Paeds · nephrology-urology-fluids-and-electrolytes
Kidney replacement therapy and dialysis in children
Also known as Renal replacement therapy · KRT · Peritoneal dialysis · Haemodialysis · Continuous renal replacement therapy · CRRT
Fellowship guide to kidney replacement therapy in children: the four modalities of peritoneal dialysis, haemodialysis, continuous renal replacement therapy, and kidney transplantation; the AEIOU indications for urgent dialysis in acute kidney injury; why peritoneal dialysis is preferred in infants and small children while continuous renal replacement therapy suits the haemodynamically unstable child in intensive care; and why transplantation remains the gold standard for end-stage kidney disease.
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Red flags
- Refractory hyperkalaemia, severe metabolic acidosis, or fluid overload unresponsive to diuretics in a child with acute kidney injury
- Uraemic complications such as pericarditis, encephalopathy, or a rapidly rising urea requiring urgent dialysis
- An oliguric or anuric critically ill child with positive fluid balance and falling oxygenation needing continuous renal replacement therapy
- Cloudy peritoneal dialysis effluent with abdominal pain and fever indicating peritoneal dialysis-related peritonitis
- Severe hyperammonaemia from an inborn error of metabolism requiring emergency dialysis to clear ammonia
- Haemodialysis access catheter with fever, bacteraemia, or thrombosis threatening the only viable access
- Rapid solute removal in a child with very high urea risking dialysis disequilibrium syndrome
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Board mappings
- Recognises the indications for urgent kidney replacement therapy in a child with acute kidney injury
- Distinguishes peritoneal dialysis, haemodialysis, and continuous renal replacement therapy
- Refers urgently to paediatric nephrology and intensive care when dialysis is needed
- Justifies modality choice based on age, haemodynamic stability, and resources
- Manages peritoneal dialysis prescription, peritonitis, and dialysis adequacy in children
- Explains the role of transplantation as the preferred treatment for end-stage kidney disease
- Definition and four modalities of kidney replacement therapy
- AEIOU indications for urgent dialysis in acute kidney injury
- Principles of modality selection in infants versus older children
- Recognises a deteriorating child needing dialysis and escalates appropriately
- Communicates modality choice, prognosis, and the transplant pathway to families
- Manages peritoneal dialysis peritonitis and dialysis access complications
- Level 1: Recognition that dialysis supports the failing kidney for fluid and solute removal
- Level 2: Application of indications for dialysis and modality selection by age and stability
- Level 3: Management of the dialysis prescription, complications, and transition to transplantation
- Four modalities of kidney replacement therapy and their principles
- AEIOU indications and the choice between peritoneal dialysis and haemodialysis
- Complications including peritonitis, dialysis disequilibrium, and access infection
- Assessment of a child with acute kidney injury to decide on dialysis
- Choice of continuous renal replacement therapy in the haemodynamically unstable child
- Counselling families on chronic dialysis and the pathway to transplantation
- Recognition of indications for renal replacement therapy in paediatric acute kidney injury
- Modality selection favouring peritoneal dialysis in infants and small children
- Prevention and treatment of peritoneal dialysis peritonitis
- Recognition of acute kidney injury needing urgent dialysis
- Initiation of the appropriate dialysis modality and nephrology referral
- Family communication on chronic dialysis, growth, and transplantation
- Canadian approach to paediatric dialysis modality selection and adequacy
- Peritoneal dialysis in resource-limited and remote settings
- Transition from dialysis to transplantation
Overview & Definition
A toddler in septic shock who has not passed urine for a day, whose potassium is climbing and whose chest is filling with fluid, cannot wait for his kidneys to recover. He needs kidney replacement therapy, the umbrella term for any treatment that takes over the work of the failing kidney by removing solute waste and excess water, and by correcting acid-base and electrolyte disturbance. The therapy does not heal the kidney. It buys time, either for the kidney to recover in acute kidney injury or for transplantation in end-stage kidney disease, and the choice of how to deliver it is one of the most consequential decisions in paediatric nephrology and intensive care. [12]
There are four ways to deliver kidney replacement therapy, and the differences between them are practical rather than philosophical. Peritoneal dialysis uses the lining of the child's own abdomen as the filter. Haemodialysis pumps blood through an artificial membrane in a machine and is fast and efficient but demands stable blood pressure and reliable vascular access. Continuous renal replacement therapy is a slower, gentler version of the blood circuit run continuously at the bedside for the child too unstable to tolerate intermittent haemodialysis. Kidney transplantation replaces the failing organ with a working one and is the definitive treatment for end-stage kidney disease, offering the best survival and quality of life. [5]
References12ShowHide
- [1]Nourse P, Cullis B, Finkelstein F, et al. ISPD guidelines for peritoneal dialysis in acute kidney injury: 2020 Update (paediatrics). Perit Dial Int, 2021.PMID 33523772
- [2]Cullis B, Al-Hwiesh A, Kilonzo K, et al. ISPD guidelines for peritoneal dialysis in acute kidney injury: 2020 update (adults). Perit Dial Int, 2021.PMID 33267747
- [3]Warady BA, Same R, Borzych-Duzalka D, et al. Clinical practice guideline for the prevention and management of peritoneal dialysis-associated infections in children: 2024 update. Perit Dial Int, 2024.PMID 39313225
- [4]Li PK, Szeto CC, Piraino B, de Arteaga J, Fan S, Figueiredo AE, et al ISPD peritonitis recommendations: 2016 update on prevention and treatment. Perit Dial Int, 2016.PMID 27282851
- [5]Weaver DJ Jr, Somers MJG, Martz K, Mitsnefes MM Clinical outcomes and survival in pediatric patients initiating chronic dialysis: a report of the NAPRTCS registry. Pediatr Nephrol, 2017.PMID 28762101
- [6]Sanderson KR, Yu Y, Dai H, et al. Outcomes of infants receiving chronic peritoneal dialysis: an analysis of the USRDS registry. Pediatr Nephrol, 2019.PMID 30141177
- [7]Warady BA, Schaefer F, Bagga A, et al. Prescribing peritoneal dialysis for high-quality care in children. Perit Dial Int, 2020.PMID 32063210
- [8]Kaddourah A, Basu RK, Bagshaw SM, et al. Epidemiology of acute kidney injury in critically ill children and young adults. N Engl J Med, 2017.PMID 27959707
- [9]Akcan-Arikan A, Zappitelli M, Loftis LL, Washburn KK, Jefferson LS, Goldstein SL Modified RIFLE criteria in critically ill children with acute kidney injury. Kidney Int, 2007.PMID 17396113
- [10]Raina R, Davenport A, Warady B, et al. Dialysis disequilibrium syndrome (DDS) in pediatric patients on dialysis: systematic review and clinical practice recommendations. Pediatr Nephrol, 2022.PMID 34609583
- [11]Querfeld U, Schaefer F Cardiovascular risk factors in children on dialysis: an update. Pediatr Nephrol, 2020.PMID 30382333
- [12]Neri M, Villa G, Garzotto F, Bagshaw S, Bellomo R, Cerda J, et al Nomenclature for renal replacement therapy in acute kidney injury: basic principles. Crit Care, 2016.PMID 27719682