Chronic peritoneal dialysis in children

Cost Analysis of End-Stage Renal Disease in Pediatric Patients in Greece

BACKGROUND/OBJECTIVES

The cost resulting from peritoneal dialysis (PD), conventional hemodialysis (HD) and online hemodiafiltration (OL-HDF) in pediatric patients with end-stage renal disease (ESRD) has not been estimated to date in Greece. The present single-center retrospective study aimed to estimate the mean annual cost of the above methods, as well as the individual components of this cost.

METHODS

Twenty pediatric patients undergoing the three different methods of renal replacement therapy were included in this study. Their mean total annual cost was estimated by the method of micro-costing and the bottom-up approach.

RESULTS

The mean total annual cost for PD patients (n = 7) was estimated at EUR 56,676.04; for conventional HD patients (n = 9), it was EUR 39,786.86; and for OL-HDF patients (n = 4), it was EUR 43,894.73. The PD method was found to be more expensive than the other two methods (p < 0.001 vs. conventional HD and p = 0.024 vs. OL-HDF). PD consumables used for daily application had the greatest contribution to the total annual cost. The total mean annual cost in the groups of patients undergoing HD and OL-HDF did not differ significantly (p = 0.175). The total operating cost of the renal dialysis unit had the greatest contribution to the total mean annual costs of both the conventional HD and OL-HDF techniques.

CONCLUSIONS

This cost analysis provides useful information to healthcare policymakers who make decisions about the treatment of children with ESRD.

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.

Chronic peritoneal dialysis in children with chronic kidney disease: An experience from a North Indian teaching institute

INTRODUCTION

Chronic peritoneal dialysis (CPD) is an important modality of renal replacement therapy (RRT) in children of all ages with end-stage renal disease (ESRD). We retrospectively assessed the clinical profile of children with chronic kidney disease (CKD) initiated on CPD at a tertiary care centre in Northern India.

MATERIALS AND METHODS

Retrospective data of 13 children with CKD and initiated on CPD between 2016 and 2019 were retrieved and analysed. The demographic and clinical profile, aetiology of CKD, method of catheter insertion, mode of dialysis, complications, and catheter survival rate were analysed.

RESULTS

The median age at the onset of the symptoms was 81 months interquartile range (IQR 11-90) and the median age at the diagnosis was 81 months (IQR 36-103). The median age at the initiation of CPD was 92.97 months (IQR 74.43-108.79). The median serum creatinine at the initiation of CPD was 6.3 mg/dL (IQR 4.25-8.4). During a total study period of 84 CPD months, we observed 16 catheter-related complications and a complication rate of 1 per 5.25 CPD months. The overall peritonitis rate was 1 episode per 13.66 patient-months (0.87 episodes per patient-year). The catheter displacement/migration was seen in 23% of the cases. The median duration of follow-up was 175 days (IQR 85-249) with the longest follow-up duration of 502 days.

CONCLUSION

CPD is the modality of choice for smaller children with ESRD as venous access is difficult to achieve in smaller children. Complications especially related to infections are a major concern in addition to poor growth associated with ESRD.

The current status of kidney transplantation in Nigerian children: still awaiting light at the end of the tunnel

BACKGROUND

Kidney transplantation (KT) is the gold standard treatment for children with chronic kidney disease stage 5 (CKD5). It is easily accessible in well-resourced countries, but not in low/middle-income countries (LMICs). We present, a multicentre experience of paediatric KT of children domiciled in Nigeria. We aim to highlight the challenges and ethical dilemmas that children, their parents or guardians and health care staff face on a daily basis.

METHODS

A multicentre survey of Nigerian children who received KTs within or outside Nigeria from 1986 to 2019 was undertaken using a questionnaire emailed to all paediatric and adult consultants who are responsible for the care of children with kidney diseases in Nigeria. Demographic data, causes of CKD5, sources of funding, donor organs and graft and patient outcome were analysed. Using Kaplan-Meier survival analysis, we compared graft and patient survival.

RESULTS

Twenty-two children, aged 4-18 years, received 23 KTs, of which 12 were performed in Nigeria. The male-to-female ratio was 3.4:1. Duration of pre-transplant haemodialysis was 4-48 months (median 7 months). Sixteen KTs were self-funded. State governments funded 3 philanthropists 4 KTs. Overall differences in graft and patient survival between the two groups, log rank test P = 0.68 and 0.40, respectively were not statistically significant.

