Inside Pediatrics Winter 2019

PIONEERING NEONATE DIALYSIS

Using a novel approach and a machine designed to remove fluid from adults with heart failure, Children’s of Alabama gives its tiniest patients a chance at survival

“A clever person solves a problem. A wise person avoids it.” T his Albert Einstein quote is a favorite of pediatric nephrologist David Askenazi, M.D., MSPH, University of Alabama at Birmingham (UAB) professor and director of the Pediatric and Infant Center for Acute Nephrology at Children’s of Alabama. The problem? High rates of patient complications and technical challenges to support neonates with kidney failure and excess fluid accumulation. Traditional continuous renal replacement therapy (CRRT) machines in neonates require at least 100 milliliters of blood to live outside the body. This can be half or even more of the baby’s entire blood volume. “Until 2013, the biggest problem in taking care of babies undergoing CRRT was that their blood pressure would come crashing down,” Askenazi said. “We devised different ways to prepare for this challenge. Two attendings would be ready at the bedside with code medications drawn up. We would discuss what would be the first, second and third intervention we would use prior to starting the therapy. We realized that there had to be better way, so we hypothesized that if we could use a smaller circuit, we could avoid all these problems.” And so that’s what they did. In 2013, Askenazi realized that an ultrafiltration device designed for fluid removal in adults with diuretic heart failure could be repurposed for neonate dialysis. “If we could adapt a machine that requires one- third of the blood of the traditional machine volume to do what we needed, we knew we could improve our ability to support these babies.” Pediatric use of the Aquadex FlexFlow® System yielded higher survival rates and lower complications than previous studies, according to a study published in the October 2019 issue of the Clinical Journal of the American Society of Nephrology (CJASN). The study evaluated the 119 patients and more than 800 circuits at three institutions — Children’s of Alabama, Cincinnati Children’s and Seattle Children’s — and suggested that the Aquadex can successfully be adjusted for use on babies who weigh as little as 2 pounds and are critically ill.

“This machine allows us to do the job of the kidneys for the baby without the risk associated with using so much blood to prime the machine,” said Askenazi, also the study’s senior author. “Now we have complete control over their fluids, electrolytes and waste products.” In 2018, babies in Children’s of Alabama’s Neonatal Intensive Care Unit (NICU) spent 1,100 days on dialysis compared to just 30 days in 2013. Today, Children’s of Alabama has five Aquadex machines with two to three babies receiving dialysis at any one time. Aquadex’s manufacturer is now pursuing a pediatric indication for the machine.

It’s been a game changer to our program.

David Askenazi, M.D., MSPH

“Our neonatologists and cardiac intensivists are no longer afraid of doing this therapy, even in really tiny, really sick infants. Our nurses have become proficient at it, and our babies hardly know that they’re on the therapy,” Askenazi said. “It’s been a game changer to our program. Without this machine, many of our babies wouldn’t have had a chance to live.” Kara Short, MSN, CRNP, an acute dialysis nurse practitioner at Children’s of Alabama, agrees, saying that the Aquadex has given pediatric healthcare practitioners the ability to safely dialyze babies from birth. “For our babies born with diseased or absent kidneys, Aquadex has given them a chance at life, because in the past, the machines to treat these patients came with too many complications,” Short said.

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