Managing heart failure in dialysis patients.

The heart and the kidney are intimately connected. They communicate in a bidirectional manner through a variety of pathways, forming an interdependent relationship. Recognition of this co-dependency is crucial in managing patients with cardiorenal syndrome, as we begin to realise the inevitability of disease progression to both organs; and an approach that focuses treatment on one organ may result in worsening outcome on the other organ. When faced with patients with deteriorating cardiac disease, nephrologists tend to focus on stabilisation of cardiac function and accept the heart disease to be unmodifiable. Likewise, cardiac patients with persistent kidney failure are presented with a poor renal prognosis and prepared for kidney transplantation. Adopting a cardio-protective approach in combination with dialysis optimisation raises hope for a more positive outcome with evidence of cardiac and renal recovery in some patients.

Genetic Identification of Two Novel Loci Associated with Steroid-Sensitive Nephrotic Syndrome.

BACKGROUND: Steroid-sensitive nephrotic syndrome (SSNS), the most common form of nephrotic syndrome in childhood, is considered an autoimmune disease with an established classic HLA association. However, the precise etiology of the disease is unclear. In other autoimmune diseases, the identification of loci outside the classic HLA region by genome-wide association studies (GWAS) has provided critical insights into disease pathogenesis. Previously conducted GWAS of SSNS have not identified non-HLA loci achieving genome-wide significance. METHODS: In an attempt to identify additional loci associated with SSNS, we conducted a GWAS of a large cohort of European ancestry comprising 422 ethnically homogeneous pediatric patients and 5642 ethnically matched controls. RESULTS: The GWAS found three loci that achieved genome-wide significance, which explain approximately 14% of the genetic risk for SSNS. It confirmed the previously reported association with the HLA-DR/DQ region (lead single-nucleotide polymorphism [SNP] rs9273542, P=1.59×10-43; odds ratio [OR], 3.39; 95% confidence interval [95% CI], 2.86 to 4.03) and identified two additional loci outside the HLA region on chromosomes 4q13.3 and 6q22.1. The latter contains the calcium homeostasis modulator family member 6 gene CALHM6 (previously called FAM26F). CALHM6 is implicated in immune response modulation; the lead SNP (rs2637678, P=1.27×10-17; OR, 0.51; 95% CI, 0.44 to 0.60) exhibits strong expression quantitative trait loci effects, the risk allele being associated with lower lymphocytic expression of CALHM6. CONCLUSIONS: Because CALHM6 is implicated in regulating the immune response to infection, this may provide an explanation for the typical triggering of SSNS onset by infections. Our results suggest that a genetically conferred risk of immune dysregulation may be a key component in the pathogenesis of SSNS.

Pediatric intradialytic hypotension: recommendations from the Pediatric Continuous Renal Replacement Therapy (PCRRT) Workgroup.

Intradialytic hypotension (IDH) is a common adverse event resulting in premature interruption of hemodialysis, and consequently, inadequate fluid and solute removal. IDH occurs in response to the reduction in blood volume during ultrafiltration and subsequent poor compensatory mechanisms due to abnormal cardiac function or autonomic or baroreceptor failure. Pediatric patients are inherently at risk for IDH due to the added difficulty of determining and attaining an accurate dry weight. While frequent blood pressure monitoring, dialysate sodium profiling, ultrafiltration-guided blood volume monitoring, dialysate cooling, hemodiafiltration, and intradialytic mannitol and midodrine have been used to prevent IDH, they have not been extensively studied in pediatric population. Lack of large-scale studies on IDH in children makes it difficult to develop evidence-based management guidelines. Here, we aim to review IDH preventative strategies in the pediatric population and outlay recommendations from the Pediatric Continuous Renal Replacement Therapy (PCRRT) Workgroup. Without strong evidence in the literature, our recommendations from the expert panel reflect expert opinion and serve as a valuable guide.

Renal Association Clinical Practice Guideline on Haemodialysis.

