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

Pediatric Emergent Peritoneal Dialysis in Intensive Care Units: Indications, Techniques, and Outcomes

INTRODUCTION

This study aimed to identify risk factors affecting outcomes in pediatric patients requiring emergent peritoneal dialysis (PD) for all causes, focusing on survival rates, kidney function recovery, PD duration, complications, and quality of life.

METHODS

A retrospective review was conducted on medical records of pediatric patients who received emergent bedside PD in the intensive care unit from January 2010 to February 2023. Thirty-four catheters were placed, with demographic, preoperative, and procedural data collected. MedCalc® Statistical Software was used for analysis with a significance level set at p < 0.05. Prophylactic antibiotics were administered prior to surgery, and catheters were placed using a consistent technique by a single team of pediatric surgeons.

RESULTS

The median age at catheter placement was 39 days (range 2-2,286), and the median body weight was 3.53 kg (range 1.2-48.8). The majority were male (64.7%), with 17.6% preterm. The most common indication for PD was acute kidney injury (AKI) (88.2%), followed by hyperammonemia, metabolic acidosis, and abdominal compartment syndrome. The median waiting period for PD placement was 1 day, and the median duration of PD was 7 days. Complications included dialysate leakage (22.8%) and catheter obstruction leading to PD discontinuation (31.4%). The mortality rate was high at 71.4%.

CONCLUSION

It is advisable to advocate for the early initiation of PD in pediatric patients following cardiac surgery. AKI is a significant risk factor for mortality, while prematurity increases the risk of dialysate leakage. Omentectomy and the method of catheter exit did not significantly affect outcomes. The study's limitations highlight the need for larger prospective studies to better understand and improve emergent PD management in this vulnerable population.

Continuous renal replacement therapy in neonates and children: what does the pediatrician need to know? An overview from the Critical Care Nephrology Section of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC)

Continuous renal replacement therapy (CRRT) is the preferred method for renal support in critically ill and hemodynamically unstable children in the pediatric intensive care unit (PICU) as it allows for gentle removal of fluids and solutes. The most frequent indications for CRRT include acute kidney injury (AKI) and fluid overload (FO) as well as non-renal indications such as removal of toxic metabolites in acute liver failure, inborn errors of metabolism, and intoxications and removal of inflammatory mediators in sepsis. AKI and/or FO are common in critically ill children and their presence is associated with worse outcomes. Therefore, early recognition of AKI and FO is important and timely transfer of patients who might require CRRT to a center with institutional expertise should be considered. Although CRRT has been increasingly used in the critical care setting, due to the lack of standardized recommendations, wide practice variations exist regarding the main aspects of CRRT application in critically ill children.     Conclusion: In this review, from the Critical Care Nephrology section of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC), we summarize the key aspects of CRRT delivery and highlight the importance of adequate follow up among AKI survivors which might be of relevance for the general pediatric community. What is Known: • CRRT is the preferred method of renal support in critically ill and hemodynamically unstable children in the PICU as it allows for gentle removal of fluids and solutes. • Although CRRT has become an important and integral part of modern pediatric critical care, wide practice variations exist in all aspects of CRRT. What is New: • Given the lack of literature on guidance for a general pediatrician on when to refer a child for CRRT, we recommend timely transfer to a center with institutional expertise in CRRT, as both worsening AKI and FO have been associated with increased mortality. • Adequate follow-up of PICU patients with AKI and CRRT is highlighted as recent findings demonstrate that these children are at increased risk for adverse long-term outcomes.

Peritoneal Dialysis Catheter Placement in Children: Initial Experience with a "2+1"-Port Laparoscopic-Assisted Technique

The placement of a peritoneal dialysis catheter (PDC) is currently a common procedure in pediatric surgeon practice, and the search for the ultimate technique never stops. The purpose of this study is to evaluate our experience with the laparoscopic PDC placement approach, performing a "2+1" ("two plus one") technique, where the "+1" trocar is placed in an oblique manner, pointing toward the Douglas pouch when passing through the abdominal wall. This tunnel is further used to place and maintain the proper position of the PDC.

MATERIALS AND METHODS

We assessed a cohort of five children who underwent laparoscopic-assisted PDC placement between 2018 and 2022.

RESULTS

This procedure is a simple, relatively quick, and safe technique for PDC placement. Furthermore, in our experience, concomitant omentectomy is necessary to reduce the risk of catheter obstruction and migration due to omental wrapping.

CONCLUSIONS

The laparoscopic approach allows for improved visualization and more accurate placement of a catheter inside the abdominal cavity. Concomitant omental excision is necessary to prevent PDC malfunction and migration.

Metabolic Acidosis in Children: A Literature Review

Metabolic acidosis is characterised by a primary decrease in the serum bicarbonate concentration, a secondary decrease in the arterial partial pressure of CO­2, and a reduction in blood pH. Metabolic acidosis, acute or chronic, may have deleterious effects on cellular function and cause increased morbidity and mortality. A systematic review of the available literature was performed to identify data on the prevalence, manifestations, cause, outcomes, and treatment of metabolic acidosis in children. Online databases (Ovid Medline, Embase, and PubMed), commercial search engines (including Google), and chapters on metabolic acidosis in the standard textbooks of paediatrics and medicine were reviewed. Systematic approach to acute metabolic acidosis starts with proper history taking and examination. This is followed by assessment of acid-base parameters, including pH, partial pressure of CO2, and bicarbonate concentration in arterial blood. Blood gas is needed to differentiate primary metabolic acidosis from compensated respiratory alkalosis. Once the diagnosis of a metabolic acidosis has been confirmed, serum electrolyte values are used to determine the serum anion gap. The various causes of increased and normal anion gap metabolic acidosis have been discussed in the article. The main aim of treatment in metabolic acidosis is to reverse the primary pathophysiology. In acute metabolic acidosis, sodium bicarbonate therapy is not beneficial due to potential complications and is reserved for specific situations. Base therapy is used in chronic metabolic acidosis where it ameliorates many of its untoward effects. Other modalities of treatment of metabolic acidosis include peritoneal or haemodialysis and tris-hydroxymethyl aminomethane.

