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Care of the Pediatric Patient
on Peritoneal Dialysis
Clinical Process for Optimal Outcomes

PediatricCovers.QX

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CONTRIBUTING AUTHORS

Bradley A. Warady, M.D.
Franz Schaefer, M.D.
Steven R. Alexander, M.D.
Catherine Firanek, B.S.N.
Salim Mujais, M.D.

Cover art by Morgan Ghosey, age 16

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Care of the Pediatric Patient
on Peritoneal Dialysis
Clinical Process for Optimal Outcomes

Introduction
Ensuring adequate dialysis and optimal patient care is a multifaceted process in children
with end stage renal disease who receive peritoneal dialysis. Whereas clinicians typically
utilize clinical and laboratory indices when attempting to define and achieve adequate
dialysis, optimal care cannot be achieved by focusing on solute clearances alone. Attention
to nutrition therapy, correction of anemia and growth retardation, control of osteodystrophy, prevention/treatment of peritonitis and preparation for transplantation are also
mandatory, and excellence in each aspect of management is necessary if an optimal
patient outcome is to be achieved.
“Care of the Pediatric Patient on Peritoneal Dialysis” was developed based on a review
of the current medical literature and the authors’ clinical experience. It has been designed
to serve as a resource that can be easily integrated into clinical programs caring for
children, with the “discussion” of each major topic consisting of a treatment algorithm
and a brief but pertinent review of associated background material. An appendix with a
variety of clinical tools and list of references is also included. By its nature, this guide
cannot be considered to be exhaustive, and users are encouraged to pursue specific issues
that may not be covered herein. This guide is also not intended to be the practice of
medicine, nor does it replace sound medical clinical judgment.
Children who receive peritoneal dialysis and their families are deserving of the best care
we can possibly provide, in order to give them every opportunity to achieve their desired
goals. The authors hope that the information contained within this guide assists you to
that end.

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Care of the Pediatric Patient
on Peritoneal Dialysis
Clinical Process for Optimal Outcomes

Table of Contents
Predialytic Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Modality Selection and Preparation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
PD Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Automated Peritoneal Dialysis (APD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Continuous Ambulatory Peritoneal Dialysis (CAPD)
Ultrafiltration Management

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Peritonitis Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Management of Growth Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Recombinant Growth Hormone Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Management of Malnutrition

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Mineral Metabolism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Management of Anemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Preparation for Transplantation

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

Appendix:
Guidelines for 24-Hr Dialysate Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Guidelines for 24-Hr Urine Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Clearance Calculations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Residual Renal Clearance Calculations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
PET in Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Measurement of Intraperitoneal Pressure (IPP)

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Baxter Healthcare Corporation.2/17/04 1:30 PM Page 7 Predialytic Monitoring Pediatric Guide-SC3. All rights reserved. .qxd Predialytic Monitoring © Copyright 2004.

intact PTH.qxd 2/17/04 1:30 PM Page 8 Predialytic Monitoring CLINICAL PROCESS FOR OPTIMAL OUTCOMES Predialytic Monitoring TREATMENT GOAL • Full compensation for the complications of chronic kidney disease • Timely preparation for transplantation • Seamless transition to dialysis DIALYSIS INITIATION: ABSOLUTE INDICATIONS • GFR <8 mL/min/1. echocardiography. electrolytes. serum ferritin.73m2. wasting • Persistent hypertension despite antihypertensive treatment • Repeated hyperkalemic episodes DIALYSIS INITIATION: RELATIVE INDICATIONS • GFR 9–14 mL/min/1. . head circumference (infants).73m2 • Fatigue • Deteriorating school performance • Hyperphosphatemia despite maximal medication • Excessive serum calcium-phosphate product • Poorly controlled hyperparathyroidism EVALUATION SCHEME • Assessment of length/height and weight gain. serum albumin. pleuritis) • Manifest edema • Congestive heart failure • Clinical or biochemical signs of malnutrition. serum creatinine. blood pressure. acid-base status. hemoglobin/hematocrit. hand X-ray every 6–12 months • Neurodevelopmental assessment in infants every 6 months • When GFR <30 mL/min/1. initiate discussion regarding dialysis modality choice versus pre-emptive transplant 8 © Copyright 2004. 24-hour urine collection or Schwartz determination for GFR measurement every 2–3 months • Ambulatory blood pressure monitoring (ABPM). All rights reserved.73m2 (average of urea and creatinine clearances) • Overt uremia (uremic pericarditis.Pediatric Guide-SC3. Baxter Healthcare Corporation. BUN. transferrin saturation (TSAT).

