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Intensive In-Center Hemodialysis forChildren: A Case for Longer DialysisDuration
Lorraine Bell1,2, Pauline Espinosa1,3
1Montreal Children’s Hospital, 2Department of Pediatrics,Division of Nephrology, and 3Department of Nursing,McGill University Health Center, Montreal, Quebec,Canada
Background: Children with renal failure need their dialysis
time optimized. Although traditional surrogate markers
of outcome in pediatric patients have been growth and
development, increasing attention is being focused on
cardiovascular risk factors, such as hypertension, volume
overload, malnutrition, and elevated calcium (Ca) and
phosphorus (P) levels. We have previously shown catch-
up growth without growth hormone, in children undergoing
long intermittent hemodialysis. Recently we analyzed ret-
rospectively cardiovascular risk factors in patients treated
with this regimen.
Methods: Patients starting dialysis between 1997 and 2001
and on dialysis at least 6 months were evaluated. Charts
were reviewed for Ca, P, parathyroid hormone (PTH),
albumin, hemoglobin and blood pressure levels, Ca intake,
blood pressure medications, dialysis time, and clearance
and ultrafiltration rates. Means were calculated for
6- month intervals, up to 36 months.
Results: Mean equilibrated dialyzer Kt/Vurea ranged from
1.9 to 2.1, and mean weekly dialysis time for oliguric
patients varied from 14.8 to 16.3 hr, with average hourly
ultrafiltration rates from 0.3 to 0.4 L. Mean values for P
and Ca�P were below 1.8mM and 4.4 mmol 2/L2, respec-
tively. Mean hemoglobin levels were 115 to 126 g/L, albu-
min 39 to 41 g/L, and PTH 156 to 231 pg/mL. Most
patients had normal predialysis blood pressures.
Conclusions: In this pediatric cohort, intensive center
hemodialysis was associated with excellent growth, nutri-
tion, Ca, P, and anemia control and reasonable blood
pressure values. Large multicenter studies are needed to
better determine optimal dialysis therapy for children.
Hemodial Int. 2003; 7(4):290–295.
Key words
Pediatrics, hemodialysis, adequacy, time, cardiovascular
risks
Introduction
Time can have many meanings for a child on dialysis:
treatment time, ‘‘feeling well’’ time, transplant waiting
time, and lifetime. For some, treatment time seems like
an eternity. Feeling well time may be fleeting, if dialysis is
suboptimal and treatment is difficult. Transplant waitingtime is progressively increasing. Lifetime may be all too
short. The life expectancy of a child on chronic dialysis is
about 30% that of normal children, with one-third of
deaths from cardiovascular causes [1,2]. A major challenge
in caring for children with renal failure is to use time on
dialysis to optimize both quality of life and life expectancy.
Optimal dialysis is an evolving concept. Common
indicators of dialysis adequacy in adults, mortality, car-diac morbidity, and hospitalization rates are less pertin-
ent to pediatric patients. Traditionally, growth and
development have been surrogate measures for adequate
and optimal dialysis in children. Nevertheless, outcome
markers predicting long-term complications, particularly
premature cardiovascular disease, are receiving more
attention. They include anemia, hypertension, fluid over-
load, calcium (Ca) phosphate balance, malnutrition, lipidabnormalities, and systemic inflammation.
The benefits of daily dialysis in reducing these
risk factors are substantial and include better blood pres-
sure (BP) control, nutrition, and phosphorus (P) levels;
diminished left ventricular hypertrophy; and enhanced
middle-molecule clearance [3,4]. Nevertheless, there are
potential disadvantages as well. Particularly relevant for
children are caregiver stress and burnout [5] and loss ofschool time. Long slow intermittent dialysis is a viable
alternative, with improved fluid removal and BP control
because of longer vascular refill time, better P removal
because of slow intercompartmental diffusibility, greater
middle-molecule toxin removal (which is proportional to
dialysis time and dialyzer surface area), and diminished
postdialysis fatigue, because of slower osmolar fluxes and
ultrafiltration [6]. Charra’s group in Tassin has shownstriking results in adults with this approach [7].
