Van Wesemael Pauline, Eloot Sunny, Raes Ann, Shroff Rukshana, Snauwaert Evelien
Department of Pediatric Nephrology, Ghent University Hospital, Ghent, Belgium.
Department of Nephrology, Ghent University Hospital, Ghent, Belgium.
Pediatr Nephrol. 2025 May;40(5):1565-1578. doi: 10.1007/s00467-024-06598-w. Epub 2024 Dec 6.
Three-weekly 4-h hemodialysis/hemodiafiltration (HD/HDF) per week has become the "standard HD/HDF" regimen in children across the globe, although increasingly criticized, since crucial determinants such as residual kidney function and patient preferences are not considered. As a consequence, several children fail to achieve adequate dialysis while on a "standard HD/HDF." In these circumstances, an extended dialysis prescription such as short daily (2-3 h/session, 5-7 days a week) or nocturnal HD/HDF (6-9 h/session, 3-5 days a week), either at home or in a dialysis center, may be considered. The purpose of this educational review is to summarize the impact of dialysis duration and frequency on uremic toxin and fluid removal. Moreover, we aim to summarize the existing literature on HD/HDF strategies with extended dialysis duration and/or increased frequency (> 12 h dialysis time per week) in pediatrics. Dialysis duration and frequency plays a crucial role in uremic toxin removal, in particular for uremic toxins with retarded transport in patients, such as phosphate, β-microglobulin (βm), and protein-bound uremic toxins. Also, increasing dialysis duration and/or frequency decreases the gap between plasma refilling and ultrafiltration volume), thereby decreasing the need for a high ultrafiltration rate. Observational studies in children demonstrate a beneficial effect of extended dialysis regimens (i.e., more frequent or longer duration) on blood pressure control, left ventricular hypertrophy, growth, and quality of life. PTH levels tend to decrease in the majority of studies, while hypocalcemia or suppressed PTH levels were also reported. Dietary restrictions were decreased or stopped, along with tapering of phosphate binders and potassium chelators. Extended HD/HDF regimens are beneficial in a particular group of children. Pediatric-specific international guidelines are needed to support pediatric nephrologists in determining for which children extended HD regimens are beneficial, along with increasing efforts to decrease the financial, organizational, and psychosocial barriers that are present in extended HD/HDF.
每周进行三次、每次4小时的血液透析/血液透析滤过（HD/HDF）已成为全球儿童的“标准HD/HDF”方案，尽管该方案越来越受到批评，因为它没有考虑诸如残余肾功能和患者偏好等关键决定因素。因此，一些儿童在接受“标准HD/HDF”治疗时未能达到充分透析。在这种情况下，可以考虑延长透析处方，如在家中或透析中心进行每日短时间（每次2 - 3小时，每周5 - 7天）或夜间HD/HDF（每次6 - 9小时，每周3 - 5天）。本教育综述的目的是总结透析时长和频率对尿毒症毒素清除及液体清除的影响。此外，我们旨在总结儿科领域中关于延长透析时长和/或增加频率（每周透析时间>12小时）的HD/HDF策略的现有文献。透析时长和频率在尿毒症毒素清除中起着关键作用，特别是对于在患者体内转运缓慢的尿毒症毒素，如磷酸盐、β-微球蛋白（βm）和蛋白结合尿毒症毒素。此外，增加透析时长和/或频率可缩小血浆再充盈量与超滤量之间的差距，从而减少对高超滤率的需求。儿童观察性研究表明，延长透析方案（即更频繁或更长时间）对血压控制、左心室肥厚、生长和生活质量有有益影响。在大多数研究中，甲状旁腺激素（PTH）水平往往会下降，同时也有低钙血症或PTH水平受抑制的报道。饮食限制减少或停止，同时磷酸盐结合剂和钾螯合剂的用量也逐渐减少。延长HD/HDF方案对特定儿童群体有益。需要儿科专用的国际指南来支持儿科肾病学家确定哪些儿童适合延长HD方案，同时加大力度减少延长HD/HDF中存在的经济、组织和社会心理障碍。