This guideline is written primarily for doctors and nurses working in dialysis units and related areas of medicine in the UK, and is an update of a previous version written in 2009. It aims to provide guidance on how to look after patients and how to run dialysis units, and provides standards which units should in general aim to achieve. We would not advise patients to interpret the guideline as a rulebook, but perhaps to answer the question: "what does good quality haemodialysis look like?"The guideline is split into sections: each begins with a few statements which are graded by strength (1 is a firm recommendation, 2 is more like a sensible suggestion), and the type of research available to back up the statement, ranging from A (good quality trials so we are pretty sure this is right) to D (more like the opinion of experts than known for sure). After the statements there is a short summary explaining why we think this, often including a discussion of some of the most helpful research. There is then a list of the most important medical articles so that you can read further if you want to - most of this is freely available online, at least in summary form.A few notes on the individual sections: 1. This section is about how much dialysis a patient should have. The effectiveness of dialysis varies between patients because of differences in body size and age etc., so different people need different amounts, and this section gives guidance on what defines "enough" dialysis and how to make sure each person is getting that. Quite a bit of this section is very technical, for example, the term "eKt/V" is often used: this is a calculation based on blood tests before and after dialysis, which measures the effectiveness of a single dialysis session in a particular patient. 2. This section deals with "non-standard" dialysis, which basically means anything other than 3 times per week. For example, a few people need 4 or more sessions per week to keep healthy, and some people are fine with only 2 sessions per week - this is usually people who are older, or those who have only just started dialysis. Special considerations for children and pregnant patients are also covered here. 3. This section deals with membranes (the type of "filter" used in the dialysis machine) and "HDF" (haemodiafiltration) which is a more complex kind of dialysis which some doctors think is better. Studies are still being done, but at the moment we think it's as good as but not better than regular dialysis. 4. This section deals with fluid removal during dialysis sessions: how to remove enough fluid without causing cramps and low blood pressure. Amongst other recommendations we advise close collaboration with patients over this. 5. This section deals with dialysate, which is the fluid used to "pull" toxins out of the blood (it is sometimes called the "bath"). The level of things like potassium in the dialysate is important, otherwise too much or too little may be removed. There is a section on dialysate buffer (bicarbonate) and also a section on phosphate, which occasionally needs to be added into the dialysate. 6. This section is about anticoagulation (blood thinning) which is needed to stop the circuit from clotting, but sometimes causes side effects. 7. This section is about certain safety aspects of dialysis, not seeking to replace well-established local protocols, but focussing on just a few where we thought some national-level guidance would be useful. 8. This section draws together a few aspects of dialysis which don't easily fit elsewhere, and which impact on how dialysis feels to patients, rather than the medical outcome, though of course these are linked. This is where home haemodialysis and exercise are covered. There is an appendix at the end which covers a few aspects in more detail, especially the mathematical ideas. Several aspects of dialysis are not included in this guideline since they are covered elsewhere, often because they are aspects which affect non-dialysis patients too. This includes: anaemia, calcium and bone health, high blood pressure, nutrition, infection control, vascular access, transplant planning, and when dialysis should be started.

The cardiovascular phenotype of childhood hypertension: a cardiac magnetic resonance study.

BACKGROUND: The cardiovascular phenotype is poorly characterized in treated pediatric hypertension. Cardiovascular magnetic resonance imaging (MRI) can be used to better characterize both cardiac and vascular phenotype in children with hypertension. OBJECTIVE: To use MRI to determine the cardiac and vascular phenotypes of different forms of treated hypertension and compare the results with those of healthy children. MATERIALS AND METHODS: Sixty children (15 with chronic renal disease with hypertension, 15 with renovascular hypertension, 15 with essential hypertension and 15 healthy subjects) underwent MRI with noninvasive blood pressure measurements. Cardiovascular parameters measured include systemic vascular resistance, total arterial compliance, left ventricular mass and volumetric data, ejection fraction and myocardial velocity. Between-group comparisons were used to investigate differences in the hypertension types. RESULTS: Renal hypertension was associated with elevated vascular resistance (P≤0.007) and normal arterial compliance. Conversely, children with essential hypertension had normal resistance but increased compliance (P=0.001). Renovascular hypertension was associated with both increased resistance and compliance (P≤0.03). There was no difference in ventricular volumes, mass or cardiac output between groups. Children with renal hypertension also had lower systolic and diastolic myocardial velocities. CONCLUSION: Cardiovascular MRI may identify distinct vascular and cardiac phenotypes in different forms of treated childhood hypertension. Future studies are needed to investigate how this may inform further optimisation of blood pressure treatment in different types of hypertension.

A comprehensive characterization of myocardial and vascular phenotype in pediatric chronic kidney disease using cardiovascular magnetic resonance imaging.

