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dialysis

Nephrology

Studying outcomes in Continuous Renal Replacement Therapy

Children’s of Alabama is part of international research effort designed to improve care for CRRT patients.

With most research that evaluates a vital form of dialysis care in children called continuous renal replacement therapy (CRRT) lacking in size and scope—hampering efforts to glean practice-changing insights—an international effort in which Children’s of Alabama is integral is expected to fill the gap.

Dubbed WE ROCK (Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease), the retrospective study involves a total of nearly 1,000 children treated at 32 centers in seven countries between 2018 and 2021. Representing the largest international registry of children receiving CRRT for acute kidney injury or fluid overload—which can result from a variety of factors, including congenital anomalies, nephrotoxins and others—WE ROCK aims to evaluate the association of factors such as fluid balance and timing of CRRT initiation and duration with patient outcomes.

“It’s so hard to get data of this type, so this study is very significant,” said Children’s of Alabama pediatric nephrologist Tennille Webb, M.D., who’s also assistant director of the Pediatric and Infant Center for Acute Nephrology (PICAN) and an assistant professor of nephrology and pediatrics at University of Alabama at Birmingham (UAB). At Children’s, research nurse coordinator Jessica Potts, RN, is carrying out the crucial task of collecting and analyzing the data.     

Children’s serves as a hub for CRRT care for a high volume of pediatric kidney patients. In the decade-plus between 2013 and mid-2024, 602 patients were treated with CRRT at Children’s. Just over half of CRRT is performed in the neonatal intensive care unit (NICU), while 32% is done in the pediatric intensive care unit (PICU) and the remaining 15% in the cardiovascular intensive care unit (CVICU).

Children’s has long stood out among pediatric hospitals by offering CRRT to the tiniest infants using modified Aquadex equipment. Aquadex had initially been developed for adult patients with heart failure to remove fluid from the heart, but Children’s nephrologist and PICAN director David Askenazi, M.D., seized on the technology’s small filters to adapt it for use in neonates. Now, other centers offer neonatal dialysis with modified Aquadex, as well.

“Other dialysis machines pull a lot of blood out of babies because the filters are so large, which makes everyone nervous,” Webb explained. “CRRT is gentler than hemodialysis because you can remove fluid at a slower rate over an extended amount of time, allowing for fewer fluid shifts and blood pressure swings, especially in those who may have low blood pressure. We’re still meeting our goals, but not being as aggressive.”

The WE ROCK effort has generated at least 10 published manuscripts so far by study collaborators, with the promise of many more to come, Webb says. By looking at outcomes such as major adverse kidney events 90 days after CRRT (including mortality, dialysis dependence, and persistent kidney dysfunction) as well as functional outcomes, investigators should be able to derive data that could change pediatric nephrology practice. 

Insights will be bidirectional: Children’s specialists will learn from other centers, and others will learn from Children’s. Researchers can also determine new questions and angles that fuel future research. It’s an exciting prospect for Webb and her colleagues.

“Having that data from 32 centers, we can see what they’re doing, model it and make some improvements in these patients,” Webb said.

January 8, 2025 by
Nephrology

New Leadership on Dialysis Unit

Kaci Caradine and Dr. Daniel Feig took on new leadership roles on the Children’s of Alabama Pediatric Dialysis Unit in the fall of 2023.

As more children requiring kidney dialysis survive and thrive—able to leave the hospital and return for treatment on an outpatient basis—the Pediatric Dialysis Unit at Children’s of Alabama has needed to adapt and grow. New leadership is poised to tackle this shift with aplomb, planning to increase staffing, expand education for team members and boost current programs for patients and families.

As of fall 2023, the unit is headed by medical director Daniel Feig, M.D., Ph.D., MPH, medical director of pediatric nephrology at Children’s, along with nursing director Kaci Caradine, BSN, RN, CNML. The pair replace the outstanding former medical director Sahar Fathallah, M.D., who is pursuing other professional opportunities at Children’s, and former nursing director Suzanne White, RN, who retired.

Within the last several years, the dialysis unit’s patient load doubled. It now includes about 20 patients who undergo outpatient hemodialysis treatments three times weekly, along with another 15 who receive home-based, nightly peritoneal dialysis and visit the unit about once a month. Most commonly, pediatric dialysis patients are affected by congenital abnormalities of the kidneys or urinary tract that lead to irreversible kidney failure, Feig said. Others require dialysis due to problems such as sepsis, solid organ transplantation, autoimmune diseases and other chronic issues.

