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Kidney support for babies: building a comprehensive and integrated neonatal kidney support therapy program

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Abstract

Kidney support therapy (KST), previously referred to as Renal Replacement Therapy, is utilized to treat children and adults with severe acute kidney injury (AKI), fluid overload, inborn errors of metabolism, and kidney failure. Several forms of KST are available including peritoneal dialysis (PD), intermittent hemodialysis (iHD), and continuous kidney support therapy (CKST). Traditionally, extracorporeal KST (CKST and iHD) in neonates has had unique challenges related to small patient size, lack of neonatal-specific devices, and risk of hemodynamic instability due to large extracorporeal circuit volume relative to patient total blood volume. Thus, PD has been the most commonly used modality in infants, followed by CKST and iHD. In recent years, CKST machines designed for small children and novel filters with smaller extracorporeal circuit volumes have emerged and are being used in many centers to provide neonatal KST for toxin removal and to achieve fluid and electrolyte homeostasis, increasing the options available for this unique and vulnerable group. These new treatment options create a dramatic paradigm shift with recalibration of the benefit: risk equation. Renewed focus on the infrastructure required to deliver neonatal KST safely and effectively is essential, especially in programs/units that do not traditionally provide KST to neonates. Building and implementing a neonatal KST program requires an expert multidisciplinary team with strong institutional support. In this review, we first describe the available neonatal KST modalities including newer neonatal and infant-specific platforms. Then, we describe the steps needed to develop and sustain a neonatal KST team, including recommendations for provider and nursing staff training. Finally, we describe how quality improvement initiatives can be integrated into programs.

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Authors and Affiliations

  1. Division of Nephrology and Hypertension, Nationwide Children’s Hospital and The Ohio State University College of Medicine, Columbus, OH, USA

    Tahagod H. Mohamed

  2. The Kidney and Urinary Tract Center, Nationwide Children’s Hospital, 700 Children’s Dr, Columbus, OH, 430205, USA

    Tahagod H. Mohamed

  3. The Center for Acute Care Nephrology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA

    Jolyn Morgan

  4. Division of Nephrology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA

    Theresa A. Mottes

  5. Pediatric and Infant Center for Acute Nephrology, Division of Pediatric Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA

    David Askenazi

  6. Section of Nephrology, Medical College of Wisconsin/Children’s Hospital of Wisconsin, Milwaukee, WI, USA

    Jennifer G. Jetton

  7. Division of Pediatric Nephrology, Department of Pediatrics, Seattle Children’s Hospital and University of Washington, Seattle, WA, USA

    Shina Menon

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Contributions

THM and SM conceived and designed the review. THM, JM, and TAM drafted the initial manuscript. THM, JM, TAM, DA, JJ, and SM reviewed, revised, and edited several drafts of the manuscript. All authors contributed substantially and provided critical feedback. All authors approved the final version of the manuscript.

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Correspondence to Tahagod H. Mohamed.

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Conflict of interest

All authors declare no real conflicts of interest that could affect the study design, collection, analysis, and interpretation of data, writing of the report, or the decision to submit for publication. For full disclosure, we provide here an additional list of other author’s commitments and funding sources that are not directly related to this study: Jolyn Morgan is a consultant for Medtronic Inc. Theresa A. Mottes is a consultant for Medtronic Inc. David J Askenazi is a consultant for Baxter, Nuwellis, Medtronic Bioporto, and Seastar. His institution receives grant funding for education and research that is not related to this project from NIH, Baxter, Nuwellis, Medtronic, Bioporto and Seastar. He has patents pending on inventions to improve the kidney care of neonates. He is the Founder and Chief Scientific Officer for Zorro-Flow Inc. Shina Menon is a consultant for Nuwellis. Her institution receives grant funding for research that is not related to this project from Nuwellis, and Bioporto.

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1. c; 2. b; 3. e; 4. c; 5. a, b, d.

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Mohamed, T.H., Morgan, J., Mottes, T.A. et al. Kidney support for babies: building a comprehensive and integrated neonatal kidney support therapy program. Pediatr Nephrol 38, 2043–2055 (2023). https://doi.org/10.1007/s00467-022-05768-y

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