BACKGROUND: Children with chronic kidney disease (CKD) have increased cardiovascular mortality. Identifying high-risk children who may benefit from further therapeutic intervention is difficult as cardiovascular abnormalities are subtle. Although transthoracic echocardiography may be used to detect sub-clinical abnormalities, it has well-known problems with reproducibility that limit its ability to accurately detect these changes. Cardiovascular magnetic resonance (CMR) is the reference standard method for assessing blood flow, cardiac structure and function. Furthermore, recent innovations enable the assessment of radial and longitudinal myocardial velocity, such that detection of sub-clinical changes is now possible. Thus, CMR may be ideal for cardiovascular assessment in pediatric CKD. This study aims to comprehensively assess cardiovascular function in pediatric CKD using CMR and determine its relationship with CKD severity. METHODS: A total of 120 children (40 mild, 40 moderate, 20 severe pre-dialysis CKD subjects and 20 healthy controls) underwent CMR with non-invasive blood pressure (BP) measurements. Cardiovascular parameters measured included systemic vascular resistance (SVR), total arterial compliance (TAC), left ventricular (LV) structure, ejection fraction (EF), cardiac timings, radial and longitudinal systolic and diastolic myocardial velocities. Between group comparisons and regression modelling were used to identify abnormalities in CKD and determine the effects of renal severity on myocardial function. RESULTS: The elevation in mean BP in CKD was accompanied by significantly increased afterload (SVR), without evidence of arterial stiffness (TAC) or increased fluid overload. Left ventricular volumes and global function were not abnormal in CKD. However, there was evidence of LV remodelling, prolongation of isovolumic relaxation time and reduced systolic and diastolic myocardial velocities. CONCLUSION: Abnormal cardiovascular function is evident in pre-dialysis pediatric CKD. Novel CMR biomarkers may be useful for the detection of subtle abnormalities in this population. Further studies are needed to determine to prognostic value of these biomarkers.

Dalteparin anticoagulation in paediatric home haemodialysis.

BACKGROUND: The aim of this study was to investigate whether dalteparin is a safe and effective anticoagulant for paediatric home haemodialysis (HD) and to assess the determinants of dosing. METHODS: Data were collected for all children (< 18 years) undergoing home HD from 2011 to 2017 at one large paediatric nephrology centre in the UK. All children had anticoagulation with dalteparin sodium according to a standardised protocol. Dalteparin safety was assessed by monitoring for accumulation, adequate clearance of dalteparin and adverse events. Dalteparin efficacy was assessed through monitoring for clot formation in dialysis circuits. Potential determinants of dalteparin dosing were assessed. RESULTS: Eighteen children were included, their median age at start was 12 years, and 50% were male. Eighty-three percent of children had four home HD sessions each week, with a median total dialysis hours of 20 h/week. Thirty-three percent of children had nocturnal home HD. Median dalteparin dose at 12-month follow-up was 40 IU/kg (range 8-142 IU/kg). Factors associated with higher dalteparin dosing requirements included a younger age of the child (p < 0.01), a lower blood flow rate (p < 0.01) and the use of a central venous line for dialysis access (p = 0.038). No children had evidence of bioaccumulation of dalteparin or inadequate clearance. No significant bleeding or adverse events were reported. CONCLUSIONS: Dalteparin is a safe and effective anticoagulant when used for paediatric home HD. In this study, there was no evidence of bioaccumulation or significant adverse events. Further research is required to directly compare dalteparin with unfractionated heparin (UFH) and evaluate anticoagulant choice for paediatric home HD.

Use of a low-dose prednisolone regimen to treat a relapse of steroid-sensitive nephrotic syndrome in children.