“As we continue to make great improvements in the care we deliver, more kids are able to leave the hospital and lead full lives,” said Caradine, previously the director of nursing for Children’s Cardiovascular ICU.

Feig agreed, noting that referrals to the Children’s dialysis unit have also increased, both from the Southeast and around the nation. “We’ve gotten better at treating kidney failure in the Neonatal ICU and the very youngest patients, so kids who didn’t use to survive are now growing up with kidney failure,” said Feig, who’s also a professor of pediatrics and director of the Division of Pediatric Nephrology at the University of Alabama at Birmingham (UAB). “Now, the average age in the dialysis population is dropping from young teenager to about 5 to 7 years old.”

To keep pace, Feig and Caradine intend to quickly add to the dialysis team, which currently consists of 17 nurses, three nurse practitioners, nine attending physicians, and other roles that include a social worker, a dietitian and a counselor.

But many new clinicians to the unit don’t have experience in dialysis, making it crucial to “develop education and career development programs that get new staff up to speed,” Feig said. “We’re pulling together a didactic program involving the physicians and nurse practitioners who care for these patients, so they have a greater understanding of kidney disease and the challenges these kids face.”

“We want to develop a comprehensive educational program and onboarding curriculum for our new nurses,” Caradine agreed, “as well as ensure our current nurses are able to grow their knowledge base to continue to provide state-of-the-art care for our patients.”

Additional priorities include enhancing the Food as Medicine program, which provides packages of ingredients to patients’ families to assist them in preparing dialysis-safe meals. “This program is associated with huge improvements in patients’ quality of life and lab testing, and they’re much more able to stick to a prescription diet,” Feig said. “Expanding the program to a larger portion of the unit is a goal that will allow us to help all of our families.”

January 29, 2024 by
Nephrology

Getting Creative to Address the Nursing Shortage in the Dialysis Unit

Dr. Sahar Fathallah-Shaykh is a pediatric nephrologist at Children’s of Alabama.

The pandemic hit the dialysis unit at Children’s of Alabama with a double whammy: increased census and staff shortages—particularly among nurses. “Similar to many other centers, we are searching for additional outstanding nurses” Children’s nephrologist Sahar Fathallah-Shaykh, M.D., said. Despite this deficit, the dialysis team is finding creative ways to give patients the attention they need while still prioritizing work-life balance for nurses.

Because of the nature of dialysis patients’ needs, it’s tough for the dialysis unit to compensate for staffing issues by limiting patient access. “We provide life-saving care, and patients have to get dialysis,” Fathallah-Shaykh said. “Otherwise, they cannot survive.” Children’s is also home to the only pediatric dialysis unit in the state. “The dialysis unit is not just a machine,” Fathallah-Shaykh said. “It’s not just a physician or just a nurse. It’s all of us working together. And if one is understaffed, that affects the whole dialysis unit.”

In addition, the unit provides dialysis to a significant number of infants and toddlers. While most dialysis patients wait about a year on average for a transplant, Fathallah-Shaykh says little infants or toddlers may have to wait until they’re big enough to be able to successfully receive a transplant. This can require them to be on dialysis longer.

Those patients also require dialysis four to five days a week, with one nurse assigned to a patient for three to four hours. “We have to be very careful to pay attention to details so we can do a good job,” Fathallah-Shaykh said.

The team has been working closely with the administration at Children’s to come up with alternatives. “It starts with recruiting more nurses and retaining nurses in their jobs,” Fathallah-Shaykh said. They also get help from nurses from other service areas, such as the intensive care unit, although they need significant training. “But they have some dialysis experience and have been a good help to us,” she said.

The team has also hired traveling nurses, but their availability is limited because they are in high demand nationwide. In some cases, physicians have stepped in to cover night calls. A newly hired nurse practitioner is also taking some of the pressure off and standardizing care.

For the long term, however, the unit is identifying ways to improve nurses’ work-life balance—the lack of which is one of the main reasons some healthcare professionals are changing careers. For example, dialysis nurses must be on-call at night for patients who require acute dialysis, so one change is to assign nurses to cover either acute dialysis on nights and weekends or chronic dialysis during the week to reduce the amount of on-call time overall. “We feel that dividing the acute dialysis from the chronic dialysis may help with a work-life balance and recruitment,” Fathallah-Shaykh said.

“We are very grateful for the nurses for everything they do,” she said. “Without them, these kids would not survive.”

