While a healthy kidney can fit into the palm of a hand, when these blood-cleansing organs fail to function, the result not only threatens organ mortality, but often inflicts a debilitating disease even upon the very young. The Renal Replacement Therapy program at St. Louis Children’s Hospital provides progressive treatment of acute and chronic renal failure that children and their families can only find in a pediatric setting.
An early pioneer in dialysis treatment, the hospital established one of the first dialysis centers in the nation. “What began in 1973 is still evident today,” says Dialysis Director Anne Beck, MD. “St. Louis Children’s Hospital fosters an approach that separates its dialysis program from others — advanced pediatric renal replacement therapy combined with an unrivaled commitment to patient care.”
“In our intensive care units, acute renal failure is secondary most often to congenital heart disease, followed by solid organ transplantation and sepsis,” says Dr. Beck, assistant professor of pediatrics at Washington University School of Medicine (WUSM). “Therapy differs in pediatrics from adult treatment. When a child goes into acute renal failure, we prefer continuous cycling peritoneal dialysis (CCPD) or continuous venovenous hemofiltration (CVVHD). We have the capability to dialyze very small infants with CCPD, or larger patients with CVVHD.”
The ICU staff relies upon the expertise of the hospital’s highly trained dialysis nurses to initiate therapy with the attending physician and remain until patients are stable. “Our nurses are very technically competent, and it is well known that the nephrologists and dialysis nurses maintain a collaborative approach in terms of making a plan for each patient,” states Debera Witty, RN, nurse clinician. “The physicians know what their goals are for the patient, and the nurses possess the expertise and most up-to-date knowledge to know what is possible.”
Because many very sick patients tolerate continous dialysis better than intermittent therapy, the hospital equips its units with Prisma™ Dialysis machines, one of the safest and most convenient therapy systems available. This state-of-the-art technology allows all functions to take place in one machine, and because of its accuracy and alarm system, the Prisma has reduced CVVHD complications.
According to Dr. Beck, ICU stays and complications at St. Louis Children’s Hospital have decreased following complex surgical procedures, thanks to citrate — a new anti-coagulation protocol. Prompted by S. Paul Hmiel, MD, PhD, medical director of the pediatric kidney transplant program at St. Louis Children’s Hospital and WUSM assistant professor of pediatrics, the citrate protocol has replaced heparin, the once preferred anti-coagulant used in continuous dialysis.
“Without question, peritoneal dialysis is the modality of choice for long-term dialysis because we can manage patients from far away,” Dr. Beck explains. “Peritoneal dialysis is better for kids because it doesn’t require blood access, it’s easier to remove fluids, and it allows children to maintain a more normal childhood by attending school regularly.” It is her belief that the peritoneal dialysis program’s real strength is the dedicated dialysis nurses patients and families come to rely on.
“We troubleshoot, talk parents through procedures and problems over the phone, even in the middle of the night,” says Witty. “The nurses are proactive, teaching parents how to add heparin or antibiotics to a bag along with all the labor-intensive duties associated with the therapy.” The dialysis nurses spend upwards of 40 hours with each family, educating them on everything from the mechanics of the machine to which solution to select each night. “Some parents call every day at first, but it’s worth it for the kids,” Witty shares.
Dr. Beck says the hospital’s goal for patients with chronic renal failure is to use dialysis as a bridge to renal transplantation. “Despite our best intentions to ameliorate the symptoms of kidney disease, the reality is that quality of life improves dramatically for the patient and family after a kidney transplant,” she adds. “Therefore, we rapidly move our patients to transplant when they are medically and emotionally stable.”
For the past nine years, Witty has directed these highly skilled dialysis nurses, who are not only on call for the hospital’s ICU and the peritoneal dialysis patients and their families, but also conduct hemodialysis therapy in the hospital’s Dialysis/Infusion Center.
“It’s at this family-oriented Dialysis Center that children with end stage renal disease spend at least a dozen hours each week in dialysis treatment,” says Meg Shea, RN, BC, PNP, the hospital’s renal pediatric nurse practitioner. “It’s also where bonds like no other are created between our nurses and the hemodialysis patients.” Two of the hospital’s child life specialists provide children play therapy and other activities to pass the time.
Shea works exclusively for the renal division, but spends a great deal of time in the Dialysis Center . As a “physician extender,” she manages medication changes, counsels families, provides examinations and is typically the first person the nurses call with patient care issues.
Many Dialysis Center patients participate in an exercise program based on a recent study by neighboring Barnes-Jewish Hospital researchers that proved the beneficial effects of exercise on dialysis. “Children at the center have the option of using one of two stationary bikes and free weights while they are dialyzing,” offers Dr. Beck. “We are so aggressive with our ultrafiltration, we keep kids off blood pressure medicine. Research shows the positive impact exercise has on reducing heart disease and increasing bone mineral density, both of which are exacerbated by chronic kidney disease.”
Following her fellowship at Children’s Hospital Medical Center in Cincinnati, Ohio, Dr. Beck joined the St. Louis Children’s Hospital staff to direct dialysis and infusion services. For the past eight years, Dr. Beck has cared for hundreds of children along with Dr. Hmiel and Keith Hruska, MD, nephrology division director at St. Louis Children’s Hospital and WUSM, and Ira M. Lang professor of nephrology. Together, these nephrologists lead a clinical team of nurses, transplant coordinators, dietitians, social workers, psychologists and child life specialists that meets weekly to discuss patient progress.
Dr. Beck sees more and more children heading toward dialysis because of the improvements in other organ transplantation. “Minimizing nephrotoxicity of multiple drug exposures will be our biggest task in the future,” she cautions. “Taking care of more and more complicated kids and protecting the kidneys while treating other disease processes is a huge challenge.”