Percutaneous endoscopic gastrostomy in children receiving peritoneal dialysis: A tertiary centre long-term experience and literature review

BACKGROUND

Children with severe chronic kidney disease receiving maintenance peritoneal dialysis (PD) are often malnourished and may require nutritional supplementation. Recent PD guidelines address laparoscopic and open surgical gastrostomy as safe approaches in children established on PD, while existing evidence on percutaneous endoscopic gastrostomy (PEG) is still lacking; as well as the role of perioperative antibiotic and antifungal prophylaxis. Hence, this study aimed to report our experience with PEG placement in patients on PD and compare it with the available literature.

METHODS

We retrospectively reviewed the medical records from patients on PD, who underwent PEG placement at a tertiary referral centre between 2000 and 2020. Data on perioperative management, complications and outcomes were retrieved. An extensive literature search was performed; studies describing PEG placement and perioperative prophylaxis in patients on PD were used as a comparison. Descriptive statistical analysis was conducted.

RESULTS

Seven patients (five males) were included. Perioperative antibiotic and antifungal prophylaxis were standard practice. At a median follow-up of 27 months (10-75), the peritonitis rate was 0.2 patient/years. No statistical significance was found between the peritonitis rate before and after PEG placement (p = 0.2). Patients' demographics and postoperative complications were comparable to the reported studies.

CONCLUSIONS

Based on our experience, our technique of PEG insertion with antimicrobial prophylaxis is feasible and associated with an acceptable complication risk in patients on PD. Further multicentric studies about surgical technique in patients on PD will be necessary to verify the feasibility of PEG and standardise the perioperative protocol.

Assessment of potential peritonitis risk factors in pediatric patients receiving maintenance peritoneal dialysis

BACKGROUND

Many recommendations regarding peritonitis prevention in international consensus guidelines are opinion-based rather than evidence-based. The aim of this study was to examine the impact of peritoneal dialysis (PD) catheter insertion technique, timing of gastrostomy placement, and use of prophylactic antibiotics prior to dental, gastrointestinal, and genitourinary procedures on the risk of peritonitis in pediatric patients on PD.

METHODS

We conducted a retrospective cohort study of pediatric patients on maintenance PD using data from the SCOPE collaborative from 2011 to 2022. Data pertaining to laparoscopic PD catheter insertion (vs. open), gastrostomy placement after PD catheter insertion (vs. before/concurrent), and no prophylactic antibiotics (vs. yes) were obtained. Multivariable generalized linear mixed modeling was used to assess the relationship between each exposure and occurrence of peritonitis.

RESULTS

There was no significant association between PD catheter insertion technique and development of peritonitis (aOR = 2.50, 95% CI 0.64-9.80, p = 0.19). Patients who had a gastrostomy placed after PD catheter insertion had higher rates of peritonitis, but the difference was not statistically significant (aOR = 3.19, 95% CI 0.90-11.28, p = 0.07). Most patients received prophylactic antibiotics prior to procedures, but there was no significant association between prophylactic antibiotic use and peritonitis (aOR = 1.74, 95% CI 0.23-13.11, p = 0.59).

CONCLUSIONS

PD catheter insertion technique does not appear to have a significant impact on peritonitis risk. Timing of gastrostomy placement may have some impact on peritonitis risk. Further study must be done to clarify the effect of prophylactic antibiotics on peritonitis risk. A higher resolution version of the Graphical abstract is available as Supplementary information.

Gastrostomy Tube Use in Pediatrics: A Systematic Review

CONTEXT

Despite frequency of gastrostomy placement procedures in children, there remains considerable variability in preoperative work-up and procedural technique of gastrostomy placement and a paucity of literature regarding patient-centric outcomes.

OBJECTIVES

This review summarizes existing literature and provides consensus-driven guidelines for patients throughout the enteral access decision-making process.

DATA SOURCES

PubMed, Google Scholar, Medline, and Scopus.

STUDY SELECTION

Included studies were identified through a combination of the search terms "gastrostomy," "g-tube," and "tube feeding" in children.

DATA EXTRACTION

Relevant data, level of evidence, and risk of bias were extracted from included articles to guide formulation of consensus summaries of the evidence. Meta-analysis was conducted when data afforded a quantitative analysis.

EVIDENCE REVIEW

Four themes were explored: preoperative nasogastric feeding tube trials, decision-making surrounding enteral access, the role of preoperative imaging, and gastrostomy insertion techniques. Guidelines were generated after evidence review with multidisciplinary stakeholder involvement adhering to GRADE methodology.

RESULTS

Nearly 900 publications were reviewed, with 58 influencing final recommendations. In total, 17 recommendations are provided, including: (1) tTrial of home nasogastric feeding is safe and should be strongly considered before gastrostomy placement, especially for patients who are likely to learn to eat by mouth; (2) rRoutine contrast studies are not indicated before gastrostomy placement; and (3) lLaparoscopic placement is associated with the best safety profile.

LIMITATIONS

Recommendations were generated almost exclusively from observational studies and expert opinion, with few studies describing direct comparisons between GT placement and prolonged nasogastric feeding tube trial.

CONCLUSIONS

Additional patient- and family-centric evidence is needed to understand critical aspects of decision-making surrounding surgically placed enteral access devices for children.