January 16, 2023 by
Inside Pediatrics, Nephrology

Children’s Clinicians Teach the Rest of the World How to Start a Neonatal Dialysis Program

Pediatric nephrologist David Askenazi, MD.

It’s always wonderful when something you created exceeds your expectations. That’s what’s happened with the Neonatal and Infant Course for Kidney Support (NICKS), a one-and-a-half-day educational program on infant dialysis that combines didactic teaching from a variety of specialists, an opportunity to hear a parental perspective, “hands-on” skills sessions, and virtual small group case simulations.

Pediatric nephrologist David Askenazi, MD, co-founded the course in 2019 with acute dialysis nurse practitioner Kara Short, MSN, CRNP, after new technology enabled safer and more effective dialysis on neonates and small children. The two realized there was a huge need for clinicians to understand how dialysis is different for this population. 

The program was supposed to be held in person, but COVID drove it online, which worked to their benefit by making the course more accessible. They’ve held nine courses so far, all sold out with large waiting lists (they try to limit it to 50 a class). “We don’t just talk about the dialysis machines,” Askenazi said, “but also clinical scenarios, troubleshooting, medications, nutrition, educating the nursing staff and tracking quality improvement. Participants learn how to build a program, not just run a machine.”

To date, 359 clinicians have attended the training, including 120 nephrologists and 52 neonatologists, as well as nurses and nurse practitioners. Attendees have logged on from as far as Qatar, Israel and South Africa, and nearly every major children’s hospital in the country has had at least one attendee. 

“We find it so important to share our patient stories and our lessons learned the hard way in order to empower other programs to confidently treat their patients and hopefully help babies like we have,” Short said.

The course will begin live sessions this fall, with a limit of 20 participants. Askenazi and Short are also planning an international neonatal nephrology symposium for fall 2024.

For more information, contact David Askenazi, MD, MSPH, FASN, at daskenazi@peds.uab.edu or Kara Short, MSN, CRNP, at kara.short@childrensal.org.

September 2, 2022 by
Inside Pediatrics, Nephrology

Overflow at Children’s of Alabama’s Dialysis Unit

As the only pediatric dialysis unit in the state, Children’s of Alabama’s hemodialysis unit is used to being busy. But with COVID-19, “Our census has doubled,” said Children’s nephrologist Sahar Fathallah-Shaykh, M.D. One reason is that transplants were paused during the height of the pandemic, leaving many children who might have been able to stop dialysis forced to continue.  

Another reason is that more infants born with chronic kidney disease (CKD) are surviving because of new equipment capable of providing them dialysis. “We have seen many patients with CKD surviving who, just a few years ago, had no chance of surviving,” Dr. Fathallah-Shaykh said. Because these infants are so small, they must come to the hospital up to five times a week for the procedure, compared to three times a week for older children. Once infants are older, the team tries to transition them to peritoneal dialysis at home; but babies may have medical contraindications that require continuing on hemodialysis. 

The impact on the staff is significant, she said. “It’s a challenge.” Dialysis charge nurse Suzanne White, RN, ECP agrees. “It takes a lot of coordination to schedule treatments for 18 patients,” she said, particularly when treatment times last up to four hours. “Our days last 10 to 12 hours,” she said. 

One reason caring for infants on dialysis calls for intense attention, said Dr. Fathallah-Shayk, is that “nurses are at the bedside the entire time monitoring these babies. Babies move a lot, and if they move, the dialysis may not work as well.” The nurses console the babies, try to distract them and sometimes even hold them while they are dialyzed.  

The team includes a child life specialist who also tries to distract the infants during dialysis; social workers who support the families, including coordinating transportation and ensuring families keep their appointments; a dietician to help with nutrition and ensure proper growth; and a pharmacist to help with medications. “We all work as a team to make this happen,” Dr. Fathallah-Shayk said, “otherwise we couldn’t do it.”  

And, said White, “we have a good support system from the administration on down,” which helps avoid burnout. The unit also added more staff in anticipation of continued growth. “We are trying to coordinate their care to the best of our ability, troubleshoot and really communicate and work with each other,” she said. 

August 27, 2021 by
Inside Pediatrics, Nephrology

Welcoming the new PRISMAX Dialysis Machines to the PICU & CVICU

When you’re talking about continuous dialysis and plasmapheresis for sick kids, you want state-of-the-art technology. And that’s just what Children’s of Alabama got this year when hospital administrators approved a significant investment in the newest generation of the PRISMAX system for the Pediatric and Infant Center for Acute Nephrology (PICAN).  

