchange (PE) and hemodialysis (HD). Combining both methods (i.e., connecting the PE and HD circuits in series [tandem dialysis]) should allow for a more efficient treatment. This work reviews the authors' experience with tandem blood purification.
  
  
  METHODS
  Chart review was utilized to retrospectively analyze the efficacy and tolerability of 92 combined PE/HD (cPE/HD) sessions in 26 children in comparison with 113 sequential PE/HD (sPE/HD) treatments performed in 32 children between 1988 and 2012 at the University of Heidelberg Center for Pediatric and Adolescent Medicine. Eleven children received both treatment modalities.
  
  
  RESULTS
  The mean treatment duration was 3.8 ± 2.2 hours per cPE/HD and 5.9 ± 1.6 hours per sPE/HD session (P<0.001). Dialyzer surface areas per body surface area (in meters squared) and blood flow rates were similar. Although a 3-fold higher initial bolus of heparin was administered with cPE/HD, the heparin dose per hour was similar with both modalities and the total heparin load was only slightly lower with cPE/HD, with a median 2939 IU/m(2) per session (interquartile range, 1868, 4189) versus 3341 IU/m(2) per session (interquartile range, 2126, 4792). In sessions with regional anticoagulation, equal citrate and calcium infusion rates were applied. Plasma turnover, ultrafiltration rates, and solute removal were comparable. Procedure-related problems developed in 14.0% of cPE/HD and 7.0% of sPE/HD sessions (P=0.37). Clinical symptoms occurred in 19.6% and 6.2% (P=0.05), necessitating treatment discontinuation in 12.0% and 5.3% of the sessions (P=0.14). Intra-individual comparison of both dialysis methods in 11 children reconfirmed these findings.
  
  
  CONCLUSIONS
  cPE/HD is a time-saving procedure relative to sPE/HD, but may be associated with a higher rate of procedure-related and clinical adverse events.
authors.affiliation: Division of Pediatric Nephrology, Center for Pediatric and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany; and.
authors.forename: Betti
authors.initials: B
authors.lastname: Schaefer
authors.affiliation: Institute of Pathophysiology, Semmelweis University, Budapest, Hungary.
authors.forename: Akos
authors.initials: A
authors.lastname: Ujszaszi
authors.affiliation: Division of Pediatric Nephrology, Center for Pediatric and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany; and.
authors.forename: Susanne
authors.initials: S
authors.lastname: Schaefer
authors.affiliation: Division of Pediatric Nephrology, Center for Pediatric and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany; and.
authors.forename: Karl Heinz
authors.initials: KH
authors.lastname: Heckert
authors.affiliation: Division of Pediatric Nephrology, Center for Pediatric and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany; and.
authors.forename: Franz
authors.initials: F
authors.lastname: Schaefer
authors.affiliation: Division of Pediatric Nephrology, Center for Pediatric and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany; and claus.peter.schmitt@med.uni-heidelberg.de.
authors.forename: Claus Peter
authors.initials: CP
authors.lastname: Schmitt
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D003131:Combined Modality Therapy; D005260:Female; D006801:Humans; D007223:Infant; D007674:Kidney Diseases / Q000628:therapy*; D017093:Liver Failure / Q000628:therapy*; D008297:Male; D010951:Plasma Exchange / Q000009:adverse effects; D006435:Renal Dialysis / Q000009:adverse effects / Q000379:methods*; D012189:Retrospective Studies; D055815:Young Adult
keywords: children; hemodialysis; hemodialysis adequacy