Pediatric cancer and hematopoietic stem cell transplantation patients requiring renal replacement therapy: results of the retrospective nationwide AIEOP study

In children affected by malignancies and/or who received hematopoietic stem cell transplantation (HSCT), acute kidney injury (AKI) may occur causing a high mortality rate, despite the implementation of renal replacement therapy (RRT). We performed a nationwide, multicenter, retrospective, observational cohort study including consecutive patients between January 2010 and December 2019. One hundred and fourteen episodes of AKI requiring RRT coming from nine different Italian centers were included. The overall mortality rate was 61.4%. At the 3-month follow-up, the mortality rate was 47.4%. The mortality rate was higher in transplanted patients than those receiving chemotherapy. In particular, HSCT (p = 0.048) and invasive mechanical ventilation (p = 0.040) were significantly associated with death at three months after the end of dialysis in the multivariate analysis. Pediatric patients affected by malignancies complicated by AKI requiring RRT have a high mortality. The main factors associated to death are respiratory failure and having received HSCT.

Delivering optimal renal replacement therapy to critically ill patients with acute kidney injury

Critical illness is often complicated by acute kidney injury (AKI). In patients with severe AKI, renal replacement therapy (RRT) is deployed to address metabolic dysfunction and volume excess until kidney function recovers. This review is intended to provide a comprehensive update on key aspects of RRT prescription and delivery to critically ill patients. Recently completed trials have enhanced the evidence base regarding several RRT practices, most notably the timing of RRT initiation and anticoagulation for continuous therapies. Better evidence is still needed to clarify several aspects of care including optimal targets for ultrafiltration and effective strategies for RRT weaning and discontinuation.

Proteomics and Extracellular Vesicles as Novel Biomarker Sources in Peritoneal Dialysis in Children

Peritoneal dialysis (PD) represents the dialysis modality of choice for pediatric patients with end-stage kidney disease. Indeed, compared with hemodialysis (HD), it offers many advantages, including more flexibility, reduction of the risk of hospital-acquired infections, preservation of residual kidney function, and a better quality of life. However, despite these positive aspects, PD may be associated with several long-term complications that may impair both patient's general health and PD adequacy. In this view, chronic inflammation, caused by different factors, has a detrimental impact on the structure and function of the peritoneal membrane, leading to sclerosis and consequent PD failure both in adults and children. Although several studies investigated the complex pathogenic pathways underlying peritoneal membrane alterations, these processes remain still to explore. Understanding these mechanisms may provide novel approaches to improve the clinical outcome of pediatric PD patients through the identification of subjects at high risk of complications and the implementation of personalized interventions. In this review, we discuss the main experimental and clinical experiences exploring the potentiality of the proteomic analysis of peritoneal fluids and extracellular vesicles as a source of novel biomarkers in pediatric peritoneal dialysis.

Risk factors and outcomes of neonates with acute kidney injury needing peritoneal dialysis: Results from the prospective TINKER (The Indian PCRRT-ICONIC Neonatal Kidney Educational Registry) study

BACKGROUND

Acute kidney injury (AKI) is common in neonates admitted to neonatal intensive care units (NICUs). There is a need to have prospective data on the risk factors and outcomes of acute peritoneal dialysis (PD) in neonates. The use of kidney replacement therapy in this population compared to older populations has been associated with worse outcomes (mortality rates 17-24%) along with a longer stay in the NICU and/or hospital.

METHODS

The following multicentre, prospective study was derived from the TINKER (The Indian PCRRT-ICONIC Neonatal Kidney Educational Registry) database, assessing all admitted neonates ≤28 days who received intravenous fluids for at least 48 h. The following neonates were excluded: death within 48 h, presence of any lethal chromosomal anomaly, requirement of congenital heart surgery within the first 7 days of life and those receiving only routine care in nursery. Demographic data (maternal and neonatal) and daily clinical and laboratory parameters were recorded. AKI was defined according to the Neonatal Kidney Disease: Improving Global Outcomes criteria.

RESULTS

Of the included 1600 neonates, a total of 491 (30.7%) had AKI. Of these 491 neonates with AKI, 44 (9%) required PD. Among neonates with AKI, the odds of needing PD was significantly higher among those with significant cardiac disease (odds ratio (95% confidence interval): 4.95 (2.39-10.27); p < 0.001), inotropes usage (4.77 (1.98-11.51); p < 0.001), severe peripartum event (4.37 (1.31-14.57); p = 0.02), requirement of respiratory support in NICU (4.17 (1.00-17.59); p = 0.04), necrotising enterocolitis (3.96 (1.21-13.02); p = 0.03), any grade of intraventricular haemorrhage (3.71 (1.63-8.45); p = 0.001), evidence of fluid overload during the first 12 h in NICU (3.69 (1.27-10.70); p = 0.02) and requirement of resuscitation in the delivery room (2.72 (1.45-5.12); p = 0.001). AKI neonates with PD as compared to those without PD had a significantly lower median (interquartile range) duration of stay in NICU (7 (4-14) vs. 11 (6-21) days; p = 0.004), but significantly higher mortality (31 (70.5%) vs. 50 (3.2%); p < 0.001). This discrepancy is likely attributable to the critical state of the neonates with AKI.

