1
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Paglialonga F, Schmitt CP. Sodium handling in pediatric patients on maintenance dialysis. Pediatr Nephrol 2023; 38:3909-3921. [PMID: 37148342 DOI: 10.1007/s00467-023-05999-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/18/2023] [Accepted: 04/19/2023] [Indexed: 05/08/2023]
Abstract
The risk of cardiovascular disease remains exceedingly high in pediatric patients with chronic kidney disease stage 5 on dialysis (CKD 5D). Sodium (Na+) overload is a major cardiovascular risk factor in this population, both through volume-dependent and volume-independent toxicity. Given that compliance with a Na+-restricted diet is generally limited and urinary Na+ excretion impaired in CKD 5D, dialytic Na+ removal is critical to reduce Na+ overload. On the other hand, an excessive or too fast intradialytic Na+ removal may lead to volume depletion, hypotension, and organ hypoperfusion. This review presents current knowledge on intradialytic Na+ handling and possible strategies to optimize dialytic Na+ removal in pediatric patients on hemodialysis (HD) and peritoneal dialysis (PD). There is increasing evidence supporting the prescription of lower dialysate Na+ in salt-overloaded children on HD, while improved Na+ removal may be achieved in children on PD with an individual adaptation of dwell time and volume and with icodextrin use during the long dwell.
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Affiliation(s)
- Fabio Paglialonga
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 9, 20122, Milan, Italy.
| | - Claus Peter Schmitt
- Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
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2
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Bartosova M, Zarogiannis SG, Schmitt CP. How peritoneal dialysis transforms the peritoneum and vasculature in children with chronic kidney disease-what can we learn for future treatment? Mol Cell Pediatr 2022; 9:9. [PMID: 35513740 PMCID: PMC9072612 DOI: 10.1186/s40348-022-00141-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/09/2022] [Indexed: 01/04/2023] Open
Abstract
Children with chronic kidney disease (CKD) suffer from inflammation and reactive metabolite-induced stress, which massively accelerates tissue and vascular aging. Peritoneal dialysis (PD) is the preferred dialysis mode in children, but currently used PD fluids contain far supraphysiological glucose concentrations for fluid and toxin removal and glucose degradation products (GDP). While the peritoneal membrane of children with CKD G5 exhibits only minor alterations, PD fluids trigger numerous molecular cascades resulting in major peritoneal membrane inflammation, hypervascularization, and fibrosis, with distinct molecular and morphological patterns depending on the GDP content of the PD fluid used. PD further aggravates systemic vascular disease. The systemic vascular aging process is particularly pronounced when PD fluids with high GDP concentrations are used. GDP induce endothelial junction disintegration, apoptosis, fibrosis, and intima thickening. This review gives an overview on the molecular mechanisms of peritoneal and vascular transformation and strategies to improve peritoneal and vascular health in patients on PD.
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Affiliation(s)
- Maria Bartosova
- Center for Pediatric and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Sotirios G Zarogiannis
- Center for Pediatric and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany.,Department of Physiology, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Claus Peter Schmitt
- Center for Pediatric and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany.
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3
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Comparison of Isotonic Activation of Cell Volume Regulation in Rat Peritoneal Mesothelial Cells and in Kidney Outer Medullary Collecting Duct Principal Cells. Biomolecules 2021; 11:biom11101452. [PMID: 34680085 PMCID: PMC8533553 DOI: 10.3390/biom11101452] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/23/2021] [Accepted: 09/23/2021] [Indexed: 01/14/2023] Open
Abstract
In disease states, mesothelial cells are exposed to variable osmotic conditions, with high osmotic stress exerted by peritoneal dialysis (PD) fluids. They contain unphysiologically high concentrations of glucose and result in major peritoneal membrane transformation and PD function loss. The effects of isotonic entry of urea and myo-inositol in hypertonic (380 mOsm/kg) medium on the cell volume of primary cultures of rat peritoneal mesothelial cells and rat kidney outer medullary collecting duct (OMCD) principal cells were studied. In hypertonic medium, rat peritoneal mesothelial cells activated a different mechanism of cell volume regulation in the presence of isotonic urea (100 mM) in comparison to rat kidney OMCD principal cells. In kidney OMCD cells inflow of urea into the shrunken cell results in restoration of cell volume. In the shrunken peritoneal mesothelial cells, isotonic urea inflow caused a small volume increase and activated regulatory volume decrease (RVD). Isotonic myo-inositol activated RVD in hypertonic medium in both cell types. Isotonic application of both osmolytes caused a sharp increase of intracellular calcium both in peritoneal mesothelial cells and in kidney OMCD principal cells. In conclusion, peritoneal mesothelial cells exhibit RVD mechanisms when challenged with myo-inositol and urea under hyperosmolar isotonic switch from mannitol through involvement of calcium-dependent control. Myo-inositol effects were identical with the ones in OMCD principal cells whereas urea effects in OMCD principal cells led to no RVD induction.