uncontrolled hyperparathyroidism despite adequate medical treatment? ood matocrit. blood pressure. echocardiogram every 6–12 months. ABPM. fluid retention. TSAT. ur urine no at least one yes every Select dialysis modality. initiate discussions regarding dialysis modality choice vs. acidosis. hyperkalemia. All rights reserved. Baxter Healthcare Corporation. hemoglobin/hematocrit.Pediatric Guide-SC3. hyperphosphatemia.73 m2) Monitor renal function. serum ferritin. anthropometric and nutritional status. pre-emptive transplant GFR <8 GFR 9–14 GFR 15–29 Evidence of malnutrition. 9 .qxd 2/17/04 1:30 PM Page 9 CLINICAL PROCESS FOR OPTIMAL OUTCOMES g PREDIALYTIC MONITORING Child with advanced chronic renal failure (calculated GFR <30 mL/min/1. electrolytes. hypertension. intact PTH at least every 2–3 months. Initiate dialysis choice © Copyright 2004. compromised cardiac function.

qxd 2/17/04 1:30 PM Page 10 © Copyright 2004. All rights reserved. . Baxter Healthcare Corporation.Pediatric Guide-SC3.

All rights reserved. Baxter Healthcare Corporation.qxd Modality Selection and Preparation © Copyright 2004.2/17/04 1:30 PM Page 11 Modality Selection and Preparation Pediatric Guide-SC3. .

qxd 2/17/04 1:30 PM Page 12 CLINICAL PROCESS FOR OPTIMAL OUTCOMES Modality Selection Modality Selection and Preparation TREATMENT GOAL • Improvement of patient’s physical and mental well-being • Adequate performance of home dialysis by caregivers • Minimal interference with family/school/social life INDICATIONS FOR PD IN PREFERENCE TO HD • Patient/caregiver choice if the modality is medically suitable • Very small/very young patients • Lack of vascular access • Contraindications to anticoagulation • Cardiovascular instability • Poorly controlled hypertension/hypertensive cardiomyopathy (relative) M PD TRAIN Theory (>15 • Functions Practical/Tech • Aseptic te exchanges feeding (in Peritonitis an • Recognitio treatment Noninfectiou • Hypotensi • Lack of proximity to a pediatric HD center (relative) • Desire for normal school attendance • More liberal fluid intake ABSOLUTE CONTRAINDICATIONS TO PD • Omphalocoele • Gastroschisis • Bladder extrophy • Diaphragmatic hernia • Obliterated peritoneal cavity and peritoneal membrane failure HOME V Psychosocial • Family stru Environment • Presence o formula p for treatm Safety Asses • Locked me Equipment A • Blood pres RELATIVE CONTRAINDICATIONS TO PD • Imminent living-related transplantation • Impending/recent major abdominal surgery • Lack of an appropriate caregiver • Patient/caregiver choice if an alternate modality is available and medically suitable 12 © Copyright 2004. Treatment As • Dressing c blood pres Cycler Manag • Average st plan for an .Pediatric Guide-SC3. Baxter Healthcare Corporation. All rights reserved.

school schedule Environmental Assessment • Presence of heat. performance of PD exchanges. osmosis. tube feeding pump Treatment Assessment • Dressing care. initiating treatment. diffusion. scale. medicating bags for ongoing treatment Noninfectious Complications • Hypotension/hypertension. setup and function of cycler. formula preparation facilities (infants/small children). hernias HOME VISIT CONTENT Psychosocial Assessment • Family structure. proximity of caregiver bedroom to treatment area. All rights reserved. NG/gastrostomy tube feeding (infants/small children) Peritonitis and Exit site/Tunnel Infection • Recognition of signs and symptoms. home records. blood pressure monitoring. Baxter Healthcare Corporation.qxd 2/17/04 1:30 PM Page 13 CLINICAL PROCESS FOR OPTIMAL OUTCOMES Modality Preparation PD TRAINING CONTENT Theory (>15 hours) • Functions of the kidney. location of local hospital Equipment Assessment • Blood pressure monitor.able Pediatric Guide-SC3. fluid balance Practical/Technical (>15 hours) • Aseptic technique. cycler. running water and electricity. plan for answering alarms © Copyright 2004. purity of water supply. blood pressure assessment Cycler Management • Average start/end time for dialysis. isolated area for treatment Safety Assessment • Locked medicine cabinet. pathophysiology of renal failure. financial status. dialysis supply location. medications. thermometer. function of smoke detector and telephone. exit site care. storage of needles. catheter flow problems. hand washing station. problem-solving alarms. 13 .

.Pediatric Guide-SC3.qxd 2/17/04 1:30 PM Page 14 © Copyright 2004. All rights reserved. Baxter Healthcare Corporation.

qxd PD Prescription © Copyright 2004. Baxter Healthcare Corporation. .2/17/04 1:30 PM Page 15 PD Prescription Pediatric Guide-SC3. All rights reserved.

