Hemodialysis in the pediatric patient: state of the art.

The prevalence of pediatric patients receiving hemodialysis as renal replacement therapy has increased over the past decade. Although numerous technologic advances have been developed and their impact assessed for adult patients receiving hemodialysis, no long-term outcome study currently exists for children receiving hemodialysis. Barriers to such study include the necessity for long-term multicenter participation to enroll enough patients to make definitive statements regarding outcome, lack of consensus for an acceptable and practical method for hemodialysis adequacy measurement in children, and the need for pediatric end-stage renal disease (ESRD)-specific tools for assessment of quality of life. The first part of this article reviews issues surrounding hemodialysis adequacy measurement in children. In particular, simple but accurate Kt/V and normalized protein catabolic rate (nPCR) estimation methods are proposed that should allow for more widespread use of Kt/V and nPCR for measurement of urea clearance and nutritional status in children receiving hemodialysis, important for both patient care and to control for hemodialysis adequacy in pediatric outcome studies. In addition, the principles and pediatric study of 2 technologic advances, continuous noninvasive monitoring of hematocrit and noninvasive ultrasound dilution vascular access flow measurement, are reviewed. Finally, suggestions are provided for future study pertinent to both short-term and long-term outcomes in children receiving hemodialysis.