Surgical Antimicrobial Prophylaxis in Abdominal Surgery for Neonates and Paediatrics: A RAND/UCLA Appropriateness Method Consensus Study

Surgical site infections (SSIs), i.e., surgery-related infections that occur within 30 days after surgery without an implant and within one year if an implant is placed, complicate surgical procedures in up to 10% of cases, but an underestimation of the data is possible since about 50% of SSIs occur after the hospital discharge. Gastrointestinal surgical procedures are among the surgical procedures with the highest risk of SSIs, especially when colon surgery is considered. Data that were collected from children seem to indicate that the risk of SSIs can be higher than in adults. This consensus document describes the use of preoperative antibiotic prophylaxis in neonates and children that are undergoing abdominal surgery and has the purpose of providing guidance to healthcare professionals who take care of children to avoid unnecessary and dangerous use of antibiotics in these patients. The following surgical procedures were analyzed: (1) gastrointestinal endoscopy; (2) abdominal surgery with a laparoscopic or laparotomy approach; (3) small bowel surgery; (4) appendectomy; (5) abdominal wall defect correction interventions; (6) ileo-colic perforation; (7) colorectal procedures; (8) biliary tract procedures; and (9) surgery on the liver or pancreas. Thanks to the multidisciplinary contribution of experts belonging to the most important Italian scientific societies that take care of neonates and children, this document presents an invaluable reference tool for perioperative antibiotic prophylaxis in the paediatric and neonatal populations.

Is percutaneous gastrostomy tube insertion contraindicated in adult peritoneal dialysis patients? A single-centre experience of three successful cases: It is time to revisit

Percutaneous endoscopic gastrostomy (PEG) tube placement in adults who are already established on peritoneal dialysis (PD) remains challenging due to the limited experience and data in this area which lacks clear guidance. Given the fact that peritoneal dialysis is one of the relative contraindications for PEG tube insertion, and PEG tube on its own is a risk for peritonitis, how to overcome these obstacles and utilize the advantage of PEG tube for feeding malnourished PD patients remains uncertain. Here we report our unique successful experience of treating three adult peritoneal dialysis patients in whom the PEG tube was inserted successfully with no complications. To the best of our knowledge, this is the first successful case series in the literature for treating adult prevalent PD patients by PEG tube placement.

Feasibility of percutaneous endoscopic gastrostomy insertion in children receiving peritoneal dialysis

BACKGROUND

Peritoneal dialysis (PD) is the preferred dialysis modality for paediatric patients with end-stage kidney disease. Frequently, malnutrition is encountered. Percutaneous endoscopic gastrostomy (PEG) is the preferred mode of feeding because of its minimal invasive mode of placement and easy handling in daily life. However, reports of a high risk for early post-interventional peritonitis hampered this procedure during PD and controlled studies on the benefit of peri-interventional management to prevent peritonitis are lacking. Here, we report the safety profile of PEG insertion among a cohort of children on PD by using a prophylactic antibiotic and antifungal regimen as well as modification of the PD programme.

METHODS

We performed a single-centre analysis of paediatric PD patients receiving PEG placement between 2015 and 2020. Demographic data, peri-interventional prophylactic antibiotic and antifungal treatment as well as modification of the PD programme were gathered and the incidence of peritonitis within a period of 28 days after PEG was calculated.

RESULTS

Eight PD patients (median weight 6.7 kg) received PEG insertion. Antibiotic and antifungal prophylaxis were prescribed for median time of 4.0 and 5.0 days, respectively. After individual reduction of PD intensity, all patients continued their regular PD programme after a median of 6 days. One patient developed peritonitis within 24 h after PEG insertion and simultaneous surgery for hydrocele.

CONCLUSIONS

Applying an antibiotic and antifungal prophylactic regime as well as an adapted PD programme may reduce the risk for peritonitis in paediatric PD patients who receive PEG procedure.

Peritoneal Dialysis Guidelines 2019 Part 1 (Position paper of the Japanese Society for Dialysis Therapy)

Approximately 10 years have passed since the Peritoneal Dialysis Guidelines were formulated in 2009. Much evidence has been reported during the succeeding years, which were not taken into consideration in the previous guidelines, e.g., the next peritoneal dialysis PD trial of encapsulating peritoneal sclerosis (EPS) in Japan, the significance of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), the effects of icodextrin solution, new developments in peritoneal pathology, and a new international recommendation on a proposal for exit-site management. It is essential to incorporate these new developments into the new clinical practice guidelines. Meanwhile, the process of creating such guidelines has changed dramatically worldwide and differs from the process of creating what were “clinical practice guides.” For this revision, we not only conducted systematic reviews using global standard methods but also decided to adopt a two-part structure to create a reference tool, which could be used widely by the society’s members attending a variety of patients. Through a working group consensus, it was decided that Part 1 would present conventional descriptions and Part 2 would pose clinical questions (CQs) in a systematic review format. Thus, Part 1 vastly covers PD that would satisfy the requirements of the members of the Japanese Society for Dialysis Therapy (JSDT). This article is the duplicated publication from the Japanese version of the guidelines and has been reproduced with permission from the JSDT.

Antibiotic Prophylaxis for Percutaneous Endoscopic Gastrostomy in Children: A Randomised Controlled Trial

OBJECTIVES

Paediatric studies on the role of antibiotic prophylaxis in the prevention of postoperative infections in children undergoing percutaneous endoscopic gastrostomy (PEG) are lacking. The aim of this study was to assess if a single dose of co-amoxiclav before PEG can decrease the rate of peristomal wound and systemic infection in children.

METHODS

In this prospective, randomised, double-blind, multicentre trial, children undergoing PEG were randomized to antibiotic prophylaxis with co-amoxiclav versus placebo and the rate of local and systemic infections were assessed.

