Adapting Technology Saves Tiny Patients

Repurposed Aquadex machine provides neonatal nephrology therapy.

A repurposed hemofiltration machine is saving the lives of many neonates with severe kidney problems. Designed by a physician at Children's of Alabama, this adapted technology has led to higher survival rates and fewer complications for these small patients.

"Prior to 2014, it was challenging to perform dialysis in small children using machines designed for adults because we needed to use large vascular catheters and the amount of blood outside the body made up a large portion of their total blood volume. For these reasons, the rates of patient complications and technical challenges were high so we rarely dialyzed infants in need," says David Askenazi, MD, MSPH, director of the Pediatric and Infant Center for Acute Care Nephrology at Children's of Alabama. "We had the idea to adapt the Aquadex FlexFlow® System, a machine with much smaller blood circuit using external infusion pumps and Y-connectors. The repurposed machine now allows us to do what is necessary to maintain normal electrolytes, to clear waste products, and to remove excess fluid with fewer complications. In essence, it allows us to do the job of the kidneys for these babies without them even knowing that it's happening."

When using the adult machine in the past, the procedure was complex and resulted in a lot of alarms and complications. Now, Askenazi can trust that the machine is going to provide therapy without complications. "By showing that the complication rates are as low as pediatric and adult patients, our ICU physician colleagues are reaching out to us sooner. The number of babies with kidney failure that we support has increased exponentially," he says.

Children's of Alabama was the first program to use this approach, and Askenazi and his colleagues have helped five other programs throughout the country to use the Aquadex for their tiny patients. Today, Children's of Alabama has six Aquadex machines, and babies in the NICU spent more than 1,100 days on dialysis in 2018 compared to just 30 days in 2013.

"In our hands, 97 percent of the therapy initiations occur without any hemodynamic changes. That shows that we get even tiny and/or sick babies on the machine safely," Askenazi says. "That reduction in patient complications has changed our collective approach to dialysis in infants.

"We are dedicated to continued improvement. It is an iterative process, and we have made modifications to our processes and procedures for the needs of our patients. We are working with the Aquadex company to help them as they consider their next steps. We hope they can incorporate additional features in the design of future machines to allow us do our jobs even better."

Askenazi and his team published results of their first 12 patients in the Pediatric Nephrology journal in 2016. Since then, they have treated more than 90 patients, the smallest just two pounds, seven ounces. They recently published their experience at Children's of Alabama and two other centers in the Clinical Journal of the American Society of Nephrology. They also have taught nephrologists from children's hospitals around the country to use the Aquadex, which has saved many lives. As a result, the machine's manufacturer is pursuing a pediatric indication for Aquadex, something that will be important for these tiny patients.

"It is important to recognize that this program to save babies lives is not just one person or one physician group. Our success is built on partnerships between multiple units and groups in our program. These babies are in contact with neonatologists, nephrologists, surgeons, nurses, nurse practitioners, nutritionists, administration and many others," Askenazi says. "It takes a lot of time and energy to build this program and care for these tiny patients, but it is rewarding for us to give these babies the best chance to live."


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MD; Pediatric Nephrology Journal 2016; Children's of Alabama nephrology for neon, Repurposed Aquadex FlexFlow® System for infants; David Askenazi


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