Pediatric Dialysis

Introduction

If your child has been told they need dialysis, you are likely holding a lot at once — medical information, fear about the future, practical questions about school and family life, and the simple wish that your child could just be a child. This guide is written for you.

Pediatric dialysis is the treatment that takes over the cleaning and balancing work of the kidneys when a child’s own kidneys can no longer keep up. For some children, dialysis is a temporary bridge while the kidneys recover from a sudden injury. For many others, it is the daily or weekly support that keeps them well while they wait for a kidney transplant. Either way, it is not the end of a normal childhood. Children on dialysis go to school, play, grow, make friends, and plan their futures.

This article explains what pediatric dialysis is, the two main ways it is done, how families prepare, what daily life looks like, the role of nutrition and medications, and what to expect over time. It is meant to support — not replace — the conversations you are already having with your child’s pediatric nephrologist (a doctor who specialises in kidney conditions in children).

What Is Pediatric Dialysis?

When a child’s kidneys lose most of their function — whether suddenly (acute kidney injury) or gradually (chronic kidney disease that has reached an advanced stage) — waste and fluid build up, and the body’s chemistry becomes dangerously unbalanced. Dialysis is the medical treatment that does some of this filtering and balancing work for the body.

Dialysis in children is not simply a smaller version of adult dialysis. Children are still growing, their bodies are smaller and more sensitive to fluid shifts, their nutritional needs are higher per kilogram of body weight, and their emotional and educational lives must be protected. Pediatric dialysis programmes are designed around these differences, with specialist pediatric nephrologists, dialysis nurses trained in pediatric care, renal dietitians, and often psychologists or play therapists.

There are two main forms of dialysis used in children:

• Peritoneal dialysis (PD) — uses the lining of the child’s own belly (the peritoneum) as a natural filter. It is usually done at home, often overnight while the child sleeps.
• Hemodialysis (HD) — uses a machine and a filter outside the body to clean the blood. It is usually done in a hospital or dialysis centre several times a week.

Both keep a child alive and well. Each has practical and medical trade-offs, and the choice depends on the child’s age, medical situation, family circumstances, and the long-term plan — especially whether and when a kidney transplant is possible.

Why Children Need Dialysis

The reasons children develop kidney failure are quite different from the reasons adults do. Lifestyle factors like diabetes, high blood pressure and smoking, which dominate adult kidney disease, are uncommon causes in childhood.

Common causes of kidney failure in children

• Congenital anomalies of the kidney and urinary tract (CAKUT) — structural problems present from birth, such as kidneys that did not develop fully, blocked urine flow, or reflux of urine back toward the kidneys. CAKUT is the single largest cause of chronic kidney disease in young children worldwide.
• Inherited (genetic) kidney disorders — conditions such as polycystic kidney disease, nephronophthisis, Alport syndrome, and others passed down in families.
• Glomerular diseases — conditions that damage the tiny filtering units of the kidney, including focal segmental glomerulosclerosis (FSGS) and certain forms of nephrotic syndrome that do not respond to treatment.
• Hemolytic uremic syndrome (HUS) — a serious illness that can follow some infections and cause sudden kidney injury.
• Lupus nephritis and other autoimmune conditions — more common in older children and adolescents.
• Severe acute kidney injury that does not recover — for example, after major surgery, severe infection (sepsis), or certain medications.

In some children, especially very young ones, the underlying cause is identified before birth or in infancy. In others, kidney disease is diagnosed only when symptoms appear later in childhood. Whatever the cause, by the time dialysis is being discussed, the kidneys have usually lost most of their working capacity.

Signs That Dialysis May Be Needed

Most families reading this article already know that their child’s kidneys are failing. The signs described here are not meant for first-time diagnosis, but to help you understand what your pediatric nephrologist is watching for as they decide on timing.

Doctors generally consider starting dialysis when both of the following are true:

• Kidney function (measured by the glomerular filtration rate, or GFR) has dropped to a very low level, and
• The child is developing symptoms or laboratory changes that cannot be controlled with medications, diet and fluid restriction alone.

Symptoms that often prompt the move to dialysis include persistent tiredness and poor energy, loss of appetite or vomiting, swelling of the face, legs or abdomen, breathlessness from fluid overload, poor growth or weight gain despite good nutritional care, and difficulty thinking clearly or concentrating at school. Laboratory signs include rising creatinine and urea (waste products in the blood), dangerously high potassium levels (which can affect the heart), severe acidosis (acidic blood chemistry), and uncontrollable high blood pressure.