Correspondence to:
Lorraine Bell, MD, Montreal Children’s Hospital, Division of
Nephrology, McGill University Health Center, Room E222, 2300
Tupper Street, Montreal, Quebec, Canada H3H 1P3.
email: [email protected]
290
Since the inception of the hemodialysis program at
the Montreal Children’s Hospital in 1990, our standard
of care has been to dialyze patients for 5 hr, thriceweekly. Only those with significant residual renal func-
tion at the start of dialysis have shorter treatments (12 hr
per week). Patients with large fluid intakes receive even
longer or more frequent treatments. The target Kt/Vurea
has been at least 1.8 (initially single-pool variable volume
[VVSP]; since 2000, double pool variable volume
[VVDP]) [8]. A nutritionist closely follows all patients.
We previously published the impact of this regimen onthe growth of 12 consecutive chronic hemodialysis
patients, in pre- or early puberty at the start of dialysis,
treated between 1991 and 1996 (before Canadian
approval of growth hormone for children with renal fail-
ure). Catch-up growth occurred in all but 2 patients. The
mean height standard deviation score (HSDS) at the start
of dialysis was�2.28 and increased to�1.77 at the end of
the observation period (P ¼0.01) [9]. In comparison, theNorth American Pediatric Renal Transplant Cooperative
Study (NAPRTCS) data for hemodialysis patients in the
same period showed a loss of height potential, with a
mean delta HSDS of �0.35 after Year 1 and �0.52 after
Year 2 [10]. Recently we analyzed retrospectively cardio-
vascular risk factors in our patients who have been on
intensive in-center hemodialysis for 6 or more months.
Methods
For children followed in our predialysis clinic, dialysis is
normally initiated when the glomerular filtration rate
falls below 10mL/min/1.73m2. For those who are oligu-
ric or anuric, hemodialysis time is at least 5 hr, three
times a week. Children with polyuric renal failure usually
begin with 4-hr treatments, three times a week, and their
dialysis time is increased if growth or nutritional status is
poor or BP inadequately controlled and when urine out-put falls. Blood flows are prescribed to achieve a target
urea clearance of at least 5mL/kg/min and Kt/Vurea of 1.8
or more. Bicarbonate dialysate is used and the flow rate
is 500mL/min. Before 2000, dialysis prescriptions were
adjusted based on the VVSP Kt/Vurea; since 2000 all
prescriptions have been based on the VVDP model [8].
Results using each model have been generated for all
patients dialyzed since 1991.A nutritionist closely follows all patients, prescribing
supplements where necessary to maintain caloric intake
at 100% of the recommended nutrient intake for age and
protein intake according to the K/DOQI pediatric nutri-
tion guidelines [11]. When serum P levels are at or above
the upper limit of normal for age, P intake is restricted as
follows: 600 to 800mg per day for children above 1 year
of age; low P formula (e.g. Similac PM 60/401, RossProducts Division, Abbott Laboratories, Inc., Colum-
bus, OH, USA) for infants 12 months and less, as recom-
mended by National Kidney Foundation pediatric
nutrition guidelines [12]. Supplements are given orally,
by gavage, and/or as intradialytic parenteral nutrition.Erythropoietin is used to maintain hemoglobin levels
between 110 and 120 g/L, and oral iron supplementation
is prescribed to keep the transferrin saturation above
20% and serum ferritin greater than 100 ng/mL. Intraven-
ous iron is used for patients who do not tolerate oral iron
or who respond poorly to conventional doses of oral iron
and of erythropoietin. Calcitriol (oral or intravenous)
doses are adjusted to maintain intact PTH levels in therange of two to three times the upper limit of normal.
Most patients receive calcium carbonate (CaCO3) as a
phosphate binder; sevelamer is used if serum ionized Ca
levels increase to greater than 1.35mM. Laboratory
parameters are closely monitored, with hemoglobin, Ca,
P, urea, creatinine, and electrolytes measured weekly;
albumin, bicarbonate, and hemoglobin at least monthly;
and parathyroid hormone (PTH) every 1 to 2 months.Stadiometer heights and anthropometrics are measured
quarterly and 3-day diet histories requested every 1 to 3
months. Urea kinetics (Kt/Vurea and urea reduction
ratio) and normalized protein equivalent of total nitro-
gen appearance are calculated monthly, using a VVDP
computer-modeling program developed by Sharma et al.
[8]. The model incorporates data on measured dialyzer
clearance and uses actual, not prescribed, dialysis time.Residual renal function is measured every 3 to 6 months.
The charts of all patients who began hemodialysis
between January 1997 and December 2001 and who
were treated for a minimum of 6 months were reviewed.
