Daily peritoneal dialysis using a surgically placed Tenckhoff catheter for acute renal failure in children

Prevention and Therapy of AKI in Asia: A Big Challenge

Asia is the largest and most populous continent and has huge differences in socioeconomic status, development, and health care between the different countries and regions within each country. This manifests in the varied causes of acute kidney injury (AKI), particularly higher rates of community-acquired AKI and in the differential access to health care for the population. Because of resource limitations, prevention and treatment of AKI is a difficult challenge. This review highlights the differences in AKI in Asia compared with the developed world and discusses prevention and treatment of AKI within the context of resource limitations.

Peritoneal Dialysis for Management of Pediatric Acute Renal Failure

Background

While the use of continuous renal replacement therapies in the management of children with acute renal failure (ARF) has increased, the role of peritoneal dialysis (PD) in the treatment of pediatric ARF has received less attention.

Design

Retrospective database review of children requiring PD for ARF over a 10-year period.

Setting

Pediatric intensive care unit at a tertiary-care referral center.

Patients

Sixty-three children without previously known underlying renal disease who required PD for treatment of ARF.

Results

Causes of ARF were congestive heart failure (27), hemolytic-uremic syndrome ( 13 ), sepsis ( 10 ), nonrenal organ transplant ( 7 ), malignancy ( 3 ), and other ( 3 ). Mean duration of PD was 11 ± 13 days. Children with ARF were younger (30 ± 48 months vs 88 ± 68 months old, p < 0.0001) and smaller (11.9 ± 15.9 kg vs 28 ± 22 kg, p < 0.0001) than children with known underlying renal disease who began PD during the same time period. Percutaneously placed PD catheters were used in 62% of children with ARF, compared to 4% of children with known renal disease ( p < 0.0001). Hypotension was common in patients with ARF (46%), which correlated with a high frequency of vasopressor use (78%) at the time of initiation of PD. Complications of PD occurred in 25% of patients, the most common being catheter malfunction. Recovery of renal function occurred in 38% of patients; patient survival was 51%.

Conclusions

Peritoneal dialysis remains an appropriate therapy for pediatric ARF from many causes, even in severely ill children requiring vasopressor support. Such children can be cared for without the use of more expensive and technology-dependent forms of renal replacement therapies.

Acute Kidney Injury in the Tropics: Epidemiology, Presentation, Etiology, Specific Diseases, and Treatment

The characteristics of AKI are significantly influenced by the setting in which it develops. The unique characteristics in the tropical ecosystem along with the prevailing socioeconomic circumstances in the region make AKI in the tropics different regarding etiology, clinical characteristics, and outcomes. Community-acquired AKI caused by infections; animal, plant, or chemical toxins; and obstetric complications are common in the tropics, compared to predominantly hospital-acquired AKI from sepsis and diagnostic and therapeutic interventions elsewhere. It is possible to discern certain distinct “AKI syndromes” in the tropics, like febrile illness with AKI, envenomation-related AKI, and obstetric AKI, where the patients develop AKI along with a typical constellation of clinical features, allowing more specific and quick diagnostic and therapeutic approach. Changes in disease epidemiology and ongoing socioeconomic transitions in the tropics are reflected in changing epidemiology of tropical AKI. While the incidence of obstetric AKI has shown a steady decline, HIV-associated AKI emerged as a significant entity in regions where HIV was endemic in the past few decades. There is better recognition of scrub typhus as a significant contributor to AKI with availability of better diagnostic techniques, and it is well recognized that the epidemiology of AKI associated with post-infectious glomerulonephritis is different in the tropics. Rapid urbanization has made large swaths of population susceptible to emerging infections like dengue fever, with increased incidence of AKI. Climate change and scarcity of potable water are expected to pose significant challenges to kidney health in the tropics in the future. However, community-acquired AKI in the tropics also presents a unique opportunity for prevention of AKI, and attendant morbidity and mortality as most of the contributing factors can be addressed by public health interventions and innovative strategies to deliver healthcare.

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

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.