BACKGROUND: Relapses of nephrotic syndrome are common and are treated with a course of prednisolone (2 mg/kg/day or 60 mg/m2/day). This is associated with major adverse effects including diabetes, weight gain, hypertension and behavioural problems. This study is a retrospective review examining the success of treating relapses in steroid-sensitive nephrotic syndrome (SSNS) with low-dose prednisolone and the consequences on subsequent relapse rates. Furthermore, a follow-up study looked at the side-effect profile during treatment with high- versus low-dose prednisolone. METHODS: Between January 2012 and July 2013, all well children with SSNS presenting with a relapse were advised to start 1 mg/kg prednisolone daily for a maximum of 7 days. In July 2015, we compared the side-effect profile of prednisolone therapy using the parent proxy PedsQL questionnaire for quality of life (QoL). RESULTS: Fifty patients were included in the study, with a total of 87 relapses. Sixty-one of the 87 relapses (70 %) responded within a week. Treating relapses with a reduced dose of steroids did not adversely affect the relapse rate in the 6 months preceding and following the current relapse (1.01 vs 0.86, p = 0.3). Fifteen parents completed the PedsQL questionnaire. Comparison of scores in each category showed significantly higher values in each domain during treatment with low-dose prednisolone compared with high-dose treatment (35.6 vs 18.3, p < 0.0001; 31.1 vs 15.0, p < 0.001; 38.3 vs 20.1, p < 0.0001). CONCLUSION: A low-dose prednisolone regimen was successful in achieving remission in 70 % of relapses of children with SSNS, without adversely affecting the relapse rate. Parent-completed QoL questionnaires showed significantly higher scores on low-dose treatment, indicating better QoL.

Intensified home haemodialysis for managing severe cardiac failure.

BACKGROUND: Conventional thrice weekly haemodialysis (HD) provides adequate dialysis to prevent mortality, but morbidity is prevalent in both the paediatric and adult population. There has been growing interest in the potential of intensive dialysis regimes entering the realm of optimal dialysis, with superior health and quality of life outcomes. CASE DIAGNOSIS/TREATMENT: We present the case of a 13-year-old girl who had bilateral nephrectomies as a result of bilateral Wilms tumors. In the third year of treatment with conventional HD, she presented with symptomatic progressive cardiac failure, presumably secondary to anthracycline-induced cardiomyopathy. Consequently, she was taken off the renal transplant list and became increasingly dependent on frequent in-centre dialysis sessions to manage her symptoms. Five months after switching to a frequent and extended home HD regime, we observed a tremendous improvement in her health and well-being, with complete reversal of her cardiac dysfunction. CONCLUSIONS: Home HD is a practically viable option in children with severe cardiac dysfunction. Gentler, more intensive dialysis will draw out and improve the ureamic component of heart disease. This may translate into improved cardiac function.

Designing technology to meet the therapeutic demands of acute renal injury in neonates and small infants.

Within paediatric intensive care units (PICU), clinicians face an increasing demand to support neonates and small infants with acute renal injury or medication-resistant oedema. Of all PICU admissions, fluid overload or a requirement for renal replacement therapy (RRT) is a poor prognostic factor, resulting in death in 25-50 % of such babies. For those who survive, RRT is supportive until kidney recovery, but up to 30 % of babies may have chronic kidney sequelae. Owing to their size, neonates and small infants present specific challenges for dialysis. Dialysis technology was designed for use in adults and had to be adapted for pediatric use, creating a less than ideal treatment environment fraught with complications. Consequently, wherever possible, the vast majority of physicians default to peritoneal dialysis. Clinicians now have access to two new dialysis systems with technology specifically designed for use in babies ranging from 800 g to 8 kg: the CARPEDIEM and Nidus exhibit preliminary data that demonstrates both purification and ultrafiltration capability, with safety records that exceed any existing systems presently in practice. These are truly exciting times, as these systems have the potential to revolutionise how such babies in the PICU are treated.

Health and social care professional standards need to be updated to advance leadership and action for environmental sustainability and planetary health.

BACKGROUND: Human health is inextricably linked to planetary health. The desire to nurture and protect both concurrently requires the mitigation of healthcare-associated environmental harms and global initiatives that support sustainable lifestyles. Health leadership is important to bring adequate attention and action to address planetary health challenges. Health professionals are central to this endeavour, but the will and energy of a few will not be adequate to address this urgent challenge. STUDY: We present an appraisal of the current UK health professional standards, frameworks and curricula to identify content related to planetary health and environmental sustainability. RESULTS: No current UK health professional standard provides statements and competencies to guide practising and trainee health professionals to focus on and advance the sustainability agenda within their clinical practice and across wider healthcare systems. CONCLUSION: Update of health professional standards is needed to ensure that health professionals in every specialty are supported and encouraged to lead the implementation of environmentally sustainable practices within the health sector and advocate for planetary health.

Home haemodialysis.