The decision is rarely sudden. In chronic kidney disease, the pediatric nephrology team usually prepares families weeks or months in advance — choosing a dialysis type, placing the access (catheter or fistula), and training the family. In acute kidney injury, the decision may need to be made within hours or days, and the first dialysis may begin in an intensive care setting.

Preparing for Dialysis

Before dialysis begins, the team will do a full assessment to plan the safest and most workable approach for your child and family.

Medical assessment

• Blood tests for creatinine, urea, electrolytes (sodium, potassium, bicarbonate), calcium, phosphorus, and hemoglobin (to check for anemia).
• An estimate of GFR, which tells doctors how much kidney function remains.
• Kidney and bladder ultrasound, and sometimes other imaging, to understand the underlying cause.
• An echocardiogram (heart ultrasound) and blood pressure review, because kidney disease and the heart are closely linked.
• Vaccinations brought up to date, including hepatitis B, pneumococcal and influenza vaccines, which are important before starting dialysis and before any future transplant.

Growth and nutrition assessment

A pediatric renal dietitian reviews your child’s growth, weight, eating habits and current intake. Growth is one of the most important measures in pediatric kidney care, and supporting it is central to the dialysis plan.

Choosing the dialysis modality

The team discusses peritoneal dialysis and hemodialysis with you in detail, including what each would mean for your family. Factors that influence the choice include:

• The child’s age and size — peritoneal dialysis is often favoured in infants and younger children.
• The medical situation — some conditions (recent abdominal surgery, certain abdominal problems) make peritoneal dialysis difficult.
• Family situation — whether a parent or caregiver can be trained for home dialysis, the home environment, and distance to a dialysis centre.
• Long-term plan — if a transplant is expected soon, the chosen dialysis may be a short-term bridge.

Placing the access

Dialysis needs a way in and out of the body. For peritoneal dialysis, a soft tube called a PD catheter is placed into the abdomen through a small surgery. For hemodialysis, the access may be a central venous catheter in a large vein, or, in older children, an arteriovenous (AV) fistula or graft created surgically in the arm.

Family training and home preparation

If peritoneal dialysis is chosen, the dialysis nurses train parents (and sometimes older children) over one to two weeks. This includes how to set up and operate the dialysis machine at home, how to handle the catheter and connections, how to recognise problems, and how to keep the area clean. The team often visits the home to check storage space, hygiene, water and electricity supply.

Types of Pediatric Dialysis

The two main types of pediatric dialysis — peritoneal dialysis and hemodialysis — both clean the blood, but they do so in very different ways and have very different effects on daily life.

Peritoneal dialysis (PD)

Peritoneal dialysis uses the peritoneum, the thin natural lining of the belly, as a filter. The peritoneum has a rich blood supply, and waste products from the blood can pass across it into a special fluid placed inside the abdomen.

How it works. A soft catheter is placed through the abdominal wall into the peritoneal cavity. Sterile dialysis fluid is run in through the catheter, allowed to stay (“dwell”) for a set time while it draws out wastes and excess fluid, and then drained out. This cycle is repeated several times.

There are two main ways of doing peritoneal dialysis in children:

• Automated peritoneal dialysis (APD) — a small machine called a cycler does the fill, dwell and drain cycles automatically, usually overnight while the child sleeps. This is the most common approach in children because it leaves the day free for school and activities.
• Continuous ambulatory peritoneal dialysis (CAPD) — exchanges are done by hand several times a day. It is used less often in children but can be a good option in some settings.

Advantages of PD in children. It can be done at home, which protects schooling and family routines. It is gentler and more continuous than hemodialysis, which is often easier on growing bodies and developing brains. It allows more freedom in diet and fluid intake than hemodialysis. It is often the preferred starting modality for infants and young children, in line with international pediatric nephrology guidance.

Considerations. PD requires a clean, organised space at home and a trained caregiver. The main medical concern is peritonitis — infection of the peritoneal cavity — which usually presents as a cloudy drainage bag, abdominal pain or fever, and needs prompt treatment with antibiotics. Careful hand washing, mask wearing during connections, and exit-site care reduce this risk significantly.

Hemodialysis (HD)

How it works. The child is connected to the machine through their catheter or fistula. A session typically lasts three to four hours and is done three or four times a week at a hospital or dialysis centre. Some programmes offer longer or more frequent sessions, which can be gentler and more effective but are not available everywhere.

Advantages. Care is delivered in a supervised medical setting, with nurses and doctors present. It does not require home equipment or home training of caregivers. It is often used for older children and adolescents, for children whose abdomen is not suitable for PD, and as a bridge in the hospital after sudden kidney failure.

