Peritoneal dialysis for acute renal failure in children

ISPD guidelines for peritoneal dialysis in acute kidney injury: 2020 Update (paediatrics)

SUMMARY OF RECOMMENDATIONS

1.1 Peritoneal dialysis is a suitable renal replacement therapy modality for treatment of acute kidney injury in children. (1C)2. Access and fluid delivery for acute PD in children.2.1 We recommend a Tenckhoff catheter inserted by a surgeon in the operating theatre as the optimal choice for PD access. (1B) (optimal)2.2 Insertion of a PD catheter with an insertion kit and using Seldinger technique is an acceptable alternative. (1C) (optimal)2.3 Interventional radiological placement of PD catheters combining ultrasound and fluoroscopy is an acceptable alternative. (1D) (optimal)2.4 Rigid catheters placed using a stylet should only be used when soft Seldinger catheters are not available, with the duration of use limited to <3 days to minimize the risk of complications. (1C) (minimum standard)2.5 Improvised PD catheters should only be used when no standard PD access is available. (practice point) (minimum standard)2.6 We recommend the use of prophylactic antibiotics prior to PD catheter insertion. (1B) (optimal)2.7 A closed delivery system with a Y connection should be used. (1A) (optimal) A system utilizing buretrols to measure fill and drainage volumes should be used when performing manual PD in small children. (practice point) (optimal)2.8 In resource limited settings, an open system with spiking of bags may be used; however, this should be designed to limit the number of potential sites for contamination and ensure precise measurement of fill and drainage volumes. (practice point) (minimum standard)2.9 Automated peritoneal dialysis is suitable for the management of paediatric AKI, except in neonates for whom fill volumes are too small for currently available machines. (1D)3. Peritoneal dialysis solutions for acute PD in children3.1 The composition of the acute peritoneal dialysis solution should include dextrose in a concentration designed to achieve the target ultrafiltration. (practice point)3.2  Once potassium levels in the serum fall below 4 mmol/l, potassium should be added to dialysate using sterile technique. (practice point) (optimal) If no facilities exist to measure the serum potassium, consideration should be given for the empiric addition of potassium to the dialysis solution after 12 h of continuous PD to achieve a dialysate concentration of 3-4 mmol/l. (practice point) (minimum standard)3.3  Serum concentrations of electrolytes should be measured 12 hourly for the first 24 h and daily once stable. (practice point) (optimal) In resource poor settings, sodium and potassium should be measured daily, if practical. (practice point) (minimum standard)3.4  In the setting of hepatic dysfunction, hemodynamic instability and persistent/worsening metabolic acidosis, it is preferable to use bicarbonate containing solutions. (1D) (optimal) Where these solutions are not available, the use of lactate containing solutions is an alternative. (2D) (minimum standard)3.5  Commercially prepared dialysis solutions should be used. (1C) (optimal) However, where resources do not permit this, locally prepared fluids may be used with careful observation of sterile preparation procedures and patient outcomes (e.g. rate of peritonitis). (1C) (minimum standard)4. Prescription of acute PD in paediatric patients4.1 The initial fill volume should be limited to 10-20 ml/kg to minimize the risk of dialysate leakage; a gradual increase in the volume to approximately 30-40 ml/kg (800-1100 ml/m²) may occur as tolerated by the patient. (practice point)4.2 The initial exchange duration, including inflow, dwell and drain times, should generally be every 60-90 min; gradual prolongation of the dwell time can occur as fluid and solute removal targets are achieved. In neonates and small infants, the cycle duration may need to be reduced to achieve adequate ultrafiltration. (practice point)4.3 Close monitoring of total fluid intake and output is mandatory with a goal to achieve and maintain normotension and euvolemia. (1B)4.4 Acute PD should be continuous throughout the full 24-h period for the initial 1-3 days of therapy. (1C)4.5  Close monitoring of drug dosages and levels, where available, should be conducted when providing acute PD. (practice point)5. Continuous flow peritoneal dialysis (CFPD)5.1   Continuous flow peritoneal dialysis can be considered as a PD treatment option when an increase in solute clearance and ultrafiltration is desired but cannot be achieved with standard acute PD. Therapy with this technique should be considered experimental since experience with the therapy is limited. (practice point) 5.2  Continuous flow peritoneal dialysis can be considered for dialysis therapy in children with AKI when the use of only very small fill volumes is preferred (e.g. children with high ventilator pressures). (practice point).

Challenges of acute peritoneal dialysis in extremely-low-birth-weight infants: a retrospective cohort study

Background

Peritoneal dialysis (PD) has been used occasionally in extremely-low-birth-weight (ELBW) infants with acute kidney injury (AKI). This study aimed to evaluate the clinical characteristics and outcomes of ELBW infants with AKI treated with PD.

Methods

In this retrospective cohort study, the medical records of ELBW infants with AKI, who underwent PD from January 2008 to February 2018, were reviewed. A PD catheter (7.5–9.0 Fr) or central venous catheter (4 Fr) was used for the peritoneal access. Treatment with PD solutions (2.5 or 4.25%) was started at 10 mL/kg, which was increased to 20–30 mL/kg for 60–120 min/cycle continuing for 24 h.

Results

Twelve ELBW infants (seven male and five female infants) were treated, and their mean (±SD) gestational age and birth weight were 27.2 (±3.3) weeks and 706.5 (±220.5) g, respectively. Two patients had severe perinatal asphyxia (5-min Apgar score ≤ 3). The most important indication for starting PD was AKI due to sepsis. The average (±SD) duration of PD was 9.4 (± 7.7) days. The potassium levels in the ELBW infants with hyperkalemia decreased from 6.8 to 5.0 mg/mL after 9.3 (± 4.4) days. The most common complication of PD was mechanical dysfunction of the catheters, such as dialysate leakage (75%). Two patients were successful weaned off PD. The mortality rate of the infants treated with PD was 91.7%.

