Hemodialysis International 2014; ••:••–••
Case Report
Experience with continuous venovenous hemodiafiltration in four newborns: A case series and review of the literature Ali Ulas TUGCU,1 Asli KANTAR,2 Aslihan ABBASOGLU,1 Ayse ECEVIT,1 Aylin TARCAN,1 Esra BASKIN,2 Department of Pediatrics, Divisions of 1Neonatology and 2Pediatric Nephrology, Baskent University Faculty of Medicine, Ankara Hospital, Ankara, Turkey
Abstract When conventional methods for treating complicated problems such as acute and chronic renal failure or metabolic diseases fail, the therapy of choice is peritoneal dialysis (PD) in neonatal period. However, in cases that involve technical difficulties, such as bulky lesions in the abdomen or complications from previous abdominal surgeries, it is not always possible to place a peritoneal catheter. In such situations, continuous venovenous hemodiafiltration (CVVHDF) can be effective. This case series presents our experience in 2013 with the administration of CVVHDF to four patients in our neonatal intensive care unit who could not undergo PD for various reasons. Key words: Peritoneal dialysis, hemodiafiltration, catheter
INTRODUCTION In cases where conventional treatments cannot adequately address complicated conditions, such as renal failure or metabolic diseases in newborns, the preferred treatment is peritoneal dialysis (PD).1,2 However, when a PD catheter cannot be placed due to technical difficulties, such as bulky lesions in the abdomen, continuous venovenous hemodiafiltration (CVVHDF) is another treatment option.1,3,4 This therapy is used in adults and pediatric age groups but is known to cause difficulties in newborns. In neonates, the quantity of plasma that must be drawn initially for CVVHDF can cause hemodynamic disorders.5 Also, electrolyte imbalance may occur during CVVHDF and this causes significant complications in newborns.5,6 Also,
Correspondence to: A. U. Tugcu, MD, 6. Cadde, No. 72, Bahcelievler, Cankaya, Ankara, Turkey. E-mail: [email protected]
neonates may not have sufficiently large venous diameter for CVVHDF, and the required dose of anticoagulant can cause problems in this age group.7 Further, hypothermia can take place during the long CVVHDF process, as a complication in newborns.7 All of these issues are reasons why application of CVVHDF is more restricted in neonates. In this article, we describe our experience in administering CVVHDF to 4 patients in our hospital’s newborn intensive care unit (NICU) in 2013, who could not undergo PD for various reasons (Table 1). In each patient, CVVHDF was performed by using an “EQUAsmart CRRT hemofiltration device” (Figure 1) and 7F-10 cm doublelumen intravenous catheter.
Case 1 A male infant was born to a 28-year-old mother at another center via normal spontaneous vaginal delivery in the 40th gestational week. His birthweight was 3650 g. A sibling had died from “maple syrup urine disease”
© 2014 International Society for Hemodialysis DOI:10.1111/hdi.12234
1
Tugcu et al.
Table 1 Case details for the newborns treated with continuous venovenous hemodiafiltration
Case Case Case Case
1 2 3 4
Birthweight (g)
Gestational age at birth (wks)
Sex
Disease
3650 1900 3440 3700
40 33 37 38
Male Male Female Male
MSUD Polycystic kidneys Polycystic kidneys SVT + multiple organ failure
Age at admission (postnatal day)
Hospital stay (d)
Complication (catheter or procedure origin)
Mortality
11 13 3 13
23 123 67 48
− + + +
− + − +
MSUD = maple syrup urine disease; SVT = supraventricular tachycardia.
(MSUD). After discharge, the newborn was brought to another center with complaints of vomiting and decreased nursing. Tandem mass results confirmed diagnosis of MSUD together with the family history of MSUD. Appropriate formula was administered and PD treatment was started. Despite treatment, elevated levels of leucine and isoleucine were revealed. The baby was transferred to our hospital on postnatal day 11. Laboratory testing upon admission revealed serum leucine level of 1720 μmol/L. A double-lumen catheter was inserted in the patient’s subclavian vein and CVVHDF treatment was initiated with no anticoagulation. No complications related to CVVHDF or the catheter, specifically, were observed. By postnatal day 33, the infant’s serum leucine level had dropped to
400 μmol/L and he was discharged and followed up closely.