Considerations. The schedule is more rigid. Travel to and from the dialysis unit several times a week can disrupt school and family life. Because cleaning happens in concentrated sessions rather than continuously, diet and fluid restrictions are stricter between treatments. Vascular access needs to be protected and monitored. Some children find the machines and needles frightening at first, and the play therapy or psychology team can help them adjust.

How the choice is made

For most children with chronic kidney failure, particularly young children, pediatric nephrology societies generally favour starting with peritoneal dialysis when it is medically suitable, because of its advantages for growth, schooling and family life. Hemodialysis is chosen when PD is not possible, when older children prefer it, or when the medical situation calls for it. The choice is not permanent; some children move from one modality to the other over time.

How Dialysis Fits into the Larger Treatment Plan

It can help to step back and see where dialysis sits among the options for advanced kidney disease in children:

• Conservative medical care — medications, diet, fluid management and treatment of the underlying cause, used while kidney function is declining but dialysis is not yet needed.
• Dialysis — takes over the kidneys’ work when conservative care is no longer enough.
• Kidney transplantation — replacement of the failed kidneys with a healthy kidney from a living or deceased donor. Pediatric nephrology societies consider transplantation the preferred long-term treatment for most children with kidney failure, because transplanted children typically grow better, feel better and have fewer restrictions than children on long-term dialysis.

For most children, dialysis is best understood as a bridge to transplant rather than a permanent state. In some cases, a child may even receive a transplant before ever needing dialysis — this is called pre-emptive transplantation, and it is often the goal when chronic kidney disease is diagnosed early. When dialysis is needed first, the transplant work-up usually begins in parallel.

Daily Life on Pediatric Dialysis

Once treatment is established, families often find that what felt overwhelming at the start becomes a routine. Children are remarkably adaptable. The aim of the medical team is not just to keep your child alive, but to keep their childhood intact.

School and learning

Most children on dialysis attend school. Children on overnight peritoneal dialysis can usually keep a full school day. Children on hemodialysis may miss part of certain days because of treatment sessions, and schools can help by allowing flexible attendance, catching up on missed work, and arranging quiet rest if the child is tired after a session. Teachers should know the basics of the condition, what activities are safe, and what to do in case of concerns. With good communication, most children stay on track academically.

Play, sports and physical activity

Physical activity is encouraged. It supports growth, mood, sleep and overall health. Children on peritoneal dialysis can usually take part in most activities, with some care to protect the catheter; swimming in chlorinated pools or the sea may need extra precautions or be limited, depending on local guidance. Children on hemodialysis with a fistula are advised to protect that arm from injury during contact sports. The dialysis team will give specific advice for your child.

Friendships and emotional life

Children on dialysis sometimes feel different from their friends — because of food restrictions, body image, hospital visits, or tiredness. Older children and adolescents may struggle particularly with feelings of being out of step with peers. Open conversation, age-appropriate explanations, time with friends, and access to a psychologist or counsellor when needed all help. Many dialysis units run camps and peer support groups for children with kidney conditions, which can be powerful.

Family life

Caring for a child on dialysis affects the whole family. Parents often take on demanding new responsibilities, especially with home peritoneal dialysis. Siblings may feel less attention is being given to them. Allowing space for everyone’s feelings, sharing tasks where possible, and accepting support from extended family or the dialysis team’s social worker can make the journey more sustainable.

Nutrition and Fluid Management

Nutrition is one of the most important parts of pediatric dialysis care. Children need enough calories and protein to grow, but their failing kidneys cannot handle some nutrients normally. The pediatric renal dietitian builds an individual plan and adjusts it over time.

General principles

• Energy (calories) — usually kept at or above the normal requirement for the child’s age, to support growth.
• Protein — adjusted to the dialysis type. Children on dialysis lose some protein with treatment (especially PD), so intake is often higher than for children with kidney disease who are not on dialysis.
• Sodium (salt) — usually limited, to help control blood pressure and fluid retention.
• Potassium — managed carefully, because high potassium can cause dangerous heart rhythms. High-potassium foods such as bananas, oranges, potatoes, tomatoes and certain dried fruits may need to be limited, particularly for children on hemodialysis.
• Phosphorus — limited to protect bones and blood vessels. Phosphorus is found in dairy products, processed foods, colas and many packaged snacks.
• Fluids — individualised. Children with little or no urine output need a fluid limit; those still passing urine may have more flexibility.