Haemodialysis (HD) began as an intensive care treatment offered to a very select number of patients in an attempt to keep them alive. Outcomes were extremely poor, and the procedure was cumbersome and labor intensive. With increasing expertise and advances in dialysis equipment, HD is now recognised as a life-sustaining treatment that is considered a standard of care for children with end stage renal disease (ESRD). Assessment of efficacy has evolved from mere survival, through achieving minimal standards of "adequate" dialysis with reduced morbidity, towards the provision of "optimal dialysis", which includes attempts to more closely mimic normal renal function, and of individualised care that maximizes the patient's health, psychosocial well-being and life potential. There is a renewed interest in dialysis, and the research profile has extended, exploring themes around convective versus diffusive treatments, HD time versus frequency and home versus in-centre dialysis. The results thus far have led dialysis care full circle from prolonged, home-based therapies to shorter, intense in-centre dialysis back to the belief that long or frequent HD at home achieves the best outcomes.

A comparison of arteriovenous fistulas and central venous lines for long-term chronic haemodialysis.

BACKGROUND: Despite the Fistula First initiative there is still reluctance to use arteriovenous fistulas (AVF) for chronic haemodialysis (HD) in children. Our aim was to compare outcomes of AVFs and central venous lines (CVL) in children on chronic HD in a centre where AVF is the primary choice for vascular access. PATIENTS AND METHODS: This was a retrospective case notes analysis of access complications, dialysis adequacy and laboratory outcomes in children who underwent dialysis for at least a year by AVF (n = 20, median age 14.2 years, range (2.9-16.5) and CVL (n = 5, median age 2.4 years, range 2.0-12.2) between January 2007 and December 2010. RESULTS: Primary access failure rate (patient-months) was 1 per 78.8 for AVF (n = 5) and 1 per 15.5 for CVLs (n = 7, p = 0.3). Failure thereafter was 1 per 131.3 and 1 per 18.5 for AVF and CVLs respectively (n = 3 and 6 respectively; p = 0.2). The annualised hospitalisation rate for access malfunction was 0.44% and 3.1% for AVFs and CVLs respectively (p = 0.004). Patients with AVFs had a lower infection rate of 0.25 per 100 patient-months compared with CVL at 3.2 per 100 (p = 0.002). There was no difference in dialysis adequacy or laboratory values between AVF and CVL groups. Access survival rates (including both primary and secondary access failure) were significantly higher for AVF compared with CVL (p = 0.0002, hazard ratio = 0.15, 95% confidence interval 0.04-0.37). CONCLUSIONS: Patients with AVF spend less time in hospital than those dialysed by CVLs and have a much lower access infection rate. These findings emphasise the need to use AVF as first-line access for paediatric patients on chronic HD.

Hemodialysis-induced acute myocardial dyssynchronous impairment in children.

UNLABELLED: In adults, recurrent hemodialysis (HD)-induced cardiac injury results in ischemic myocardial dysfunction. Uremic children, like adults, share the full complement of uremia-related cardiovascular abnormalities but without significant atheromatous coronary artery disease. The aim of this study was, to assess the impact of HD on left ventricular (LV) myocardial function in children. METHOD: We assessed all single-center chronic HD patients (n = 15, range 1-17 years) excluding those with overt cardiac disease. Regional LV function and mechanical synchronicity was measured echographically by two-dimensional segmental longitudinal, circumferential and radial myocardial strain. All patients were assessed pre-dialysis and at the end of dialysis. In addition, we scanned age-matched controls at rest. RESULTS: The peak longitudinal strain was lower in uremic patients compared with controls with a significant fall during HD (mean peak strain -19.9 controls, -17.9 pre-HD, -15.3 end of HD, p < 0.05). Radial strain was lower in uremic patients and increased during HD. Circumferential strain was preserved in uremic patients and fell during HD. Intrasegmental deformation synchronicity was progressively worse pre-dialysis and end of dialysis compared with controls. Intradialytic peak longitudinal strain reduction was significantly associated with systolic blood pressure and ultrafiltrate volume (p < 0.05). CONCLUSION: Uremic children have impaired regional LV function, with a predisposition to longitudinal axis dysfunction and LV mechanical dyssynchrony, both of which are established markers of ischemic injury. This is further evidence for a characteristic cardiovascular phenotype in uremic patients that predisposes them to subclinical demand ischemia during dialysis.

Intradialytic hypotension.