CONCLUSIONS

This is the largest prospective, multicentre study specifically looking at neonatal AKI and need for dialysis in neonates. AKI was seen in 30.7% of neonates (with the need for acute PD in 9% of the AKI group). The odds of needing acute PD were significantly higher among those with significant cardiac disease, inotropes usage, severe peripartum event, requirement of respiratory support in NICU, necrotising enterocolitis, any grade of intraventricular haemorrhage, evidence of fluid overload more than 10% during the first 12 h in NICU and requirement of resuscitation in the delivery room. AKI neonates with PD as compared to AKI neonates without PD had a significantly higher mortality. There is a need to keep a vigilant watch in neonates with risk factors for the development of AKI and need for PD.

Lesión renal aguda en el paciente pediátrico: revisión integrativa

Introducción: La lesión renal aguda se ha convertido en una complicación común en los niños hospitalizados, especialmente cuando están en una situación clínica crítica. Objetivo: Conocer y sintetizar la bibliografía científica más actualizada sobre la lesión renal aguda en la población pediátrica. Metodología: Estudio descriptivo de revisión integrativa. La búsqueda de artículos se ha realizado en las bases de datos Pubmed, Scopus y Google Scholar. La estrategia de búsqueda se estableció con los siguientes términos MeSH: ”acute kidney injury”, “children” y “pediatric”. La calidad metodológica se realizó mediante la escala STROBE. Resultados: Se incluyeron 35 artículos, 19 de diseño observacional retrospectivo, 12 observacionales prospectivos, 3 revisiones bibliográficas y 1 estudio cualitativo. No hay variables sociodemográficas destacables que impliquen mayor probabilidad de presentar lesión renal aguda. Tanto la etiología como los factores de riesgo son muy variables. La lesión renal aguda se asocia a mayor número de complicaciones y estancia hospitalaria. No hay evidencia de cuidados enfermeros en la lesión renal aguda en pacientes pediátricos. Conclusiones: Se observa una falta de homogeneidad en los criterios de definición, incidencia, etiología, factores de riesgo y de tratamiento en los pacientes pediátricos con lesión renal aguda, y escasez de artículos originales de investigación. La lesión renal aguda pediátrica se asocia a mayor mortalidad, morbilidad, mayor estancia hospitalaria y mayor duración de la ventilación mecánica. El papel de enfermería en el manejo del tratamiento conservador y de las terapias de reemplazo renal de este cuadro, es fundamental en la supervivencia de estos pacientes.

LA, Vasudevan A. Peritoneal Dialysis with Rigid Catheters in Children with Acute Kidney Injury: A Single-Centre Experience

Peritoneal dialysis (PD) is a simple and preferred modality of dialysis for children with acute kidney injury (AKI) in resource poor countries. The aim of the study is to evaluate the utility and safety of acute PD using rigid catheter in critically ill children admitted to pediatric intensive care unit (PICU) with emphasis on short-term patient and renal outcome and complications. In this retrospective study, outcome and complications of PD using rigid catheter were evaluated in 113 critically ill children admitted in PICU of a tertiary care hospital from 2014 to 2019. The most common causes for AKI were sepsis (39.8%), dengue infection (16.8%), and hemolytic uremic syndrome (13.2%). In 113 patients, 122 PD catheters were inserted, and the median duration of PD was 60 (IQR: 36–89) hours. At the initiation of PD, 64 (56.6%) patients were critically ill requiring mechanical ventilation and inotropes, 26 (23%) had disseminated intravascular coagulation, and 42 (37%) had multiorgan dysfunction syndrome. PD was effective and there was a significant improvement in urea and creatinine, and one-third patients (n = 38; 33.6%) had complete renal recovery at the end of PD. Total complications were seen in 67% children but majority of them were metabolic (39.8%). Total catheter related complications were seen in 21.2% and peritonitis was seen in 4.4%. Catheter removal due to complications was required in 8.8% children. Overall, among children on PD, 53.7% survived. Acute PD with rigid catheters can be performed bedside in absence of soft catheters and significant clearance can be obtained without major life-threatening complications.