RESULTS

Of the 106 patients considered for inclusion, 49 patients were randomized. In the per-protocol analysis, the occurrence of wound infection was 5% (1/20) in the antibiotic group and 21% (4/19) in the placebo group (P = 0.13, 16% difference in proportions, odds ratio [OR] 0.19, 95% confidence interval [CI] 0.02-1.9). The occurrence of systemic infection was 9% (2/22) in the antibiotic group and 27.2% (6/25) in the placebo group [P = 0.17, 18% difference in proportions, OR 0.32, 95% CI 0.06%-1.80%]. Similar results were obtained in intention-to-treat analysis. Interestingly, the overall infection rate was significantly higher in the placebo group as compared with the antibiotic group (40% vs 13.6%; P = 0.04) and the duration of hospital stay was significantly longer in the placebo group as compared with the antibiotic group (4.4 ± 1.6 vs 3.5 ± 1.05; P = 0.02). The number-needed-to-treat (NTT) to prevent 1 peristomal infection on average are 6.7 patients.

CONCLUSIONS

A preoperative dose of co-amoxiclav reduces the overall infection rate and the duration of hospital stay. Our data suggest that antibiotic prophylaxis should be recommended in every children undergoing PEG placement.

Delivery of a nutritional prescription by enteral tube feeding in children with chronic kidney disease stages 2-5 and on dialysis-clinical practice recommendations from the Pediatric Renal Nutrition Taskforce

The nutritional prescription (whether in the form of food or liquid formulas) may be taken orally when a child has the capacity for spontaneous intake by mouth, but may need to be administered partially or completely by nasogastric tube or gastrostomy device ("enteral tube feeding"). The relative use of each of these methods varies both within and between countries. The Pediatric Renal Nutrition Taskforce (PRNT), an international team of pediatric renal dietitians and pediatric nephrologists, has developed clinical practice recommendations (CPRs) based on evidence where available, or on the expert opinion of the Taskforce members, using a Delphi process to seek consensus from the wider community of experts in the field. We present CPRs for delivery of the nutritional prescription via enteral tube feeding to children with chronic kidney disease stages 2-5 and on dialysis. We address the types of enteral feeding tubes, when they should be used, placement techniques, recommendations and contraindications for their use, and evidence for their effects on growth parameters. Statements with a low grade of evidence, or based on opinion, must be considered and adapted for the individual patient by the treating physician and dietitian according to their clinical judgement. Research recommendations have been suggested. The CPRs will be regularly audited and updated by the PRNT.

Peritoneal dialysis patient selection from a comorbidity perspective

Despite many medical and socioeconomic advantages, peritoneal dialysis (PD) is an underutilized dialysis modality that in most countries is used by only 5%-20% of dialysis patients, while the vast majority are treated with in-center hemodialysis. Several factors may explain this paradox, such as lack of experience and infrastructure for training and monitoring of PD patients, organizational issues, overcapacity of hemodialysis facilities, and lack of economic incentives for dialysis centers to use PD instead of HD. In addition, medical conditions that are perceived (rightly or wrongly) as contraindications to PD represent barriers for the use of PD because of their purported potential negative impact on clinical outcomes in patients starting PD. While there are few absolute contraindications to PD, high age, comorbidities such as diabetes mellitus, obesity, polycystic kidney disease, heart failure, and previous history of abdominal surgery and renal allograft failure, may be seen (rightly or wrongly) as relative contraindications and thus barriers to initiation of PD. In this brief review, we discuss how the presence of these conditions may influence the strategy of selecting patients for PD, focusing on measures that can be taken to overcome potential problems.

Do Antibiotics Reduce the Incidence of Infections After Percutaneous Endoscopic Gastrostomy Placement in Children?

OBJECTIVE

Percutaneous endoscopic gastrostomy (PEG) provides a long-term solution for tube dependency. Pediatric guidelines recommend prophylactic antibiotic treatment (ABT) based on adult studies.

AIM

To compare wound infection and other complications in children receiving a PEG with and without prophylactic ABT.

METHODS

Retrospective study including children 0 to 18 years undergoing PEG placement. Patients with (2010-2013) and without (2000-2010) ABT were compared with respect to the occurrence of wound infection and other complications.

RESULTS

In total, 297 patients were included (median age 2.9 years, 53% boys). Patients receiving ABT per PEG protocol (n = 78) had a similar wound infection rate (17.9% vs 21%, P = 0.625), significantly less fever (3.8% vs 14.6%, P = 0.013), leakage (0% vs 9.1%, P = 0.003) and shorter hospital admission (2 vs 4 days, P = 0.000), but more overgranulation (28.2% vs 8.7%, P = 0.000) compared with those without (n = 219). Patients receiving any ABT, per PEG protocol or clinical indication (n = 115), had similar occurrence of wound infection (19.1% vs 20.9%, P = 0.768), fever (7.8% vs 14.3%, P = 0.100) and leakage (3.5% vs 8.8%, P = 0.096), a significantly shorter hospital admission (3 vs 4 days, P = 0.000), but more overgranulation (21.7% vs 8.8%, P =0.003) compared with those without (n = 182).

CONCLUSIONS

Prophylactic ABT does not seem to reduce the occurrence of wound infection but it might be beneficial with respect to fever, leakage and duration of hospital admission, but not overgranulation. A randomized controlled trial is needed to confirm our results.

When end-stage kidney disease complicates abdominal surgery

Patients receiving peritoneal dialysis (PD) encounter an increased risk for infection, bleeding, and PD fluid leakage after abdominal surgery. These complications may affect the future use of PD. Appropriate patient preparation may mitigate complications. Certain complications or procedures allow patients to remain on PD while others require transition to hemodialysis. We review the etiology and management of infection, bleeding, and PD fluid leakage associated with abdominal surgery as well as the relationship of specific abdominal procedures to continuing PD.

