Mechanical stress-related haemolysis in a paediatric haemodialysis patient.

Haemodialysis (HD) is a common kidney replacement therapy (KRT) used in the management of children with end-stage kidney disease (ESKD). We describe the case of a 2-year-old child who developed mechanical intraluminal haemolytic anaemia secondary to the acute angulation of the HD line. In contrast to reports of arteriovenous fistula-associated haemolysis, onset was insidious in nature and detected through review of subtle serial biochemical and haematological changes. Development of hyperbilirubinaemia during HD was modest due to the partial clearance of bilirubin via HD-enabled diffusion. The only persistent and consistent marker was the post-HD rise in lactate dehydrogenase in association with decreasing haemoglobin. We propose that mechanical stress-induced haemolysis should be considered in children on HD who develop unexplained or persistent anaemia with resistance to increasing doses of iron and erythropoiesis-stimulating agent supplementation.

Trace element and vitamin concentrations in paediatric dialysis patients.

BACKGROUND: There are few recent data regarding blood micronutrient concentrations and supplementation in children on maintenance dialysis. We investigated micronutrient concentrations following dialysis commencement. METHODS: Retrospective review, including all children on maintenance dialysis (peritoneal dialysis, PD; intermittent haemodialysis, IHD), for nutritional blood concentrations measured over the first 12 months. Patients received pyridoxine and Dialyvit® daily with planned 3-monthly micronutrient concentration monitoring including selenium, manganese, copper, zinc, folate and vitamins A, D, B12 and E. RESULTS: We reviewed 47 children (24 girls) including 19 PD and 28 IHD, median age (IQR) 11.4 (2.8,14.4) years. 33 were white, 5 Asian, 5 black and 4 of other ethnic origins. Vitamin A, B12 and E concentrations were within range in 6%, 20% and 13% respectively, with all others above normal range. Serum folate and vitamin D concentrations were within the desired range of 55%, with the rest above or below target. For trace elements, 37%, 60%, 65% and 89% achieved normal ranges for zinc, manganese, copper and selenium respectively. Deficiencies were seen for zinc (43%), copper (28%), folate (6%) and selenium (4%), whereas 7%, 7%, 20% and 40% had copper, selenium, zinc and manganese levels above normal ranges. Despite standard pyridoxine supplementation, only 6 children were monitored during the study period. CONCLUSIONS: Concentrations of several trace elements and vitamins were outside reference ranges. Response to systematic monitoring and targeted supplementation should be evaluated in future studies. Paediatric dialysis centres should consider undertaking routine nutritional bloods monitoring, particularly for vitamin D, zinc and copper.