Feasibility of percutaneous endoscopic gastrostomy insertion in children receiving peritoneal dialysis

Long-term need and potential for withdrawal of enteral feeding in children with chronic kidney disease stage 5D or 5T

BACKGROUND

Children with chronic kidney disease (CKD) stage 5 may require long-term enteral tube feeding. However, the factors associated with the need for tube feeding and the potential for its withdrawal are unclear.

METHODS

This single-center, retrospective cohort study included patients with CKD stage 5D or 5T aged <18 years between 2004 and 2021. We evaluated data on the initiation of enteral tube feeding and its associated factors, the potential and timing of the withdrawal of enteral tube feeding, and improvements in feeding difficulties before and after kidney transplantation.

RESULTS

Of the 58 study participants, 33 (57%) received enteral tube feeding for more than 1 month. After adjusting for males and major congenital complications, logistic regression analyses identified a younger age at the initiation of kidney replacement therapy as a factor associated with the need for enteral tube feeding (odds ratio: 1.82, 95% confidence interval: 1.28‒2.56, P < 0.001). During the study period, enteral tube feeding was withdrawn from 24 of the 33 (73%) children (withdrawal rates: 2 years, 26%; 3 years, 50%; and 5 years, 66%). Of the nine patients in whom enteral tube feeding was not withdrawn before kidney transplantation, six underwent withdrawal at 0.1, 0.1, 1.1, 1.6, 2.9, and 3.3 years after kidney transplantation, respectively. The remaining three patients continued enteral tube feeding after kidney transplantation.

CONCLUSIONS

Although withdrawal from enteral nutrition is difficult in children with CKD stage 5D or 5T, it may be possible with kidney transplantation or over time.

Clinical practice guideline for the prevention and management of peritoneal dialysis associated infections in children: 2024 update

Infection-related complications remain the most significant cause for morbidity and technique failure in infants, children and adolescents who receive maintenance peritoneal dialysis (PD). The 2024 update of the Clinical Practice Guideline for the Prevention and Management of Peritoneal Dialysis Associated Infection in Children builds upon previous such guidelines published in 2000 and 2012 and provides comprehensive treatment guidance as recommended by an international group of pediatric PD experts based upon a review of published literature and pediatric PD registry data. The workgroup prioritized updating key clinical issues contained in the 2012 guidelines, in addition to addressing additional questions developed using the PICO format. A variety of new guideline statements, highlighted by those pertaining to antibiotic therapy of peritonitis as a result of the evolution of antibiotic susceptibilities, antibiotic stewardship and clinical registry data, as well as new clinical benchmarks, are included. Recommendations for future research designed to fill important knowledge gaps are also provided.

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.

Peritoneal dialysis in children, what's different: Your questions answered

Maintenance peritoneal dialysis (PD) is the most used kidney replacement therapy for children with kidney failure throughout the world. Underlying causes of kidney failure, indications for dialysis, body size, and nutritional requirements differ between children and adults on PD. These differences, along with the ongoing growth and development that occurs throughout childhood, impact PD access, prescription, and monitoring in children. This review highlights the unique challenges and management approaches to optimize the care of children on maintenance PD.

Frequency and prognosis of peritoneal dialysis-associated peritonitis in children

BACKGROUND

Peritonitis is the leading cause of peritoneal dialysis (PD) discontinuation. However, few data concern risk factors of peritonitis development and catheter removal caused by treatment failure in pediatric patients.

METHODS

This single-center, retrospective study analyzed data from pediatric patients who underwent chronic PD between March 2002 and June 2022. The incidence rates of peritonitis by the person-year method were calculated, and they were stratified by patient age groups. Risk factors for peritonitis development and catheter removal were also analyzed by multivariate analysis using logistic regression model.

RESULTS

Ninety patients were enrolled, and 62 peritonitis episodes were observed in 41 (46%) patients. The incidence rate of peritonitis was 0.21 episodes per patient-year, which was the highest in children aged under 2 years old (0.26 episodes per patient-year). Moreover, 44 (71%) cases were successfully cured by antibiotics alone, although 17 (27%) cases required catheter removal, and 4 (6%) cases transitioned to chronic hemodialysis because of peritoneal dysfunction. One patient died. The risk factor for peritonitis development and catheter removal caused by treatment failure was PD insertion at under 2 years old (odds ratio = 2.5; P = 0.04) and Pseudomonas aeruginosa (odds ratio = 11.0; P = 0.04) in the multivariate analysis. P. aeruginosa was also a risk factor for difficulty in re-initiating PD (P = 0.004).

CONCLUSIONS

The incidence rate of peritonitis was the highest in children under 2 years old. P. aeruginosa peritonitis is a risk factor for catheter removal and peritoneal dysfunction.

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.