Peritoneal dialysis in infants

Long-Term Peritoneal Dialysis in Infants

Although the numbers of infants requiring dialysis are small, management of these patients presents many challenges. Mortality is high in infants with comorbidities, complications of dialysis are common, and most of these infants need enteral feeding. However, the long-term outcome for otherwise healthy infants is comparable to that for older children.

Peritoneal Dialysis in Very Low Birth Weight Neonates

Background

The aim of this retrospective study is to evaluate clinical characteristics and outcomes of very low birth weight (VLBW) neonates with acute kidney injury (AKI) treated with peritoneal dialysis (PD).

Methods

This retrospective study included 10 VLBW neonates treated with PD. Intravenous (IV) cannula and umbilical venous catheter were used for the peritoneal access.

Results

Mean age at the moment of starting PD was 14.9 ± 9.3 days. Mean body weight (BW) was 825 ± 215 g. The average gestational age was 26.3 ± 1.1 weeks. The average duration of dialysis was 20.5 ± 14.7 h. The average ultrafiltration was 7.7 ± 4.2 mL/kg/h. At the moment of starting PD, the average BW was 302 ± 317g (22 ± 13%), higher than at birth (in patients who had PD started in first 2 weeks of their lives) or higher than the BW before AKI was diagnosed (patients who had PD started when they were older than 2 weeks). The main cause of AKI was sepsis ( n = 8/10). Dialysate leak was registered in 2 patients, 1 patient had peritonitis and the other had a blocked PD catheter. Six patients died during PD (severe sepsis), 1 died due to hypoxic encephalopathy and coma, and 2 patients survived. One patient (with hypoxic encephalopathy and coma) died 10 days after PD was stopped due to sepsis. The overall mortality was 80%.

Conclusion

Acute PD is still an appropriate treatment choice for VLBW neonates with AKI. In VLBW neonates, PD can be performed with an improvised PD system and catheters.

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.

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.

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.

Infants Requiring Maintenance Dialysis: Outcomes of Hemodialysis and Peritoneal Dialysis

BACKGROUND

The impact of different dialysis modalities on clinical outcomes has not been explored in young infants with chronic kidney failure.

STUDY DESIGN

Cohort study.

SETTING & PARTICIPANTS

Data were extracted from the ESPN/ERA-EDTA Registry. This analysis included 1,063 infants 12 months or younger who initiated dialysis therapy in 1991 to 2013.

FACTOR

Type of dialysis modality.

OUTCOMES & MEASUREMENTS

Differences between infants treated with peritoneal dialysis (PD) or hemodialysis (HD) in patient survival, technique survival, and access to kidney transplantation were examined using Cox regression analysis while adjusting for age at dialysis therapy initiation, sex, underlying kidney disease, and country of residence.

RESULTS

917 infants initiated dialysis therapy on PD, and 146, on HD. Median age at dialysis therapy initiation was 4.5 (IQR, 0.7-7.9) months, and median body weight was 5.7 (IQR, 3.7-7.5) kg. Although the groups were homogeneous regarding age and sex, infants treated with PD more often had congenital anomalies of the kidney and urinary tract (CAKUT; 48% vs 27%), whereas those on HD therapy more frequently had metabolic disorders (12% vs 4%). Risk factors for death were younger age at dialysis therapy initiation (HR per each 1-month later initiation, 0.95; 95% CI, 0.90-0.97) and non-CAKUT cause of chronic kidney failure (HR, 1.49; 95% CI, 1.08-2.04). Mortality risk and likelihood of transplantation were equal in PD and HD patients, whereas HD patients had a higher risk for changing dialysis treatment (adjusted HR, 1.64; 95% CI, 1.17-2.31).

LIMITATIONS

Inability to control for unmeasured confounders not included in the Registry database and missing data (ie, comorbid conditions). Low statistical power because of relatively small number of participants.

CONCLUSIONS

Despite a widespread preconception that HD should be reserved for cases in which PD is not feasible, in Europe, we found 1 in 8 infants in need of maintenance dialysis to be initiated on HD therapy. Patient characteristics at dialysis therapy initiation, prospective survival, and time to transplantation were very similar for infants initiated on PD or HD therapy.

Prolonged respiratory disorder predicts adverse prognosis in infants with end-stage kidney disease

BACKGROUND

Among comorbidities, pulmonary hypoplasia (PH) is known as a significant risk factor for mortality in infants with end-stage kidney disease (ESKD). However, the final outcomes of infants with both ESKD and PH are still not well defined, as the diagnosis modality, and definition of PH severity remain ambiguous.