Case 2 A male infant, who was antenatally diagnosed with polycystic kidney disease (PKD) (autosomal recessive form), was born to a 26-year-old mother at another center via cesarean section in the 33rd gestational week. His birthweight was 1900 g. After birth, PD was started. Three PD catheter revisions were attempted but effective dialysis could not be achieved. The patient was admitted to our NICU on postnatal day 13. A double-lumen catheter was inserted in his subclavian vein and CVVHDF treatment
Figure 1 EQUAsmart CRRT hemofiltration device for continuous venovenous hemodiafiltration.
2
Hemodialysis International 2014; ••:••–••
Hemodiafiltration with four newborns
was initiated without anticoagulant. The baby was hemodynamically unstable to go under nephrectomy; so to reduce the size of the baby’s kidneys and enable future PD, bilateral renal artery embolization was carried out on postnatal day 15. The CVVHDF had continued for 45 days. The CVVHDF catheter had to be replaced 3 times due to coagulation. On postnatal day 47, the patient had CVVHDF catheter-induced sepsis (Klebsiella sp.), and vancomycin, meropenem, and amikacin were administered. Evaluation with abdominal ultrasonography on postnatal day 50 revealed no reduction in the size of the left kidney. The infant died of ventilator-related pneumonia on postnatal day 135.
Case 3 A female infant was born to a 33-year-old mother at another center via cesarean section in the 37th gestational week. Her birthweight was 3440 g. During routine physical examination, a filling mass was palpated in the baby’s abdomen. Results from pathological examination of excisional biopsy from kidneys indicated that the mass was compatible with a PKD (autosomal recessive form). On postnatal day 3, attempts to insert a PD catheter failed and the infant was admitted to our NICU. A double-lumen catheter was placed in her external jugular vein and CVVHDF treatment was started without anticoagulant. The baby was hemodynamically unstable to go under nephrectomy; so to reduce the size of the kidneys and to facilitate future PD, bilateral renal artery embolization was performed on postnatal day 5. She was diagnosed with Staphylococcus epidermidis sepsis originating from the CVVHDF catheter on postnatal day 27. Vancomycin and meropenem were administered. Abdominal ultrasonography on postnatal day 45 revealed that both kidneys had reduced in size. The CVVHDF treatment regimen was terminated on postnatal day 61. The parents were instructed on how to continue PD at home and the patient was added to the renal transplantation list. The patient was discharged on postnatal day 69 with PD.
Case 4 A male infant was born to a 23-year-old mother at another center via normal spontaneous vaginal delivery in the 37th gestational week. His birthweight was 3700 g. On postnatal day 13, the newborn developed respiratory problems. He was diagnosed to have respiratory distress and supraventricular tachycardia in our emergency department. When the patient did not respond to adenosine administration, cardioversion was applied. Following
Hemodialysis International 2014; ••:••–••
this, he entered cardiac arrest and responded to cardiopulmonary resuscitation. On postnatal day 17, the newborn developed multiorgan failure, and then PD was started. His PD catheter became obstructed and had to be replaced 3 times. On postnatal day 27, a double-lumen intravenous catheter was inserted in the patient’s subclavian vein and CVVHDF was started without anticoagulation. No complications developed. The patient died on postnatal day 60, in the intensive care unit of the department of pediatrics, of our hospital, due to respiratory and renal failure.