Proteomic profile of mesothelial exosomes isolated from peritoneal dialysis effluent of children with focal segmental glomerulosclerosis

Peritoneal dialysis (PD) is the worldwide recognized preferred dialysis treatment for children affected by end-stage kidney disease (ESKD). However, due to the unphysiological composition of PD fluids, the peritoneal membrane (PM) of these patients may undergo structural and functional alterations, which may cause fibrosis. Several factors may accelerate this process and primary kidney disease may have a causative role. In particular, patients affected by steroid resistant primary focal segmental glomerulosclerosis, a rare glomerular disease leading to nephrotic syndrome and ESKD, seem more prone to develop peritoneal fibrosis. The mechanism causing this predisposition is still unrecognized. To better define this condition, we carried out, for the first time, a new comprehensive comparative proteomic mass spectrometry analysis of mesothelial exosomes from peritoneal dialysis effluent (PDE) of 6 pediatric patients with focal segmental glomerular sclerosis (FSGS) versus 6 patients affected by other primary renal diseases (No FSGS). Our omic study demonstrated that, despite the high overlap in the protein milieu between the two study groups, machine learning allowed to identify a core list of 40 proteins, with ANXA13 as most promising potential biomarker, to distinguish, in our patient population, peritoneal dialysis effluent exosomes of FSGS from No FSGS patients (with 100% accuracy). Additionally, the Weight Gene Co-expression Network Analysis algorithm identified 17 proteins, with PTP4A1 as the most statistically significant biomarker associated to PD vintage and decreased PM function. Altogether, our data suggest that mesothelial cells of FSGS patients are more prone to activate a pro-fibrotic machinery. The role of the proposed biomarkers in the PM pathology deserves further investigation. Our results need further investigations in a larger population to corroborate these findings and investigate a possible increased risk of PM loss of function or development of encapsulating peritoneal sclerosis in FSGS patients, thus to eventually carry out changes in PD treatment and management or implement new solutions.

Risk factors for mortality in critically ill infants with acute kidney injury: A resource-limited setting experience

Infants with acute kidney injury (AKI) who are critically ill often will have multiorgan dysfunctions. Objective of the present study was to find out mortality, recovery of kidney function at discharge and at 3 months, and to determine risk factors for mortality. Fifty-two infants (24 newborns and 28 postneonatal) with AKI were included. Staging was done as per Kidney Disease Improving Global Outcomes classification. Patients were subjected to medical treatment and peritoneal dialysis (PD), wherever indicated. Kidney function tests were performed at admission, discharge, and at 3 months follow-up. Median age of neonates was 8 days and postneonatal infants were 4.5 months. Stage 1, 2, and 3 AKI were present in 14 (26.9%), 16 (30.7%), and 22 (42.3%) cases, respectively. PD was required in 22 (42.3%) infants, and significantly higher in postneonatal than in neonates (57.1% vs. 25%, p < 0.05). Significant recovery of kidney function occurred at discharge and cases had normal parameters at 3 months. Mortality was 17.3%. Patients had significantly higher risk of mortality, if they had metabolic acidosis (OR 13.22, CI 2.33-74.94, p = 0.002) and needed ventilation (OR 14.93, 95% CI 1.7-130.97, p = 0.006) and PD (OR 6.53, 95% CI 1.20-35.48, p = 0.026). In logistic regression analysis, fluid overload (p < 001), hypotension (p < 0.01), and higher PRISM-III score (p < 0.05) were found as significant risk factors for mortality. Medical management including PD led to good recovery of kidney function. Presence of fluid overload, hypotension, and higher PRISM-III score adversely affected the outcome.

Neonatal Renal Failure in the Setting of Anorectal Malformation: A Case Report and Literature Review

Anorectal malformations (ARMs) can occur in isolation or in association with other anomalies, most commonly those of the genitourinary systems. Morbidity and mortality are highest among patients who develop end-stage renal disease (ESRD) either from severe congenital anomalies (dysplastic kidneys) or from repeated infections in those who have vesicoureteral reflux or persistent recto-urinary fistulas. We describe our management strategy for a patient born with an ARM and bilateral dysplastic kidneys to highlight the nuances and complex decision-making considerations required in taking care of this complex patient population. Our patient is a male twin born at 32 weeks' gestational age who was found to have bilateral dysplastic kidneys on prenatal ultrasound. On initial examination, an imperforate anus was identified along with a severe urethral stricture. Full workup also revealed sacral dysgenesis and confirmation of the dysplastic kidneys. On day of life 3, a laparoscopic diverting sigmoid colostomy was performed; urologic evaluation confirmed the severe urethral stricture, which required dilation to place an 8F council tip catheter. Due to his small size, peritoneal dialysis could not be initiated until five weeks of age. As full volumes could not be reached with peritoneal dialysis, he was soon transitioned to continuous renal replacement therapy. At five months of age, a laparoscopic-assisted posterior sagittal anorectoplasty (PSARP) was performed. As his urethral stricture had worsened, a suprapubic catheter had been placed for bladder decompression. Reversal of his colostomy was performed 15 days after PSARP. Unfortunately, the patient required three further surgical interventions due to abdominal wall and inguinal hernias contributing to filling and emptying dysfunction when utilizing peritoneal dialysis. He is currently 16 months of age and remains inpatient due to intermittent hemodialysis requirements along with autocycling of his peritoneal dialysis. He is working on developmental milestones, can pull to a stand, and is currently being evaluated for kidney transplantation. The development of ESRD in a neonate or infant with an ARM is rare and can be due to congenital dysplasia or agenesis of bilateral kidneys. While peritoneal dialysis is the preferred approach, catheter dysfunction can result from intra-abdominal adhesions or inadequate fluid removal from inguinal or abdominal wall hernias that form in the setting of increased intra-abdominal pressure required for peritoneal dialysis. Close collaboration is required between pediatric surgeons, nephrologists, and urologists to facilitate colonic and urologic reconstruction and manage catheter-related complications.

