More, younger children receiving dialysis for acute kidney injuries

Rahul Chanchlani, MD, MSc, FASN

Hemodialysis use in children hospitalized with acute kidney injuries (AKIs) has increased over the last 2 decades, but it is not necessarily improving the outlook for these patients.

Researchers in Canada published a report in the Clinical Journal of the American Society of Nephrology revealing that although the use of hemodialysis to treat patients hospitalized with acute injury has increased, so has the risk for short-term mortality.

The research team studied 30-day mortality in more than 1300 children hospitalized AKI who received their first dialysis treatment. Data was collected on children aged 29 days to 18 years between 1996 and 2015 in the province of Ontario. The total incidence of children receiving dialysis for AKI was 0.58 per 1000 person years in 1996, but that number rose to 0.65 per 1000 person years by 2015. Over the same period, 30-day mortality rates rose in the cohort, according to the report, jumping from 14% in 1996 to 25% in 2009. Since 2009, however, 30-day mortality has sustained at 20. During the same period, use of peritoneal dialysis in this population has decreased, and the median age at which dialysis initiated dropped from age 13 in 1996 to age 3 from 2010 to 2015.

Rahul Chanchlani, MD, MSc, FASN, assistant professor of pediatric nephrology and associate faculty in the department of health research methods, evidence and impact at McMaster Children’s Hospital and McMaster University in Hamilton, Canada, led the study and says pediatricians need to take note of the increasing incidence of severe acute injury requiring dialysis in children.

“These high-risk patients need close follow-up, and not just during the hospital stay, but also after discharge, as they are at a higher risk of death,” Chanchlani says.

Pediatricians can help by working to reduce AKIs and the need for dialysis, he adds, offering some advice.

“The important ones are avoiding nephrotoxic medications such as nonsteroidal anti-inflammatory drugs and antibiotics, if possible; counseling children and their parents about benefits of adequate hydration and frequent voiding; keeping a close eye on children at high risk of AKI during hospital stay such as preterm babies or those admitted to the intensive care unit; and those with sepsis, shock, cardiac issues, malignancy, or some renal and urological abnormalities,” Chanchlani says. “Any rise in creatinine during the hospital stay should be taken seriously.”

He offered some analysis on the decline of peritoneal dialysis and the reasons behind the increase in hemodialysis as treatment modalities for AKI.

“In our study, there was initially an increase in the 30-day mortality from 14% to 25% until 2009 followed by a decline to around 20% in the more recent years despite an increasing burden of comorbid conditions such as cardiac surgery and mechanical ventilation,” Chanchlani says. “This may be due to various reasons including significant advancement in clinical care of the underlying conditions, better availability of intensive care units, and earlier initiation of dialysis.”

Chanchlani says he was surprised at the rising risk of severe AKI in children over the last 2 decades, as well as the dramatic reduction in the use of peritoneal dialysis for AKI compared to dialysis or continuous renal replacement therapy (CRRT).

“The reasons for the relative decline in peritoneal are significant advances in extracorporeal therapy technology tailored to the pediatric population. This includes the availability of smaller dialyzers permitting the use of smaller extracorporeal volumes, which has made the delivery of hemodialysis and CRRT feasible and safe even in extremely-low-birth-weight babies,” he says. “With the introduction of newer machines for CRRT, it is expected that CRRT utilization will continue to grow.”

Chanchlani says he hopes the study will increase awareness about the problem among pediatricians and stress the need for additional follow-up with high-risk patients.

“I think this paper will further increase the awareness about this important problem among pediatricians. With increased awareness, children with severe AKI during hospital stay will have a follow-up blood work arranged after discharge to check creatinine and blood pressure as research has also shown that severe AKI can put these children at higher risk for long-term outcomes such as chronic kidney disease and hypertension,” he says, adding he intends to continue his research on this topic. “That is the aim of our next project, in which we are trying to understand what proportion of neonates and children who are discharged after severe AKI requiring dialysis develop chronic kidney disease and hypertension during follow up.”