# Survey of legislative frameworks and national recommendations governing paediatric maintenance haemodialysis in Europe

## TL;DR

This paper surveys the legal and national guidelines for pediatric hemodialysis in European countries, finding significant gaps and inconsistencies.

## Contribution

The study provides the first comprehensive survey of legislative frameworks for pediatric hemodialysis across Europe.

## Key findings

- Laws or national recommendations for pediatric hemodialysis are rare and inconsistent across European countries.
- Only a small percentage of countries have specific guidelines for staffing and child care requirements during dialysis.
- There is a need for improved coordination between pediatric and adult nephrology practices.

## Abstract

The application of international recommendations for paediatric maintenance haemodialysis (HD) could be strengthened by national laws or written recommendations. Our aim was therefore to describe the national rules governing paediatric maintenance HD in European countries.

A national representative, approved by the president of each paediatric nephrology society, was contacted in all 42 European countries to complete two online questionnaires.

Answers were received from 36 countries. The population served by HD centres varies from 83,000 to 1,197,000 residents below 18 years of age and the estimated mean number of children on HD per centre from 0.2 to 13.5. The lowest age at which a child can be dialysed in an adult centre varies from 0 to 18 years. Laws or written national recommendations specifying: this age, the need for a paediatrician as part of medical team in mixed adult–paediatric centres, the minimum number of doctors per centre and the number of patients per nurse or nurse’s aide required during sessions exist in only 25, 22, 22, 44 and 8% of the countries, respectively. Similarly, dietitians, social workers, school service, psychologists and play specialists/youth workers are required by law or written national recommendations in 36, 28, 36, 31 and 14% of countries, respectively.

Laws or written national recommendations for paediatric maintenance HD are rare in European countries and very heterogeneous when they exist. This calls for discussion among paediatric and adult nephrologists and health authorities on the organisation of safe and effective paediatric HD practices.

A higher resolution version of the Graphical abstract is available as Supplementary information

A higher resolution version of the Graphical abstract is available as Supplementary information

The online version contains supplementary material available at 10.1007/s00467-025-06667-8.