Skip to main content
SpringerLink
Log in

Adequacy of dialysis in children: does small solute clearance really matter?

  • Editorial Commentary
  • Published:
Pediatric Nephrology Aims and scope Submit manuscript

Abstract

Measurement of dialysis adequacy relies on an assessment of small molecule clearance during the dialysis procedure. However, recent adult studies (HEMO and ADEMEX) that pushed clearance to maximally achievable levels within practical constraints of thrice-weekly hemodialysis or four times daily continuous ambulatory peritoneal dialysis failed to demonstrate improvements in patient outcome above current guidelines. The relatively low incidence of pediatric compared with adult end-stage renal disease limits large-scale study of pediatric dialysis. Several single-center pediatric studies demonstrate a lack of association between small solute clearance alone and patient growth. The aim of the current article is to review the relevant pediatric and adult studies of small solute clearance and put them in the context of optimal dialysis provision. While small solute clearances do indeed matter, clearance is not all that matters. Our quest to provide optimal dialysis requires that we also focus our attention on patient nutritional status, increased dialysis delivery (daily/nocturnal hemodialysis), and adjunctive dialysis modalities (hemofiltration and renal tubular replacement therapy).

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

References

  1. Lowrie EG, Laird NM, Parker TF, Sargent JA (1981) Effect of the hemodialysis prescription of patient morbidity: report from the National Cooperative Dialysis Study. N Engl J Med 305:1176–1181

    CAS  PubMed  Google Scholar 

  2. Gotch FA, Sargent JA (1985) A mechanistic analysis of the National Cooperative Dialysis Study (NCDS). Kidney Int 28:526–534

    CAS  PubMed  Google Scholar 

  3. Daugirdas JT (1993) Second generation logarithmic estimates of single-pool variable volume Kt/V: an analysis of error. J Am Soc Nephrol 4:1205–1213

    CAS  PubMed  Google Scholar 

  4. Goldstein SL, Sorof JM, Brewer ED (1999) Natural logarithmic estimates of Kt/V in the pediatric hemodialysis population. Am J Kidney Dis 33:518–522

    CAS  PubMed  Google Scholar 

  5. Sharma A, Espinosa P, Bell L, Tom A, Rodd C (2000) Multicompartment urea kinetics in well-dialyzed children. Kidney Int 58:2138–2146

    Article  CAS  PubMed  Google Scholar 

  6. Maduell F, Garcia-Valdecasas J, Garcia H, Hernandez-Jaras J, Siguenza F, Pozo C del, Giner R, Moll R, Garrigos E (1997) Validation of different methods to calculate Kt/V considering postdialysis rebound. Nephrol Dial Transplant 12:1928–1933

    Article  CAS  PubMed  Google Scholar 

  7. Paniagua R, Amato D, Vonesh E, Correa-Rotter R, Ramos A, Moran J, Mujais S (2002) Effects of increased peritoneal clearances on mortality rates in peritoneal dialysis: ADEMEX, a prospective, randomized, controlled trial. J Am Soc Nephrol 13:1307–1320

    Google Scholar 

  8. Eknoyan G, Beck GJ, Cheung AK, Daugirdas JT, Greene T, Kusek JW, Allon M, Bailey J, Delmez JA, Depner TA, Dwyer JT, Levey AS, Levin NW, Milford E, Ornt DB, Rocco MV, Schulman G, Schwab SJ, Teehan BP, Toto R (2002) Effect of dialysis dose and membrane flux in maintenance hemodialysis. N Engl J Med 347:2010–2019

    Article  PubMed  Google Scholar 

  9. Himmelfarb J (2002) Success and challenge in dialysis therapy. N Engl J Med 347:2068–2070

    Article  PubMed  Google Scholar 

  10. Canada-USA (CANUSA) Peritoneal Dialysis Study Group (1996) Adequacy of dialysis and nutrition in continuous peritoneal dialysis: association with clinical outcomes. J Am Soc Nephrol 7:198–207

    PubMed  Google Scholar 

  11. Bloembergen WE, Stannard DC, Port FK, Wolfe RA, Pugh JA, Jones CA, Greer JW, Golper TA, Held PJ (1996) Relationship of dose of hemodialysis and cause-specific mortality. Kidney Int 50:557–565

    CAS  PubMed  Google Scholar 

  12. Held PJ, Port FK, Wolfe RA, Stannard DC, Carroll CE, Daugirdas JT, Bloembergen WE, Greer JW, Hakim RM (1996) The dose of hemodialysis and patient mortality. Kidney Int 50:550–556

    CAS  PubMed  Google Scholar 

  13. National Kidney Foundation (1997) NKF-DOQI clinical practice guidelines for hemodialysis adequacy. Am J Kidney Dis 30:S15–S66