CONCLUSIONS

The transplant access rate for Nigerian children is dismal at < 0.2%. Poor funding is a major challenge. There is an urgent need for the federal government to fund health care and particularly KTs. Graphical Abstract.

Fungal peritonitis in children on peritoneal dialysis at a tertiary care Centre

BACKGROUND

Fungal peritonitis (FP) is an infrequent but serious complication in children undergoing peritoneal dialysis (PD). This study aimed to explore the risk factors, clinical manifestations, causative organisms, fungal susceptibility findings, and outcomes of FP in children from Saudi Arabia.

METHODS

In this case-control study, the medical records and laboratory results of paediatric patients aged 0-14 years who underwent PD were reviewed for FP episodes. All FP episodes were matched with PD-related bacterial peritonitis episodes (1:4 ratio).

RESULTS

A total of 194 episodes of PD-related peritonitis occurred between 2007 and 2017, among which 11 were FP episodes (5.6%), representing a rate of 0.03 episodes per patient-year. Of these 11 episodes, 9 were caused by Candida species (82%). Compared with the bacterial peritonitis group, the FP group had a higher proportion of patients with congenital/infantile nephrotic syndrome (p = 0.005) and those younger than 5 years of age (p = 0.001). We observed a higher rate of catheter removal in the FP group than in the bacterial peritonitis group (p <  0.001); however, 1 patient died despite catheter removal. Moreover, 75% of Candida species isolates were susceptible to fluconazole.

CONCLUSIONS

This study revealed that FP is associated with a significant risk of peritoneal membrane failure among children undergoing PD. Therefore, early diagnosis and prompt management are essential. We also found that congenital/infantile nephrotic syndrome and young age (5 years old or younger) were risk factors for FP in children undergoing PD.

Chronic peritoneal dialysis in children: a single-centre experience in Jordan

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.

Five-year experience of continuous ambulatory peritoneal dialysis in children: a single center experience in a developing country

BACKGROUND The pediatric peritoneal dialysis (PD) program in Cipto Mangunkusumo Hospital, Indonesia was started in 2014. However, there has been no published data on the patients’ outcome. This study was aimed to report the characteristics and outcomes of a continuous ambulatory peritoneal dialysis (CAPD) program for children. METHODS This retrospective study was conducted in Cipto Mangunkusumo Hospital as a national referral hospital. Data were collected from medical records of patients aged ≤18 years with end-stage renal disease who underwent CAPD in 2014–2019. The baseline characteristics, PD-related infection rate, as well as patient and technique survivals were analyzed. RESULTS Out of 60 patients who underwent CAPD, 36 (60%) were boys on the age range of 4 months–18 years. The mean follow-up duration was 12 (95% confidence interval [CI] = 9.4–15.3) months. The number of PD related infections increased along with the growing number of patients on CAPD. The peritonitis rate was 0.42 episodes per year at risk, and the most common etiology was alpha-hemolytic Streptococcus (5/24, [20.8%]). The 1- and 3-year technique survival rates were 60.3% (95% CI = 44.5–72.9) and 43.9% (95% CI = 23.2–62.9). The 1- and 3-year patient survival rates were 69.6% (95% CI = 52.5–81.5) and 58% (95% CI = 31.2–77.5). CONCLUSIONS In this unit, CAPD could be performed in children as young as 4 months of age. The peritonitis rate was relatively low which was likely caused by skin-derived microorganisms. Both technique survival and patient survival were also relatively low.

Long-term outcomes in children on chronic continuous ambulatory peritoneal dialysis: a retrospective cohort study from a developing country

BACKGROUND

Peritoneal dialysis (PD) is the preferred modality of dialysis among children with end-stage renal disease.

METHODS

To study the incidence of technique failure and survival among children with end-stage renal disease on continuous ambulatory peritoneal dialysis (CAPD), we included children younger than 18 years of age who commenced and continued PD for more than 3 months as their primary form of dialysis between 1st January 2005 and 31st December 2016. Kaplan-Meier survival analysis was applied to analyze the CAPD outcomes.