Data for the following variables were extracted at dialysis
initiation (baseline) then every 2 months, up to 36
months: serum Ca, P, PTH, albumin, and hemoglobin
levels and predialysis BP. Values for dry weight, Kt/Vurea,hours and days of dialysis per week, blood flow, dialyzer
type, and ultrafiltration/treatment were extracted at
monthly intervals. Means were then computed for 6-
month periods. The number of prescribed BP medica-
tions and type and doses of phosphate binders were
recorded for each patient every 6 months. Vascular
access type and reasons for cessation of hemodialysis
were noted.
Results
Twenty patients fit the inclusion criteria. Demographic
data were as follows: median age at hemodialysis initi-
ation, 12.2 years (range 0.8–20 years); numbers of trans-
fers from peritoneal dialysis, 8; number of patients with
travel time to hospital of more than 1 hr, 8; and numberof single-parent families, 8. The etiologies of renal failure
were renal dysplasia (with or without reflux or obstruc-
tion): 12 patients; cystinosis: 4 patients; glomerular
disease: 2 patients; post-ischemic: 1 patient; and Bartter’s
Hemodialysis International, Vol. 7, No. 4, 2003 Bell and Espinosa
291
syndrome: 1 patient. Patient weight ranged from 5.7 to
66 kg. Fifty percent of patients were severely oliguric or
anuric at the start of hemodialysis, and the proportionincreased with time on dialysis. Reasons for transfer
from hemodialysis before 36 months were as follows:
renal transplantation (12 patients) and transfer to adult
hemodialysis unit after 18 years of age (3 patients). Five
patients in the cohort were still on hemodialysis at the
time of data analysis.
All treatments were performed with Cobe Centrysys-
tem 31 dialysis machines (Cobe Laboratories Inc., Lake-wood, CO, USA). The majority of patients (16/20) were
dialyzed through central venous catheters, almost all
internal jugular. Subclavian catheters were used only if
internal jugular access was impossible. Four patients had
arteriovenous fistulas. All patients with hemodialysis
catheters received low-dose warfarin to minimize access
clotting; the target international normalized ratio was 1.5
to 1.8. Dialyzer membranes were hemophan (13patients), polysulfone (4 patients), and polysulfone high
flux (3 patients). The high-flux dialyzers were used in
larger patients on dialysis for more than 2 years. No
dialyzers were reused. Dialyzer size and blood flow
rates were based on patient size and target urea clearance
of 5mL/kg/min. CaCO3 was the phosphate binder used in
almost all patients. Occasionally sevelamer was prescribed.
Mean values for Ca, P, albumin, and hemoglobinlevels and for daily oral Ca binders are presented in
Table I. After dialysis initiation, the mean Ca�P never
exceeded 4.4 mmol2/L2 (55 mg2/dL2) and mean serum P
levels were never greater than 1.8mM (5.6mg/dL). Mean
albumin levels were in the midnormal range for our
laboratory (34–56g/L) throughout the observation period.
Anemia was well controlled, with average hemoglobin
levels ranging from 115 to 126 g/L, at the defined timepoints. Average daily oral Ca intake, for phosphate bind-
ing, ranged from 915 to 1833 mg. Mean intact PTH levels
(� SD) at baseline, 6, 12, 18, and 24 months were 157
�152, 156 �117, 189 �114, 231 �282, and 198 �238 pg/
mL, respectively. There were insufficient numbers to cal-
culate PTH means at 30 and 36 months. BP data are
summarized in Table II. The majority of patients had
predialysis BPs within the normal range for age.Approximately half required antihypertensive treatment,
with the average number of medications per treated
patient ranging from 1.5 (Months 18 and 24) to 1.86
(Month 12).
Clearance data are summarized in Table III. Mean
equilibrated (VVDP) dialyzer KT/Vurea ranged from 1.9
to 2.1; mean residual renal urea clearance, measured as
equivalent dialyzer urea clearance (renal Kt/Vurea),declined progressively and was minimal after 18 months
(Fig. 1). The majority of patients were oligoanuric after
12 months. Mean hourly ultrafiltration rates, normalized
for body size, varied from 5.2 to 12.4mL/kg, with mean
absolute values ranging from 0.2 to 0.4 L/hr (Table IV).
Mean weekly dialysis hours for the oligoanuric patients
ranged from 14.8 to 16.3 during the 6-month intervals
(Table IV). A few patients had complex transportationarrangements, which made it difficult to extend their
treatment times for marked fluid overload or access dys-
function.