DISCUSSION Until relatively recently, in cases where attempts at PD have failed in an infant or newborn with acute renal failure or metabolic disease, the treatment attempted was continuous arteriovenous hemodiafiltration. However, the need for arterial access and for high arterial pressure to ensure continuity of flow caused difficulties in applying this technique for newborns and preterm babies.6 These problems led to the advancement of CVVHDF for newborns and young infants.7 The literature contains only a limited number of studies on the administration of CVVHDF to newborns. Goldstein et al. were the first to report success with application of an early method of CVVHDF in infants with renal failure and multiple organ failure.8 Klee et al. conducted a retrospective study of 20 infants who underwent CVVHDF and reported successful results.9 George et al. compared findings for 25 infants—in both groups—who had undergone PD or CVVHDF, and observed minimal differences between the two groups with respect to metabolic and clinical outcomes.10 Rödl et al. reported 9 years of follow-up (2000–2009) for 4 newborns with end-stage renal failure who underwent successful alternating treatments with PD and CVVHDF and showed that, in case of PD complications, CVVHDF may be an appropriate bridge to achieve long-term survival until kidney transplantation.11 Coulthard and Sharp investigated the success of CVVHDF vs. continuous arteriovenous hemodiafiltration in 4 newborns with very low birthweights; they used different techniques for venous access. CVVHDF had continued successfully until 3 of 4 babies had died due to their primary kidney diseases.6 The major difficulty in placing double-lumen intravenous catheters to venous access for CVVHDF application in newborns seems to be their lumens’ greater sizes. We had seen that no complications occurred during insertion procedure.
3
Tugcu et al.
Table 2 Specifications for continuous venovenous hemodiafiltration
Manuscript received July 2014; revised August 2014.
Vascular access
REFERENCES
7F-10 cm MedCOMP REF T74M double-lumen intravenous catheter Hemofilter EQUAsmart CRRT hemofiltration device Anticoagulant None Dialysate Physioneal® 40 1.36% glucose Replacement fluid Physioneal® 40 1.36% glucose Qb 30–50 mL/min Qf 50–100 mL/h Qd 300–500 mL/h Qb = blood flow rate; Qf = filtration rate; Qd = dialysate flow rate.
Yorgin et al. reported that the use of anticoagulant to prevent congestion in the set during the process may cause some problems (hemorrhage, thrombocytopenia, etc.) during CVVHDF application.7 Morabito et al. adapted a new strategy—regional citrate anticoagulation usage—for patients who are at high risk of bleeding, who had gone under continuous renal replacement therapies.12 Because of possible complications of anticoagulants and inadequate information about regional citrate anticoagulant usage in newborns, we did not use any anticoagulant during CVVHDF application. We administered CVVHDF with certain specifications (Table 2). CVVHDF application is widely used in infants with metabolic diseases. Puliyanda et al. reported that CVVHDF application together with enteral feeding of a metabolically appropriate formula is the most efficacious modality of therapy for neonates with MSUD.13 In our case, infant with MSUD who did not respond to PD underwent CVVHDF, and serum levels of leucine and isoleucine had declined. Continuous venovenous hemodiafiltration should be considered as a treatment option for neonates in whom PD cannot be performed or is ineffective. It is not ideal to attempt application in the neonatal period because of the technical difficulties involved, but this treatment can be life saving in this patient group.
ACKNOWLEDGMENT No external funding was received or used to carry out this article.