Peritoneal dialysis in children with sepsis-associated AKI (SA-AKI): an experience in a low- to middle-income country

Background: In critically ill children, sepsis-associated acute kidney injury (SA-AKI) has significant morbidity and mortality.Aim: To estimate whether early initiation of peritoneal dialysis (PD) has a better short-term outcome than standard PD.Methods: Early PD (n = 25) was defined as a need for PD in Kidney Disease: Improving Global Outcomes (KDIGO) stage 2 AKI, while those fulfilling the criteria for stage 3 KDIGO were categorised as a standard PD group (n = 25). The primary outcome measure was the estimated glomerular filtration rate (eGFR) at discharge or at 4 weeks after initiation of PD, whichever occurred earlier.Results: A prospective cohort of 50 children (32 boys) aged 2 months to 16 years with SA-AKI who underwent PD were recruited. The most frequent indication for PD was fluid overload (40%), followed by persistent metabolic acidosis (36%). Children in the early PD group had lower creatinine and higher eGFR at discharge/4-week follow-up (p < 0.001). The duration of PD was less if it was commenced early (p < 0.04); 24 of 25 (96%) children in the early PD group were off PD within 6 days of initiation compared with 13 of 25 (52%) in the standard PD group (p < 0.001).Conclusions: Compared with standard PD, early PD in SA-AKI resulted in a favourable renal outcome, decreased duration of PD and early discontinuation of dialysis.Abbreviations : AKI: acute kidney injury; CRRT: continuous renal replacement therapy; CS-AKI: cardiac surgery-associated acute kidney injury; eGFR: estimated glomerular filtration rate; ELAIN: early versus late initiation of renal replacement therapy in critically ill patients with acute kidney injury; ESCAPE: effect of strict blood pressure control and ACE inhibition on the progression of chronic kidney disease in paediatric patients; HIC: high-income countries; ISN: international society of nephrology; KDIGO: Kidney Disease: Improving Global Outcomes; LMIC: low- to middle-income countries; PD: peritoneal dialysis; PICU: paediatric intensive care unit; RRT: renal replacement therapy; SA-AKI: sepsis-associated acute kidney injury; SYL: Saving Young Lives; SOFA: sequential (sepsis-related) organ failure assessment score; STARRT-AKI: standard versus accelerated initiation of renal replacement therapy in acute kidney injury.

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

SUMMARY OF RECOMMENDATIONS

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

Canadian Association of Paediatric Nephrologists COVID-19 Rapid Response: Home and In-Center Dialysis Guidance

PURPOSE OF THE PROGRAM

This article provides guidance on optimizing the management of pediatric patients with end-stage kidney disease (ESKD) who will be or are being treated with any form of home or in-center dialysis during the COVID-19 pandemic. The goals are to provide the best possible care for pediatric patients with ESKD during the pandemic and ensure the health care team's safety.

SOURCES OF INFORMATION

The core of these rapid guidelines is derived from the Canadian Society of Nephrology (CSN) consensus recommendations for adult patients recently published in the Canadian Journal of Kidney Health and Disease (CJKHD). We also consulted specific documents from other national and international agencies focused on pediatric kidney health. Additional information was obtained by formal review of the published academic literature relevant to pediatric home or in-center hemodialysis.

METHODS

The Leadership of the Canadian Association of Paediatric Nephrologists (CAPN), which is affiliated with the CSN, solicited a team of clinicians and researchers with expertise in pediatric home and in-center dialysis. The goal was to adapt the guidelines recently adopted for Canadian adult dialysis patients for pediatric-specific settings. These included specific COVID-19-related themes that apply to dialysis in a Canadian environment, as determined by a group of senior renal leaders. Expert clinicians and nurses with deep expertise in pediatric home and in-center dialysis reviewed the revised pediatric guidelines.

KEY FINDINGS

We identified 7 broad areas of home dialysis practice management that may be affected by the COVID-19 pandemic: (1) peritoneal dialysis catheter placement, (2) home dialysis training, (3) home dialysis management, (4) personal protective equipment, (5) product delivery, (6) minimizing direct health care providers and patient contact, and (7) caregivers support in the community. In addition, we identified 8 broad areas of in-center dialysis practice management that may be affected by the COVID-19 pandemic: (1) identification of patients with COVID-19, (2) hemodialysis of patients with confirmed COVID-19, (3) hemodialysis of patients not yet known to have COVID-19, (4) management of visitors to the dialysis unit, (5) handling COVID-19 testing of patients and staff, (6) safe practices during resuscitation procedures in a pandemic, (7) routine hemodialysis care, and (8) hemodialysis care under fixed dialysis resources. We make specific suggestions and recommendations for each of these areas.

LIMITATIONS

At the time when we started this work, we knew that evidence on the topic of pediatric dialysis and COVID-19 would be severely limited, and our resources were also limited. We did not, therefore, do formal systematic review or meta-analysis. We did not evaluate our specific suggestions in the clinical environment. Thus, this article's advice and recommendations are primarily expert opinions and subject to the biases associated with this level of evidence. To expedite the publication of this work, we created a parallel review process that may not be as robust as standard arms' length peer-review processes.

IMPLICATIONS

We intend these recommendations to help provide the best care possible for pediatric patients prescribed in-center or home dialysis during the COVID-19 pandemic, a time of altered priorities and reduced resources.