Conclusions

In this series, the mortality rate of ELBW infants with AKI treated with PD was relatively high because of their incompletely developed organ systems. Therefore, the use of PD should be carefully considered for the treatment of ELBW infants with AKI in terms of decisions regarding resuscitation.

Peritoneal Dialysis for Management of Pediatric Acute Renal Failure

Background

While the use of continuous renal replacement therapies in the management of children with acute renal failure (ARF) has increased, the role of peritoneal dialysis (PD) in the treatment of pediatric ARF has received less attention.

Design

Retrospective database review of children requiring PD for ARF over a 10-year period.

Setting

Pediatric intensive care unit at a tertiary-care referral center.

Patients

Sixty-three children without previously known underlying renal disease who required PD for treatment of ARF.

Results

Causes of ARF were congestive heart failure (27), hemolytic-uremic syndrome ( 13 ), sepsis ( 10 ), nonrenal organ transplant ( 7 ), malignancy ( 3 ), and other ( 3 ). Mean duration of PD was 11 ± 13 days. Children with ARF were younger (30 ± 48 months vs 88 ± 68 months old, p < 0.0001) and smaller (11.9 ± 15.9 kg vs 28 ± 22 kg, p < 0.0001) than children with known underlying renal disease who began PD during the same time period. Percutaneously placed PD catheters were used in 62% of children with ARF, compared to 4% of children with known renal disease ( p < 0.0001). Hypotension was common in patients with ARF (46%), which correlated with a high frequency of vasopressor use (78%) at the time of initiation of PD. Complications of PD occurred in 25% of patients, the most common being catheter malfunction. Recovery of renal function occurred in 38% of patients; patient survival was 51%.

Conclusions

Peritoneal dialysis remains an appropriate therapy for pediatric ARF from many causes, even in severely ill children requiring vasopressor support. Such children can be cared for without the use of more expensive and technology-dependent forms of renal replacement therapies.

Fibrin Glue Used Successfully in Peritoneal Dialysis Catheter Leakage in Children

Background

Acute renal failure in infants and small children is generally treated with peritoneal dialysis (PD). Dialysis has to be started immediately after catheter implantation. Early dialysate leakage can complicate the effectiveness of dialysis. Fibrin glue applied to the external part of the tunnel may stop dialysate leakage and eliminate the need for surgical intervention. The use of fibrin glue in the treatment of PD catheter leakage in children was studied.

Methods

Fibrin glue was used in 8 children (age 0.8 – 57 months) on PD in whom dialysate leakage was seen during the first 24 to 48 hours after catheter insertion. The dialysis volume initially administered was 20 mL/kg body weight. Fibrin glue (1 mL) was applied to the external part of the subcutaneous catheter tunnel through the exit site, as close to the cuff as possible. The occurrence of dialysate leakage and complications such as exit-site or tunnel infection and peritonitis were evaluated.

Results

Nine single-cuff straight Tenckhoff catheters were implanted in 8 children. In 5 cases, no subcutaneous tunnel was created. One child had catheter replacement due to obstruction of the catheter; on both occasions, catheter leakage was seen and treated with fibrin glue. In all 8 patients, no relapse of dialysate leakage was seen after application of the fibrin glue. During the time of PD, exit-site infections, tunnel infections, and peritonitis did not occur.

Conclusion

Fibrin glue is a successful, simple, and safe substance for the treatment of peritoneal dialysate leakage in infants and small children with acute renal failure treated with PD.

Acute Peritoneal Dialysis Access in Infant Renal Failure

Rapid onset of acute peritoneal dialysis (PD) in the infant population is, in part, dependent upon equipment availability. From March 1991 until June 1995, over 200 children at the University of Michigan have undergone dialysis for acute renal failure. Of these children, 29 infants (mean±SEM) (age 4.5±1.3 months; weight 4.8±0.5 kg) have had placement of an acute 5 French Cook PD catheter for dialysis. Complications including inadequate inflow in one case, bleeding in one case, and accidental removal in one case were infrequent. Duration of the placed catheters was 9.9±2.7 days, without the problems associated with chronic placement of a stiff catheter. Onset of dialysis occurred within minutes due to rapid access. We conclude that the placement of a 5 French Cook acute PD catheter for acute PD in the infant population is easily performed with minimal risk. Moreover, this allows for more rapid onset of PD when conditions mandate this need.

Utilization of Peritoneal Dialysis in the Acute Setting

Peritoneal dialysis (PD), although classically described and utilized in the treatment of patients with end-stage renal disease, can also be utilized in the acute setting in different clinical situations. Recent studies showed that, in patients with acute renal failure, it is possible to obtain reasonable dialysis doses with adequate metabolic and electrolytic control and low incidence of complications by utilizing continuous PD through a cycler at high volume. In patients with congestive heart failure without end-stage renal disease, PD is capable of promoting clinical improvement with slow removal of liquids, becoming an attractive alternative for situations of rapidly or slowly worsening cardiac function. In patients submitted to chronic hemodialysis but who have vascular access difficulties, PD can also be utilized as a “bridge,” thereby avoiding the use of central venous catheters, which can be associated with infectious complications such as bacterial endocarditis. New studies must be realized showing other indications for PD.

Peritoneal Dialysis in Pediatric Postoperative Cardiac Surgical Patients

Background

We determined the prevalence of acute kidney injury requiring peritoneal dialysis (PD), the factors associated with early PD initiation, prolonged PD and mortality among pediatric postoperative cardiac surgical patients.

