Nephrologist with experience in continuous renal replacement therapy.

Dialysis nurses: with experience in continuous renal replacement therapy.

Continuous renal replacement therapy, (CAVH, CAVHD) is superior to intermittent hemodialysis. However, its practice should be organized in any center according to a clear pre-set protocol.

Peritoneal dialysis can be used in non-catabolic patients. However, it should not be regarded as a substitute for extra corporeal methods of blood purification on the grounds of lack of facilities.

Machines and/or CAVH sets that can perform continuous renal replacement should be available only if use for at least two patients per month is expected, for specifications of the machines.

Fluids: for specifications of the fluids used with continuous renal replacement therapy.

Laboratory
Basic laboratory tests including checking CPK, Myoglobinuria, sodium practional excretion should be available besides the blood renal function tests.

Appropriate management requires multidisciplinary care in which the nephrologist plays a crucial role. The protocol of continuous replacement therapy should involve ICU staff as well.

Survival following acute renal failure depends on the underlying disease and case mix, but over all a third is alive at two years. In those with simple acute renal failure uncomplicated by other organ failure, the mortality should be low (<10%). Patients with multiple organ failure have a worse prognosis (mortality (40-90%), those with four or more organ system failures or an Apache II score > 35 will have a mortality of greater than 90%.

Nephrology sections should record data annually of ARF patients requiring renal support with, causes - duration of support - organ failing, outcome. Also should have number of patients with significant ARF (serum urea > 30 mmol/L, creatinine > 300 mmol/L) not requiring dialysis, and there outcome. Submission of data to SCOT is advisable.

A high quality pediatric renal service must be family oriented and delivered by a multi disciplinary team, which includes specialist nursing, child psychiatry and psychology, dietician, social worker, teaching and playa therapy in addition to medical and surgical staff.

All children with renal disease should be investigated and treated by pediatricians, pediatric nephrologists, pediatric urologists, and pediatric surgeons. In areas where some or all of these specialists are lacking, adult nephrologist and urologist can treat children in conjunction with a management plan laid by a referral center of pediatric nephrology.

The estimated prevalence of pediatric population in ESRD (below 18 years) in Saudi Arabia on renal replacement therapy is almost 10%.

Newborn infants are accepted into ESRD programs. Co-morbidity may be an important factor in children with multiple congenital abnormalities. Rates of hospital admissions of such patients do not reflect morbidity.

All children should receive bicorbonate dialysis.

Urea kinetic modeling is hard to measure in children whose urine collection and satisfactory estimations of total body water (TBW) are difficult. The best parameter for assessment of treatment adequacy in children is rate of growth, which should be formally assessed on a 6 monthly basis. Head growth should also be assessed. Pre-dialysis urea should be maintained below 30 mmol/L.

Some children may need internal feeding (nasogastric, Jejunal or by gastrostomy) to achieve adequate caloric intake.

Blood pressure should be maintained within 2 standard deviations from the mean for normal children of the same height.

The normal range for plasma phosphate falls throughout childhood, and should be kept within 2 standard deviations from the mean. There is no evidence that iPTH above normal is beneficial in childhood, so iPTH should be maintained below twice the upper limit of the normal range.

Automated peritoneal dialysis is the most appropriate type of dialysis for infants, and for older children with loss of ultrafiltration.

Control of hyperparathyroidism is important in children to prevent long-term disability from bone disease and to maximize growth. Most children are best managed with low calcium dialysate.

Patient and graft survival post transplantation improves with age during childhood. Three-year patient and graft survival is respectively 89% and 59% in those <6 years of age at grafting 94% and 65% in 6-9 year olds, and 96% and 68% in children aged 10-14 years (EDTA-1992).

The incidence of acute renal failure in children is almost half of that in adults. Among the important causes is hemolytic uremic syndrome.

Most children are managed by peritoneal dialysis using automated peritoneal dialysis machines, unless there is a need for plasma exchange.