Advances in Kidney Replacement Therapy in Infants

Acute kidney injury continues to be a highly occurring disease in the intensive care unit, specifically affecting up to a third of critically ill neonates as per various studies. Although first-line treatments of acute kidney injury are noninvasive, kidney replacement therapy (KRT) is indicated when conservative management modes fail. There are various modalities of KRT which can be used for neonatal populations, including peritoneal dialysis, hemodialysis, and continuous KRT. However, these KRT modalities present their own challenges in this specific patient population Thus, it is the aim of this review to introduce each of these KRT modalities in terms of their challenges, advances, and future directions, with specific emphasis on new technology including the Cardio-Renal Pediatric Emergency Dialysis Machine, Newcastle infant dialysis and ultrafiltration system, and the Aquadex system for ultrafiltration.

Acute Peritoneal Dialysis During the COVID-19 Pandemic at Bellevue Hospital in New York City

Background

The COVID-19 pandemic strained hospital resources in New York City, including those for providing dialysis. New York University Medical Center and affiliations, including New York City Health and Hospitals/Bellevue, developed a plan to offset the increased needs for KRT. We established acute peritoneal dialysis (PD) capability, as usual dialysis modalities were overwhelmed by COVID-19 AKI.

Methods

Observational study of patients requiring KRT admitted to Bellevue Hospital during the COVID surge. Bellevue Hospital is one of the largest public hospitals in the United States, providing medical care to an underserved population. There were substantial staff, supplies, and equipment shortages. Adult patients admitted with AKI who required KRT were considered for PD. We rapidly established an acute PD program. A surgery team placed catheters at the bedside in the intensive care unit; a nephrology team delivered treatment. We provided an alternative to hemodialysis and continuous venovenous hemofiltration for treating patients in the intensive-care unit, demonstrating efficacy with outcomes comparable to standard care.

Results

From April 8, 2020 to May 8, 2020, 39 catheters were placed into ten women and 29 men. By June 10, 39% of the patients started on PD recovered kidney function (average ages 56 years for men and 59.5 years for women); men and women who expired were an average 71.8 and 66.2 years old. No episodes of peritonitis were observed; there were nine incidents of minor leaking. Some patients were treated while ventilated in the prone position.

Conclusions

Demand compelled us to utilize acute PD during the COVID-19 pandemic. Our experience is one of the largest recently reported in the United States of which we are aware. Acute PD provided lifesaving care to acutely ill patients when expanding current resources was impossible. Our experience may help other programs to avoid rationing dialysis treatments in health crises.

Acute pediatric peritoneal dialysis: impact of an opt-out model and adaptable methods in a hospital in Nigeria

BACKGROUND Despite efforts to scale peritoneal dialysis (PD) uptake, access is still limited in Sub-Saharan Africa, including Nigeria. Thus, this study evaluated access to PD, cost-effectiveness, complications, and in-hospital mortality rate following the adoption of a local opt-out model approach for all children with acute kidney injury (AKI) that required PD.  METHODS This work was a retrospective review of 33 children with AKI that required dialysis between December 2014 and November 2016. PD was carried out using locally adaptable consumables in place of commercially produced consumables. All patients that required renal replacement therapy (RRT) were offered an option to opt-out irrespective of their financial status. Patients’ relevant data were retrieved from the case notes and analyzed.  RESULTS The median age was 7 years (range 3–12). 23 patients (70%) were males. Of the 33 patients that required RRT, 29 had PD. The children had an access rate of 88% (95% CI = 76.77–99.03). The access rate was not related to gender (p = 1.000), age group (p = 0.240), or socioeconomic status (p = 0.755). Complications were pericatheter leakage of fluid (n = 7, 24%), catheter malfunction (n = 5, 17%), abdominal wall edema (n = 3, 10%), scrotal edema (n = 2, 7%), and peritonitis (n = 1, 3%). In-hospital mortality was 3/29 (10%; 95% CI = 2.2–27.3). Cost analysis revealed that the cost of consumables was reduced by 88.5%.  CONCLUSIONS An opt-out model with the use of locally adaptable consumables improved PD access (88%) with a low in-hospital mortality rate. 

Peritoneal dialysis in critically ill children in resource-limited setting: A prospective cohort study

BACKGROUND

Peritoneal dialysis (PD) is easily available and simple lifesaving procedure in children with renal impairment. There is paucity of reports on efficacy of PD in critically ill children in presence of shock and those requiring mechanical ventilation.

METHODS

In this prospective observational study, efficacy and outcome of PD were evaluated in 50 critically ill children aged 1 month to 14 years admitted in pediatric intensive care unit of a tertiary care teaching hospital in India.

RESULTS

Indication of PD was acute kidney injury (AKI) in 66% of patients followed by chronic kidney disease with acute deterioration due to infectious complications in 34%. Bacterial sepsis was the most common cause of AKI (22%), others being malaria (14%) and severe dengue (12%). At initiation of PD, 26% of patients were in shock and 46% were mechanically ventilated. PD was effective and improvement in pH, bicarbonate, and lactate started within hours, with consistent improvement in estimated glomerular filtration rate by 24 h, which continued till the end of procedure, including the subgroup of patients with shock and mechanical ventilation. Total complications were seen in 14% and of which peritonitis was present in 4.0% of patients. Mortality was seen in 14% (7/50) of patients. Shock at initiation of PD (odds ratio (OR), 5.03; 95% confidence interval (CI), 0.95-26.69; p < 0.04) and requirement of mechanical ventilation (OR, 9.17; 95% CI, 1.01-83.10; p < 0.02) were associated with mortality.