Materials and Methods

The hospital records of 23 children, aged 12 years or younger, who had undergone cardiac surgery and required PD subsequently, during a 1-year period were reviewed. Demographic data, intraoperative variables, and postoperative complications were compared between survivors and nonsurvivors of PD, between the short and long duration PD groups, and between the early and late PD initiation groups.

Results

Six hundred and eight pediatric patients who underwent open heart surgery were enrolled in this study. 23 (3.78%) of them required PD. When compared with survivors (n = 11), non survivors (n =12) were more likely to have a higher serum procalcitonin (p = 0.01), higher serum potassium on day 2 (p = 0.001), day 3 (p = 0.04), day of termination of PD (p = 0.001) and a lower urine output on day 3 of PD (p = 0.03). Prolonged PD was associated with time of PD initiation (p = 0.01), a higher postoperative serum creatinine on day 3 (p = 0.01) of PD initiation as well on the day of PD termination (p = 0.01) and the final outcome in terms of survival (p = 0.02). Factors significantly associated with an early PD initiation were CPB time (p = 0.04), sepsis (p = 0.02) and shorter PD duration (p = 0.003).

Conclusion

PD is very useful mode of renal replacement therapy among pediatric postoperative cardiac surgical patients. The intraoperative and postoperative variables have important association with the time of PD initiation, PD duration and patient survival.

How to cite this article

Sahu MK, Bipin C, Arora Y, Singh SP, Devagouru V, Rajshekar P, et al. Peritoneal Dialysis in Pediatric Postoperative Cardiac Surgical Patients. Indian J Crit Care Med 2019;23(8):371-375.

Peritoneal Infections in Children Undergoing Acute Peritoneal Dialysis at a Tertiary/Quaternary Central Hospital in Kwazulu-Natal, South Africa

Background

In a resource-limited setting, acute peritoneal dialysis (APD) is the modality of choice as a form of renal replacement therapy in children with acute kidney injury (AKI). However, there is a high risk of peritonitis that causes significant morbidity and mortality. Data on PD and peritonitis in developing countries are scarce. The purpose of this retrospective study was to determine the prevalence of APD-related peritonitis at a central referral hospital in KwaZulu-Natal, South Africa.

Methods

A retrospective study from January 2010 until December 2014 was done at Inkosi Albert Luthuli Central Hospital (IALCH). All children under the age of 13 years with AKI requiring APD were included in the study.

Results

Forty children were included in the study. Age ranged from 0.2 years to 12.25 years; 25 (62.5%) were male and 15 (37.5%) female. Twenty-seven (67.5%) were admitted to the intensive care unit (ICU) and 13 (32.5%) to the pediatric high care ward. Septicemia with multi-organ dysfunction was the was the main cause of AKI requiring APD in 18 (45%) children followed by poststreptococcal glomerulonephritis in 8 (20%). Acute PD was complicated by culture-proven peritonitis in 19 (47.5%) children of whom 16 (84.2%) had a single organism cultured while in 3, (15.7%) there was a mixed culture. The total number of organisms cultured was 24: 8 (33.3%) were gram-positive organisms, 12 (50%) gram-negative organisms, and 4 (16.67%) fungal. The Paediatric Index of Mortality (PIM) 2 Score risk of mortality was 99.4% for patients admitted to ICU. Mortality rate was 65%, and 14 (53%) of the children who demised had peritonitis.

Conclusion

This study showed an inordinately high complication rate of peritonitis, mostly secondary to gram-negative organisms, of children undergoing APD in a central referral hospital. The use of surgically placed, tunneled catheters, meticulous attention to aseptic techniques and judicious use of antimicrobials is highly recommended in reducing the incidence of peritonitis in children undergoing APD.

Acute peritoneal dialysis in neonatal intensive care unit: An 8-year experience of a referral hospital

BACKGROUND

The aim of present study was to evaluate the indications, complications and outcomes of acute peritoneal dialysis (APD) in neonates at a referral university hospital during the previous 8 years.

METHODS

This retrospective analysis included a total of 52 newborn infants who underwent APD in a neonatal intensive care unit between January 2008 and March 2016. Demographic, clinical, laboratory and microbiological data were extracted from patients' medical files.

RESULTS

The primary causes for requiring APD were acute tubular necrosis (n = 36, 69.2%), inborn error of metabolism (n = 10, 19.2%), congenital nephrotic syndrome (n = 2, 3.9%), bilateral polycystic kidney (n = 2, 3.9%), renal agenesis (n = 1, 1.9%), and obstructive uropathy (n = 1, 1.9%). The mean duration of APD was 8.7 ± 15.87 days (range: 1-90 days). Procedural complications were mainly hyperglycemia (n = 16, 47.1%), dialysate leakage (n = 7, 20.6%), peritonitis (n = 3, 8.8%), catheter obstruction (n = 3, 8.8%), bleeding at the time of catheter insertion (n = 2, 5.9%), catheter exit site infection (n = 2, 5.9%), and bowel perforation (n = 1 2.9%). There were 40 deaths (76.9%), mainly due to underlying causes. Ten of the 12 survivors showed full renal recovery, but mild chronic renal failure (n = 1) and proteinuria with hypertension were seen (n = 1) in each of remaining patients.

CONCLUSION

Peritoneal dialysis is an effective route of renal replacement therapy in the neonatal period for management of metabolic disturbances as well as renal failure. Although major complications of the procedure are uncommon, these patients still have a high mortality rate due to serious nature of the underlying primary causes.