1 Shroff R, Ledermann S. Long-term outcome of chronic dialysis in children. Pediatr Nephrol. 2009; 24:463–474. 2 Ronco C. Can peritoneal dialysis be considered an option for the treatment of acute kidney injury? Perit Dial Int. 2007; 27:251–253. 3 Pichler G, Rödl S, Mache C, Trop M, Ring E, Zobel G. Two decades’ experience of renal replacement therapy in pediatric patients with acute renal failure. Eur J Pediatr. 2007; 166:139–144. 4 Litwin M, Grenda R, Prokurat S, et al. Patient survival and causes of death on hemodialysis and peritoneal dialysis—Single-center study. Pediatr Nephrol. 2001; 16:996–1001. 5 Shiga H, Hirasawa H, Oda S, Matsuda K, Ueno H, Nakamura M. Continuous hemodiafiltration in pediatric critical care patients. Ther Apher Dial. 2004; 8:390–397. 6 Coulthard MG, Sharp J. Hemodialysis and ultrafiltration in babies weighing under 1000 g. Arch Dis Child Fetal Neonatal Ed. 1995; 73:162–165. 7 Yorgin PD, Krensky AM, Tune BM. Continuous venovenous hemofiltration. Paediatr Nephrol. 1990; 4:640– 642. 8 Goldstein SL, Currier H, Graf C, Cosio CC, Brewer ED, Sachdeva R. Outcome in children receiving continuous venovenous hemofiltration. Pediatrics. 2001; 107:1309– 1312. 9 Klee KM, Greenleaf K, Fouser L, Watkins SL. Continuous venovenous hemofiltration with and without dialysis in pediatric patients. ANNA J. 1996; 23:35–39. 10 George J, Varma S, Kumar S, Thomas J, Gopi S, Pisharody R. Comparing continuous venovenous hemodiafiltration and peritoneal dialysis in critically ill patients with acute kidney injury: A pilot study. Perit Dial Int. 2001; 31:422– 429. 11 Rödl S, Marschitz I, Mache CJ, Nagel B, Koestenberger M, Zobel G. Hemodiafiltration in infants with complications during peritoneal dialysis. Artif Organs. 2012; 36:590– 593. 12 Morabito S, Pistolesi V, Tritapepe L, et al. Regional citrate anticoagulation in CVVH: A new protocol combining citrate solution with a phosphate-containing replacement fluid. Hemodial Int. 2013; 17:313–320. 13 Puliyanda DP, Harmon WE, Peterschmitt MJ, Irons M, Somers MJ. Utility of hemodialysis in maple syrup urine disease. Pediatr Nephrol. 2002; 7:239–242.
CONFLICT OF INTEREST The authors declare that they have no conflict of interest.
4
Hemodialysis International 2014; ••:••–••
Case Report
Experience with continuous venovenous hemodiafiltration in four newborns: A case series and review of the literature Ali Ulas TUGCU,1 Asli KANTAR,2 Aslihan ABBASOGLU,1 Ayse ECEVIT,1 Aylin TARCAN,1 Esra BASKIN,2 Department of Pediatrics, Divisions of 1Neonatology and 2Pediatric Nephrology, Baskent University Faculty of Medicine, Ankara Hospital, Ankara, Turkey
Abstract When conventional methods for treating complicated problems such as acute and chronic renal failure or metabolic diseases fail, the therapy of choice is peritoneal dialysis (PD) in neonatal period. However, in cases that involve technical difficulties, such as bulky lesions in the abdomen or complications from previous abdominal surgeries, it is not always possible to place a peritoneal catheter. In such situations, continuous venovenous hemodiafiltration (CVVHDF) can be effective. This case series presents our experience in 2013 with the administration of CVVHDF to four patients in our neonatal intensive care unit who could not undergo PD for various reasons. Key words: Peritoneal dialysis, hemodiafiltration, catheter
INTRODUCTION In cases where conventional treatments cannot adequately address complicated conditions, such as renal failure or metabolic diseases in newborns, the preferred treatment is peritoneal dialysis (PD).1,2 However, when a PD catheter cannot be placed due to technical difficulties, such as bulky lesions in the abdomen, continuous venovenous hemodiafiltration (CVVHDF) is another treatment option.1,3,4 This therapy is used in adults and pediatric age groups but is known to cause difficulties in newborns. In neonates, the quantity of plasma that must be drawn initially for CVVHDF can cause hemodynamic disorders.5 Also, electrolyte imbalance may occur during CVVHDF and this causes significant complications in newborns.5,6 Also,
Correspondence to: A. U. Tugcu, MD, 6. Cadde, No. 72, Bahcelievler, Cankaya, Ankara, Turkey. E-mail: [email protected]
neonates may not have sufficiently large venous diameter for CVVHDF, and the required dose of anticoagulant can cause problems in this age group.7 Further, hypothermia can take place during the long CVVHDF process, as a complication in newborns.7 All of these issues are reasons why application of CVVHDF is more restricted in neonates. In this article, we describe our experience in administering CVVHDF to 4 patients in our hospital’s newborn intensive care unit (NICU) in 2013, who could not undergo PD for various reasons (Table 1). In each patient, CVVHDF was performed by using an “EQUAsmart CRRT hemofiltration device” (Figure 1) and 7F-10 cm doublelumen intravenous catheter.