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4
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Nelms CL, Shaw V, Greenbaum LA, Anderson C, Desloovere A, Haffner D, Oosterveld MJS, Paglialonga F, Polderman N, Qizalbash L, Rees L, Renken-Terhaerdt J, Tuokkola J, Vande Walle J, Shroff R, Warady BA. Assessment of nutritional status in children with kidney diseases-clinical practice recommendations from the Pediatric Renal Nutrition Taskforce. Pediatr Nephrol 2021; 36:995-1010. [PMID: 33319327 PMCID: PMC7910229 DOI: 10.1007/s00467-020-04852-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 10/03/2020] [Accepted: 11/06/2020] [Indexed: 02/07/2023]
Abstract
In children with kidney diseases, an assessment of the child's growth and nutritional status is important to guide the dietary prescription. No single metric can comprehensively describe the nutrition status; therefore, a series of indices and tools are required for evaluation. The Pediatric Renal Nutrition Taskforce (PRNT) is an international team of pediatric renal dietitians and pediatric nephrologists who develop clinical practice recommendations (CPRs) for the nutritional management of children with kidney diseases. Herein, we present CPRs for nutritional assessment, including measurement of anthropometric and biochemical parameters and evaluation of dietary intake. The statements have been graded using the American Academy of Pediatrics grading matrix. Statements with a low grade or those that are opinion-based must be carefully considered and adapted to individual patient needs based on the clinical judgment of the treating physician and dietitian. Audit and research recommendations are provided. The CPRs will be periodically audited and updated by the PRNT.
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Affiliation(s)
| | - Vanessa Shaw
- University College London Great Ormond Street Hospital Institute of Child Health, London, WC1N 3JH, UK
- University of Plymouth, Plymouth, UK
| | - Larry A Greenbaum
- Emory University, Atlanta, GA, USA
- Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Caroline Anderson
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Dieter Haffner
- Children's Hospital, Hannover Medical School, Hannover, Germany
| | - Michiel J S Oosterveld
- Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Fabio Paglialonga
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | | | - Lesley Rees
- University College London Great Ormond Street Hospital Institute of Child Health, London, WC1N 3JH, UK
| | - José Renken-Terhaerdt
- Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jetta Tuokkola
- Children's Hospital and Clinical Nutrition Unit, Internal Medicine and Rehabilitation, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | - Rukshana Shroff
- University College London Great Ormond Street Hospital Institute of Child Health, London, WC1N 3JH, UK.