Peritoneal dialysis for the management of pediatric patients with acute kidney injury

Renal replacement therapy (RRT) is the most important supportive measure used in the management of acute kidney injury (AKI). Peritoneal dialysis (PD) is a safe, simple and inexpensive procedure and has been used in pediatric AKI patients, ranging from neonates to adolescents. It is the modality of choice for RRT in developing countries with cost constraints and limited resources. However, its use has declined with the availability of newer types of extracorporeal modalities for RRT in the developed world. Much controversy exists regarding the dosing and adequacy of PD in the management of AKI. Data in infants and children have shown that PD can provide adequate clearance, ultrafiltration and correction of metabolic abnormalities even in those who are critically ill. Although there are no prospective studies in children, data from retrospective studies reveal no differences in mortality rates between different modalities of RRT. In this review, we discuss the advantages and limitations of PD, indications for acute PD, strategies to improve the efficiency of acute PD and outcomes of PD in children with AKI.

Acute kidney injury in the fetus and neonate

Acute kidney injury (AKI) is an under-recognized morbidity of neonates; the incidence remains unclear due to the absence of a unified definition of AKI in this population and because previous studies have varied greatly in screening for AKI with serum creatinine and urine output assessments. Premature infants may be born with less than half of the nephrons compared with term neonates, predisposing them to chronic kidney disease (CKD) early on in life and as they age. AKI can also lead to CKD, and premature infants with AKI may be at very high risk for long-term kidney problems. AKI in neonates is often multifactorial and may result from prenatal, perinatal, or postnatal insults as well as any combination thereof. This review focuses on the causes of AKI, the importance of early detection, the management of AKI in neonates, and long-term sequela of AKI in neonates.

The Use of Acute Peritoneal Dialysis in Critically Ill Newborns

Background

To evaluate the efficacy, complications, and mortality rate of acute peritoneal dialysis (APD) in critically ill newborns.

Material/Methods

The study included 31 newborns treated in our center between May 2012 and December 2014.

Results

The mean birth weight, duration of peritoneal dialysis, and gestational age of the patients were determined as 2155.2±032.2 g (580–3900 g), 4 days (1–20 days), and 34 weeks (24–40 weeks), respectively. The main reasons for APD were sepsis (35.5%), postoperative cardiac surgery (16%), hypoxic ischemic encephalopathy (13%), salting of the newborn (9.7%), congenital metabolic disorders (6.1%), congenital renal diseases (6.5%), nonimmune hydrops fetalis (6.5%), and acute kidney injury (AKI) due to severe dehydration (3.2%). APD-related complications were observed in 48.4% of the patients. The complications encountered were catheter leakages in nine patients, catheter obstruction in three patients, peritonitis in two patients, and intestinal perforation in one patient. The general mortality rate was 54.8%, however, the mortality rate in premature newborns was 81.3%.

Conclusions

APD can be an effective, simple, safe, and important therapy for renal replacement in many neonatal diseases and it can be an appropriate treatment, where necessary, for newborns. Although it may cause some complications, they are not common. However, it should be used carefully, especially in premature newborns who are vulnerable and have a high mortality risk. The recommendation of APD therapy in such cases needs to be verified by further studies in larger patient populations.

Use of a simply modified drainage catheter for peritoneal dialysis treatment of acute renal failure associated with cardiac surgery in infants

Acute renal failure (ARF) is a common complication in infants who undergo cardiac surgery in the intensive care unit. We report on a modified drainage catheter used in peritoneal dialysis (PD) for the treatment of ARF associated with cardiac surgery in infants. Thirty-nine infants with congenital heart disease undergoing cardiac surgery who developed ARF at our center between January 2009 and January 2012 were assessed. A modified drainage catheter for PD was used in these infants. Their demographic, clinical, and surgical data were analyzed. Thirty infants with ARF were cured by PD, and the other 9 died in the first 48 hours because of the severity of the acute cardiac dysfunction. All these infants were dependent upon mechanical ventilation during the postoperative period and used vasoactive drugs. In the survival group, the interval between the procedure and initiation of PD was 13.6 ± 6.5 (range, 6-30) hours. PD duration was 3.9 ± 0.9 (3-6) days. Minor complications were encountered in some patients (asymptomatic hypokalemia, hyperglycemia, and thrombocytopenia). These complications were readily treated by drugs or resolved spontaneously. Hemodynamics, cardiac function, and renal function improved significantly during PD. These data suggest that PD using a modified drainage catheter for ARF after cardiac surgery in infants is safe, feasible, inexpensive, and yields good results.

Acute peritoneal dialysis in neonates with acute kidney injury and hypernatremic dehydration

OBJECTIVE

We aimed to evaluate the efficacy of acute peritoneal dialysis (PD) and clinical outcomes in neonates with acute kidney injury (AKI) and hypernatremic dehydration. ♢

METHODS

The medical records of 15 neonates with AKI and hypernatremic dehydration who were treated with acute PD were reviewed. The diagnoses were AKI with hypernatremic dehydration with or without sepsis in 13 patients and AKI with hypernatremia and congenital nephropathy in 2 patients. The main indications for PD were AKI with some combination of oligoanuria, azotemia, hyperuricemia, and metabolic acidosis unresponsive to initial intensive medical treatment. ♢

RESULTS

The mean age of the patients at dialysis initiation was 11.9 ± 9 days, and the mean duration of PD was 6.36 ± 4.8 days. In 7 patients (46.7%), hypotension required the use of vasopressors, and in 6 patients (40%), mechanical ventilation was required. Peritoneal dialysis-related complications occurred in 7 patients (46.7%), the most common being catheter malfunction (n = 6). Four episodes of peritonitis occurred in the 15 patients (26.7%), 2 episodes in patients with congenital renal disease and 2 episodes in patients with sepsis and multiorgan failure, who did not survive. Congenital renal disease, septicemia, and the need for mechanical ventilation were important factors influencing patient survival. All patients with no pre-existing renal disease or sepsis recovered their renal function and survived. ♢

CONCLUSIONS

In neonates with AKI and hypernatremic dehydration, PD is safe and successful, and in patients without congenital renal disease or sepsis, the prognosis is good. Peritoneal dialysis should be the treatment of choice in neonates with AKI and hypernatremic dehydration who do not respond to appropriate medical treatment.