End-stage kidney disease in infancy: an educational review

An increasing number of infants with end-stage kidney disease (ESKD) are surviving and receiving renal replacement therapy (RRT). Unique clinical issues specific to this age group of patients influence their short- and long-term outcomes. This review summarizes current epidemiology, clinical characteristics, ethical dilemmas, management concerns, and outcomes of infants requiring chronic dialysis therapy. Optimal care during infancy requires a multidisciplinary team working closely with the patient's family. Nutritional management, infection prevention, and attention to cardiovascular status are important treatment targets. Although mortality rates remain higher among infants on dialysis compared to older pediatric dialysis patients, outcomes have improved over time. Most importantly, infants who subsequently receive a kidney transplant are now experiencing graft survival rates that are comparable to older pediatric patients.

Complications in children with percutaneous endoscopic gastrostomy (PEG) placement

INTRODUCTION

The aim of this study was to analyze the complication rates and mortality in association with different operative techniques of percutaneous endoscopic gastrostomy (PEG), age, underlying diseases and other risk factors. Moreover, analysis of the indications of PEG insertion and the underlying comorbidities was also performed.

METHODS

This study performs a literature analysis of PEG-related complications in children. Literature was searched on PubMed^® (1994-2017) using terms "percutaneous endoscopic gastrostomy", "complications", "mortality" and "children".

RESULTS

Eighteen articles with 4631 patients were analyzed. The mean age was 3 years (0-26 years). Operative techniques were: pull technique in 3507 (75.7%), 1 stage PEG insertion in 449 (9.7%), introducer technique in 435 (9.4%), image-guided technique in 195 (4.2%) and laparoscopic-assisted PEG in 45 (1.6%). Most frequent indications for PEG insertion were dysphagia (n = 859, 32.6%), failure to thrive (n = 723, 27.5%) and feeding difficulties (n = 459,17.4%). Minor complications developed in n1518 patients (33%), including granulation  (n = 478, 10.3%), local infection (n = 384, 8.3%) and leakage (n = 279, 6%). In 464 (10%) patients, major complications occurred; the most common were systemic infection (n = 163, 3.5%) and cellulitis (n = 47, 1%). Severe complication like perforation occurred in less than 0.3%. Patients with lethal outcomes (n = 7, 0.15%) had severe comorbidities; and the cause of mortality was sepsis in all cases. Prematurity or young age did not affect complication rate. Patients with ventriculoperitoneal (VP) shunt had higher risk of major complications. In high-risk patients, laparoscopic-assisted PEG insertion had less major and severe complication than traditional pull technique.

CONCLUSIONS

PEG is a safe operative technique; although minor complications are relatively common and occur in up to 1/3 of patients, there is a fairly low rate of severe complications. Two-thirds of PEG patients have at least one comorbidity. Patients with VP shunt have higher risk of major complications. In high-risk patients, laparoscopic-assisted PEG is recommended.

The rate of PD catheter complication does not increase with simultaneous abdominal surgery

INTRODUCTION

Children with kidney failure requiring PD catheter placement often require additional intraabdominal surgery. However, the risk of complication related to simultaneous abdominal surgery at time of catheter placement is unknown.

METHODS

Patients (0-18years) who underwent PD catheter placement (2012-2015) in the NSQIP-P database were reviewed. Complication rates between patients who underwent additional abdominal surgery at the time of PD catheter placement and those that did not were evaluated. One to one case control matching was performed for additional adjusted analysis.

RESULTS

Of 563 patients who met inclusion criteria, 82 underwent simultaneous abdominal surgery at time of PD catheter placement. Patients in the simultaneous group had a higher rate of wound contamination but there was no difference in rates of SSI, 30-day PD catheter complication, or 30-day mortality compared with the nonsimultaneous group. There was no difference when overall simultaneous abdominal surgery or gastrointestinal surgery was evaluated. In our 1:1 adjusted analysis, there was a higher rate of PD catheter complication (11.3% vs. 2.8%, p=0.049) and SSI (31.0% vs. 4.2%, p<0.001) in the nonsimultaneous group.

CONCLUSIONS

Thirty-day PD catheter complication and SSI in patients who underwent simultaneous abdominal surgery at time of catheter placement were noninferior to outcomes in the nonsimultaneous.

LEVEL OF EVIDENCE

Level III, Treatment study, Retrospective comparative study.

Epidemiology of peritonitis following maintenance peritoneal dialysis catheter placement during infancy: a report of the SCOPE collaborative

BACKGROUND

Maintenance peritoneal dialysis (PD) is the dialysis modality of choice for infants and young children. However, there are limited outcome data for those who undergo PD catheter insertion and initiate maintenance PD within the first year of life.

METHODS

Using data from the Children's Hospital Association's Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (ESRD) Collaborative (SCOPE), we examined peritonitis rates and patient survival in 156 infants from 29 North American pediatric dialysis centers who had a chronic PD catheter placed prior to their first birthday.

RESULTS

In-hospital and overall annualized rates of peritonitis were 1.73 and 0.76 episodes per patient-year, respectively. Polycystic kidney disease was the most frequent renal diagnosis and pulmonary hypoplasia the most common co-morbidity in infants with peritonitis. Multivariable regression models demonstrated that nephrectomy at or prior to PD catheter placement and G-tube insertion after catheter placement were associated with a nearly sixfold and nearly threefold increased risk of peritonitis, respectively. Infants with peritonitis had longer initial hospital stays and lower overall survival (86.3 vs. 95.6%, respectively; P < 0.02) than those without an episode of peritonitis.