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5
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Schmitz L, Hoermann P, Trutnau B, Jankauskiene A, Zaloszyc A, Edefonti AC, Schmitt CP, Klaus G. Enteral Ca-Intake May Be Low and Affects Serum-PTH-Levels in Pre-school Children With Chronic Kidney Disease. Front Pediatr 2021; 9:666101. [PMID: 34354967 PMCID: PMC8329332 DOI: 10.3389/fped.2021.666101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 05/17/2021] [Indexed: 11/13/2022] Open
Abstract
Treatment of chronic kidney disease (CKD) mineral bone disorder (MBD) is challenging in growing children due to the high amount of calcium needed for normal bone mineralization and the required dietary phosphate restriction, which often includes intake of calcium-rich products such as milk. Therefore, enteral calcium-intake (Ca-I) was calculated. Patients: We looked at pediatric CKD-Patients aged 0-6 years. Design: We used a retrospective analysis of Ca-I from dietary data collections. Ca-I below 60% or above 100% of the D-A-CH and the KDOQI reference values were considered as severe Ca deficiency or Ca overload, respectively. Results: We had 41 children, median age 1.1 (range 0-5.8) years, body weight 7.3 (2.4-19.9) kg, and length 68 (48-105) cm at the time of first dietary data collection. Renal function was classified as CKD stage III in 20, IV in 28, V in 44, and VD in 142 dietary data collections. At the first dietary data collection, 5 children were in the CKD stage III, 10 in IV, 9 in V, and 17 were on dialysis. Only one child progressed to a higher CKD stage. In total, 234 dietary data collections were analyzed, and 65 follow-up collections were available from 33 children after a time interval of 26 (1-372) days. The median caloric intake was 120 (47-217)% of D-A-CH RDI. In 149 (63.6%) of the dietary data collections, enteral Ca-I was below the target (<100% of the D-A-CH and KDOQI RDI). Severe Ca-deficiency was found in 11 (26%) and 4 (12%) of the children at the first and second dietary data collection, respectively. In total, 11 children were on Ca-containing phosphate binders. In dietary data collection 1 and 2, there were seven children. From these, 4/7 and 4/7 patients had an enteral total Ca-I above the 100% D-A-CH-limit or above the KDOQI limit, respectively. Absolute dietary Ca-I and Ca-I normalized to body weight correlated negatively with PTH (r = -0.196, p < 0.005 and r = -0.13, p < 0.05). Conclusion: Enteral Ca-I should repeatedly be monitored in CKD children because many may may otherwise be underexposed to enteral calcium and overexposed when calcium-containing phosphate binders are given. Our findings suggest a major impact of dietary calcium supply on bone health in pediatric CKD.
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Affiliation(s)
- Lilith Schmitz
- Department of Pediatric Nephrology, University of Marburg, Marburg, Germany
| | - Pamela Hoermann
- KfH Pediatric Kidney Center and University Hospital, University of Marburg, Marburg, Germany
| | - Birgit Trutnau
- KfH Pediatric Kidney Center and University Hospital, University of Marburg, Marburg, Germany
| | | | - Ariane Zaloszyc
- Division of Pediatric Nephrology, University Hospital Strassbourg, Strassbourg, France
| | - Alberto Carlo Edefonti
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione Cà Granda, Ospedale Policlinico, Milan, Italy
| | - Claus Peter Schmitt
- Division of Pediatric Nephrology, University Hospital Heidelberg, Heidelberg, Germany
| | - Guenter Klaus
- Department of Pediatric Nephrology, University of Marburg, Marburg, Germany.,KfH Pediatric Kidney Center and University Hospital, University of Marburg, Marburg, Germany
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6
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Frehat MQF, Al-Salaita GM, Al-Bderat JT, Alhadidi AM, Mohammad SA, Shaaban AM, Al Mardini R. Chronic peritoneal dialysis in children: a single-centre experience in Jordan. Sudan J Paediatr 2020; 20:34-41. [PMID: 32528199 DOI: 10.24911/sjp.106-1578945921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The aim of the present study is to share the experience of chronic peritoneal dialysis (PD) at King Hussein Medical Center, Amman, Jordan, and to highlight the complications of this procedure. This is a retrospective chart review study for all the children from day 1 of life to 14 years, who underwent chronic PD for end-stage renal disease (ESRD) during the period of 10 years extending from 2009 to 2019. The following data were collected: mode of dialysis, type of peritoneal dialysis, age of starting peritoneal dialysis, gender, aetiology of ESRD, duration on PD, complications and outcome. A total number of 269 children were included: 229 patients received haemodialysis and 40 children (22 boys and 18 girls) received PD. Of those, two children were on automated PD and 38 children were on continuous ambulatory peritoneal dialysis. The mean age at the start of PD was 62 ± 38 months. The mean duration of PD was 43 months. The mean catheter duration was 34 months. Six patients were shifted to haemodialysis permanently and four patients received a kidney transplant. Eleven patients died. The most common complications were peritonitis (52.5%), exit-site infection (30%) and malfunctioning catheter (12.5%). The rate of peritonitis was one episode per 22 patient-months. Peritoneal dialysis is a promising mode of dialysis for children in Jordan. Peritonitis is the most common complication associated with PD. Kidney transplantation is the best modality of renal replacement therapy in terms of long-term survival and quality of life and should be encouraged on national level.