Use of a simply modified drainage catheter for peritoneal dialysis treatment of acute renal failure associated with cardiac surgery in infants

Acute renal failure (ARF) is a common complication in infants who undergo cardiac surgery in the intensive care unit. We report on a modified drainage catheter used in peritoneal dialysis (PD) for the treatment of ARF associated with cardiac surgery in infants. Thirty-nine infants with congenital heart disease undergoing cardiac surgery who developed ARF at our center between January 2009 and January 2012 were assessed. A modified drainage catheter for PD was used in these infants. Their demographic, clinical, and surgical data were analyzed. Thirty infants with ARF were cured by PD, and the other 9 died in the first 48 hours because of the severity of the acute cardiac dysfunction. All these infants were dependent upon mechanical ventilation during the postoperative period and used vasoactive drugs. In the survival group, the interval between the procedure and initiation of PD was 13.6 ± 6.5 (range, 6-30) hours. PD duration was 3.9 ± 0.9 (3-6) days. Minor complications were encountered in some patients (asymptomatic hypokalemia, hyperglycemia, and thrombocytopenia). These complications were readily treated by drugs or resolved spontaneously. Hemodynamics, cardiac function, and renal function improved significantly during PD. These data suggest that PD using a modified drainage catheter for ARF after cardiac surgery in infants is safe, feasible, inexpensive, and yields good results.

Community-acquired acute kidney injury in tropical countries

Community-acquired acute kidney injury (AKI) in developing tropical countries is markedly different from AKI in developed countries with a temperate climate, which exemplifies the influence that environment can have on the epidemiology of human diseases. The aetiology and presentation of AKI reflect the ethnicity, socioeconomic factors, climatic and ecological characteristics in tropical countries. Tropical zones are characterized by high year-round temperatures and the absence of frost, which supports the propagation of infections that can cause AKI, including malaria, leptospirosis, HIV and diarrhoeal diseases. Other major causes of AKI in tropical countries are envenomation; ingestion of toxic herbs or chemicals; poisoning; and obstetric complications. These factors are associated with low levels of income, poor access to treatment, and social or cultural practices (such as the use of traditional herbal medicines and treatments) that contribute to poor outcomes of patients with AKI. Most causes of AKI in developing tropical countries are preventable, but strategies to improve the outcomes and reduce the burden of tropical AKI require both improvements in basic public health, achieved through effective interventions, and increased access to effective medical care (especially for patients with established AKI).

Peritoneal dialysis in childhood acute kidney injury: experience in southwest Nigeria

BACKGROUND

The choices for renal replacement therapy (RRT) in childhood acute kidney injury (AKI) are limited in low-resource settings. Peritoneal dialysis (PD) appears to be the most practical modality for RRT in young children with AKI in such settings. Data from sub-Saharan Africa on the use of PD in childhood AKI are few.

METHODS

We performed a retrospective study of children who underwent PD for AKI at a tertiary-care hospital in southwest Nigeria from February 2004 to March 2011 (85 months).

RESULTS

The study included 27 children (55.6% female). Mean age was 3.1 ± 2.6 years, with the youngest being 7 days, and the oldest, 9 years. The causes of AKI were intravascular hemolysis (n = 11), septicemia (n = 8), acute glomerulonephritis (n = 3), gastroenteritis (n = 3), and hemolytic uremic syndrome (n = 2). Peritoneal dialysis was performed manually using percutaneous or adapted catheters. Duration of PD ranged from 6 hours to 12 days (mean: 5.0 ± 3.3 days). The main complications were peritonitis (n = 10), pericatheter leakage (n = 9), and catheter outflow obstruction (n = 5). Of the 27 patients, 19 (70%) survived till discharge.

CONCLUSIONS

In low-resource settings, PD can be successfully performed for the management of childhood AKI. In our hospital, the use of adapted catheters may have contributed to the high complication rates. Peritoneal dialysis should be promoted for the management of childhood AKI in low-resource settings, and access to percutaneous or Tenckhoff catheters, dialysis fluid, and automated PD should be increased.