PD Prescription This section prescription are based on • Document (See pages ADJUST • Adjust the dialysis do Prescriptio 16 © Copyright 2004.Pediatric Guide-SC3. Each therapy offers distinct lifestyle and clinical advantages. physical condition and physician’s recommendation. All rights reserved.qxd 2/17/04 1:30 PM Page 16 CLINICAL PROCESS FOR OPTIMAL OUTCOMES PD Prescription DETERMINE BSA • Determine BSA by using the patient’s height and weight on the BSA chart located on INITIATE • Initiate dia pages 18-19. patients may be started on either APD or CAPD. . Baxter Healthcare Corporation. page 33 (C SELECT MODALITY MEASUR • Based on the patient’s lifestyle. Prescription recommendations are based on patient size.

© Copyright 2004. if available.ated on ation. 17 . festyle and Pediatric Guide-SC3. INITIATE THERAPY • Initiate dialysis therapy by using the prescription options offered on page 23 (APD) and page 33 (CAPD).qxd 2/17/04 1:30 PM Page 17 CLINICAL PROCESS FOR OPTIMAL OUTCOMES This section of the guide was designed to assist you in integrating a simple peritoneal dialysis prescription process into the management of individual patients. Recommended prescriptions are based on patient Body Surface Area (BSA) and residual creatinine clearance (CrCl).) ADJUST PRESCRIPTION • Adjust the prescription if the patient is not achieving desired clearance or an increase in dialysis dose is required by clinical evaluation. Baxter Healthcare Corporation. MEASURE CLEARANCES • Document an adequate dose of dialysis by measuring the actual clearances achieved. All rights reserved. (See pages 82–85. using the guidelines in the “Adjust Prescription” sections on pages 27 (APD) and 36 (CAPD).

79 0.49 0.60 0.54 0.38 0.56 0.57 0.65 0.37 0.65 0.41 0.74 0.40 0.25 0.35 0.59 0.57 0.50 0.54 0.qxd Page 18 CLINICAL PROCESS FOR OPTIMAL OUTCOMES Determine Body Surface Area (BSA) Tailoring the BSA can be d .70 0.46 0.76 102 0. kg)0.42 0.56 0.58 0.42 0.57 Height (cm) Pediatric Guide-SC3.68 0.35 0.58 0.66 0.51 0.33 0.28 0.59 0.53 0.45 0.57 0.51 0.49 0.34 0.39 0.Weight (kg) 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 18 58 0.54 0.41 0.45 0.41 0.51 0.45 0.49 0.58 0.77 0.75 0.40 0.46 0.77 0.50 0.59 0.51 0.34 0.32 0.30 0.51 0.72 0.59 50 0.38 0.29 0.32 0.67 0.61 0.21 0.62 0.66 0.51 0.61 62 0.19 0.42 0.39 0. All rights reserved.54 0.51 0.40 0.23 0.40 0.28 0.68 0.47 0.81 2/17/04 1:30 PM © Copyright 2004.36 0.19 0.42 0.70 0.59 0.22 0.67 0.58 0.57 0.54 0.63 0. 1970).49 0.66 0.29 0.48 0.24 0.62 0.70 0.26 0.44 0.59 0.69 0.39 0.36 0.54 0.53 0.64 0.63 0.44 0.58 0.35 0.34 0.56 0.73 94 0.39 0.37 0.51 0.37 0.48 0.63 0.22 0.62 0.20 0.37 0.33 0.24 0.48 0.52 0.48 0.45 0.69 0.71 0.46 0.71 0.53 0.73 0.43 0.61 0.30 0.61 0.74 0.54 0.64 70 0.61 0. cm)0.27 0.63 0.44 0.27 0.34 0.22 0.27 0.67 0.24 0.70 0.32 0. Baxter Healthcare Corporation.68 0. 54 0.48 0.59 0.0235 x (Patient’s Height.69 82 0.71 86 0.56 0.44 0.72 0.24 0.60 0.44 0.47 0.34 0.31 0.48 0.42246 x (Patient’s Weight.30 0.25 0.55 0.25 0.42 0.50 0.51 0.31 0.67 0.23 0.64 0.32 0.29 0.66 0.70 0.63 66 0.75 0.33 0.53 0.40 0.63 0.64 0.30 0.56 0.60 0.21 0.60 0.75 98 0.31 0.49 0.38 0.46 0.54 0.61 0.45 0.54 0.69 0.29 0.76 0.68 0.52 0.61 0.62 0.50 0.52 0.47 0.66 0.54 0.59 0.77 106 0.55 0.20 0.33 0.35 0.31 0.50 0.55 0.47 0.26 0.43 0.75 0. Calculated by the formula: Body Surface Area = 0.56 0.61 0.33 0.55 0.47 0.52 0.42 0.62 0.38 0.58 0.80 114 0.36 0.73 0.72 90 0.56 0.36 0.69 0.72 0.30 0.53 0.56 0.50 0.22 0.55 0.36 0. George SL: Estimation of human body surface area from height and weight.39 0.25 0.58 0.47 0.60 0.68 78 0.44 0.62 0.78 0.46 0.47 0. Cancer Chemother Rep Part 1 54:225-235.66 0.47 0.64 0.63 0.40 0.72 0.68 0.53 0.43 0.28 0.51456 (Gehan E.39 0.65 0.56 0.58 0.38 0.41 0.43 0.24 0.27 0.37 0.22 0.18 0.60 0.57 0.49 0.64 0.53 0.35 0.38 0.46 0.71 0.44 0.44 0.52 0.53 0.59 0.31 0.67 0.79 110 0.49 0.28 0.46 0.61 0.66 74 0.64 0.23 0.52 0.43 0.40 0.18 0.