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Affiliation(s)
- Mahdi Qasem Farah Frehat
- Pediatric Nephrology Department, Queen Rania Al Abdallah Hospital for Children, King Hussein Medical Center, Amman, Jordan
| | - Ghazi Mohammad Al-Salaita
- Pediatric Nephrology Department, Queen Rania Al Abdallah Hospital for Children, King Hussein Medical Center, Amman, Jordan
| | - Jwaher Thiab Al-Bderat
- Pediatric Nephrology Department, Queen Rania Al Abdallah Hospital for Children, King Hussein Medical Center, Amman, Jordan
| | - Aghadir Mohammad Alhadidi
- Pediatric Department, Queen Rania Al Abdallah Hospital for Children, King Hussein Medical Center, Amman, Jordan
| | - Samera Adnan Mohammad
- Dialysis Unit, Queen Rania Al Abdallah Hospital for Children, King Hussein Medical Center, Amman, Jordan
| | - Ahmad Mohammad Shaaban
- Pediatric Department, Queen Rania Al Abdallah Hospital for Children, King Hussein Medical Center, Amman, Jordan
| | - Reham Al Mardini
- Pediatrics and Pediatric nephrology, Private Practice, Amman, Jordan
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7
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End-stage kidney disease in infancy: an educational review. Pediatr Nephrol 2020; 35:229-240. [PMID: 30465082 PMCID: PMC6529305 DOI: 10.1007/s00467-018-4151-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 11/05/2018] [Accepted: 11/12/2018] [Indexed: 12/15/2022]
Abstract
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.
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8
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Bartosova M, Schmitt CP. Biocompatible Peritoneal Dialysis: The Target Is Still Way Off. Front Physiol 2019; 9:1853. [PMID: 30700974 PMCID: PMC6343681 DOI: 10.3389/fphys.2018.01853] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 12/07/2018] [Indexed: 01/01/2023] Open
Abstract
Peritoneal dialysis (PD) is a cost-effective, home-based therapy for patients with end-stage renal disease achieving similar outcome as compared to hemodialysis. Still, a minority of patients only receive PD. To a significant extend, this discrepancy is explained by major limitations regarding PD efficiency and sustainability. Due to highly unphysiological composition of PD fluids, the peritoneal membrane undergoes rapid morphological and long-term functional alterations, which limit the treatment and contribute to adverse patient outcome. This review is focused on the peritoneal membrane ultrastructure and its transformation in patients with kidney disease and chronic PD, underlying molecular mechanisms, and potential systemic sequelae. Current knowledge on the impact of conventional and second-generation PD fluids is described; novel strategies and innovative PD fluid types are discussed.
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Affiliation(s)
| | - Claus Peter Schmitt
- Center for Pediatric and Adolescent Medicine Heidelberg, University of Heidelberg, Heidelberg, Germany
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9
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Rees L, Schaefer F, Schmitt CP, Shroff R, Warady BA. Chronic dialysis in children and adolescents: challenges and outcomes. THE LANCET CHILD & ADOLESCENT HEALTH 2017; 1:68-77. [PMID: 30169229 DOI: 10.1016/s2352-4642(17)30018-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 06/09/2017] [Accepted: 06/14/2017] [Indexed: 12/23/2022]
Abstract
Chronic dialysis is rarely required during childhood. Despite technical advances that have facilitated the treatment of even the youngest children, morbidity and mortality remain higher with chronic dialysis than after renal transplantation. The cost of equipment and skilled personnel to provide the service compromises the availability of such dialysis in parts of the world where financial resources are constrained. This Review describes the incidence and causes of end-stage kidney disease in children on long-term dialysis, and highlights management issues, including dialysis modality selection, complications, and patient outcome data.