Infants and very young children

Babies on dialysis have particular nutritional needs and often require feeding support, including specialised formulas and sometimes feeding through a nasogastric tube or gastrostomy (a feeding tube placed into the stomach). This is not a failure of feeding by the family — it is a recognised, evidence-based way to give a very young child the calories they need to grow while their kidneys are failing.

Medications

Children on dialysis usually take several medications. The exact combination depends on the child, but commonly includes:

• Blood pressure medicines to protect the heart and remaining kidney function.
• Erythropoiesis-stimulating agents (such as erythropoietin) given as injections, to help the body make red blood cells and treat anemia.
• Iron supplements by mouth or as injections.
• Phosphate binders taken with meals to reduce the amount of phosphorus absorbed from food.
• Active vitamin D and calcium to support bone health.
• Growth hormone in selected children whose growth has slowed despite good nutrition and dialysis — pediatric nephrology guidelines support its use in carefully chosen cases.
• Other medications depending on the underlying disease (for example, immune-modulating medications for lupus).

Doses are adjusted to the child’s weight, age, growth and laboratory results, and are reviewed at every clinic visit. Some medications used in adults are not safe or not approved for children, and the pediatric nephrology team chooses options carefully.

Risks and Complications

Like any major medical treatment, pediatric dialysis carries some risks. Understanding them helps you recognise problems early and act quickly.

Common complications and what they look like

• Infection — peritonitis in children on PD (cloudy drainage, abdominal pain, fever) and bloodstream infections in children on HD with a catheter (fever, chills, feeling unwell). Strict hygiene during connections and good exit-site care reduce risk; any suspected infection needs prompt medical review.
• Access problems — the PD catheter can become blocked or displaced; the HD catheter or fistula can clot or narrow. These often need a procedure to fix.
• Anemia — common in kidney failure and managed with iron and erythropoiesis-stimulating agents.
• Bone and mineral disease — long-term imbalances of calcium, phosphorus and vitamin D can weaken bones, which is why diet, binders and vitamin D are so important.
• Growth delay — one of the most stressful issues for families. Good nutrition, adequate dialysis, and, where appropriate, growth hormone can significantly improve growth.
• Heart and blood vessel changes — longstanding kidney disease affects the cardiovascular system; blood pressure control and avoiding fluid overload are key.
• Emotional and psychological stress — for the child and the family. Psychological support is part of good pediatric dialysis care.

When to call the dialysis team urgently

Contact the team or go to the hospital straight away if your child has:

• Fever, chills or signs of feeling unwell, especially if on dialysis access.
• Cloudy PD drainage fluid, or pain when running in or draining out fluid.
• Redness, pain or discharge around the catheter or fistula site.
• Severe headache, confusion, very high blood pressure, or seizures.
• Sudden swelling, breathlessness or chest pain.
• Vomiting that prevents medications or fluids being kept down.

You know your child best. If something feels seriously wrong, trust that instinct and seek help.

Working with the Pediatric Dialysis Team

Pediatric dialysis is a team effort. The team usually includes:

• A pediatric nephrologist, the doctor leading kidney care.
• Pediatric dialysis nurses, who run the day-to-day treatment and train families.
• A pediatric renal dietitian, who plans nutrition for growth and dialysis.
• A surgeon, for access placement and transplantation when the time comes.
• A social worker, who supports families with schooling, finances and practical issues.
• A psychologist, counsellor or play therapist, especially in larger centres.
• The child’s general pediatrician and school health team.

What to look for when choosing or working with a pediatric dialysis programme:

• A pediatric nephrologist with specific training and experience in caring for children on dialysis.
• A unit that handles a reasonable volume of pediatric dialysis cases, with pediatric-specific equipment and protocols.
• Access to pediatric renal dietetics, psychology or counselling support, and social work.
• A clear connection to a pediatric kidney transplant programme — either within the same hospital or via a defined referral pathway.
• Willingness to involve you as a partner in decisions, answer questions in language you understand, and meet your child where they are emotionally.

It is entirely reasonable to ask questions, to seek a second opinion, and to take time to feel confident in the team caring for your child.

The Path Toward Kidney Transplantation

For most children, dialysis is part of a longer journey that points toward kidney transplantation. Children who receive a successful transplant generally grow better, feel more energetic, eat with fewer restrictions, take less time off school, and have better long-term outcomes than children who remain on dialysis for many years.