Discussion
Optimizing dialysis in pediatric patients requires consid-
eration of both their short-term and their long-term needs.
These include growth, nutrition, cardiovascular risk fac-
tors, bone metabolism, schooling, and quality of life.Premature cardiovascular disease is a serious concern
with childhood onset kidney failure. Two recent analyses
of the USRDS database examined cardiovascular disease
and death with pediatric renal failure. Thirty-one percent
of children on dialysis had a cardiovascular event and 3%
suffered cardiac arrest [13]. Cardiovascular mortality
before age 30, in those with end-stage renal disease
(ESRD) onset in childhood, was 1000-fold higher thanin the general population and 10 to 15 times higher for
dialysis patients compared with transplant recipients [14].
Vascular abnormalities are striking in both children and
young adults with childhood onset ESRD. Biopsies of
TABLE I Cardiovascular and metabolic risk factors and intensive pediatric center hemodialysisa.
Time (months) after dialysis initiation
Baseline 6 12 18 24 30 36
Number of patients 20 20 18 12 7 5 3
Total Ca (mM) 2.22 (0.38) 2.41 (0.13) 2.36 (0.11) 2.37 (0.13) 2.35 (0.14) 2.46 (0.20) 2.32 (0.07)
P (mM) 1.90 (0.71) 1.60 (0.30) 1.64 (0.41) 1.51 (0.27) 1.37 (0.40) 1.40 (0.33) 1.37 (0.43)
Ca�P (mmol2/L2) 4.1 (1.4) 3.8 (0.8) 3.8 (0.9) 3.6 (0.6) 3.2 (0.8) 3.4 (0.9) 3.2 (1.1)
CaCO3 dose (mg Ca/day) 915 (720) 1228 (1065) 1283 (648) 1675 (1134) 1433 (1266) 1700 (1565) 1833 (1607)
CaCO3 dose (mg Ca/kg/day) 30 (26) 34 (23) 43 (38) 59 (78) 48 (52) 35 (34) 36 (34)
Serum albumin (g/L) 34 (12) 39 (6) 39 (4) 39 (4) 41 (3) 40 (3) 40 (3)
Hemoglobin (g/L) 101 (24) 118 (11) 115 (10) 119 (7) 117 (11) 126 (17) 124 (22)
aData are reported as mean (SD).
Ca ¼ calcium; P ¼ phosphorus; CaCO3 ¼ calcium carbonate.
Intensive Hemodialysis for Children Hemodialysis International, Vol. 7, No. 4, 2003
292
internal iliac arteries procured at time of renal transplant
from 12 children showed arterial wall abnormalities in 7
[15]. Both coronary artery calcification and carotidartery abnormalities have been demonstrated in young
adults with childhood onset renal failure [16,17]. Eleva-
tions in serum Ca, P, Ca P product, and PTH and high
Ca intake are associated with vascular and visceral calci-fication and an increased risk of cardiovascular death in
adult renal failure patients [16,18]. Recent recommenda-
tions for adults on dialysis are to maintain total serum Ca
in the normal range of 2.3 to 2.4mM (9.2–9.6mg/dL),
serum P under 1.8mM (5.5mg/dL), Ca�P below 4.4
mmol2/L2 (55 mg2/dL2), and intact PTH at 100 to
200 pg/mL (unless there is adynamic bone disease) [18].
Nutrition is particularly important in children withrenal failure, not only because of its influence on growth
and development, but also because of its link with
cardiovascular risk. In adult HD patients, with no
known history of cardiovascular disease, a low serum
albumin or falling albumin level has each been associ-
ated with a significantly increased risk of cardiovascular
death [19].
Previously we demonstrated excellent catch-upgrowth with long in-center dialysis, high urea clearance,
TABLE II Blood pressure and intensive pediatric center hemodialysis.
Time (months) after dialysis initiation
Baseline 6 12 18 24 30 36
Number of patients 20 20 18 12 7 5 3
SBP before dialysisa 113 (16) 117 (12) 123 (15) 123 (10) 122 (7) 117 (6) 110 (5)
DBP before dialysisa 66 (12) 70 (11) 75 (14) 72 (7) 73 (14) 67 (10) 61 b
SBP (number of patients)
> 95th percentile 2 0 3 2 1 0 0
> 99th percentile 0 0 1 2 0 0 0
DBP (number of patients)
> 95th percentile 2 1 1 1 0 0 0
> 99th percentile 0 0 1 0 0 0 0
Percentage of patients taking BP
medication
50 45 47 60 57 0 0
Number of BP medications per patienta 0.8 (1.2) 0.7 (0.9) 0.9 (1.1) 0.9 (0.9) 0.9 (0.9) 0 0
aData are reported as mean (SD).bn¼ 1, as BP measured by Doppler.