13 1.09 1. George SL: Estimation of human body surface area from height and weight.12 1.94 0.16 1.15 1.30 1.14 1.55 1.24 1.42246 x (Patient’s Weight.21 1.25 1.98 1.56 1.50 1.24 1.36 1.49 1.22 1.56 1.29 1.42 1.51 1.36 1.94 0.99 1.46 1.54 1.16 1.39 1.41 1.48 1.24 1.04 1.93 0.39 1.40 1. Calculated by the formula: Body Surface Area = 0.32 1.98 1.42 1.11 1.47 126 0.23 1.05 1.41 1.92 0.00 1.49 1.55 1.05 1.36 1.44 1.90 0.14 1.47 1.60 1.46 1.66 1.59 1.11 1.34 1.37 1.45 122 0.32 1.41 1.17 1.02 1.92 0. 19 .28 1.95 1.37 1.18 1.36 1.21 1.62 1.49 1.81 0.52 1.11 1.0235 x (Patient’s Height.29 1.18 1. 1970).11 1.22 1.08 1.22 1.96 1.46 1.08 1.91 0.61 1.27 1.00 1.33 1.90 0.26 1.09 1.00 1.30 1.35 1.57 1.41 1.92 0.37 1.83 0.07 1.15 1.34 1.33 1.01 1.19 1.31 1.57 1.85 0.25 1.01 1.89 0.34 1.20 1.16 1.60 154 0.84 0.01 1.34 1.38 1. cm)0.95 0.27 1.21 1.22 1.30 1.48 1.16 1.40 1.26 1.26 1.26 1. Baxter Healthcare Corporation.24 1.49 1.51 1.03 1.63 1.11 1.05 1.30 1.62 158 0.45 1.46 1.53 138 0.51456 (Gehan E.02 1.44 1.10 1.12 1.06 1.32 1.38 1.10 1.97 1.06 1.13 1.33 1.57 146 0.88 0.99 1.87 0.96 1.38 1. All rights reserved.98 1.49 130 0.04 1.29 1.30 1.47 1.51 1.08 1.35 1.22 1.20 1.28 1.25 1.53 1.57 1.24 1.32 1.45 1.64 162 0.07 1.36 1.15 1.54 1.48 1.17 1.10 1.17 1.37 1.17 1.19 1.99 1.13 1.25 1.34 1.38 1.92 0.67 170 0.03 1.54 1.63 1.13 1.82 0.07 1.94 0.66 166 0.51 134 0.38 1.01 1.60 1.85 0.96 0.58 1.39 Height (cm) Pediatric Guide-SC3.91 0.33 1.21 1.59 1.89 0.27 1.44 1.16 1.95 0.48 1.21 1.90 0.35 1.86 0.28 1.52 1.88 0.35 1.33 1.93 0.27 1.43 1.30 1.10 1.20 1.21 1.35 1.qxd Page 19 CLINICAL PROCESS FOR OPTIMAL OUTCOMES Tailoring the prescription to patient size is essential to achieve desired peritoneal clearances.10 1.26 1.58 1.25 1.22 1.51 1.59 150 0.31 1.79 0.27 1.84 0.25 1.08 1.18 1.44 1.94 0.97 1.12 1.43 1.23 1.94 0.95 0.26 1.41 1.52 1.99 1. BSA can be determined from height and weight by referring to the tables below.00 1.03 1. kg)0.18 1.98 1.29 1.05 1.19 1.90 0.08 1.08 1.40 1. 110 0.12 1.02 1.93 0.03 1.31 1.40 1.15 1. Cancer Chemother Rep Part 1 54:225-235.18 1.97 1.07 1.44 1.19 1.99 1.69 2/17/04 1:30 PM © Copyright 2004.86 0.42 1.38 1.43 1.52 1.43 1.14 1.40 1.35 1.21 1.32 1.38 1.55 142 0.35 1.02 1.97 1.87 0.50 1.43 1.80 0.40 1.42 1.38 1.06 1.32 1.88 0.39 1.19 1.14 1.Weight (kg) 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 114 0.97 1.18 1.37 1.46 1.23 1.03 1.06 1.24 1.01 1.16 1.27 1.06 1.65 1.29 1.07 1.10 1.49 1.30 1.15 1.54 1.37 1.45 1.43 118 0.29 1.46 1.41 106 0.89 0.48 1.31 1.13 1.11 1.03 1.

qxd 2/17/04 1:30 PM Page 20 A APD is perfor exchanges p exchange in This therapy ultrafiltratio patients are © Copyright 2004. Baxter Healthcare Corporation.Pediatric Guide-SC3. All rights reserved. .