Case 1 A male infant was born to a 28-year-old mother at another center via normal spontaneous vaginal delivery in the 40th gestational week. His birthweight was 3650 g. A sibling had died from “maple syrup urine disease”
© 2014 International Society for Hemodialysis DOI:10.1111/hdi.12234
1
Tugcu et al.
Table 1 Case details for the newborns treated with continuous venovenous hemodiafiltration
Case Case Case Case
1 2 3 4
Birthweight (g)
Gestational age at birth (wks)
Sex
Disease
3650 1900 3440 3700
40 33 37 38
Male Male Female Male
MSUD Polycystic kidneys Polycystic kidneys SVT + multiple organ failure
Age at admission (postnatal day)
Hospital stay (d)
Complication (catheter or procedure origin)
Mortality
11 13 3 13
23 123 67 48
− + + +
− + − +
MSUD = maple syrup urine disease; SVT = supraventricular tachycardia.
(MSUD). After discharge, the newborn was brought to another center with complaints of vomiting and decreased nursing. Tandem mass results confirmed diagnosis of MSUD together with the family history of MSUD. Appropriate formula was administered and PD treatment was started. Despite treatment, elevated levels of leucine and isoleucine were revealed. The baby was transferred to our hospital on postnatal day 11. Laboratory testing upon admission revealed serum leucine level of 1720 μmol/L. A double-lumen catheter was inserted in the patient’s subclavian vein and CVVHDF treatment was initiated with no anticoagulation. No complications related to CVVHDF or the catheter, specifically, were observed. By postnatal day 33, the infant’s serum leucine level had dropped to
400 μmol/L and he was discharged and followed up closely.
Case 2 A male infant, who was antenatally diagnosed with polycystic kidney disease (PKD) (autosomal recessive form), was born to a 26-year-old mother at another center via cesarean section in the 33rd gestational week. His birthweight was 1900 g. After birth, PD was started. Three PD catheter revisions were attempted but effective dialysis could not be achieved. The patient was admitted to our NICU on postnatal day 13. A double-lumen catheter was inserted in his subclavian vein and CVVHDF treatment
Figure 1 EQUAsmart CRRT hemofiltration device for continuous venovenous hemodiafiltration.
2
Hemodialysis International 2014; ••:••–••
Hemodiafiltration with four newborns
was initiated without anticoagulant. The baby was hemodynamically unstable to go under nephrectomy; so to reduce the size of the baby’s kidneys and enable future PD, bilateral renal artery embolization was carried out on postnatal day 15. The CVVHDF had continued for 45 days. The CVVHDF catheter had to be replaced 3 times due to coagulation. On postnatal day 47, the patient had CVVHDF catheter-induced sepsis (Klebsiella sp.), and vancomycin, meropenem, and amikacin were administered. Evaluation with abdominal ultrasonography on postnatal day 50 revealed no reduction in the size of the left kidney. The infant died of ventilator-related pneumonia on postnatal day 135.