Acute dialysis-associated peritonitis in children with D+ hemolytic uremic syndrome

Acute peritoneal dialysis (PD) is the preferred therapy for renal replacement in children with post-diarrheal hemolytic uremic syndrome (D+ HUS), but peritonitis remains a frequent complication of this procedure. We reviewed data from 149 patients with D+ HUS who had undergone acute PD with the aim of determining the prevalence and risk factors for the development of peritonitis. A total of 36 patients (24.2%) presented peritonitis. The median onset of peritonitis manifestations was 6 (range 2-18) days after the initiation of dialysis treatment, and Gram-positive microorganisms were the predominant bacterial type isolated (15/36 patients). The patients were divided into two groups: with or without peritonitis, respectively. Univariate analysis revealed that a longer duration of the oligoanuric period, more days of dialysis, catheter replacement, stay in the intensive care unit, and hypoalbuminemia were significantly associated to the development of peritonitis. The multivariate analysis, controlled by duration of PD, identified the following independent risk factors for peritonitis: catheter replacement [p = 0.037, odds ratio (OR) 1.33, 95% confidence interval (CI) 1.02-1.73], stay in intensive care unit (p = 0.0001, OR 2.62, 95% CI 1.65-4.19), and hypoalbuminemia (p = 0.0076, OR 1.45, 95% CI 1.10-1.91). Based on these findings, we conclude that the optimization of the aseptic technique during catheter manipulation and early nutritional support are targets for the prevention of peritonitis, especially in critically ill patients.

Peritoneal dialysis in renal replacement therapy for patients with acute kidney injury

Peritoneal dialysis (PD) was the first modality used for renal replacement therapy (RRT) of patients with acute kidney injury (AKI) because of its inherent advantages as compared to Hemodialysis. It provides the nephrologist with nonvascular alternative for renal replacement therapy. It is an inexpensive modality in developing countries and does not require highly trained staff or a complex apparatus. Systemic anticoagulation is not needed, and it can be easily initiated. It can be used as continuous or intermittent procedure and, due to slow fluid and solute removal, helps maintain hemodynamic stability especially in patients admitted to the intensive care unit. PD has been successfully used in AKI involving patients with hemodynamic instability, those at risk of bleeding, and infants and children with AKI or circulatory failure. Newer continuous renal replacement therapies (CRRTs) are being increasingly used in renal replacement therapy of AKI with less use of PD. Results of studies comparing newer modalities of CRRT versus acute peritoneal dialysis have been conflicting. PD is the modality of choice in renal replacement therapy in pediatric patients and in patients with AKI in developing countries.

Management of calculus anuria in children: experience of 54 cases

OBJECTIVE

To evaluate the outcome of different treatment plans for calculus anuria in children.

PATIENTS AND METHODS

Patients were subdivided into three groups, A, B and C. Group A included patients who were critically ill, had serum creatinine> or =3.5mg/dl, blood urea> or =100mg/dl, serum potassium> or =7meq/l and/or blood pH< or =7.1; and they were treated initially by peritoneal dialysis. Patients in groups B and C were stable with serum creatinine<3.5mg/dl, blood urea<100mg/dl, serum potassium level<7meq/l and blood pH>7.1. In group B, the obstructing stone could not be localized, and they were treated either by percutaneous nephrostomy or JJ stent. In group C, stone level was confidently determined and patients were treated by open surgery.

RESULTS

Fifty-four patients were included. All patients regained normal serum creatinine levels within 72-120h. Overall complication rate in groups A and C was 26% and 13%, respectively. In group B, overall complication rate was 66% for percutaneous nephrostomy and 50% for internal stent.

CONCLUSIONS

Urinary diversion in children is associated with a high complication rate while dialysis is highly effective in children. Formal surgery in compensated children is associated with a low complication rate with good outcome and early recovery.

Dialysis and pediatric acute kidney injury: choice of renal support modality

Dialytic intervention for infants and children with acute kidney injury (AKI) can take many forms. Whether patients are treated by intermittent hemodialysis, peritoneal dialysis or continuous renal replacement therapy depends on specific patient characteristics. Modality choice is also determined by a variety of factors, including provider preference, available institutional resources, dialytic goals and the specific advantages or disadvantages of each modality. Our approach to AKI has benefited from the derivation and generally accepted defining criteria put forth by the Acute Dialysis Quality Initiative (ADQI) group. These are known as the risk, injury, failure, loss, and end-stage renal disease (RIFLE) criteria. A modified pediatrics RIFLE (pRIFLE) criteria has recently been validated. Common defining criteria will allow comparative investigation into therapeutic benefits of different dialytic interventions. While this is an extremely important development in our approach to AKI, several fundamental questions remain. Of these, arguably, the most important are "When and what type of dialytic modality should be used in the treatment of pediatric AKI?" This review will provide an overview of the limited data with the aim of providing objective guidelines regarding modality choice for pediatric AKI. Comparisons in terms of cost, availability, safety and target group will be reviewed.

Hyperglycemia and the outcome of pediatric cardiac surgery patients requiring peritoneal dialysis

OBJECTIVE

To study the nature of the association between glycemia and ICU mortality in pediatric cardiac surgery patients treated with peritoneal dialysis (PD).

MATERIALS AND METHODS

Retrospective observational study in the ICU of a tertiary hospital involving forty pediatric cardiac surgery patients treated with PD. We selected patients requiring PD, extracted glucose measurements and nutritional intake data during ICU stay and calculated mean and maximum blood glucose values i) during ICU stay; ii) during dependence on PD; and iii) during independence from PD. We statistically assessed the relationship between glycemia-related variables and ICU mortality.