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Affiliation(s)
- Lesley Rees
- Renal Office, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.
| | - Franz Schaefer
- Division of Pediatric Nephrology and Center for Pediatrics and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Claus Peter Schmitt
- Division of Pediatric Nephrology and Center for Pediatrics and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Rukshana Shroff
- Renal Office, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Bradley A Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
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10
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Vasudevan A, Phadke K, Yap HK. Peritoneal dialysis for the management of pediatric patients with acute kidney injury. Pediatr Nephrol 2017; 32:1145-1156. [PMID: 27796620 DOI: 10.1007/s00467-016-3482-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 07/02/2016] [Accepted: 07/05/2016] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- Anil Vasudevan
- Department of Pediatric Nephrology, St. John's Medical College Hospital, Bengaluru, Karnataka, India, 560034.
| | | | - Hui-Kim Yap
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, Singapore, Singapore
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11
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Is there such a thing as biocompatible peritoneal dialysis fluid? Pediatr Nephrol 2017; 32:1835-1843. [PMID: 27722783 PMCID: PMC5579143 DOI: 10.1007/s00467-016-3461-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 07/01/2016] [Accepted: 07/01/2016] [Indexed: 10/31/2022]
Abstract
Introduction of the so-called biocompatible peritoneal dialysis (PD) fluids was based on a large body of experimental evidence and various clinical trials suggesting important clinical benefits. Of these, until now, only preservation of residual renal function-likely due to lower glucose degradation product load and, in case of icodextrin, improved fluid and blood pressure control-have consistently been proven, whereas the impact on important clinical endpoints such as infectious complications, preservation of PD membrane transport function, and patient outcome, are still debated. In view of the high morbidity and mortality rates of PD patients, novel approaches are warranted and comprise the search for alternative osmotic agents and enrichment of PD fluids with specific pharmacologic agents, such as alanyl-glutamine, potentially counteracting local but also systemic sequelae of uremia and PD.
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12
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Optimizing peritoneal dialysis prescription for volume control: the importance of varying dwell time and dwell volume. Pediatr Nephrol 2014; 29:1321-7. [PMID: 23903692 DOI: 10.1007/s00467-013-2573-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 07/01/2013] [Accepted: 07/09/2013] [Indexed: 01/24/2023]
Abstract
Not only adequate uremic toxin removal but also volume control is essential in peritoneal dialysis (PD) to improve patient outcome. Modification of dwell time impacts on both ultrafiltration (UF) and purification. A short dwell favors UF but preferentially removes small solutes such as urea. A long dwell favors uremic toxin removal but also peritoneal fluid reabsorption due to the time-dependent loss of the crystalloid osmotic gradient. In particular, the long daytime dwell in automated PD may result in significant water and sodium reabsorption, and in such cases icodextrin should be considered. Increasing dwell volume favors the removal of solutes such as sodium due to the increased volume of diffusion and the recruitment of peritoneal surface area. A very large fill volume with too high an intraperitoneal pressure (IPP) may, however, result in back-filtration and thus reduced UF and sodium clearance. Based on these principles and the individual transport and pressure kinetics obtained from peritoneal equilibration tests and IPP measurements, we suggest combining short dwells with a low fill volume to favor UF with long dwells and a large fill volume to favor solute removal. Results from a recent randomized cross-over trial and earlier observational data in children support this concept: the absolute UF and UF relative to the administered glucose increased and solute removal and blood pressure improved.
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13
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Strategies for the preservation of residual renal function in pediatric dialysis patients. Pediatr Nephrol 2014; 29:825-36; quiz 832. [PMID: 23868107 DOI: 10.1007/s00467-013-2554-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Revised: 06/05/2013] [Accepted: 06/18/2013] [Indexed: 10/26/2022]
Abstract
In adults with end-stage renal disease (ESRD), the preservation of residual renal function (RRF) has been shown to be associated with decreased mortality and improved control of complications of chronic kidney disease. However, less is known on the benefits of RRF in the pediatric dialysis population. The purpose of this article is to review the clinical significance of RRF and to discuss strategies for the preservation of RRF in children with ESRD.