© Copyright 2004. Baxter Healthcare Corporation.This final exchange dwells in the peritoneal cavity during the day.qxd .2/17/04 1:30 PM Page 21 Automated Peritoneal Dialysis (APD) APD is performed at night with the help of a “cycler. All rights reserved. This therapy is especially well-suited for pediatric patients. Automated Peritoneal Dialysis Pediatric Guide-SC3.” A typical APD prescription includes five exchanges performed by the cycler while the patient is sleeping. and decreased intra-abdominal pressure since patients are supine.The cycler instills a final (sixth) exchange in the morning. Additional benefits include better ultrafiltration due to shorter nighttime dwells.

care should be taken to consider the number of cycles in relation to the total time on cycler. as diminishing returns may occur because of fill/drain requirements.Pediatric Guide-SC3. When an increase in dialysis dose is needed. A “wet day” makes effective use of the full 24 hours. In all patients. Init (usually Use 22 © Copyright 2004. All rights reserved. Increasing the amount of solution included in each fill is more effective than increasing the number of cycles at night.73 m2) patients must end with a fill for a daytime dwell (“wet day”). A starting time of 10 hours is generally recommended. STEP 3 MAXIMIZE FILL VOLUME 2then start usin increas Automated Peritoneal Dialysis Maximizing the fill volume improves the efficiency of dialysis. . STEP 2 ANURIC APD PATIENTS REQUIRE “WET” DAYS All functionally anuric (CrCl<2mL/min/1. it may be beneficial to add a midday exchange. STEP 4 ADJUST CYCLE FREQUENCY TO TRANSPORT STATUS E Use of a higher number of exchanges will be more effective in patients with a higher transport status by PET. Baxter Healthcare Corporation.qxd 2/17/04 1:30 PM Page 22 CLINICAL PROCESS FOR OPTIMAL OUTCOMES APD Prescription Principles The following APD prescription principles improve the efficiency of APD therapy: STEP 1 ADEQUATE TIME ON CYCLER Actual time on the cycler may vary by patient and should be adapted to the patient’s clinical needs and lifestyle.

ount of es at night. a daytime an ge. increase fill volume to ~1100 mL/m2 BSA within 14–21 days Establish maximally tolerable fill volume by either repeated IPP measurements or clinical judgment.Pediatric Guide-SC3. 23 .qxd 2/17/04 1:30 PM Page 23 CLINICAL PROCESS FOR OPTIMAL OUTCOMES ples herapy: INITIATION OF APD ient’s d. igher mber of ecause of Implant catheter Provide educational materials to caregivers. patients no Immediate PD required? 2. All rights reserved. then start dialysis with 12–24 exchanges using 300 mL/m2 BSA volume* increase fill volume to ~1100 mL/m2 BSA within 7–14 days yes Start supine dialysis with 12–24 exchanges using 300 mL/m2 BSA volume* for 7 days. Baxter Healthcare Corporation.to 6-week healing period. measure urinary and dialysate creatinine and urea clearances at the end of training (preferably 4 weeks after start of PD) Use PD dosing tables or software (PD Adequest or RenalSoft PD Rx Management) to adjust PD prescription * ~200 mL/m2 BSA during infancy © Copyright 2004. adjust to maximally tolerable fill volume Initial prescription: 5–6 90–120 min cycles with maximally tolerable fill volume (usually ~1100 mL/m2 BSA) + 1 daytime cycle with >50% of nocturnal fill volume (CCPD) or <50% of nocturnal fill volume (NIPD) Perform PET.

All rights reserved. Baxter Healthcare Corporation. g 24 © Copyright 2004. pleuritis) • Noncomp • Poorly fun • Manifest edema • Clinical or biochemical signs of malnutrition. excessive serum calcium-phosphate product CRITERIA • CCPD (AP Total K Total C averag • NIPD (APD Total K Total C averag • Clearance pressure. .Pediatric Guide-SC3. absence of uremic symptoms • Insufficien • Minimal interference with family/school/social life • Loss of res • Prescriptio • Reduced p • Loss of me MANIFESTATIONS OF INADEQUATE DIALYSIS • Overt uremia (uremic pericarditis.qxd 2/17/04 1:30 PM Page 24 CLINICAL PROCESS FOR OPTIMAL OUTCOMES Management of APD Prescriptions TREATMENT GOAL FACTORS • Physical and mental well-being. wasting • Congestive heart failure • Arterial hypertension requiring more than one antihypertensive agent • Absolute BUN value • Weekly Kt/Vurea and CrCl below K/DOQI recommendations • Hyperkalemic episodes • Hyperphosphatemia.