METHODS

Children initiating peritoneal dialysis during infancy from 1990 to 2015 were followed until death, date of last contact, or the end of 2015. We examined the long-term outcome of children with congenital pulmonary disorders by studying infants with prolonged respiratory disorders of greater than 28 days duration after birth and evaluated risk factors for mortality.

RESULTS

Forty-six children were followed (median follow-up, 9.23 years), and classified as children without (n = 38; Group A) or with (n = 8; Group B) a prolonged respiratory disorder. Overall actuarial 5 year survival rate in this cohort was 79.5 %. The survival curve in Group B showed a significant decline compared with Group A. Prolonged respiratory disorder was significantly associated with mortality by multivariate analysis (hazard ratio, 8.32).

CONCLUSIONS

Infants who initiate peritoneal dialysis complicated by prolonged respiratory disorders have increased adverse risk factors for mortality; therefore, withholding aggressive treatment should be considered.

Acute renal failure in critically ill newborns increases the risk of death: a prospective observational study from India

OBJECTIVE

To determine the incidence and risk factors of acute renal failure (ARF) in hospitalized critically ill neonates and analyze outcome of all neonates with renal failure in relation to risk factors.

MATERIAL & METHODS

In this prospective observational study 815 infants were enrolled. Renal profile (blood urea and serum creatinine) was done after 12 h of life (or at the time of admission for outborn babies) and then every 12 hourly. Daily 24 h urine output was evaluated.

RESULTS

Incidence of renal failure in critically ill neonates was 10.67%. Out of 87 ARF neonates 52 (60%) expired. Mortality in the renal failure group was significantly higher in comparison to control group (p < 0.01). Non-oliguric renal failure was more common than oliguric renal failure, but mortality in the oliguric renal failure group was more. Neonatal sepsis was the most common cause of ARF. Eight neonates underwent peritoneal dialysis (PD) out of which there were seven neonatal deaths.

CONCLUSION

Prognosis of neonates with ARF requiring PD was very poor. It can thus be concluded that the health care personal should do rapid diagnosis of ARF in neonates with potential risk factors and also goal at an early and effective treatment of these risk factors in neonates with ARF.

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.

Factors associated with survival in patients who undergo peritoneal dialysis catheter placement following cardiac surgery

PURPOSE

Pediatric post-cardiac surgery patients are at risk for acute kidney injury and intraabdominal hypertension. The present study assesses indications and outcomes of postoperative peritoneal dialysis catheter (PDC) placement in this population.

METHODS

We retrospectively reviewed single-institution patients who underwent PDC placement post-cardiac surgery between 1999 and 2011 (n=55). Baseline, clinical course, and outcome data were recorded pre- and post-PDC. We used multivariable logistic and Cox analyses to assess factors associated with mortality.

RESULTS

In-hospital mortality of the study cohort was 67.3% (n=37). Peritoneal dialysis was performed in 21 patients (38.2%). Five patients (9.1%) experienced adverse events related to PDC placement. Greater post-PDC decreases in abdominal girth (adjusted odds ratio [OR]=2.43; P=0.02) and BUN (OR=1.06; P=0.04) were associated with survival. Additionally, preoperative ventilator independence (hazard ratio [HR]=1.18; P<0.01) and lower creatinine (HR=8.32; P<0.01), as well as greater post-PDC decrease in inotrope score (HR=1.33; P<0.02) were associated with survival.

CONCLUSIONS

In-hospital mortality of the study cohort was 67%. Less severe pre-PDC renal impairment, increased pre-PDC abdominal girth, and greater post-PDC improvement of abdominal girth, renal function, and inotrope requirements were associated with survival. Prospective trials are needed to assess appropriate indications and timing of PDC placement, with consideration of more aggressive treatment for intraabdominal hypertension.

Characterizing peritoneal dialysis catheter use in pediatric patients after cardiac surgery

OBJECTIVE

Children who undergo cardiac surgery are at high risk for renal insufficiency and abdominal compartment syndrome. Peritoneal dialysis catheter (PDC) implantation is used in this population for abdominal decompression and access for dialysis. However, there is no consensus regarding PDC use, and the practice varies widely. This study was undertaken to assess associated factors, outcomes, and variability in the use of PDC in patients who have undergone cardiac surgery.

