The Choice of Dialysis Solutions in Pediatric Chronic Peritoneal Dialysis: Guidelines by AnAD HOCEuropean Committee

Objective

To provide guidelines on choosing dialysis solutions for children on chronic peritoneal dialysis (PD).

Setting

European Paediatric Peritoneal Dialysis Working Group.

Data Source

Literature on the application of PD solutions in children ( Evidence), and discussions within the group ( Opinion).

Conclusions

Glucose is the standard osmotic agent for PD in children ( Evidence). The lowest glucose concentration needed should be used ( Opinion). Low calcium solution (1.25 mmol/L) should be applied, wherever possible, with careful monitoring of parathyroid hormone levels ( Opinion). The use of amino acid-containing dialysis fluids can be considered in malnourished children, although aggressive enteral nutrition is preferred ( Opinion). There is insufficient evidence documenting the efficacy of intraperitoneally administered amino acids ( Evidence). When ultrafiltration and/or solute removal are insufficient, poly-glucose solutions are a welcome addition to the treatment of children on nocturnal intermittent PD ( Evidence). However, in the absence of any reported long-term experience with children, their use must be closely monitored ( Opinion). Bicarbonate would appear to be the preferred buffer for PD in children, but more in vivo studies are required before it replaces the present lactate-containing solutions ( Evidence/Opinion).

Recent developments in osmotic agents for peritoneal dialysis

Although glucose is still the most widely used osmotic agent for peritoneal dialysis, it has several disadvantages that challenge its long-term use. During the past years several nonglucose molecules have been tested as osmotic agents for peritoneal dialysis. Most of these molecules have some advantages over glucose, but they also have drawbacks. Every new agent should be carefully tested for performance and long-term safety. In the following review, alternative osmotic agents are discussed, including their potential indications and drawbacks. Major issues include the improvement of biocompatibility and preservation of peritoneal membrane integrity by using dialysate with more physiologic pH, the effect on nutritional status by using dialysate with amino acids, and maintenance of peritoneal ultrafiltration in the long-term by using dialysate with polyglucose. It is believed that in the near future, mixtures of osmotic agents will become most appropriate to obtain the best performance.

Effect of glucose and pyruvate in acidic and non-acidic peritoneal dialysis fluids on leukocytes cell functions

A new peritoneal dialysate containing pyruvate anions has been tested for its effects on cell functions and compared with conventional lactate and bicarbonate based solutions. The dialysate has a final pH of 5.4 to 5.6 and is composed of 1.36 to 3.86% glucose-monohydrate, 132 mmol/liter sodium, 1.75 mmol/liter calcium, 0.75 mmol/liter magnesium, 102 mmol/liter chloride and 35 mmol/liter pyruvate. For cytotoxicity testing peritoneal macrophages and peripheral blood mononuclear cells (PBMC) were exposed to conventional lactate dialysate, pyruvate dialysate, bicarbonate dialysate and a control medium RPMI 1640 (Biochrom KG, Berlin, Germany), followed by activation with different bacterial stimuli. In addition, the study further investigated the effect of varying glucose concentration in the different dialysates ranging from 0 to 3.86% and pH changes between 5.2 and 7.4 on the cytotoxicity effect on the selected cells. Mononuclear cells exposed to pyruvate-based dialysate before stimulation with endotoxin exhibited a tumor necrosis factor (TNF)-mRNA signal comparable to those of cells exposed to RPMI. In contrast, exposure to lactate-based dialysate completely inhibited TNF-mRNA synthesis. In addition, cytokine synthesis in macrophages and PBMCs after exposure to pyruvate was less inhibited when compared to the corresponding levels measured after exposure to lactate. The chemotactic response of polymorphonuclear cells and O-2 generation in all tested cell types after exposure to pyruvate was found not to be inhibited, whereas a complete inhibition was observed after exposure to lactate. The results demonstrate that cytotoxicity effects of peritoneal dialysate on cell lines can be minimized by using a new dialysate formulation containing pyruvate anions instead of lactate.