CONCLUSIONS

In this large cohort of infants with ESRD, the frequency of peritonitis was high and several risk factors associated with the development of peritonitis were identified. Given that peritonitis was associated with a longer duration of initial hospitalization and increased mortality, increased attention to the potentially modifiable risk factors for infection is needed.

Peritoneal dialysis and infants: further insights into a complicated relationship

Peritoneal dialysis (PD) in infants represents one of the greatest challenges for pediatric nephrologists. Over recent years, positive outcome data described by several multicenter experiences and registry studies have increased the amount of information available to help determine whether to initiate a dialysis program in this high-risk patient population. There is no doubt that the rigorous implementation of strategies aimed at preventing infectious complications may have contributed to reducing the morbidity rate of these patients. However, the complex nature of infants with end-stage renal disease and the presence of multiple comorbidities still represent hallmarks that significantly impact on outcome. Although the rigorous application of improved scientific techniques can still contribute to enhancing PD results in infants, we have to acknowledge that the severity of illness in infants, especially at dialysis initiation, represents an undeniable and nonmodifiable factor.

Growth and Nutrition in Pediatric Chronic Kidney Disease

Children with chronic kidney disease (CKD) feature significant challenges to the maintenance of adequate nutrition and linear growth. Moreover, the impaired nutritional state contributes directly to poor growth. Therefore, it is necessary to consider nutritional status in the assessment of etiology and treatment of sub-optimal linear growth. The major causes of poor linear growth including dysregulation of the growth hormone/insulin-like growth factor-I (IGF-I) axis, nutritional deficiency, metabolic acidosis, anemia, renal osteodystrophy/bone mineral disease, and inflammation. This review summarizes the causes and assessment tools of growth and nutrition while providing a summary of state of the art therapies for these co-morbidities of pediatric CKD.

Gastrostomy Tube Insertion in Pediatric Patients With Autosomal Recessive Polycystic Kidney Disease (ARPKD): Current Practice

Introduction: Autosomal recessive polycystic kidney disease (ARPKD) is a severe hepatorenal disorder of childhood. Early renal disease in ARPKD may require renal replacement therapy and is associated with failure to thrive resulting in a need for nasogastric tube feeding or gastrostomy. In ARPKD patients, the benefit of a gastrostomy in nutrition and growth needs to be weighed against the potential risk of complications of congenital hepatic fibrosis (CHF) and portal hypertension like variceal bleeding. CHF in ARPKD has thus been considered as a relative contraindication for gastrostomy insertion. Yet, data on gastrostomies in pediatric patients with ARPKD is lacking. Methods: We conducted a web-based survey study among pediatric nephrologists, pediatric hepatologists and pediatric gastroenterologists on their opinions on and experiences with gastrostomy insertion in ARPKD patients. Results: 196 participants from 39 countries shared their opinion. 45% of participants support gastrostomy insertion in all ARPKD patients, but portal hypertension is considered to be a contraindication by a subgroup of participants. Patient-specific data was provided for 38 patients indicating complications of gastrostomy that were in principal comparable to non-ARPKD patients. Bleeding episodes were reported in 3/38 patients (7.9%). Two patients developed additional severe complications. Gastrostomy was retrospectively considered as the right decision for the patient in 35/38 (92.1%) of the cases. Conclusions: This report on the results of an online survey gives first insights into the clinical practice of gastrostomy insertion in ARPKD patients. For the majority of participating physicians benefits of gastrostomy insertion retrospectively outweigh complications and risks. More data will be required to lay the foundation for clinical recommendations.

[The specific nutritionnal care in peritoneal dialysis]

Protein energy wasting is a major complication in peritoneal dialysis. It is leading to a poor quality of life and increasing mortality. Diagnosis must be early, according to criteria defined by the International society of renal nutrition and metabolism. It is necessary to appropriate the diagnostic tools with dialysis method. The nutritional care is difficult in peritoneal dialysis. Indeed, studies are limited and practical nutrition is complex. In this point of view, we propose to treat guidelines for protein energy wasting, in peritoneal dialysis patients.

Practical Nutrition Management of Children with Chronic Kidney Disease

Chronic kidney disease (CKD) introduces a unique set of nutritional challenges for the growing and developing child. This article addresses initial evaluation and ongoing assessment of a child with CKD. It aims to provide an overview of nutritional challenges unique to a pediatric patient with CKD and practical management guidelines. Caloric assessment in children with CKD is critical as many factors contribute to poor caloric intake. Tube feeding is a practical option to provide the required calories and fluid in children who have difficulty with adequate oral intake. Protein intake should not be limited and should be further adjusted for protein loss with dialysis. Supplementation or restriction of sodium is patient specific. Urine output, fluid status, and modality of dialysis are factors that influence sodium balance. Hyperkalemia poses a significant cardiac risk, and potassium is closely monitored. In addition to a low potassium diet, potassium binders may be prescribed to reduce potassium load from oral intake. Phosphorus and calcium play a significant role in cardiovascular and bone health. Phosphorus binders have helped children and families manage phosphorus levels in conjunction with a phosphorus-restricted diet. Nutritional management of children with CKD is a challenge that requires continuous reassessment and readjustment as the child ages, CKD progresses, and urine output decreases.

Risk factors for complications in infants and children with percutaneous endoscopic gastrostomy tubes

OBJECTIVE

To identify risk factors associated with percutaneous endoscopic gastrostomy (PEG) tube complications in a large cohort of infants and children.