MEASUREMENTS AND RESULTS

Twenty-two patients treated with PD died (mortality 55%). In the PD cohort, 9725 blood glucose measurements were performed (every 3.3 hours on average). The mean glycemia during dependence on PD was significantly higher in non-survivors than survivors (p<0.0001), but not during independence from PD (p=0.49). The area under the receiver operator characteristic curve for the mean glycemia during dependence on PD was significantly greater than that obtained during independence from PD. Even after adjustment for severity of illness using multivariate logistic analysis, the mean glycemia and calorie intake during PD were significant and independent predictors of ICU mortality.

CONCLUSIONS

A higher mean blood glucose concentration during PD, but not during PD-free periods was associated with greater ICU mortality. Mean glycemia and calorie intake during PD were significant and independent predictors of ICU mortality.

Adequacy of peritoneal dialysis in children following cardiopulmonary bypass surgery

Acute renal failure requiring renal replacement therapy can complicate cardiopulmonary bypass in children. Peritoneal dialysis has been shown to stabilize electrolytes and improve fluid status in these patients. To assess dialysis adequacy in this setting, we prospectively measured Kt/V and creatinine clearance in five patients (6-839 days of age) requiring renal replacement therapy at our institution. Median dialysis creatinine clearance was 74.25 L/week/1.73m(2) (range 28.28-96.63 L/week/1.73m(2)). Residual renal function provided additional solute clearance as total creatinine clearance was 215.97 L/week/1.73m(2) (range 108.04-323.25 L/week/1.73m(2)). Dialysis Kt/V of >2.1 (median 4.84 [range 2.12-5.59]) was achieved in all patients. No dialysis-associated complications were observed. We conclude that peritoneal dialysis is a safe, simple method of providing adequate clearance in children who develop acute renal failure following exposure to cardiopulmonary bypass.

Pediatric acute renal failure in southwestern Nigeria

BACKGROUND

Acute renal failure (ARF) was investigated to determine the prevalence of ARF clinical types, etiology, comorbidities, and outcome in Nigerian children.

METHODS

Consecutive cases of ARF admitted from March, 1994 through February, 2003 were prospectively studied. Information were obtained concerning the following: age, gender, body surface area, early (within 48 hours of onset of ARF) or late (>48 hours of onset of ARF) presentation, admission duration, etiology, comorbidities, urine volume/day, dialysis need, reasons for considering dialysis, laboratory investigations, and outcome in each patient. Histopathologic reports of percutaneous renal and surgical biopsies, as well as autopsy specimens, were reviewed.

RESULTS

There were 78 boys and 45 girls (M:F, 1.73:1); mean age was 6.28 +/- 4.0 years. A portion of patients presented early (46.3%), while 53.7% presented late. Oliguric (63.41%), anuric (20.33%), and nonoliguric (16.26%) ARF were the clinical types seen. Dialysis requirement was significantly higher in oliguric (P < 0.005) and anuric (P < 0.005) than nonoliguric ARF. Primary and secondary etiologies accounted for 29% and 71% of ARF cases, respectively. Renal Burkitt's lymphoma (47.2%), glomerulonephritis (27.8%), nephrotic syndrome (16.7%), hemolytic uremic syndrome (5.5%), and acute tubulointerstitial nephritis (2.8%) were primary etiologies. Plasmodium falciparum malaria (42.53%), septicemia (28.73%), hypovolemia (11.49%), and obstructive uropathy (8.05%) were major secondary etiologies. Financial constraints on the part of parents of patients, as well as inadequate and/or lack of dialysis equipment, were major inhibitions to effective management of the patients; in fact, 6 patients took voluntary discharge due to inability to afford the cost of treatment. Mortality risk factors were late presentation [odds ratio (OR) 3.5, P < 0.001], dialysis eligibility (OR 3.8, P < 0.001), nondialysis (OR 23.1, P= 0.00004), primary etiology (OR 2.6, P < 0.025), and presence of > or =2 comorbidities (OR 2.9, P < 0.025); overall mortality rate was 46.2%.

CONCLUSION

These results show that many of the causes of ARF in our patients are preventable; it should be possible to reduce morbidity due to ARF through purposive preventive measures.

Predictors of mortality at initiation of peritoneal dialysis in children after cardiac surgery

BACKGROUND

The development of renal dysfunction in the postoperative course of cardiac surgery is still associated with high mortality in pediatric patients. In particular for small infants peritoneal dialysis offers a secure and useful treatment option. The aim of the present study was to investigate if routinely used laboratory and clinical variables could help predict mortality at initiation of peritoneal dialysis.

METHODS

We performed a retrospective chart analysis of pediatric intensive care unit patients with renal dysfunction who were treated with peritoneal dialysis after cardiac surgery between 1993 and 2001 and analyzed variables obtained 3 hours or less before starting peritoneal dialysis.

RESULTS

Results are documented as means and standard errors. A total of 1141 children underwent a cardiac operation on cardiopulmonary bypass. Sixty-two children (5.4%) were treated with peritoneal dialysis. Mortality was 40.3% (37 survivors, 25 nonsurvivors). The pH in survivors was 7.35 (0.01); in nonsurvivors it was 7.23 (0.03; p = 0.0037). Base excess in survivors was -1.37 mmol/L (0.61); in nonsurvivors it was -7.17 mmol/L (1.49; p = 0.0026). Lactate in survivors was 4.5 mmol/L (0.60); in nonsurvivors it was 10.5 mmol/L (1.78; p = 0.0089). Positive inspiratory pressure in survivors was 24.6 cm H(2)O (0.78); in nonsurvivors it was 28.9 cm H(2)O (1.08; p = 0.0274). Tidal volume per kilogram bodyweight in survivors was 11.0 mL/kg (0.48); in nonsurvivors it was 8.7 mL/kg (0.50; p = 0.0493).