Continuous flow peritoneal dialysis: first experience in children with acute renal failure

BACKGROUND AND OBJECTIVES

Acute renal failure can be treated with different dialysis modalities, depending on patient characteristics and hospital resources. Peritoneal dialysis (PD) can be first choice in situations like hypotension, disturbed coagulation, or difficult venous access. The main disadvantage of PD is the relatively limited efficacy. The aim of this study was to investigate whether continuous flow peritoneal dialysis (CFPD) is a more effective treatment than conventional PD in acute renal failure.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A pilot study was performed at The Red Cross University Hospital in Cape Town in six patients. Patients were treated with both CFPD and conventional PD for 8 to 16 hours. CFPD was performed with two bedside-placed catheters. After initial filling, dialysate flow rate (100 ml/1.73 m2 per minute) was maintained with an adapted continuous venovenous hemofiltration machine. Ultrafiltration flow rate was set at 2.5 ml/1.73 m2 per minute.

RESULTS

Mean ultrafiltration was 0.20 ml/1.73 m2 per minute with conventional PD versus 1.8 ml/1.73 m2 per minute with CFPD. Mean clearances of urea and creatinine were 5.0 and 7.6 ml/1.73 m2 per minute with conventional PD versus 15.0 and 28.8 ml/1.73 m2 per minute with CFPD, respectively. No complications occurred.

CONCLUSIONS

In this first report of CFPD in six pediatric patients with acute renal failure, CFPD was on average three to five times more effective for urea and creatinine clearance and ultrafiltration than conventional PD, without any complications observed. CFPD has the ability to improve therapy for acute renal failure.

Dialysis and pediatric acute kidney injury: choice of renal support modality

Dialytic intervention for infants and children with acute kidney injury (AKI) can take many forms. Whether patients are treated by intermittent hemodialysis, peritoneal dialysis or continuous renal replacement therapy depends on specific patient characteristics. Modality choice is also determined by a variety of factors, including provider preference, available institutional resources, dialytic goals and the specific advantages or disadvantages of each modality. Our approach to AKI has benefited from the derivation and generally accepted defining criteria put forth by the Acute Dialysis Quality Initiative (ADQI) group. These are known as the risk, injury, failure, loss, and end-stage renal disease (RIFLE) criteria. A modified pediatrics RIFLE (pRIFLE) criteria has recently been validated. Common defining criteria will allow comparative investigation into therapeutic benefits of different dialytic interventions. While this is an extremely important development in our approach to AKI, several fundamental questions remain. Of these, arguably, the most important are "When and what type of dialytic modality should be used in the treatment of pediatric AKI?" This review will provide an overview of the limited data with the aim of providing objective guidelines regarding modality choice for pediatric AKI. Comparisons in terms of cost, availability, safety and target group will be reviewed.

Community-acquired acute kidney injury in Asia

Asia, the largest continent in the world, is heterogeneous in the ethnic, socioeconomic, and developmental status of its populations. A vast majority of it is poor with no adequate access to modern health care, making an accurate estimation of the nature and extent of acute kidney injury (AKI) difficult. Community-acquired AKI in otherwise healthy individuals is common, and the population developing AKI is younger compared with its counterparts in Europe or North America. The etiologic spectrum varies in different geographic regions of Asia depending on environmental, cultural, and socioeconomic factors. Some of the etiologic factors include AKI in relation to infectious diseases, intravascular hemolysis caused by glucose 6-phosphate dehydrogenase deficiency, poisonings caused by industrial chemicals or copper sulphate, animal venoms, natural medicines, heat stroke, and after complications of pregnancy. Preventive opportunities are missed because of failure to recognize the risk factors and early signs of AKI. Patients often present late for treatment, leading to multi-organ involvement and increased mortality. The exact etiologic diagnosis cannot be established in many instances because of a lack of appropriate laboratory support. Modern methods of renal replacement therapy are not universally available; and intermittent peritoneal dialysis is still widely practiced in many areas.

Acute renal failure in infants, children and adults

Acute renal failure (ARF) occurs in many critically ill patients regardless of age. A combination of events often seen in critical care settings, including shock, sepsis, hypoxia, and the use of potentially nephrotoxic medications, combine to make ARF an ongoing and important management issue in critical care medicine. Since the events leading to the development of ARF differ in infants, children, adults, and the elderly, the pathophysiology, clinical features, and treatment modalities do indeed have remarkable similarities among the different age groups.