STUDY DESIGN

We performed a chart review of 591 pediatric patients undergoing PEG tube placement between 2006 and 2010 at Boston Children's Hospital. Frequency and type of major and minor complications associated with PEG tubes in children were identified. Univariate and multivariate analyses were then conducted to determine potential risk factors for complications.

RESULTS

A total of 198 PEG-related complications (72 major and 126 minor) were noted in our cohort of 591 patients. Approximately 10.5% of patients experienced at least one major complication and 16.4% experienced at least one minor complication, with the great majority of complications occurring after discharge postplacement. Age <6 months (P = .003), American Society of Anesthesiologists class III (P = .02), and presence of a neurologic disorder (P = .05) were found to be protective against experiencing a major complication, whereas the presence of a ventriculoperitoneal shunt was confirmed to be a risk factor (P = .01) for major complications.

CONCLUSION

Both minor and major complications are common in children after PEG tube placement, with most complications occurring several months postoperatively. Certain patient factors, including age, neurologic status, and American Society of Anesthesiologists class, may be protective, and the presence of a ventriculoperitoneal shunt may be associate with an increased risk of complications after PEG tube placement.

Infectious outcomes following gastrostomy in children receiving peritoneal dialysis

BACKGROUND

Early institution of enteral feeding in paediatric end-stage kidney disease (ESKD) is recommended. For patients on peritoneal dialysis (PD) there is concern that gastrostomy tube (GT) insertion may be complicated by increased peritonitis, in particular fungal. Our unit favours early planned GT insertion, and for those with late presentation, there is prompt consideration of GT insertion following dialysis initiation. This study evaluates our rates of peritonitis with GT insertion following or concurrent with PD initiation.

METHODS

This was a retrospective, single-centre, cross-sectional study of of 17 New Zealand children with ESKD who received PD in the period 2000-2011. Inclusion criteria were GT placement while on PD or initiation of PD within 72 h of GT insertion.

RESULTS

There were no cases of fungal peritonitis among the 17 children; however, two cases of early peritonitis with organisms derived from the gastrointestinal tract were identified. No statistically significant difference was found between incident rates of bacterial peritonitis before GT placement (0.6 episodes per patient-year; 95% confidence interval (CI) 0.26-1.18) and post-GT placement (1.21 episodes per patient-year; 95% CI 0.69-1.97).

CONCLUSION

Fungal peritonitis has never been encountered by out unit during its many years of experience in GT placement in patients without advanced malnutrition. When children on PD have insufficient dietary intake to maintain appropriate growth velocity, enteral feeding should be initiated promptly. A GT is considered to be safe for long-term use in selected patients.

Antibiotic prophylaxis in the management of percutaneous endoscopic gastrostomy in infants and children

BACKGROUND

In randomized controlled trials in adult patients the use of prophylactic broad-spectrum antibiotic reduces the number of insertion site and systemic infections, associated with placement of percutaneous endoscopic gastrostomy (PEG) tubes. For pediatric patients no such trials exist. The aim of this study was to assess the value of antibiotic prophylaxis in PEG placement in pediatric patients.

METHODS

In a retrospective chart review PEG placement in infants and children performed in a tertiary care center was analyzed. All PEG procedures were performed by an experienced pediatric gastroenterologist using the pull-through technique under general anesthesia.

RESULTS

A total of 103 procedures were analyzed; 33 patients received antibiotic prophylaxis and 70 did not. Two (6%) of the patients receiving prophylaxis developed local or systemic infections after PEG placement, whereas seven (10%) without prophylaxis suffered from a PEG-related infection. This difference was not significant on chi-squared test (P = 0.5). Sixty patients had a body temperature >38°C within the first 3 days after the PEG procedure. A total of 77% of these patients had no antibiotic prophylaxis. Mean body temperature differed significantly between patients with and without prophylaxis (37.9°C vs. 38.3°C, respectively; P = 0.02).

CONCLUSIONS

The incidence of PEG-related local or systemic infection after PEG-placement was not significantly different between patients with and without antibiotic prophylaxis, but the latter had a significantly higher mean body temperature after the PEG procedure. Taking elevated mean body temperature as a marker for putative bacteremia it is suggested that antibiotic prophylaxis is indicated in all pediatric patients after PEG placement.

ESPGHAN position paper on management of percutaneous endoscopic gastrostomy in children and adolescents

OBJECTIVES

This European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) position statement provides a comprehensive guide for health care providers to manage percutaneous endoscopic gastrostomy tubes in a safe, effective, and appropriate way.

METHODS

Relevant literature from searches of PubMed, CINAHL, and recent guidelines was reviewed. In the absence of evidence, recommendations reflect the expert opinion of the authors. Final consensus was obtained by multiple e-mail exchange and during 3 face-to-face meetings of the gastroenterology committee of the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

RESULTS

Endoscopically placed gastrostomy devices are essential in the management of children with feeding and nutritional problems. The article focuses on practical issues such as indications and contraindications.

CONCLUSIONS

The decision to place an endoscopic gastrostomy has to be made by an appropriate multidisciplinary team, which then provides active follow-up and care for the child and the device.

Long-term outcomes of infants and children undergoing percutaneous endoscopy gastrostomy tube placement

OBJECTIVES

Little is known about long-term outcomes of patients undergoing percutaneous endoscopic gastrostomy (PEG) placement. The purpose of this study was to examine tube-related major complications in pediatric patients undergoing PEG placement during a 10-year follow-up period.

