Particular aspects of neonatal renal replacement therapy and its use in small volume circuits

Abstract

Although developments in extracorporeal renal replacement therapy (RRT) have extended its use to neonates, several difficulties could emerge in neonatal RRT due to the application of universal RRT machines designed for adults. Neonatal RRT must be performed at low blood flow rates owing to the difficulty in obtaining vascular access. However, in cases where prompt solute removal is desired, a thick vascular access can be obtained through the internal jugular vein, which will enable optimal blood flow and continuous hemodialysis or hemodiafiltration that is not limited by blood flow rates. Meanwhile, for the safety continuous hemodialysis would be chosen to avoid hemodynamic instability, because of long RRT circuit life. The extracorporeal circuit volume of RRT is excessively larger than the circulating blood volume of neonates, thereby putting these patients at risk for hemodilution and hemodynamic instability. Thus, to avoid these complications, the RRT circuit must be primed, prior to neonatal RRT, using artificially packed red blood cells; however it is needed to associated with transfusion-related complications. Neonatal RRT devices are used clinically in Europe and have been shown to be effective and might improve the prognosis of neonates in the future. Japan is currently developing an ultra-small neonatal RRT device but is yet to analyze its effectiveness in the clinical setting. We hope that small-volume RRT devices for neonates will continue to be developed and applied in the clinical settings.