CONCLUSIONS

Acute PD in critically ill children with renal impairment is a lifesaving procedure. Treatment of shock with resuscitative measures and respiratory failure with mechanical ventilation, along with PD, resulted in favorable renal outcome.

Challenges of access to kidney care for children in low-resource settings

Kidney disease is a global public health concern across the age spectrum, including in children. However, our understanding of the true burden of kidney disease in low-resource areas is often hampered by a lack of disease awareness and access to diagnosis. Chronic kidney disease (CKD) in low-resource settings poses multiple challenges, including late diagnosis, the need for ongoing access to care and the frequent unavailability of costly therapies such as dialysis and transplantation. Moreover, children in such settings are at particular risk of acute kidney injury (AKI) owing to preventable and/or reversible causes - many children likely die from potentially reversible kidney disease because they lack access to appropriate care. Acute peritoneal dialysis (PD) is an important low-cost treatment option. Initiatives, such as the Saving Young Lives programme, to train local medical staff from low-resource areas to provide care for AKI, including acute PD, have already saved hundreds of children. Future priorities include capacity building for both educational purposes and to provide further resources for AKI management. As local knowledge and confidence increase, CKD management strategies should also develop. Increased awareness and advocacy at both the local government and international levels will be required to continue to improve the diagnosis and treatment of AKI and CKD in children worldwide.

The Epidemiology and Management of Pediatric AKI in Asia

Because of the lack of early recognition and referral, the incidence of pediatric acute kidney injury (AKI) in Asia still is underestimated. Although each diagnostic criteria has its own merits, the Kidney Disease Improving Global Outcomes classification now is widely accepted. In Asia, the spectrum of pediatric AKI is wide-ranging, from pediatric AKI in highly sophisticated tertiary-care pediatric intensive care units in resource-rich regions due to advanced procedures such as transplantation, cardiac surgery, and other hospital-acquired causes, to primary care preventable causes, such as infectious diseases, snakebite, and so forth in rural parts of the developing world. The development and application of novel biomarkers, concepts such as the Renal Angina Index and advanced renal replacement therapy have revolutionized the era of treating AKI, but the cost and feasibility are the key determinants, especially in rural areas. In view of availability and expenses, peritoneal dialysis should be the first choice in less-developed areas, however, because of various barriers, it still needs more effort. Effective educational steps to both medical carers and families are needed urgently.

RRT Selection for AKI Patients With Critical Illness

Acute kidney injury (AKI) is a critical burden on intensive care units in Asia. Renal replacement therapy (RRT) acts as strong supportive care for severe AKI. However, various RRT modalities are used in Asia because of the diversity in ethics, climate, geographic features, and socioeconomic status. Extracorporeal blood purification is used commonly in Asian intensive care units; however, intermittent RRT is preferred in developing countries because of cost and infrastructure issues. Conversely, continuous RRT is preferred in developed countries, indicating the predominance of hospital-acquired AKI patients with complications of hemodynamic instability. Peritoneal dialysis is delivered less frequently, although several studies have suggested promising results for peritoneal dialysis in AKI treatment. Of note, not all RRT modalities are available as a standard procedure in some Asian regions, and it is absolutely necessary to develop a sustainable infrastructure that can deliver optimal care for all AKI patients.

Renal replacement therapies for infants and children in the ICU

PURPOSE OF REVIEW

Pediatric acute kidney injury (AKI) in critically ill patients is associated with increased morbidity and mortality. Emerging data support that the incidence of pediatric AKI in the ICU is rising. For children with severe AKI, renal replacement therapy (RRT) can provide a lifesaving supportive therapy. The optimal timing to deliver and modality by which to deliver RRT remain a point of discussion within pediatric (and adult) literature. This review discusses the use of RRT for pediatric patients in the ICU. We discuss the most recent evidence-based methods for RRT with a focus on continuous RRT.

RECENT FINDINGS

The feasibility of dialyzing the smallest infants and more medically complex children in the ICU is dependent on the advancements in dialysis access and circuit technology. At present, data indicate that upward of 27% of children in the ICU develop AKI and 6% require RRT. Newer dialysis modalities including prolonged intermittent hemodialysis and continuous flow peritoneal dialysis as well as newer dialysis technologies such as the smaller volume circuits (e.g., Cardio-Renal Pediatric Dialysis Emergency Machine, Newcastle Infant Dialysis and Ultrafiltration System) have made the provision of dialysis safer and more effective for pediatric patients of a variety of sizes.

SUMMARY

Renal replacement in the ICU requires a multidisciplinary team approach that is facilitated by a pediatric nephrologist in conjunction with intensivists and skilled nursing staff. Although mortality rates for children on dialysis remain high, outcomes are improving with the support of the multidisciplinary team and dialysis technology advancements.

Dialysis modalities for the management of pediatric acute kidney injury

Acute kidney injury (AKI) is an increasingly frequent complication among hospitalized children. It is associated with high morbidity and mortality, especially in neonates and children requiring dialysis. The different renal replacement therapy (RRT) options for AKI have expanded from peritoneal dialysis (PD) and intermittent hemodialysis (HD) to continuous RRT (CRRT) and hybrid modalities. Recent advances in the provision of RRT in children allow a higher standard of care for increasingly ill and young patients. In the absence of evidence indicating better survival with any dialysis method, the most appropriate dialysis choice for children with AKI is based on the patient's characteristics, on dialytic modality performance, and on the institutional resources and local practice. In this review, the available dialysis modalities for pediatric AKI will be discussed, focusing on indications, advantages, and limitations of each of them.