METHODS

A retrospective chart review of patients undergoing PEG placement from April 1999 through December 2000 at Boston Children's Hospital was performed. Cumulative incident rates of major complications (defined by additional hospitalization, surgical or interventional radiology procedures) as well as time between PEG placement and major complications were evaluated using Kaplan-Meier survival analysis. Time to elective tube removal and patient mortality was also assessed.

RESULTS

One hundred thirty-eight patients (59% [n = 82] boys [median age 22.5 months] [interquartile range, IQR 9-72.5], weight 9.2 kg [IQR 6.1-15.8]), underwent PEG placement during the study period and were followed at our hospital for a median of 4.98 years (IQR 1.5-8.7) years. Median time to elective tube removal was 10.2 years, with approximately half of the patients estimated to still have an indwelling enteral tube 10 years after placement. Fifteen patients (11%) had at least 1 major complication related to their gastrostomy tubes during the examined time period. The cumulative incidence of patients having a major complication was 15% (95% confidence interval 8.9-24.5) by 5.4 years.

CONCLUSIONS

Children undergoing PEG placement have a long-term high risk of morbidity related to enteral tubes. Major complications can occur many years after PEG placement. Larger prospective studies may be useful to assess risk factors for PEG-related complications in pediatrics.

Clinical practice recommendations for the care of infants with stage 5 chronic kidney disease (CKD5)

BACKGROUND

To provide recommendations for the care of infants with stage 5 chronic kidney disease (CKD5).

SETTING

European Paediatric Dialysis Working Group.

DATA SOURCES

Literature on clinical studies involving infants with CKD5 (end stage renal failure) and consensus discussions within the group.

RECOMMENDATIONS

There has been an important change in attitudes towards offering RRT (renal replacement therapy) to both newborns and infants as data have accumulated on their improved survival and long-term outcomes. The management of this challenging group of patients differs in a number of ways from that of older children. The authors have summarised the basic recommendations for treating infants with CKD5 in order to support the multidisciplinary teams who endeavour on this difficult task.

Anorectal malformation and associated end-stage renal disease: management from newborn to adult life

BACKGROUND/OBJECTIVE

Renal failure remains one of the most significant causes of morbidity in patients with anorectal malformations (ARM). In the modern era, an increasing number of children born with ARM and genito-urinary (GU) anomalies reach adulthood and require continued multidisciplinary care for the rest of their life. The aim of this study is to present our institutional experience in the management of pediatric chronic renal failure related to severe GU anomalies and anorectal malformations.

METHODS AND RESULTS

Three hundred twenty-one patients with ARM have been followed at our institution since 1987. Six patients developed end-stage renal disease (ESRD) and received a kidney transplant at different ages. One patient is currently followed for mild, progressive chronic renal failure. These seven cases are reported along with a broad discussion concerning etiology of renal failure, neonatal surgical management, pediatric dialysis, urologic issues, and kidney transplantation.

CONCLUSION

Complex GU anomalies associated with ARM require a long-term approach by specialized pediatric and adult clinicians to optimize the care of this selected population of patients.

Risk factors for morbidity and mortality in pediatric patients with peritoneal dialysis catheters

PURPOSE

As peritoneal dialysis (PD) is the preferred long-term dialysis modality in the pediatric population, we sought to identify risk factors for mortality and reoperation.

METHODS

A retrospective review of patients undergoing PD catheter insertions at a single center from 1994-2009 was performed. The following variables were evaluated: age (<1 year), comorbidities, omentectomy, concomitant gastrostomy, and laparoscopic technique. Multivariable Cox regressions analyses were used to evaluate patient survival and reoperation-free survival of PD catheters.

RESULTS

207 patients with a median age of 10 years underwent PD insertion. Mortality was 7% with a median follow up of 72 months. Reoperation for malfunction and infection was required in 49% of patients with a median PD catheter survival of 11 months. Reoperation for hernias occurred in 14% of patients. Multivariate Cox regressions analyses identified age <1 year, lack of omentectomy, concomitant gastrostomy, and prematurity as variables significantly associated with higher rates of mortality or reoperation.

CONCLUSIONS

In this large study of pediatric patients undergoing PD, higher complication rates were noted in infants less than one year of age. Concomitant gastrostomy was associated with a higher rate of reoperation for infection. Failure to perform omentectomy was associated with a higher rate of catheter failure.

Synchronous laparoscopic-assisted percutaneous endoscopic gastrostomy and peritoneal dialysis catheter placement is a valid alternative to open surgery

OBJECTIVE

Gastrostomy feeding is frequently necessary in children receiving chronic peritoneal dialysis (PD). Synchronous laparoscopic-assisted placement of percutaneous endoscopic gastrostomy (PEG) and PD catheter has many potential advantages. This study investigates whether this technique is comparable to open placement.

METHODS

The notes of all patients over a 16-year time period were reviewed retrospectively. Peritonitis was defined as the presence of a white blood cell count > 100/mm(3) with at least 50% being polymorphonuclear leukocytes, and infection was defined as the presence of positive peritoneal cultures with peritonitis.

RESULTS

Ten patients received primary laparoscopic-assisted PEG and PD catheter insertion (LAP) and 23 patients open gastrostomy and PD catheter (OPEN). PD catheter survival was median 12 months in the LAP group and 17 months in the OPEN group. Peritonitis and infection rates per catheter-year were 0.89 and 0.7 LAP and 0.59 and 0.5 OPEN. The risk of peritonitis and infection was not related to method of placement.

CONCLUSIONS

There were no statistically significant differences in outcomes between the two groups. We conclude that laparoscopic-assisted synchronous PD and PEG catheter insertion is safe and effective.