>55 in low/low average transporters • Clearance associated with normal status for hydration. >52.qxd 2/17/04 1:30 PM Page 25 CLINICAL PROCESS FOR OPTIMAL OUTCOMES FACTORS CONTRIBUTING TO INADEQUATE DIALYSIS • Insufficient time on cycler • Loss of residual renal function • Prescription not adequate for membrane characteristics • Reduced peritoneal surface area due to extensive intra-abdominal adhesions • Loss of membrane solute transport/ultrafiltration capacity due to peritonitis • Noncompliance with PD prescription • Poorly functioning PD catheter CRITERIA OF APD ADEQUACY • CCPD (APD with daytime dwell): Total Kt/V urea >2.73m2/week in high/high average transporters.5 in low/low average transporters • NIPD (APD with dry day): Total Kt/V urea >2. nutrition and psychomotor development © Copyright 2004.1/week Total CrCl >63 L/1. Baxter Healthcare Corporation. blood pressure. electrolyte balance. All rights reserved.Pediatric Guide-SC3.2/week Total CrCl >66 L/1. 25 .73m2/week in high/high average transporters. growth.

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CLINICAL PROCESS FOR OPTIMAL OUTCOMES

Management of
APD Prescriptions
OUTCOME EVALUATION
• Monthly assessment of growth and weight gain, head circumference (infants); blood

pressure, acid-base status, electrolytes, serum creatinine, BUN, hemoglobin/hematocrit,
serum albumin, record urine output and daily ultrafiltration
• Serum ferritin, serum iron, total iron binding capacity (monthly until stable, then every
2–3 months)
• Every 3 months assessment of intact PTH, alkaline phosphatase
• Every 4 months assessment of 24-hour dialysate and urine collection for CrCl, Kt/Vurea;
possibly more frequent if prior assessment reveals failure to achieve adequacy targets;
school evaluation
• Every 6 months neurodevelopmental assessment in infants <4 years of age
• Consider annual:
- Ambulatory blood pressure monitoring (ABPM), especially if casual BP frequently
borderline or discrepant from home measurements, echocardiography
- Hand and wrist X-ray (especially if intact PTH frequently outside therapeutic range)

Ad

There are fou
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lifestyle.
STEP 1

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STEP 2

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using a dr
add a dayt

• HomeCho

MEASURE APD CLEARANCE
Measuring the dose of dialysis received by the patient is critical
to ensure adequate therapy.
• Assess the amount of clearance the patient is receiving using a 24-hour dialysate

collection. (See Appendix: Guidelines for 24-Hour Dialysate Collection—page 82,
and Clearance Calculations—page 84.)

exchange(
exchanges

STEP 3

IN

• Cycler tim

patient’s li
• For patients with residual renal function, add residual clearance to dialysis clearance to

determine total clearance. (See Appendix: Guidelines for 24-Hour Urine Collection—
page 83, and Residual Renal Clearance Calculations—page 85.)

• Increasing

time, whic

• Measurements can be done as early as 1 week after the patient is stabilized on a defined

prescription.
STEP 4

• Once a patient achieves desired clearance, repeat measurements should be completed

every 4 months.

26

IN

• An increas

patients w
may be re

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CLINICAL PROCESS FOR OPTIMAL OUTCOMES

Adjust APD Prescription

blood
matocrit,

en every

There are four basic options to adjust an APD prescription. The options must be
weighed with regard to improvements in clearance and the patient’s comfort and
lifestyle.
STEP 1

INCREASE FILL VOLUMES

• Maximizing the fill volume is an effective means of improving clearance with a minimum

Kt/Vurea;
targets;

impact on patient lifestyle. Since patients tolerate larger fill volumes when supine, adjust
prescriptions first by increasing the volume of the nighttime exchanges.

STEP 2

quently
tic range)

ate
82,

rance to
tion—

ADD A DAYTIME EXCHANGE

• Adding a daytime exchange is an effective means of improving clearance. For patients

using a dry day prescription, add a wet day. For patients using a wet day prescription,
add a daytime exchange after school.
• HomeChoice High Dose Therapy, combining conventional CCPD with additional daytime

exchange(s), minimizes impact on lifestyle by utilizing one cycler setup per day for all
exchanges. HomeChoice can be programmed to deliver the daytime exchange.

STEP 3

INCREASE TIME ON THE CYCLER

• Cycler time can be extended to increase clearances, but this must be balanced with the

patient’s lifestyle needs.
• Increasing cycler time while keeping the same number of exchanges increases the dwell

time, which results in increased clearance.

n a defined

mpleted

STEP 4

INCREASE NUMBER OF NIGHTTIME EXCHANGES

• An increase in nighttime exchanges may increase clearance in high transporters. In

patients with a different transport profile, a simultaneous increase in the time on cycler
may be required.