CONCLUSIONS

We conclude from our data that the consideration of pH, base excess, lactate, positive inspiratory pressure, and tidal volume per kilogram bodyweight help predict mortality at initiation of peritoneal dialysis. We were able to observe significant differences between survivors and nonsurvivors using these variables.

Peritoneal dialysis after surgery for congenital heart disease in infants and young children

BACKGROUND

We determined the risk factors for peritoneal dialysis (PD) in young children undergoing open heart surgery and, in those patients requiring PD, factors associated with prolonged PD and mortality.

METHODS

The clinical records of 182 children, aged 3 years or younger, who had undergone open heart surgery during a 2-year period were reviewed. Demographic data, preoperative risk factors, intraoperative variables, and postoperative complications were compared between patients requiring PD and those who did not, and between survivors and nonsurvivors of PD.

RESULTS

Of the 182 patients, 31 (17%) required PD. Patients requiring PD were lighter and more likely to have required preoperative ventilation; had undergone more complex surgery requiring longer bypass and circulatory arrest; and had experienced a pulmonary hypertensive crisis (p < 0.01). Logistic regression identified circulatory arrest (relative risk, 9.4; p = 0.002), cardiopulmonary bypass duration (relative risk, 1.02; p = 0.028), and low cardiac output syndrome (relative risk, 12.9; p < 0.0001) as significant determinants. Peritoneal dialysis was effective in achieving negative fluid balance, although serum urea and creatinine levels remained static. Prolonged PD was associated with younger age, higher preoperative serum creatinine, higher postoperative oxygen requirement, postoperative pulmonary hypertensive crisis, and low cardiac output syndrome (p < 0.05). When compared with survivors (n = 22), nonsurvivors (n = 9) were more likely to have had syndrome disorders and required preoperative ventilation and higher postoperative ventilatory settings (p < 0.05).

CONCLUSIONS

Risk factors for PD in young children undergoing open heart surgery are circulatory arrest, cardiopulmonary bypass duration, and low cardiac output syndrome. The preoperative and postoperative cardiopulmonary status has a significant bearing on PD duration and patient survival.

Acute renal failure in children: aetiology and management

This review evaluates the various causes and management of acute renal failure (ARF) in children. ARF is defined as an abrupt decline in the renal regulation of water, electrolytes and acid-base balance, and continues to be an important factor contributing to the morbidity and mortality of critically ill infants and children. The common causes of ARF in children include acute tubular necrosis secondary to various causes (including congestive heart failure and sepsis), haemolytic uremic syndrome, and glomerulonephritis and urinary tract obstruction. Ischaemia, toxins (including drugs) as well as primary parenchymal disease, have to be considered and ARF can also be a complication of systemic disease. The basic principles of management are avoidance of life-threatening complications, maintenance of fluid and electrolyte balance, and nutritional support. Only a few patients require specific management of the underlying disorder, although it is important to diagnose these conditions. Knowledge about the use of drugs for the prevention of ARF is scarce. Mannitol, low-dose dopamine, calcium channel antagonists, atrial natriuretic peptide and albumin have been evaluated and, where possible, meta-analyses are cited. Mannitol treatment appears to be warranted prophylactically after paediatric renal transplantation. Albumin infusion can reverse prerenal ARF in children with nephritic syndrome. For treatment of the complications of hyperkalaemia and volume overload, salbutamol, insulin and glucose infusion and diuretics such as furosemide and sodium bicarbonate, are discussed. All of the major dialysis modalities (peritoneal dialysis, haemodialysis and continuous haemofiltration) can be used to provide equivalent solute clearance and ultrafiltration. The indication for, and the choice of the modality depend on the patient requirements and on local resources, and should involve the care of a paediatric nephrologist. Peritoneal dialysis requires minimal equipment and infrastructure, is easy to perform and remains the favoured modality of renal replacement therapy in children. However, continuous haemofiltration is an excellent alternative to peritoneal dialysis in patients with ARF and severe fluid overload. Dialysis remains the most important tool to bridge the time needed for recovery of renal function. There is increasing evidence that more intense use of dialysis may improve the overall prognosis.

Tenckhoff catheters prove superior to cook catheters in pediatric acute peritoneal dialysis

Peritoneal dialysis (PD) is the most common form of renal replacement therapy in infants and young children with acute renal failure (ARF). The two most commonly used catheters for performing acute PD are the Cook catheter (CC), placed at the bedside, and the surgically placed Tenckhoff catheter (TC). In the present study, we compared the complications and survival rates of the two catheters. The records of 59 children (age, 1 day to 16.7 years) who underwent PD for ARF from March 1989 through June 1999 in our hospital were reviewed. The initial (primary) catheter was a TC in 22 patients and a CC in 37 patients. The age of the patients who received a primary TC (2.8 +/- 4.5 years) was no different than the age of those with a primary CC (1.4 +/- 2.0 years; P = not significant). The duration of use (mean +/- SD) of TCs (16.5 +/- 14.2 days) was significantly greater than the duration of CC use (4.9 +/- 4.2 days; P < 0.001). Only two patients with a TC (9%) developed complications, whereas 18 patients with a CC (49%) developed complications, 13 of whom required catheter replacement (P < 0.01). Thirty-five patients (59%) recovered renal function after undergoing dialysis for 11.5 +/- 8.0 days. Twenty-three of those patients (66%) required dialysis for more than 5 days. Only 4 patients with a primary CC had successful completion of dialysis without catheter-associated complications compared with 15 patients with a primary TC. Kaplan-Meier survival analysis showed that by day 6 of dialysis, only 46% of primary CCs were functioning without complications compared with 90% of TCs that were free of complications. We conclude that the use of a CC is associated with significantly more complications than a TC, and nearly one half of the CCs are likely to be nonfunctional beyond 5 days of dialysis, at a time when two thirds of the patients are still expected to be undergoing dialysis. Therefore, when possible, a TC should be the catheter of choice when initiating acute PD in children. In those patients for whom a CC is chosen as the initial catheter, an elective change to a TC should be considered once dialysis is expected to extend beyond 5 days.