SBP ¼ systolic blood pressure; DBP ¼ diastolic blood pressure.
TABLE III Clearance, blood flow, and protein nitrogen appearance during sequential 6-month intervals.
Months
0–6 7–12 13–18 19–24 25–30 31–36
Number of patients 20 18 12 7 5 3
Kt/Vureaa
Dialyzer 1.9 (0.4) 2.1 (0.5) 2.1 (0.4) 2.1 (0.6) 2.0 (0.6) 1.9 (0.6)
Renal 1.2 (1.4) 0.7 (1.0) 0.7 (1.2) 0.1 (0.2) 0.1 (0.2) 0.2 (0.2)
Total 3.1 (1.3) 2.8 (1.1) 2.8 (1.4) 2.2 (0.5) 2.2 (0.5) 2.1 (0.6)
Blood flow (mL/min)a 235 (94) 249 (91) 249 (96) 250 (93) 290 (57) 273 (75)
Blood flow (mL/kg/min)a 7.1 (1.1) 7.5 (1.0) 7.6 (1.8) 7.9 (2) 7.8 (1.9) 7.6 (3.1)
nPNA (g/kg/day)a 1.5 (0.6) 1.3 (0.4) 1.2 (0.3) 1.4 (0.4) 1.2 (0.3) 1.2 (0.4)
aData are reported as mean (SD).
nPNA ¼ normalized protein equivalent of total nitrogen appearance.
0
0.5
1
1.5
2
2.5
3
3.5
0–6 7–12 13–18 19–24 25–30 31–36
Months
Kt/
Vur
ea
dKt/Vurea rKt/Vurea
FIGURE1 Mean dialyzer KT/Vurea (dKT/Vurea) and renal KT/Vurea
(rKT/Vurea) at sequential 6-month intervals.
Hemodialysis International, Vol. 7, No. 4, 2003 Bell and Espinosa
293
and nutritional support [9]. In the present study, mean
dialysis time ranged from 14.8 to 16.3 hr per week in
oligoanuric patients, and average dialyzer Kt/Vurea for
all patients ranged from 1.9 to 2.1. The mean number ofdialysis sessions per week varied from 3 to 3.3; a few
patients, with very large fluid intakes, received four to
five treatments per week. With this approach, many cur-
rently defined cardiovascular risk factors were reduced.
Specifically these included serum P levels and Ca�P,
hyperparathyroidism, malnutrition (as assessed by
serum albumin), and anemia. Mean Ca intake in our
patients was much lower than that associated with cor-onary artery calcification in the study of Goodman et al.
[16]. Optimal BP control remains a challenge, however.
Although most patients had normal predialysis BP,
approximately half required antihypertensive therapy.
Perhaps better ultrafiltration modeling with on-line
plasma volume monitoring, lower dialysate sodium and
greater dietary sodium restriction could make a differ-
ence. Longer or more frequent dialysis sessions can alsoimprove BP control. In adults, predialysis BP correlates
with left ventricular hypertrophy [20,21]. In this respect,
the normal predialysis BP in approximately 80% of our
patients is encouraging. Of interest, Charra et al. [7]
found that reduction of dialysis treatment time in adults,
from 8 to 5 hr, was associated with an increase in the
number of patients requiring antihypertensive medica-
tion, from 2% to 13%, even though body weightdecreased. Thus, even with strict dietary sodium reduc-
tion, some patients may require longer treatment (6–8 hr)
to normalize their BP.
Daily home dialysis, particularly nocturnal, improves
BP and metabolic parameters [3,4], but it is a difficult
option for many pediatric patients and their families. Not
all caregivers have the desire or ability to learn the com-
plex and potentially stressful task of home hemodialysis.Some families consider home treatment an intrusion of
illness into the daily life of patient and family, and for
others space may be an issue. Center daily dialysis might
be an option for some; however, if travel time is long, it
could significantly impinge on school or recreational time.The children treated in our unit are likely representa-
tive of those in many other pediatric dialysis centers.