Hemodialysis versus peritoneal dialysis in resource-limited settings

PURPOSE OF REVIEW

To assess the use, access to and outcomes of hemodialysis and peritoneal dialysis in low-resource settings.

RECENT FINDINGS

Hemodialysis tends to predominate because of costs and logistics, however services tend to be located in larger cities, often paid for out of pocket. Outcomes of dialysis-requiring acute kidney injury and end-stage kidney disease may be similar with hemodialysis and peritoneal dialysis, and therefore choice of therapy is dominated by availability, accessibility and patient or physician choice. Some countries have implemented peritoneal dialysis-first policies to reduce costs and improve access, because peritoneal dialysis requires less infrastructure, can be scaled up more easily and can be cheaper when fluids are manufactured locally.

SUMMARY

Access to both hemodialysis and peritoneal dialysis remains highly inequitable in lower-resource settings. Although challenges associated with dialysis in low-resource settings are similar, and there are more adults who require dialysis in low-resource settings, addressing hemodialysis and peritoneal dialysis needs of children in low-resource settings requires attention as the global inequities are greatest in this area. Lower-income countries are increasingly seeking to improve access to dialysis through various strategies, but meeting the costs of the entire dialysis population continues to be a major challenge.

Acute dialysis in children: results of a European survey

The number of children with acute kidney injury (AKI) requiring dialysis is increasing. To date, systematic analysis has been largely limited to critically ill children treated with continuous renal replacement therapy (CRRT). We conducted a survey among 35 European Pediatric Nephrology Centers to investigate dialysis practices in European children with AKI. Altogether, the centers perform dialysis in more than 900 pediatric patients with AKI per year. PD and CRRT are the most frequently used dialysis modalities, accounting for 39.4% and 38.2% of treatments, followed by intermittent HD (22.4%). In units treating more than 25 cases per year and in those with cardiothoracic surgery programs, PD is the most commonly chosen dialysis modality. Also, nearly one quarter of centers, in countries with a gross domestic product below $35,000/year, do not utilize CRRT at all. Dialysis nurses are exclusively in charge of CRRT management in 45% of the cases and pediatric intensive care nurses in 25%, while shared management is practiced in 30%. In conclusion, this survey indicates that the choice of treatment modalities for dialysis in children with AKI in Europe is affected by the underlying ethiology of the disease, organization/set-up of centers and socioeconomic conditions. PD is utilized as often as CRRT, and also intermittent HD is a commonly applied treatment option. A prospective European AKI registry is planned to provide further insights on the epidemiology, management and outcomes of dialysis in pediatric AKI.

Fluid Management With Peritoneal Dialysis After Pediatric Cardiac Surgery

Children who undergo cardiac surgery with cardiopulmonary bypass are a unique population at high risk for postoperative acute kidney injury (AKI) and fluid overload. Fluid management is important in the postoperative care of these children as fluid overload is associated with increased morbidity and mortality. Peritoneal dialysis catheters are an important tool in the armamentarium of a cardiac intensivist and are used for passive drainage for fluid removal or dialysis for electrolyte and uremia control in AKI. Prophylactic placement of a peritoneal catheter is a safe method of fluid removal that is associated with few major complications. Early initiation of peritoneal dialysis has been associated with improved clinical markers and outcomes such as early achievement of a negative fluid balance, lower vasoactive medication needs, shorter duration of mechanical ventilation, and decreased mortality. In this review, we discuss the safety and potential benefits of peritoneal catheters for dialysis or passive drainage in children following cardiopulmonary bypass.

Acute Kidney Injury in Children

Acute kidney injury (AKI) has become one of the more common complications seen among hospitalized children. The development of a consensus definition has helped refine the epidemiology of pediatric AKI, and we now have a far better understanding of its incidence, risk factors, and outcomes. Strategies for diagnosing AKI have extended beyond serum creatinine, and the most current data underscore the diagnostic importance of oliguria as well as introduce the concept of urinary biomarkers of kidney injury. As AKI has become more widespread, we have seen that it is associated with a number of adverse consequences including longer lengths of stay and greater mortality. Though effective treatments do not currently exist for AKI once it develops, we hope that the diagnostic and definitional strides seen recently translate to the testing and development of more effective interventions.

Successful resumption of peritoneal dialysis following living donor liver transplantation in children with end-stage renal disease

Children with ESRD in need of RRT are commonly managed by PD due to difficulty with vascular access for HD and the relatively large extracorporeal blood volume required. Major abdominal surgery may result in injury to the peritoneum and consequent adhesion, thereby resulting in a reduction in the anatomical capacity and transport capability across the peritoneal membrane. Here, we report successful resumption of PD after LDLT in two pediatric patients. The causes of ESRD were PH1 and juvenile nephronophthisis, respectively. Both patients were managed by PD prior to LDLT. PD was converted to HD starting three days before LDLT and was continued postoperatively until resumption of PD on days 13 and 28, respectively. The PD weekly Kt/V urea was maintained before and after LDLT. The patients continued to do well on PD without complications. Meticulous intra-operative techniques during LDLT allow postoperative PD resumption by preservation of peritoneal integrity with effective transport capability and without added risk of peritonitis.