The transplant evaluation usually begins around the time dialysis starts (and sometimes earlier). It involves:

• Detailed assessment of the child’s overall health, heart, lungs, infections and immunisation status.
• Blood and tissue tests to find suitable donors.
• Evaluation of potential living donors in the family, where appropriate, under the legal framework that governs organ transplantation in the country of treatment.
• Listing on the deceased-donor waiting list if a living donor is not available.

Not every child can have a transplant immediately. Some need to grow to a minimum size, recover from active illness, complete vaccinations, or address other medical issues first. The dialysis team and transplant team work together to time the transplant as well as possible.

For the small number of children for whom transplantation is not an option, modern dialysis can still support a long and meaningful life, with attention to growth, schooling, mental health and adolescence.

Long-Term Outlook

The long-term outlook for a child on dialysis depends on many things, including the underlying cause of kidney failure, the child’s age at the start of dialysis, the quality of nutrition and growth support, control of blood pressure and bone health, and whether and when transplantation happens.

With good care, most children on dialysis:

• Continue to grow, although growth may be slower than peers and benefits from active nutritional and hormonal support.
• Attend school and progress in their education.
• Develop friendships, interests and hobbies.
• Move on to a kidney transplant, often within a few years of starting dialysis.
• Transition, as teenagers, from pediatric care to adult kidney care — a step the team prepares for carefully.

The honest truth is that the journey is not easy. It changes family life in real ways, and there are hard days. It is also true that children on dialysis — and their families — show extraordinary strength, and that the field of pediatric nephrology continues to improve outcomes year by year.

Frequently Asked Questions

Is dialysis permanent for children?

For most children, no. Dialysis is generally used as a bridge to a kidney transplant, which is considered the preferred long-term treatment for childhood kidney failure. Some children remain on dialysis longer because of medical reasons or while waiting for a suitable donor. In a smaller number of children with acute kidney injury, the kidneys recover and dialysis can be stopped.

Can my child go to school while on dialysis?

Yes. Children on overnight peritoneal dialysis usually attend school full time. Children on in-centre hemodialysis miss part of certain days but can keep up with the right support from the school and family. Education is an important part of pediatric dialysis care, and the team will help plan for it.

Is peritoneal dialysis safe to do at home?

For families who have been trained by the dialysis team and follow the routines carefully, home peritoneal dialysis is well established and widely used in children. The main risk is infection (peritonitis), which is reduced by strict hygiene, mask wearing during connections, and good care of the catheter exit site. The dialysis team is on call to support families with concerns.

Will dialysis affect my child’s growth?

Growth can be slower in children with kidney failure, but it is closely monitored and actively supported. Adequate dialysis, careful nutrition planning with a pediatric renal dietitian, control of bone and mineral balance, and, in some children, growth hormone therapy can all help. Pediatric nephrology guidelines treat growth as a central goal of care.

Is dialysis painful?

The dialysis treatment itself is generally not painful once the access is in place. Placement of a PD catheter or fistula is done under anesthesia. Needle sticks for hemodialysis through a fistula can be uncomfortable, and dialysis units use numbing creams and play or distraction techniques to help children cope. Most children adjust well over time.

Can my child travel while on dialysis?

Many children on dialysis travel for family events and holidays. Children on home peritoneal dialysis can often travel with their machine and supplies if arrangements are made in advance. Children on hemodialysis can sometimes arrange treatments at a dialysis unit near their destination. Plan with the dialysis team well ahead of any trip.

Can my child eat normally?

Children on dialysis follow a specific diet, but it is not as restrictive as families often fear. The pediatric renal dietitian tailors the plan to your child, family food culture and the type of dialysis. Many favourite foods can still be included with adjustments. The goals are good growth, controlled lab values and a child who still enjoys mealtimes.

Will my child need a transplant eventually?

For most children with chronic kidney failure, a kidney transplant is the long-term goal. The transplant evaluation usually starts around the time dialysis begins, and the timing of transplantation depends on the child’s medical readiness and the availability of a suitable donor. Your pediatric nephrology team will guide this process.

Conclusion

Pediatric dialysis is a serious treatment for a serious situation — but it is also, every day, a treatment that allows children to live, grow, learn and look forward. It is rarely the end of the story. For most children, it is the chapter that keeps them safe and well until a kidney transplant becomes possible, or until their own kidneys recover.

The medicine matters, and so does everything around it: nutrition planned with care, school kept in the picture, friendships and play protected, parents and siblings supported, and a child’s sense of themselves preserved through routines that, in time, simply become part of life. With a pediatric nephrology team you trust, and the patience to learn what your child needs, families navigate this journey with more strength than they often expect — and with real reasons for hope.