© Copyright 2004, Baxter Healthcare Corporation. All rights reserved.

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CLINICAL PROCESS FOR OPTIMAL OUTCOMES

Adjust APD Prescription
MAINTENANCE PD PRESCRIPTION IN NIPD
Measure dialytic and urinary CrCl and Kt/Vurea every 4 months

no

Low, low-average
transporters

High, high-average
transporters

Total weekly Kt/Vurea < 2.2
and/or CrCl <55 L/1.73m2 ?

Total weekly Kt/Vurea <2.2
and/or CrCl <66 L/1.73m2 ?

yes

yes

no

Gradually augment fill volume to maximal tolerable volume (maximum
1400 mL/m2). Check total CrCl and Kt/Vurea 1 month after intervention
yes

Adequacy targets met?
no
Low, low-average
transporters

High-average
transporters

High
transporters

Increase total cycler time
by prolonging dwell time.
Keep cycle number
constant

Increase number of
cycles or increase total
cycler time by adding
cycles keeping dwell
time constant

Increase number of
cycles with constant total
cycler time

Adequacy targets met?

yes

no
Assess clinical status:
Adequate growth/nutrition status,
psychomotor development?

yes

no

Switch to CCPD (daytime dwell)

28

© Copyright 2004, Baxter Healthcare Corporation. All rights reserved.

Continue close
monitoring

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CLINICAL PROCESS FOR OPTIMAL OUTCOMES

on

inue close
onitoring

MAINTENANCE PD PRESCRIPTION IN CCPD
Measure dialytic and urinary CrCl and Kt/Vurea every 4 months

no

Low, low-average
transporters

High, high-average
transporters

Total weekly Kt/Vurea <2.1
and/or CrCl <52.5 L/1.73m2 ?

Total weekly Kt/Vurea <2.1
and/or CrCl <63 L/1.73m2 ?

yes

yes

no

Gradually augment fill volume to maximal tolerable volume (maximum
1400 mL/m2). Check total CrCl and Kt/Vurea 1 month after intervention
yes

Adequacy targets met?
no
Low, low-average
transporters

High-average
transporters

Increase total cycler time Increase total cycler time
by adding cycles
by prolonging dwell time.
keeping dwell
Keep cycle number
time constant
constant

High
transporters
Increase number of
cycles with constant total
cycler time

Adequacy targets met?

yes

no
Assess clinical status:
Adequate growth/nutrition status,
psychomotor development?

yes

Continue close
monitoring

no

Consider adding afternoon cycle or change to hemodialysis

© Copyright 2004, Baxter Healthcare Corporation. All rights reserved.

29

t bedtime and © Copyright 2004. . All rights reserved. Baxter Healthcare Corporation.Pediatric Guide-SC3.qxd 2/17/04 1:30 PM Page 30 Co Per CAPD is perfo exchanges.

Pediatric Guide-SC3. three of which are completed during the waking hours. . All rights reserved. It usually consists of four exchanges. © Copyright 2004. and the last is performed before bedtime and allowed to dwell overnight.qxd 2/17/04 1:30 PM Page 31 Continuous Ambulatory Peritoneal Dialysis (CAPD) Continuous Ambulatory Peritoneal Dialysis (CAPD) CAPD is performed evenly over the entire course of a 24-hour period. Baxter Healthcare Corporation.

care should be taken to account for patient tolerance. When adjusting fill volumes.Pediatric Guide-SC3. Guidelines for ultrafiltration management are listed on pages 40–45. These can be increased further if clearance targets are not met. U 32 © Copyright 2004. Baxter Healthcare Corporation.qxd 2/17/04 1:30 PM Page 32 CLINICAL PROCESS FOR OPTIMAL OUTCOMES CAPD Prescription Principles The following CAPD prescription principles improve the efficiency of the therapy: STEP 1 OPTIMIZE FILL VOLUMES Fill volumes appropriate for patient body size are used in the recommended prescriptions. . All rights reserved. STEP 3 USE APPROPRIATE TONICITY FOR ULTRAFILTRATION 2 then s us incre Continuous Ambulatory Peritoneal Dialysis (CAPD) Proper fluid balance improves the effectiveness of the therapy. STEP 2 DISTRIBUTE DAYTIME EXCHANGES EVENLY OVER THE COURSE OF THE DAY Dwell times during the waking hours should be of approximately the same duration (4–6 hours).