The PICAN team is no stranger to these therapies; after all, the team has provided them for more than 500 children for over 10,000 days since 2013 in the pediatric, neonatal and cardiac intensive care units. In 2020, the newest PRISMAX became available, and Children’s became the first hospital in the state and one of the first children’s hospitals in the country to receive the new machines, said David Askenazi, M.D., who directs the PICAN. “We are very grateful to the hospital for making this available to us and our patients,” he said. “We know that patients will benefit.” 

But first, everyone had to be trained to use the new machines. While it sounds like replacing the old with the new should be a relatively simple switch, the staff required intense education. 

“The educational part of the rollout was very important,” said acute dialysis coordinator Daryl Ingram, RN, BSN, CDN. “We had to make sure the nurses and physicians were comfortable with them before they started using them on patients.” He was pleasantly surprised at how the entire team embraced the new technology and the groundbreaking opportunity the new machines offered, he said. 

One reason could be the improvements the new system brought. For instance, nurses no longer have to manually empty 5-liter effluent bags. “It definitely saves time,” said Suzanne Gurosky, RN, ECP, the dialysis charge nurse. She also touted the battery backup in the machines, which enables patients to ambulate and even do physical therapy while still connected. Another plus is the ability of the machines to decipher the cause for an alarm—because someone moved or jostled the fluids, or because there was a real issue going on. That helps avoid disruptive alarms and alarm fatigue. 

It does this through artificial intelligence, “so it understands what’s happening better than it used to,” said Dr. Askenazi.  

The new PRISMAX also sports improved safety features, such as correcting itself for fluid removal. In addition, it provides extensive data that can be integrated into the department’s quality-improvement initiatives. “We’re excited to dig into that information and incorporate it into our practice,” said Dr. Askenazi.  

After the training and the successful integration of the new PRISMAX machines into the unit, there was one more thing the team needed to do: name them. “We like to name our machines to help the kids feel more comfortable,” said Ingram. The winners were Rosie, Max, and Astro from the old “The Jetsons” cartoon, Johnny 5 from the movie “Short Circuit,” and C3PO from, of course, “Star Wars.” 

August 27, 2021 by
Nephrology

Children’s of Alabama Becomes First to Safely Provide Dialysis to Tiny Babies

Didactic and hands-on teaching on the use of CRRT using the Aquadex Pureflow.

Despite the frequent use of dialysis for critically ill children and adults, the procedure has historically been used sparingly in neonatal intensive care units (NICU) because dialysis  machines designed for adults can cause severe complications in babies. That’s no longer the case at Children’s of Alabama.

The problem is that continuous renal replacement therapy in these tiny patients requires at least 100 ml of blood to initiate the therapy. This can be half or even more of the baby’s entire blood volume, said David Askenazi, M.D., MSPH, who directs the Pediatric and Infant Center for Acute Care Nephrology. “Many times, when we started the machine, we had to open the crash cart to resuscitate infants who were coding,” he said.

That changed in 2013, when Askenazi realized that a machine designed to remove fluid and sodium from blood in adults with heart failure — the Aquadex FlexFlow® System — 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,” he said. So the team learned as much as they could about the device, developed a safety net of processes to maximize the likelihood of success and convinced the hospital to buy its first machine.

Today, the hospital has fiveAquadex machines and two or three babies are typically receiving dialysis at any one time. “Now we have complete control over their fluids, electrolytes and waste products,” Askenazi said, “while the nurses feel comfortable doing the therapy and the babies don’t even know they’re on it.” Last year, babies in the NICU spent a total of 800 days on dialysis compared to just 30 days in 2013.

“For our babies born with diseased or absent kidneys, Aquadex has given them a chance at life,” said NICU nurse practitioner Kara Short, MSN, CRNP, “because in the past, there were no options to treat these patients.”

The team published the results of its first 12 patients in the journal Pediatric Nephrology in 2016. Since then, they have treated more than 90 patients, the smallest just 1.2 kg (2 pounds, 7 ounces) and taught nephrologists at several other children’s hospitals around the country to use the Aquadex. However, there are still only a handful of hospitals offering the procedure.

“We have shown we can now support these babies safely,” Askenazi said. “The impetus now is on us to make sure the patients who can benefit from this therapy make it to Children’s so we can give them a chance for life.”

And the machine’s manufacturer? It is now pursuing a pediatric indication for Aquadex.

A Team Effort

Learn more about the neonatology program and team at Children’s of Alabama.

August 20, 2019 by