In-center daily on-line hemodiafiltration: a 4-year experience in children

Our daily dialysis program was started in September 2002: in-center daily on-line hemodiafiltration (DIH) was carried out in 3-hour sessions, 5 - 6 times weekly, on-line assessment KT/Vurea of minimal 1.5 per session, polysulfone membranes. 12 children were included: median age 7.4 years (2.10 - 16.8 years), renal residual function less than 3 ml/min/1.73 m2 (Kcreat + Kurea/2), vascular access central catheter (n = 4) or fistula (n = 8), 7/12 being converted from peritoneal dialysis to DIH. Median follow-up on DIH was 11 months (4 - 43 months), endpoint was kidney transplantation (11/12) or transfer to another center (1/12). Monthly assessments of dialysis parameters (KT/Vurea, predialysis phosphatemia), diet survey (3 consecutive days), medications (number of antihypertensive drugs, phosphate chelators, potassium chelators) and statural growth were performed. At start of DIH, diet intake due to medical prescription and limited appetite was restrictive with limitation in water, salt (20 mmol/day), potassium and proteins (median 35 g/day, range 20 - 80 g); only 2/12 children were free of antihypertensive drugs, all received phosphate and potassium chelators, and growth retardation occurred (7/12 in prepubertal children, median height SDS -1.52) despite rhGH therapy (5/12 patients). At the end of DIH, diet was free, protein intake high (2 - 3 g/kg/day, range 30 - 100), 10/12 children were free of antihypertensive drugs, 4/12 received potassium chelators, 1/12 received phosphate chelators. All the prepubertal children at inclusion (n = 7) showed catch-up growth with a median growth rate of 0.8 cm/month (0.5 - 1.6 cm/ month). DIH allowed to maintain predialysis phosphatemia in a low normal range (median 1.23 mmol/l, range 1.65 - 0.63), without (11/12 children) need of phosphate chelators. Thanks to DIH children, parents and team care discovered during DIH a new way of life with motivated children, showing natural compliance (no diet restriction, no or few drugs), and most of all children developing with catch-up of growth.