Peritoneal dialysis in children with end-stage renal disease

Peritoneal dialysis is the preferred chronic dialysis modality for most children owing to its almost universal applicability and superior compatibility with lifestyle over other modalities. Although technological advances and increasing clinical experience have impacted favorably on patient and technique survival, clinical research in pediatric peritoneal dialysis has been hampered by the low incidence of end-stage renal disease (ESRD) in the pediatric population. To overcome this limitation, several international registries have emerged in the past few years to complement other long-standing registries, which together have provided useful information regarding technique-specific complications and comorbidities associated with ESRD in children undergoing chronic peritoneal dialysis. In this Review, we summarize the most relevant findings from these studies, highlighting the substantial variation in patient conditions, peritoneal dialysis practices and management of comorbidities encountered in different parts of the world.

Peritoneal dialysis in infants and young children

Although end-stage renal disease is rare in infants and young children, its development can be associated with significant morbidity and mortality and only through the provision of experienced, multidisciplinary care can a favorable outcome be anticipated. Peritoneal dialysis is the renal replacement modality of choice for this age group and serves as an essential bridge until successful renal transplantation can occur. In this review, we discuss the practice of peritoneal dialysis in infants including the unique ethical and technical considerations facing pediatric nephrologists and caregivers. In addition, we review current guidelines concerning nutrition, growth, and adequacy, as well as the literature on complications and outcomes.

Practical approach to paediatric enteral nutrition: a comment by the ESPGHAN committee on nutrition

Enteral nutrition support (ENS) involves both the delivery of nutrients via feeding tubes and the provision of specialised oral nutritional supplements. ENS is indicated in a patient with at least a partially functioning digestive tract when oral intake is inadequate or intake of normal food is inappropriate to meet the patients' needs. The aim of this comment by the Committee on Nutrition of the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition is to provide a clinical practice guide to ENS, based on the available evidence and the clinical expertise of the authors. Statements and recommendations are presented, and future research needs highlighted, with a particular emphasis placed on a practical approach to ENS.Among the wide array of enteral formulations, standard polymeric feeds based on cow's-milk protein with fibre and age adapted for energy and nutrient content are suitable for most paediatric patients. Whenever possible, intragastric is preferred to postpyloric delivery of nutrients, and intermittent feeding is preferred to continuous feeding because it is more physiological. An anticipated duration of enteral nutrition (EN) exceeding 4 to 6 weeks is an indication for gastrostomy or enterostomy. Among the various gastrostomy techniques available, percutaneous endoscopic gastrostomy is currently the first option. In general, both patients and caregivers express satisfaction with this procedure, although it is associated with a number of well-recognised complications. We strongly recommend the development and application of procedural protocols that include scrupulous attention to hygiene, as well as regular monitoring by a multidisciplinary nutrition support team to minimise the risk of EN-associated complications.

Tube feeding in children with chronic kidney disease: technical and practical issues

This review discusses the indications for enteral feeding in children with chronic kidney disease, the types of feeding tubes that can be used, methods of insertion and their benefits and complications.

Attention to small details: big deal for gastrostomies

Gastrostomy tubes are used in the pediatric population when long-term enteral feeding is needed. A common method of placement is percutaneously with endoscopy (PEG, percutaneous endoscopic gastrostomy). Although PEG placement is a straightforward procedure most of the time, it can be associated with a significant rate of minor complications and a smaller but significantly important rate of major complications. Some of these complications may also occur after any type of gastrostomy. We will present representative case studies outlining major complications and discuss how we may be able to prevent them at the time of PEG insertion or during PEG to low-profile button gastrostomy exchange. The proposed guidelines apply to all types of gastrostomies.

Nutrition assessment and management in children on peritoneal dialysis

Protein-calorie malnutrition, otherwise known as cachexia, is a common problem in children undergoing chronic peritoneal dialysis (PD) and is a frequent source of significant morbidity and mortality. Recent evidence suggests that the main factors involved in the pathogenesis are metabolic acidosis, a decreased response to anabolic hormones, and chronic inflammation, associated with hormonal imbalances and an increased metabolic rate. Given the complexity and multifactorial nature of cachexia, the assessment of nutritional status in children on PD requires a complete history and physical examination; assessment of dietary intake, biochemical indices, and anthropometry; and possibly bioimpedance analysis and combined score systems. Its management should likewise be multidisciplinary and include ensuring an adequate energy and protein intake; optimal metabolic control, with the correction of acidosis, anaemia, and hyperparathyroidism; an optimal (or at least adequate) dialysis dose; and, if necessary, prescription of specific drugs such as recombinant human growth hormone.

Growth of prepubertal children on dialysis

Growth failure is a common and significant clinical problem for children on dialysis and often remains a major impediment to their rehabilitation. Early referral to a paediatric nephrology centre and appropriate management before the initiation of dialysis may significantly prevent growth deterioration. Growth in children on dialysis can be affected by nutritional, metabolic, and hormonal changes. Early diagnosis of malnutrition and aggressive management should be a priority. Gastrostomy feeding should be used when adequate oral intake to maintain normal height and weight velocity cannot be achieved. Active vitamin D metabolites should be used carefully, to prevent low-turnover bone disease. All children should have an adequate regimen of dialysis and an appropriate management of malnutrition, renal osteodystrophy, metabolic acidosis, salt wasting and anaemia, before recombinant human growth hormone (rhGH) administration is considered. The current challenge of reversing growth impairment in children on dialysis can only be achieved by optimization of their care.