Case 3 A female infant was born to a 33-year-old mother at another center via cesarean section in the 37th gestational week. Her birthweight was 3440 g. During routine physical examination, a filling mass was palpated in the baby’s abdomen. Results from pathological examination of excisional biopsy from kidneys indicated that the mass was compatible with a PKD (autosomal recessive form). On postnatal day 3, attempts to insert a PD catheter failed and the infant was admitted to our NICU. A double-lumen catheter was placed in her external jugular vein and CVVHDF treatment was started without anticoagulant. The baby was hemodynamically unstable to go under nephrectomy; so to reduce the size of the kidneys and to facilitate future PD, bilateral renal artery embolization was performed on postnatal day 5. She was diagnosed with Staphylococcus epidermidis sepsis originating from the CVVHDF catheter on postnatal day 27. Vancomycin and meropenem were administered. Abdominal ultrasonography on postnatal day 45 revealed that both kidneys had reduced in size. The CVVHDF treatment regimen was terminated on postnatal day 61. The parents were instructed on how to continue PD at home and the patient was added to the renal transplantation list. The patient was discharged on postnatal day 69 with PD.
Case 4 A male infant was born to a 23-year-old mother at another center via normal spontaneous vaginal delivery in the 37th gestational week. His birthweight was 3700 g. On postnatal day 13, the newborn developed respiratory problems. He was diagnosed to have respiratory distress and supraventricular tachycardia in our emergency department. When the patient did not respond to adenosine administration, cardioversion was applied. Following
Hemodialysis International 2014; ••:••–••
this, he entered cardiac arrest and responded to cardiopulmonary resuscitation. On postnatal day 17, the newborn developed multiorgan failure, and then PD was started. His PD catheter became obstructed and had to be replaced 3 times. On postnatal day 27, a double-lumen intravenous catheter was inserted in the patient’s subclavian vein and CVVHDF was started without anticoagulation. No complications developed. The patient died on postnatal day 60, in the intensive care unit of the department of pediatrics, of our hospital, due to respiratory and renal failure.
DISCUSSION Until relatively recently, in cases where attempts at PD have failed in an infant or newborn with acute renal failure or metabolic disease, the treatment attempted was continuous arteriovenous hemodiafiltration. However, the need for arterial access and for high arterial pressure to ensure continuity of flow caused difficulties in applying this technique for newborns and preterm babies.6 These problems led to the advancement of CVVHDF for newborns and young infants.7 The literature contains only a limited number of studies on the administration of CVVHDF to newborns. Goldstein et al. were the first to report success with application of an early method of CVVHDF in infants with renal failure and multiple organ failure.8 Klee et al. conducted a retrospective study of 20 infants who underwent CVVHDF and reported successful results.9 George et al. compared findings for 25 infants—in both groups—who had undergone PD or CVVHDF, and observed minimal differences between the two groups with respect to metabolic and clinical outcomes.10 Rödl et al. reported 9 years of follow-up (2000–2009) for 4 newborns with end-stage renal failure who underwent successful alternating treatments with PD and CVVHDF and showed that, in case of PD complications, CVVHDF may be an appropriate bridge to achieve long-term survival until kidney transplantation.11 Coulthard and Sharp investigated the success of CVVHDF vs. continuous arteriovenous hemodiafiltration in 4 newborns with very low birthweights; they used different techniques for venous access. CVVHDF had continued successfully until 3 of 4 babies had died due to their primary kidney diseases.6 The major difficulty in placing double-lumen intravenous catheters to venous access for CVVHDF application in newborns seems to be their lumens’ greater sizes. We had seen that no complications occurred during insertion procedure.
3
Tugcu et al.
Table 2 Specifications for continuous venovenous hemodiafiltration
Manuscript received July 2014; revised August 2014.
Vascular access
REFERENCES
7F-10 cm MedCOMP REF T74M double-lumen intravenous catheter Hemofilter EQUAsmart CRRT hemofiltration device Anticoagulant None Dialysate Physioneal® 40 1.36% glucose Replacement fluid Physioneal® 40 1.36% glucose Qb 30–50 mL/min Qf 50–100 mL/h Qd 300–500 mL/h Qb = blood flow rate; Qf = filtration rate; Qd = dialysate flow rate.