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14
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Peritoneal dialysis and inflammation. Clin Chim Acta 2014; 430:109-14. [DOI: 10.1016/j.cca.2013.12.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 11/29/2013] [Accepted: 12/01/2013] [Indexed: 11/21/2022]
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15
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Gaillot T, Ozanne B, Bétrémieux P, Tirel O, Ecoffey C. [Acute renal replacement therapy in pediatrics]. ACTA ACUST UNITED AC 2013; 32:e231-6. [PMID: 24246660 DOI: 10.1016/j.annfar.2013.10.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In pediatric intensive care unit, the available modalities of acute renal replacement therapy include intermittent hemodialysis, peritoneal dialysis and continuous renal replacement therapies. No prospective studies have evaluated to date the effect of dialysis modality on the outcomes of children. The decision about dialysis modality should therefore be based on local expertise, resources available, and the patient's clinical status. Poor hemodynamic tolerance of intermittent hemodialysis is a common problem in critically ill patients. Moreover, many pediatric intensive care units are not equipped with dedicated water circuit. Peritoneal dialysis, a simple and inexpensive alternative, is the most widely available form of acute renal replacement therapy. However, its efficacy may be limited in critically ill patients. The use of continuous renal replacement therapy permits usually to reach a greater estimated dialysis dose, a better control of fluid balance, and additionally, to provide adequate nutrition.
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Affiliation(s)
- T Gaillot
- Unité de réanimation pédiatrique, pôle anesthésie-réanimation, hôpital Sud, CHU de Rennes, 16, boulevard de Bulgarie, 35203 Rennes cedex 2, France; CIC-P Inserm 0203, université Rennes-1, 35033 Rennes, France.
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16
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Schoenmaker NJ, Tromp WF, van der Lee JH, Offringa M, Craig JC, Groothoff JW. Quality and consistency of clinical practice guidelines for the management of children on chronic dialysis. Nephrol Dial Transplant 2013; 28:3052-61. [PMID: 24097802 DOI: 10.1093/ndt/gft303] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Clinical practice guidelines aim to improve the quality of care, yet for users of guidelines it is often not clear how these guidelines were developed and whether the recommendations are robust. We aimed to identify all current published guidelines for the management of children on chronic dialysis, assess the quality of their development and evaluate consistency among their recommendations. METHODS We searched Medline (1948 to January 2012), and relevant websites of guideline development programmes. Three reviewers appraised all 17 identified guidelines with the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. RESULTS The guidelines were developed by five different professional associations. The overall mean AGREE II score from seven Kidney Disease Outcomes Quality Initiatives (KDOQI) guidelines was considered sufficient (mean scores 64-75%), and from all other 10 guidelines poor (29-44%). Five out of seven KDOQI guidelines scored weak on applicability. We found important inconsistencies between recommendations concerning initiation of renal replacement therapy, management of haemoglobin level and the use of mupirocin to prevent exit-site infections. CONCLUSIONS While the recently developed KDOQI guidelines meet the modern quality standards, advice for implementation of these recommendations is lacking. There is an urgent need for international collaboration and coordination to ensure that the management of children on chronic dialysis is informed by relevant and high-quality evidence.
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Affiliation(s)
- Nikki J Schoenmaker
- Department of Paediatric Nephrology, Emma Children's Hospital AMC, Amsterdam, The Netherlands
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Zurowska AM, Fischbach M, Watson AR, Edefonti A, Stefanidis CJ. Clinical practice recommendations for the care of infants with stage 5 chronic kidney disease (CKD5). Pediatr Nephrol 2013; 28:1739-48. [PMID: 23052647 PMCID: PMC3722439 DOI: 10.1007/s00467-012-2300-z] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Revised: 06/28/2012] [Accepted: 07/18/2012] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- Aleksandra M Zurowska
- Department Paediatric & Adolescent Nephrology & Hypertension, Medical University of Gdansk, Ul. Debinki 7, 80-211, Gdansk, Poland.