Their socioeconomic backgrounds are diverse. At any
given time, between one-third and one-half travel an
hour or more to the dialysis unit. The majority of our
patients and families have chosen center hemodialysis
because they did not want home peritoneal dialysis. Of
interest, in London, Ontario, Canada, where home dia-lysis for adult patients is being formally studied, it has
been estimated that only about 20% of the total hemo-
dialysis population would be able to perform this therapy
[22]. Clearly alternatives to both home and center daily
dialysis are needed.
Motivating patients and their families to follow an
intensive in-center dialysis program involves a team
effort. When patients begin hemodialysis in our unit, weexplain that 5-hr treatments, three times a week, are our
norm. The dialysis nurses and technologist, child life
workers, teachers, social workers, and volunteers all col-
laborate to help the patient and family adapt and to
make the dialysis experience as pleasant and productive
as possible. Dialysis schedules are tailored to minimize
time lost from school, with afternoon and Saturday treat-
ments. Dialysis time is used to help the children adjust totheir disease, learn more about their medications and
diet, and develop responsibility and autonomy for their
health. Some children in our program have actually
expressed ambivalence about getting a kidney transplant,
because they enjoy the social experience of the hemodia-
lysis sessions.
In summary, although long daily dialysis is the most
physiologic treatment, for many renal failure patients it isnot a reasonable option. This may be particularly true for
TABLE IV Dialysis time and ultrafiltration rate in all patients and in oligoanuric subgroups, at 6-month intervals.
Months
0-6 7-12 13-18 19-24 25-30 31-36
Patients: All Oligoanuric All Oligoanuric All Oligoanuric All Oligoanuric All Oligoanuric All Oligoanuric
Number of
patients
20 10 18 11 12 9 7 6 5 5 3 3
Hours/weeka 13.9 (2.1) 15.3 (1.7) 14.2 (2.2) 15.6 (1.6) 14.8 (3.0) 15.5 (3.2) 15.9 (2.9) 16.3 (3.1) 14.8 (0.1) 14.8 (0.1) 14.8 (0.5) 14.8 (0.5)
Days/weeka 3.1 (0.3) 3.1 (0.3) 3.1 (0.3) 3.2 (0.4) 3.2 (0.5) 3.2 (0.6) 3.3 (0.7) 3.3 (0.7) 3.0 (0) 3.0 (0) 3.0 (0) 3.0 (0)
UF/HD
session (L)a1.0 (1.0) 1.8 (0.5) 1.1 (1.0) 1.8 (0.6) 1.2 (1.0) 1.6 (0.8) 1.5 (0.9) 1.8 (0.8) 1.3 (0.7) 1.3 (0.7) 1.7 (0.8) 1.7 (0.8)
UF/hr (L)a 0.2 (0.2) 0.4 (0.1) 0.2 (0.2) 0.4 (0.1) 0.2 (0.2) 0.3 (0.2) 0.3 (0.2) 0.3 (0.1) 0.3 (0.1) 0.3 (0.1) 0.4 (0.2) 0.4 (0.2)
UF/wt
(ml/kg/hr)a5.2 (5.0) 9.3 (3.5) 6.3 (5.4) 10.0 (3.2) 7.4 (5.5) 9.8 (3.8) 10.8 (5.1) 12.4 (2.7) 7.0 (3.6) 7.0 (3.6) 8.7 (1.6) 8.7 (1.6)
aData are reported as mean (SD).
UF ¼ ultrafiltration; HD ¼ hemodialysis; UF/wt ¼ hourly ultrafiltration per session, adjusted for patient size.
Intensive Hemodialysis for Children Hemodialysis International, Vol. 7, No. 4, 2003
294
children, who usually need a caregiver to provide treat-
ment and who often live a fair distance from the dialysis
unit. Long, slow, intermittent treatment may be an excel-lent compromise, with reduction of cardiovascular risk
factors and improvement in growth. Thus, intermittent
intensive center hemodialysis, a viable alternative, needs
to be optimized. In addition, the social experience of the
hemodialysis unit can have a positive influence on quality
of life and, for some, may aid in preparation for trans-
plant. Multicenter studies are needed to better characterize
optimal dialysis treatment time and modalities in children.
Acknowledgments
The authors thank Dr Atul Sharma for development of thecomputer-modeling program for dialysis kinetics and MsHelen Magdalinos, Ms Elise Mok, and Mr Alexander Tomfor their assistance with data collection and analysis.
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