    Google Scholar 

  14. (deleted)

  15. Daugirdas JT, Schneditz D (1995) Overestimation of hemodialysis dose depends on dialysis efficiency by regional blood flow but not by conventional two pool urea kinetic analysis. ASAIO J 41:M719–M724

    CAS  PubMed  Google Scholar 

  16. Bargman JM, Thorpe KE, Churchill DN (2001) Relative contribution of residual renal function and peritoneal clearance to adequacy of dialysis: a reanalysis of the CANUSA study. J Am Soc Nephrol 12:2158–2162

    CAS  PubMed  Google Scholar 

  17. Schaefer F, Klaus G, Mehls O (1999) Peritoneal transport properties and dialysis dose affect growth and nutritional status in children on chronic peritoneal dialysis. Mid-European Pediatric Peritoneal Dialysis Study Group. J Am Soc Nephrol 10:1786–1792

    CAS  PubMed  Google Scholar 

  18. Brewer ED (1999) Pediatric experience with intradialytic parenteral nutrition and supplemental tube feeding. Am J Kidney Dis 33:205–207

    CAS  PubMed  Google Scholar 

  19. Tom A, McCauley L, Bell L, Rodd C, Espinosa P, Yu G, Yu J, Girardin C, Sharma A (1999) Growth during maintenance hemodialysis: impact of enhanced nutrition and clearance. J Pediatr 134:464–471

    CAS  PubMed  Google Scholar 

  20. Holtta T, Ronnholm K, Jalanko H, Holmberg C (2000) Clinical outcome of pediatric patients on peritoneal dialysis under adequacy control. 14:889–897

  21. Chadha V, Blowey DL, Warady BA (2001) Is growth a valid outcome measure of dialysis clearance in children undergoing peritoneal dialysis? Perit Dial Int 21 [Suppl 3]:S179–S184

  22. Bakkaloglu SA, Ekim M, Kocak G, Atalay S, Tumer N (2001) Impact of dialysis adequacy on cardiac function in pediatric CAPD patients. Perit Dial Int 21:395–400

    CAS  PubMed  Google Scholar 

  23. Jabs K, Warady BA (1999) The impact of the Dialysis Outcomes Quality Initiative Guidelines on the care of the pediatric end-stage renal disease patient. Adv Ren Replace Ther 6:97–106

    CAS  PubMed  Google Scholar 

  24. Sharma AK (2001) Should the DOQI adequacy guidelines be used to standardize the peritoneal dialysis dose in children? Perit Dial Int 21 [Suppl 3]:S185–S191

  25. Warady BA (2001) Should the DOQI adequacy guidelines be used to standardize peritoneal dialysis in children? Perit Dial Int 21 [Suppl 3]:S174–S178

  26. Fischbach M, Stefanidis CJ, Watson AR, European Paediatric Peritoneal Dialysis Working Group (2002) Guidelines by an ad hoc European committee on adequacy of the paediatric peritoneal dialysis prescription. Nephrol Dial Transplant 17:380–385

    Google Scholar 

  27. Dwyer JT, Larive B, Leung J, Rocco M, Burrowes JD, Chumlea WC, Frydrych A, Kusek JW, Uhlin L (2002) Nutritional status affects quality of life in hemodialysis (HEMO) study patients at baseline. J Ren Nutr 12:213–223

    Article  PubMed  Google Scholar 

  28. Allen KL, Miskulin D, Yan G, Dwyer JT, Frydrych A, Leung J, Poole D (2002) Association of nutritional markers with physical and mental health status in prevalent hemodialysis patients from the HEMO study. J Ren Nutr 12:160–169

    Article  PubMed  Google Scholar 

  29. Pierratos A (2001) Introduction: entering the era of daily hemodialysis. Adv Ren Replace Ther 8:223–226

    Article  CAS  PubMed  Google Scholar 

  30. Humes HD, Fissell WH, Weitzel WF, Buffington DA, Westover AJ, MacKay SM, Gutierrez JM (2002) Metabolic replacement of kidney function in uremic animals with a bioartificial kidney containing human cells. Am J Kidney Dis 39:1078–1087

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Pediatrics, Baylor College of Medicine, Texas, USA

    Stuart L. Goldstein

  2. Renal Dialysis Unit, Texas Children’s Hospital, 6621 Fannin Street , MC 3–2482, Houston, Texas 77030, USA

    Stuart L. Goldstein

Authors
  1. Stuart L. Goldstein
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Stuart L. Goldstein.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Goldstein, S.L. Adequacy of dialysis in children: does small solute clearance really matter?. Pediatr Nephrol 19, 1–5 (2004). https://doi.org/10.1007/s00467-003-1368-x

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00467-003-1368-x

Keywords

Search

Navigation