METHODS

The cohort was obtained from the Kids' Inpatient Database, years 2006 and 2009. Patients who underwent cardiac surgery were included and the subset that underwent PDC implantation during the same hospitalization was identified. Univariable and multivariable analyses assessed factors associated with PDC and survival.

RESULTS

A cohort of 28,259 patients underwent cardiac surgery, of whom 558 (2%) had PDCs placed. In the PDC group, 39.1% (n = 218) had acute renal failure whereas 3.5% or patients (n = 974) in the non-PDC group had acute renal failure. Among patients receiving PDC, mortality was 20.3% (n = 113; vs 3.4% overall mortality, n = 955). Excluding patients with acute renal failure, mortality remained 12% (n = 41) for the PDC group. Factors associated significantly with PDC placement in the overall cohort were younger age, greater surgical complexity, nonelective admission, hospital region, use of cardiopulmonary bypass, and acute renal failure.

CONCLUSIONS

Patients receiving PDC after cardiac surgery had 20% mortality, which remained 12% after excluding patients with acute renal failure. Given the variability in PDC use and poor outcomes, further research is needed to assess the possible benefit of earlier intervention for peritoneal access in this high-risk cohort.

The effect of timing of the first kidney transplantation on survival in children initiating renal replacement therapy

BACKGROUND

Controversy exists concerning the timing of the first kidney transplantation for children who need to start renal replacement therapy (RRT). Our aim was to estimate the effect of timing of the first transplantation on patient survival in children, for the first time also taking into account the mortality on dialysis before transplantation.

METHODS

We included 2091 patients who started RRT between the age of 3 and 18 years in the period 1988-2007, from 13 European renal registries. A multistate model was used to simulate patient survival assuming (i) pre-emptive transplantation, (ii) transplantation after 1 or 2 years on dialysis and (iii) remaining on dialysis.

RESULTS

Over the 20-year period, the highest 8-year survival probabilities were achieved in children transplanted pre-emptively {living donor (LD): 95.9% [95% confidence interval (CI): 93.1-98.8], deceased donor (DD): 95.3% (95% CI: 90.9-99.9)} rather than after 2 years of dialysis [LD: 94.2% (95% CI: 91.6-96.8), DD: 93.4% (95% CI: 91.0-95.9)], although these differences were not statistically significant.

CONCLUSIONS

Even after taking mortality on dialysis into account, the potentially negative effect of postponing transplantation for 1 or 2 years was relatively small and not statistically significant. Therefore, if pre-emptive transplantation is not possible, starting RRT with a short period of dialysis and receiving a transplant thereafter seems an acceptable alternative from the perspective of patient survival.

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.

Successes and pitfalls of chronic peritoneal dialysis in infants - a Polish nationwide outcome study

INTRODUCTION

Peritoneal dialysis (PD) is a preferred method of renal replacement therapy for end-stage renal disease in children. Recent advances have allowed chronic PD to be provided to children of all ages and sizes.

MATERIAL AND METHODS

The study was designed as a national (10 dialysis centres), multicentre retrospective analysis of the medical history of 33 children who started chronic peritoneal dialysis in their infancy between 1993 and 2005, with a follow-up period of at least 24 months.

RESULTS

The nutritional status of the infants was unsatisfactory. The mean SDS of body weight at the start was -2.0, at 1 year of age -1.7. Only 40% of infants were adequately nourished at 1 year of age. Long-term follow-up analysis showed that 12 children received a kidney transplant, 13 were still on dialysis (4 changed method) and 6 died (mortality rate in the first year of life of 9%). In 2 children we observed an improvement of renal function. We observed a relatively high (1/8.8 patient-months) peritonitis rate in the analysed children when compared to 1 : 22 patient-months in all children undergoing PD in Poland.

CONCLUSIONS

The results of our survey have shown that the management of dialysed infants is still a challenge for the medical team and families, but long-term results of the therapy are encouraging.

Normal growth and intravascular volume status with good metabolic control during peritoneal dialysis in infancy

The most demanding patient population on peritoneal dialysis (PD) consists of children under 2 years of age. Their growth is inferior to that of older children and maintaining euvolemia is difficult, especially in anuric patients. In this prospective study reported here, we enrolled 21 patients <2 years of age (mean 0.59 years) at onset of PD and monitored their uremia parameters and evaluated their nutrition. Since no good instrument currently exists for estimating intravascular volume status, we used traditional blood pressure measurements, echocardiography, and N-terminal atrial natriuretic peptide measurements. Growth was compared with midparental height. Metabolic control was good. Long-term hypertension was seen in 43% of the patients, but left ventricular hypertrophy decreased during the study period. Mean weekly urea Kt/V was 3.38 +/- 0.66 and creatinine clearance was 49 +/- 20 L/week per 1.73 m(2). Catch-up growth was documented in 57% of the patients during PD. However, these children did not attain their midparental height at the end of PD at a mean age of 1.71 years. Although favorable metabolic control and good growth were achieved during PD, these children lagged in term of their midparental height. We conclude that several instruments are needed for determining the management of intravascular volume status and that the control of calcium-phosphorus status is demanding.