Yorgin et al. reported that the use of anticoagulant to prevent congestion in the set during the process may cause some problems (hemorrhage, thrombocytopenia, etc.) during CVVHDF application.7 Morabito et al. adapted a new strategy—regional citrate anticoagulation usage—for patients who are at high risk of bleeding, who had gone under continuous renal replacement therapies.12 Because of possible complications of anticoagulants and inadequate information about regional citrate anticoagulant usage in newborns, we did not use any anticoagulant during CVVHDF application. We administered CVVHDF with certain specifications (Table 2). CVVHDF application is widely used in infants with metabolic diseases. Puliyanda et al. reported that CVVHDF application together with enteral feeding of a metabolically appropriate formula is the most efficacious modality of therapy for neonates with MSUD.13 In our case, infant with MSUD who did not respond to PD underwent CVVHDF, and serum levels of leucine and isoleucine had declined. Continuous venovenous hemodiafiltration should be considered as a treatment option for neonates in whom PD cannot be performed or is ineffective. It is not ideal to attempt application in the neonatal period because of the technical difficulties involved, but this treatment can be life saving in this patient group.
ACKNOWLEDGMENT No external funding was received or used to carry out this article.
1 Shroff R, Ledermann S. Long-term outcome of chronic dialysis in children. Pediatr Nephrol. 2009; 24:463–474. 2 Ronco C. Can peritoneal dialysis be considered an option for the treatment of acute kidney injury? Perit Dial Int. 2007; 27:251–253. 3 Pichler G, Rödl S, Mache C, Trop M, Ring E, Zobel G. Two decades’ experience of renal replacement therapy in pediatric patients with acute renal failure. Eur J Pediatr. 2007; 166:139–144. 4 Litwin M, Grenda R, Prokurat S, et al. Patient survival and causes of death on hemodialysis and peritoneal dialysis—Single-center study. Pediatr Nephrol. 2001; 16:996–1001. 5 Shiga H, Hirasawa H, Oda S, Matsuda K, Ueno H, Nakamura M. Continuous hemodiafiltration in pediatric critical care patients. Ther Apher Dial. 2004; 8:390–397. 6 Coulthard MG, Sharp J. Hemodialysis and ultrafiltration in babies weighing under 1000 g. Arch Dis Child Fetal Neonatal Ed. 1995; 73:162–165. 7 Yorgin PD, Krensky AM, Tune BM. Continuous venovenous hemofiltration. Paediatr Nephrol. 1990; 4:640– 642. 8 Goldstein SL, Currier H, Graf C, Cosio CC, Brewer ED, Sachdeva R. Outcome in children receiving continuous venovenous hemofiltration. Pediatrics. 2001; 107:1309– 1312. 9 Klee KM, Greenleaf K, Fouser L, Watkins SL. Continuous venovenous hemofiltration with and without dialysis in pediatric patients. ANNA J. 1996; 23:35–39. 10 George J, Varma S, Kumar S, Thomas J, Gopi S, Pisharody R. Comparing continuous venovenous hemodiafiltration and peritoneal dialysis in critically ill patients with acute kidney injury: A pilot study. Perit Dial Int. 2001; 31:422– 429. 11 Rödl S, Marschitz I, Mache CJ, Nagel B, Koestenberger M, Zobel G. Hemodiafiltration in infants with complications during peritoneal dialysis. Artif Organs. 2012; 36:590– 593. 12 Morabito S, Pistolesi V, Tritapepe L, et al. Regional citrate anticoagulation in CVVH: A new protocol combining citrate solution with a phosphate-containing replacement fluid. Hemodial Int. 2013; 17:313–320. 13 Puliyanda DP, Harmon WE, Peterschmitt MJ, Irons M, Somers MJ. Utility of hemodialysis in maple syrup urine disease. Pediatr Nephrol. 2002; 7:239–242.
CONFLICT OF INTEREST The authors declare that they have no conflict of interest.
4
Hemodialysis International 2014; ••:••–••
