Peritoneal dialysis in a patient with neurogenic bladder and chronic kidney disease with ventriculoperitoneal shunt

Establishing a Multidisciplinary Approach to the Management of Neurologic Disease Affecting the Urinary Tract

Neurologic diseases often affect the urinary tract and may be congential or acquired. The progressive nature of many neurologic diseases necessitates routine surveillance and treatment with a multidisciplinary approach. Urologic treatments may interact with pharmacologic or procedural interventions planned by other specialists, mandating close coordination of care and communication among providers. Primary care and nursing often can serve as the quarterbacks of the multidisciplinary team by identifying when a slowly progressive condition warrants further investigation and management by specialists.

Characteristics and survival of patients with end stage renal disease and spina bifida in the United States renal data system

PURPOSE

We describe the characteristics, treatments and survival of patients with spina bifida in whom end stage renal disease developed from 2004 through 2008 in the United States Renal Data System.

MATERIALS AND METHODS

We used ICD-9-CM code 741.* to identify individuals with spina bifida using hospital inpatient data from 1977 to 2010, and physician and facility claims from 2004 to 2008. We constructed a 5:1 comparison group of patients with end stage renal disease without spina bifida matched by age at first end stage renal disease service, gender and race/ethnicity. We assessed the risk of mortality and of renal transplantation while on dialysis using multivariate cause specific proportional hazards survival analysis. We also compared survival after the first renal transplant from the first end stage renal disease service to August 2011.

RESULTS

We identified 439 patients with end stage renal disease and spina bifida in whom end stage renal disease developed at an average younger age than in patients without spina bifida (41 vs 62 years, p <0.001) and in whom urological issues were the most common primary cause of end stage renal disease. Compared to patients with end stage renal disease without spina bifida those who had spina bifida showed a similar mortality hazard on dialysis and after transplantation. However, patients with end stage renal disease without spina bifida were more likely to undergo renal transplantation than patients with spina bifida (HR 1.51, 95% CI 1.13-2.03). Hospitalizations related to urinary tract infections were positively associated with the risk of death on dialysis in patients with end stage renal disease and spina bifida (HR 1.42, 95% CI 1.33-1.53).

CONCLUSIONS

Spina bifida was not associated with increased mortality in patients with end stage renal disease on dialysis or after renal transplantation. Proper urological and bladder management is imperative in patients with spina bifida, particularly in adults.

Ventriculoperitoneal shunts in children on peritoneal dialysis: a survey of the International Pediatric Peritoneal Dialysis Network

OBJECTIVE

The aim of this study was to inform best evidence-based practice by collating and disseminating the experiences of members of the International Pediatric Peritoneal Dialysis Network with children having concurrent ventriculoperitoneal shunts (VPS) and peritoneal dialysis catheters (PDC).

METHODS

An online questionnaire was created and distributed to all 135 centers participating in the International Pediatric Peritoneal Dialysis Network; the overall response rate was 56 %.

RESULTS

A total of 18 patients with a concurrent VPS and PDC were reported. The children were 0-12 (mean 6.8) years old at the time of placement of the second indwelling device (PDC or VPS). In 15 cases, the PDC was inserted post-VPS. On average, the two catheters were present concurrently for 23 (range 1-60) months. There were 20 episodes of peritonitis observed in 11 of the 18 patients during a period of 392 months at risk, which is a peritonitis rate of 1/19.6 months. Only one patient developed both a VPS infection and an episode of peritonitis, and these events were temporally unrelated. No episodes of an ascending shunt infection or meningitis occurred in association with any episode of peritonitis, and no other complications of catheter dysfunction were described.

CONCLUSIONS

The rate of peritonitis, the absence of any documented ascending or descending infections and the lack of catheter dysfunction during the period of observation suggests that the presence of, or need for, a VPS should not preclude PD as a safe option for children requiring renal replacement therapy.

Chronic peritoneal dialysis in children with special needs or social disadvantage or both: contraindications are not always contraindications

OBJECTIVE

Our aim in the present study was to identify outcomes in children with special needs or social disadvantage, or both, receiving chronic peritoneal dialysis (CPD) treatment in a pediatric dialysis unit.

METHODS

Among 110 children started on CPD in our unit during the period between November 1995 and November 2008, we identified 13 patients (8 girls, 5 boys) with major physical, mental, or psychosocial problems. Age at CPD initiation in the group with disability ranged from 4.0 years to 16.5 years (median: 7.5 years). Under lying diseases were vesicoureteral reflux (4 patients), neuropathic bladder and vesicoureteral reflux (3 patients), chronic pyelonephritis (3 patients), amyloidosis (2 patients), and Alport syndrome (1 patient). Challenges encountered were adverse family or social circumstances (4 patients), cerebral palsy (3 patients), Down syndrome (1 patient), rectovesical fistula in conjunction with ectopic anus and previous multiple abdominal surgery (1 patient), blindness and deafness (1 patient), ventriculoperitoneal shunt (1 patient), colostomy and malnutrition (1 patient), and mental retardation and blindness (1 patient). All catheters were implanted percutaneously.

RESULTS

Median duration of dialysis was 18 months (range: 6 - 124 months). The frequency of peritonitis was not different between children with and without disability (p > 0.05). In children with disability compared with children without disability, the frequencies of catheter-related infections (1 episode/79.3 patient-months vs 1 episode/32.4 patient-months) and of catheter-related non-infectious complications (1 episode/238 patient-months vs 1 episode/115.7 patient-months) were lower (p < 0.05). Chronic peritoneal dialysis was terminated in 5 children (for renal transplantation in 3, switch to hemodialysis in 1, death in 1).

CONCLUSIONS

Our results suggest that, with appropriate family support and an experienced multidisciplinary team, CPD can be effectively performed in children with special needs or social disadvantage, or both.