Peritoneal dialysis for acute renal failure in infants: a comparison of three types of peritoneal access

Peritoneal access for peritoneal dialysis (PD) poses a significant problem in infants due to their small size and can result in considerable morbidity and occasional mortality. This study was carried out to compare the complications associated with three different types of PH catheters for intermittent PD. A total of 79 session of PD were given to 51 infants with acute renal failure. Twenty-nine infants received 1, 18 received 2 and 2 infants received 3 and 4 sessions of PD, respectively. For PD access an intravenous cannula was used in 36, stylet catheter in 18, and guide wire inserted femoral vein catheter in 25 procedures. Percentage reduction of serum creatinine per PD session was comparable in infants being dialysed with different types of PD access. Local puncture site and intraperitoneal bleed were associated with the use of a stylet catheter during 4 procedures each (22.2%). Catheter blockade was commonest with the intravenous cannula (22.2%), followed by guide wire inserted femoral vein catheter (16%), and was least with the stylet catheter (5.5%). Total mechanical complications were lower with guide wire inserted femoral vein catheter (16%) as compared to intravenous cannula (25%) and stylet catheter (66%) (p < 0.05). There were 4 episodes of peritonitis (5.0%), 3 bacterial and 1 fungal. Although peritonitis was more common with intravenous cannula (8.3%) than guide wire inserted catheter (4%) and stylet catheter (nil), the difference was not statistically significant. Total complications including mechanical and infective were least with guide wire inserted femoral vein catheter (20%), followed by intravenous cannula (33%) and stylet catheter (66%) (p < 0.05). Of 51 infants, 20 died (39.0%). The PD procedure per se resulted in mortality in 2 cases, 1 because of massive intraperitoneal bleed due to stylet induced injury of an intra abdominal blood vessel and the other due to fungal peritonitis. To conclude, of the three types of access for intermittent PD, complications related to the PD procedure are the least with guide wire inserted femoral vein catheter.

Dialysis support in the pediatric intensive care unit

Renal replacement therapy (RRT) in the pediatric intensive care unit encompasses a wide spectrum of dialysis modalities, including peritoneal dialysis, intermittent hemodialysis, and continuous hemodialysis. The choice RRT modality depends on the clinical setting, access, availability of equipment, and experience of the staff. Advances in newer access, dialysis equipment, and improved understanding of delivered dialysis have had a positive impact on survival in children with acute renal failure. Renal replacement therapy can also be used in children with specific clinical disease processes such as inborn errors of metabolism. Currently, there is no superior mode of RRT in acute renal failure. There are limited data available on the appropriate choice of modality for the specific disease state. This area requires further prospective studies to define the role of RRT in the pediatric intensive care unit.

Volumetric control of continuous haemodialysis in multiple organ failure

A system for precise volumetric control of continuous haemodialysis and its use in providing renal replacement treatment in the intensive care unit to 10 children with multiple organ failure are described. The system, termed slow efficient dialysis, provided effective clearance of urea, creatinine, potassium, and phosphate. It provided precise control of the volume of ultrafiltrate removed in a prospective manner ('dial up' fluid balance) to reduce haemodynamic instability and fluid management problems. The ease of use of this system for intensive care nurses meant that the system ran without the assistance of a second intensive care or renal nurse.

Daily peritoneal dialysis using a surgically placed Tenckhoff catheter for acute renal failure in children

Thirty-one infants and children with acute failure were treated with peritoneal dialysis using a surgically placed Tenckhoff catheter. In 10 patients a peritoneal dialysis cycler was used, and 21 were dialyzed by the manual method. Initially, hourly exchanges were given for 24 to 48 h and, as the patients stabilized, 10 exchanges per day at 1-h intervals were given. The mean stabilization period was 36 +/- 8 h. The predialysis mean serum creatinine was 5.8 +/- 1.8 mg% and the serum creatinine while on daily dialysis was 2.8 +/- 1.1 mg%. Peritoneal dialysis succeeded in controlling metabolic abnormalities and improving fluid balance. All the catheters except one functioned immediately following insertion. Median duration of catheter placement for dialysis was 18 days (range 2 to 90). The incidence of peritonitis was 12.8%, and exit site infection was 6.4%. The infection rate was decreased when a cycler was used compared with the manual method (23.8% vs. 10.0%), though not statistically significant. Two patients developed hypothermia while being dialyzed via the manual method. To conclude, 10 daily peritoneal dialysis exchanges performed at 1-h intervals after initial stabilization using a surgically placed Tenckhoff catheter is an effective and safe mode of dialytic therapy for children with acute renal failure. Complications (infection and hypothermia) are reduced with the use of a cycler.

An experience of renal replacement therapy in a combined neonatal and paediatric intensive care unit of Hong Kong

Intensive care services are expensive. The experience of developing a combined paediatric and neonatal intensive care unit (ICU) in a regional hospital is reported with reference to the provision of renal support for the critically ill patients. The combined unit is staffed by a team of paediatric intensivists, each of whom has special interest in a subspecialty, including cardiology, respiratory medicine, nephrology and neonatology. In the past 7 years, renal replacement therapy (peritoneal dialysis and haemofiltration) was provided to 40 patients, with comparable mortality and complication rates to other reports. This arrangement has been feasible and might be more efficient than running separate paediatric and neonatal ICUs or combining the paediatric ICU with the adult ICU.