RESULTS

A total of 68 Tenckhoff (58 double cuffs, and ten single cuffs) catheters were inserted in 66 patients (mean age 12.3 ± 3.91 years) during the study period. Of the 66 children, 31 (47%) experienced 45 episodes of peritonitis. The total duration on CAPD was 107.58 years with a peritonitis rate of 0.42 episodes per year. Overall, the mean patient survival was 41 (95% confidence interval (CI) 29-54) months, with mean patient survival of 72% at 12 months, declining to 30% at 36 months and then remaining stable until the end of follow-up (106 months). The overall mean technique survival was 55 (95% CI 40-69) months, with mean technique survival of 69% at 12 months, declining to 44% at 36 months and then remaining stable until the end of follow-up (106 months).

CONCLUSION

CAPD is a viable option for end-stage renal disease in children from developing countries with a lack of access to automated PD and pediatric hemodialysis centers.

Laparoscopic Peritoneal Dialysis Catheter Placement with Chest Wall Exit Site for Neonate with Stoma

Neonates requiring peritoneal dialysis (PD) catheters have been shown to have complication rates up to 70%. The presence of a concurrent stoma significantly increases the risk of peritonitis, exit-site infection, and catheter failure. As such, multiple techniques have been proposed to reduce these risks, including a chest wall exit site. In this case, the patient was born with bilateral hypoplastic kidneys and an anorectal malformation, requiring a colostomy soon after birth. At 4 weeks of life, he required placement of a PD catheter for dialysis. Given the high risk of infection, a laparoscopic-assisted PD catheter placement with a chest wall exit remote from the colostomy was performed. This report describes the operative technique including omentectomy, placement of a percutaneous stitch between the catheter cuffs, and fibrin glue injection around the catheter. The patient had no catheter-related infections. Laparoscopic-assisted PD catheter placement with chest wall exit site is a safe alternative in patients with any type of abdominal stoma.

The rate of PD catheter complication does not increase with simultaneous abdominal surgery

INTRODUCTION

Children with kidney failure requiring PD catheter placement often require additional intraabdominal surgery. However, the risk of complication related to simultaneous abdominal surgery at time of catheter placement is unknown.

METHODS

Patients (0-18years) who underwent PD catheter placement (2012-2015) in the NSQIP-P database were reviewed. Complication rates between patients who underwent additional abdominal surgery at the time of PD catheter placement and those that did not were evaluated. One to one case control matching was performed for additional adjusted analysis.

RESULTS

Of 563 patients who met inclusion criteria, 82 underwent simultaneous abdominal surgery at time of PD catheter placement. Patients in the simultaneous group had a higher rate of wound contamination but there was no difference in rates of SSI, 30-day PD catheter complication, or 30-day mortality compared with the nonsimultaneous group. There was no difference when overall simultaneous abdominal surgery or gastrointestinal surgery was evaluated. In our 1:1 adjusted analysis, there was a higher rate of PD catheter complication (11.3% vs. 2.8%, p=0.049) and SSI (31.0% vs. 4.2%, p<0.001) in the nonsimultaneous group.

CONCLUSIONS

Thirty-day PD catheter complication and SSI in patients who underwent simultaneous abdominal surgery at time of catheter placement were noninferior to outcomes in the nonsimultaneous.

LEVEL OF EVIDENCE

Level III, Treatment study, Retrospective comparative study.

Peritonitis in Children on Chronic Peritoneal Dialysis: The Experience of a Large National Pediatric Cohort

BACKGROUND

We performed this study to evaluate the incidence, risk factors, microbiology, treatment, and outcome of peritonitis in pediatric Peritoneal dialysis (PD) patients at a nationwide prospective study.

METHODOLOGY

Patients younger than 18 years recruited in the BRAZPD II study from 2004 to 2011, who presented their first peritonitis episode, were included in the study.

RESULTS

We found 125 first episodes of peritonitis in 491 children PD patients (0.43 episodes/patient-year). Patients free of peritonitis episode constituted 75.6% in 1 year. Culture-negative episodes were very high (59.2%) and gram-positive (GP) bacteria were the most commonly found organisms (58.8%). First-generation cephalosporin was the initial choice to cover GP (40.5%) and aminoglycosides was the most prescribed antibiotics used for gram-negative agents (27.5%). Treatment failure was 26.4%. Technique failure (TF) occurred in 12.1% and peritonitis was the main cause (65.1%). Pseudomonas (p = 0.04) and negative cultures (p < 0.001) were identified as predictors of TF.

CONCLUSION

Peritonitis remains a common complication of PD in children and negative cultures and pseudomonas had a negative impact on TF.