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Stone ML, LaPar DJ, Barcia JP, Norwood VF, Mulloy DP, McGahren ED, Rodgers BM, Kane BJ. Surgical outcomes analysis of pediatric peritoneal dialysis catheter function in a rural region. J Pediatr Surg 2013; 48:1520-7. [PMID: 23895966 PMCID: PMC4219559 DOI: 10.1016/j.jpedsurg.2013.02.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Revised: 02/05/2013] [Accepted: 02/05/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE The purpose of this study was to analyze the experience with peritoneal dialysis (PD) at a high-volume, single center institution that supports a rural population. METHODS From 2000 to 2010, 88 children (median age: 1.98 years, [range: 2 days-20.2 years]) received 134 PD catheters for the management of acute and chronic renal failure. The primary outcome of interest was the incidence of primary PD catheter failure (replacement or revision within 60 days). Operative technique, longitudinal outcomes, and time intervals to transplantation were analyzed. RESULTS Median time to transplant from the institution of dialysis was 1.4 years [range: 0.3-6.4 years]. Primary catheter failure occurred in 24.6% of cases. Infants less than 6 months of age demonstrated an increased incidence of primary catheter failure (p = 0.02). The operative technique for catheter placement was not associated with the incidence of primary failure. Postoperative complications included peritonitis (22.7%), omental plugging (11.9%), pericatheter drainage (9.0%), and exit site infection (3.0%). CONCLUSION Peritoneal dialysis provides a safe and effective renal replacement therapy for regional pediatric centers that serve a rural population. However, primary catheter failure rates remain high at 24.6%. The surgical technique for placement had no effect on this failure rate in our patient population. Infants less than 6 months of age are at increased risk for primary catheter failure and warrant intensive surveillance.
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Affiliation(s)
- Matthew L. Stone
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Damien J. LaPar
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - John P. Barcia
- Department of Pediatrics, Division of Nephrology, University of Virginia Health System, Charlottesville, VA, USA
| | - Victoria F. Norwood
- Department of Pediatrics, Division of Nephrology, University of Virginia Health System, Charlottesville, VA, USA
| | - Daniel P. Mulloy
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Eugene D. McGahren
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Bradley M. Rodgers
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Bartholomew J. Kane
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA,Corresponding author. Division of Pediatric Surgery, University of Virginia Health System, Charlottesville, VA 22908-0709, USA. Tel.: +1 434 982 2796, fax: +1 434 243 0056. (B.J. Kane)
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Jörres A. Novel Peritoneal Dialysis Solutions – What Are the Clinical Implications? Blood Purif 2012; 33:153-9. [DOI: 10.1159/000334151] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Schmitt CP, Zaloszyc A, Schaefer B, Fischbach M. Peritoneal dialysis tailored to pediatric needs. Int J Nephrol 2011; 2011:940267. [PMID: 21761001 PMCID: PMC3132841 DOI: 10.4061/2011/940267] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2011] [Accepted: 03/29/2011] [Indexed: 02/02/2023] Open
Abstract
Consideration of specific pediatric aspects is essential to achieve adequate peritoneal dialysis (PD) treatment in children. These are first of all the rapid growth, in particular during infancy and puberty, which must be accompanied by a positive calcium balance, and the age dependent changes in body composition. The high total body water content and the high ultrafiltration rates required in anuric infants for adequate nutrition predispose to overshooting convective sodium losses and severe hypotension. Tissue fragility and rapid increases in intraabdominal fat mass predispose to hernia and dialysate leaks. Peritoneal equilibration tests should repeatedly been performed to optimize individual dwell time. Intraperitoneal pressure measurements give an objective measure of intraperitoneal filling, which allow for an optimized dwell volume, that is, increased dialysis efficiency without increasing the risk of hernias, leaks, and retrofiltration. We present the concept of adapted PD, that is, the combination of short dwells with low fill volume to promote ultrafiltration and long dwells with a high fill volume to improve purification within one PD session. The use of PD solutions with low glucose degradation product content is recommended in children, but unfortunately still not feasible in many countries.
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Affiliation(s)
- C P Schmitt
- Division of Pediatric Nephrology, Center for Pediatric and Adolescent Medicine, INF 430, 69120 Heidelberg, Germany
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