Intradialytic hypotension (IDH) is common in children during conventional, 4 hour haemodialysis (HD) sessions. The declining blood pressure (BP) was originally believed to be caused by ultrafiltration (UF) and priming of the HD circuit, however emerging data now supports a multifactorial aetiology. Therefore strategies to improve haemodynamic stability need to be diverse and address specific patient requirements or risks. In the treatment of IDH immediate action is required to stop or reduce the severity of symptoms that may precede or follow. Typically UF is slowed or stopped, a fluid bolus is given and in resistant cases the HD session is prematurely discontinued. Patients complete their treatment under-dialysed and volume expanded. Chronically, repeated episodes of IDH cause devastating, multi-system morbidity with an increased risk of mortality. This had provided the impetus for more haemodynamically friendly dialysis prescriptions that attenuate the risk of IDH. During pediatric HD several preventative strategies have been tested but with variable success. Of these, dialysate sodium profiling, UF guided by relative blood volume (RBV) algorithms, cooling and intradialytic mannitol appear to be the most effective. However in refractory cases one may be left with no option but to switch dialysis modality to haemodiafiltration (HDF) or more frequent or prolonged HD regimens.

The impact of home hemodialysis in children with severe cardiac failure.

When faced with patients with deteriorating cardiac disease, nephrologists tend to accept that heart disease is unmodifiable, accepting mediocrity and opting for stabilization. Likewise cardiac patients with persistent renal failure are presented with a poor renal prognosis and prepared for renal transplantation. We present three dialysis dependent children with moderate-to-severe cardiac failure in whom home hemodialysis normalized the cardiac function and restored renal function. These cases highlight the medical benefits of home hemodialysis in severe cardio-renal cases but not without acknowledgement of the resource, commitment, and safety challenges that accompanies them.

The value of sequential dialysis, mannitol and midodrine in managing children prone to dialysis failure.

The uremic state impairs compensatory responses to ultrafiltration (UF). Intradialytic symptoms and hypotension can result and lead to premature discontinuation of treatment and sub-optimal dialysis. We report the benefits of mannitol, sequential dialysis and midodrine in reducing dialysis failures in those children prone to intradialytic hypotension. Prophylactic mannitol halved the odds of intradialytic symptoms and hypotension and increased UF volumes. Sequential dialysis halved the odds of symptoms but hypotension persisted. In one patient with refractory hypotension, only intradialytic midodrine consistently maintained acceptable intradialytic blood pressures, reduced intradialytic symptoms and increased the UF potential.

Sustainable approach to reducing unnecessary combined biochemistry tests on a paediatric cardiology ward.

We describe a quality improvement project (QIP) designed to reduce unnecessary biochemistry samples requested on a paediatric cardiology ward in Great Ormond Street Hospital. Prior to the intervention biochemistry tests were requested on a daily basis by nursing and junior doctor staff at an annual cost of around £27 000 for the ward. The lead author observed that for the majority the true indication for these biochemistry tests was for the purpose of monitoring renal function and plasma electrolytes. However, during a diagnostic analysis trying to understand the behaviours around ordering tests it appeared that a broader profile and more expensive combined test set was being requested that included unnecessary liver and bone profile analyses. A driver diagram identified three areas to target in order to rationalise blood test requests: (1) a critical understanding of the purpose of the test by those requesting the tests; (2) effective communication between professionals; and (3) improved utilisation of the computer system. An education-based QIP was initiated with the aim of reducing requests of these costly, unnecessary combined biochemical tests by half, by supporting and encouraging staff to switch to a simpler renal function assay. The project was designed to be engaging and fun and invited clinical teams to consider the cost of wasted resources in terms of the financial implications for the hospital, and in terms of the wider environmental impact of wasted resources illustrated in terms of estimated carbon dioxide use. This perhaps unusual approach of encouraging an awareness of both financial and environmental cost led to a sustained reduction in the ordering of expensive combined biochemical tests, saving an estimated £11 338 (or 13.5%) on biochemistry tests and around 17.8 tonnes of carbon dioxide across a 32-month follow-up period.

Home hemodialysis in children.

Pediatric home hemodialysis is infrequently performed despite a growing need globally among patients with end-stage renal disease who do not have immediate access to a kidney transplant. In this review, we expand the scope of the Implementing Hemodialysis in the Home website and associated supplement published previously in Hemodialysis International and offer information tailored to the pediatric population. We describe the experience and outcomes of centers managing pediatric patients, and offer recommendations and practical tools to assist clinicians in providing quotidian dialysis for children, including infrastructural and staffing needs, equipment and prescriptions, and patient selection and training.