Twenty-five years of infant dialysis: a single center experience

OBJECTIVE

To perform a retrospective analysis of the long-term outcome of infants with end-stage kidney disease (ESKD) treated at our center during the past 25 years.

STUDY DESIGN

The total cohort (n = 52) was divided into era 1 (1983-1995; n = 23) and era 2 (1996-2008; n = 29). Dialysis morbidity, transplantation, and long-term survival rates were assessed and compared between the 2 eras.

RESULTS

Average age at initiation of dialysis was 4.4 +/- 5.3 months (range, 0.5-18 months), with 96% begun on peritoneal dialysis. The predominant diagnoses were dysplasia/obstructive uropathy and autosomal recessive polycystic kidney disease. The overall survival rate is 46%, with current age of survivors ranging from 1.5 to 25 years. Mortality rates in the 2 eras were not significantly different. The predominant mortality occurred within the first year. Twenty-four patients received an initial renal transplant at 2.6 +/- 1.7 years of age. Six patients (25%) required a second renal allograft. Increased risk for mortality included African-American ethnicity, oligoanuria, autosomal recessive polycystic kidney disease, and co-morbid diagnoses.

CONCLUSIONS

Long-term survival is possible in infants with ESKD, although mortality and morbidity remain high. Technical innovations are needed to accommodate smaller infants undergoing dialysis. Early initiation of dialysis treatment is preferable because prognostic indicators remain poorly defined.

Growth hormone treatment of infants with chronic kidney disease: requirement, efficacy, and safety

Growth failure is still a challenge in infants suffering from chronic kidney disease (CKD). Persistent growth failure is associated with the excessive mortality rate seen in these patients and markedly hampers later psychosocial integration. Infancy is an extremely sensitive period of growth, since physiological growth rates are several times higher than in later life. Growth failure in infants with CKD has multiple reasons, originating preferentially from malnutrition and, to a lesser extent, from water and electrolyte losses, metabolic acidosis, anemia, and renal osteodystrophy. Although, recombinant human growth hormone (rhGH) has been proven to be safe and effective for treatment of uremic growth failure in later childhood, its usage has not been adequately investigated in infants. Mencarelli et al. (Pediatric Nephrology 24:1039-1046, 2009) reported on their retrospective analysis of the longitudinal growth of 27 infants with early onset CKD that were receiving either standard therapy or additional rhGH treatment. Although their results were encouraging with respect to a sustained catch-up growth in rhGH-treated children, this issue has to be further addressed in prospective randomized controlled trials. In these trials special emphasis has to be given to the safety of this treatment modality, since rhGH might induce insulin resistance and glucose intolerance, especially in infants on high caloric intake and peritoneal dialysis.

Management of the neonate with chronic renal failure

The number of infants requiring chronic dialysis is small and has remained stable over the last decade. The majority have structural abnormalities of the urinary tract and over 50% are diagnosed antenatally. Mortality rate is high, particularly in infants with comorbidity, but has been improving. Management presents many challenges: as well as ethical issues, complications of dialysis are common and most infants need enteral feeding. Commitment from the family and medical team is crucial for success. However, the long-term outcome for otherwise healthy infants is comparable to that of older children.

Peritoneal dialysis in the neonatal intensive care unit. Management of acute renal failure after a severe subgaleal hemorrhage

Acute renal failure is common in the neonatal intensive care unit but is often not recognized in its early phases, when it is potentially reversible. The typical patient with acute renal failure is premature, but many term infants are also at risk. One such group is those with severe bleeding, such as a subgaleal hemorrhage. In these cases, hypovolemia can quickly progress to ischemia, which affects many organs but has profound effects on the kidney. In term infants, acute renal failure is most commonly diagnosed in those with perinatal depression. This article presents a unique case of an infant with subgaleal and intracranial bleeding that resulted in acute renal failure requiring peritoneal dialysis in the hopes of the eventual restoration of kidney function.