Pediatric Guide-SC3.to 6-week healing period.* increase fill volume to ~1100 mL/m2 BSA within 7–14 days Start supine dialysis with 12–24 exchanges using 300 mL/m2 BSA volume* for 7 days.to 12-hour nighttime cycles with maximally tolerable fill volume (usually ~1100 mL/m2 BSA) Perform PET. 33 .qxd 2/17/04 1:30 PM Page 33 CLINICAL PROCESS FOR OPTIMAL OUTCOMES herapy: INITIATION OF CAPD scriptions. then start dialysis with 4–8 exchanges using 300 mL/m2 BSA volume. patients OURSE OF no Immediate PD required? yes ation 2. All rights reserved.to 5-hour daytime + 1 9. measure urinary and dialysate creatinine and urea clearances at the end of training (preferaby 4 weeks after start of PD) Use PD dosing tables or software (PD Adequest or RenalSoft PD Rx Management) to adjust PD prescription * ~200 mL/m2 BSA during infancy © Copyright 2004. increase fill volume to ~1100 mL/m2 BSA within 14–21 days trafiltration Establish maximally tolerable fill volume by either repeated IPP measurements or clinical judgment. fill Implant catheter Provide educational materials to caregivers. Baxter Healthcare Corporation. Adjust to maximally tolerable fill volume Initial prescription: 3 3.

blood pressure. absence of uremic symptoms • Monthly a • Minimal interference with family/school/social life pressure. Baxter Healthcare Corporation. pleuritis) • Manifest edema • Clinical or biochemical signs of malnutrition. and Re • Measurem prescriptio • Once a pa every 4 mo 34 © Copyright 2004. wasting • Congestive heart failure • Arterial hypertension requiring more than one antihypertensive agent • Absolute BUN value • Weekly Kt/V urea and CrCl below K/DOQI recommendations • Hyperkalemic episodes • Hyperphosphatemia. and Cleara • For patien CRITERIA OF CAPD ADEQUACY • Total Kt/V urea >2. growth. .0/week • Total CrCl >60 L/1. >50 in low/low average transporters • Clearance associated with normal status for hydration.Pediatric Guide-SC3.qxd 2/17/04 1:30 PM Page 34 CLINICAL PROCESS FOR OPTIMAL OUTCOMES Management of CAPD Prescriptions TREATMENT GOAL OUTCOM • Physical and mental well-being. All rights reserved. electrolyte balance. a serum alb • Serum fer 2–3 mont • Every 3 mo • Every 4 mo possibly m school eva • Every 6 mo • Consider a — Am bor — Han MANIFESTATIONS OF INADEQUATE DIALYSIS • Overt uremia (uremic pericarditis.73m2/week in high/high average transporters. nutrition and psychomotor development determine 83. excessive serum calcium-phosphate product FACTORS CONTRIBUTING TO INADEQUATE DIALYSIS • Loss of residual renal function • Prescription not adequate for membrane characteristics • Reduced peritoneal surface area due to extensive intra-abdominal adhesions • Loss of membrane solute transport/ultrafiltration capacity due to peritonitis • Noncompliance with PD prescription • Poorly functioning PD catheter MEASUR Measuring th adequate the • Assess the collection.

echocardiography — Hand and wrist X-ray (especially if intact PTH frequently outside therapeutic range) MEASURE CAPD CLEARANCES Measuring the dose of dialysis received by the patient is critical to ensure adequate therapy. especially if casual BP frequently borderline or discrepant from home measurements. total iron binding capacity (monthly until stable. and Residual Renal Clearance Calculations—page 85. hemoglobin/hematocrit. head circumference (infants). add residual clearance to dialysis clearance to determine total clearance. • Assess the amount of clearance the patient is receiving using a 24-hour dialysate collection. then every 2–3 months) • Every 3 months assessment of intact PTH. Baxter Healthcare Corporation. repeat measurements should be completed every 4 months. record urine output and daily ultrafiltration • Serum ferritin.qxd 2/17/04 1:30 PM Page 35 CLINICAL PROCESS FOR OPTIMAL OUTCOMES OUTCOME EVALUATION • Monthly assessment of growth and weight gain. (See Appendix: Guidelines for 24-Hour Urine Collection—page 83. BUN. blood pressure. electrolytes. alkaline phosphatase • Every 4 months assessment of 24-hour dialysate and urine collection for CrCl. serum iron. 35 .) ow average od • Measurements can be done as early as 1 week after the patient is stabilized on a defined prescription. (See Appendix: Guidelines for 24-Hour Dialysate Collection—page 82. serum creatinine. acid-base status. © Copyright 2004.) • For patients with residual renal function. possibly more frequent if prior assessment reveals failure to achieve adequacy targets. • Once a patient achieves desired clearance. Kt/V urea . All rights reserved. and Clearance Calculations—page 85. school evaluation • Every 6 months neurodevelopmental assessment in infants <4 years of age • Consider annual: — Ambulatory blood pressure monitoring (ABPM).Pediatric Guide-SC3. serum albumin.

INCREASE FILL VOLUMES • Maximizing fill volume is THE most effective means of improving clearance. Increasing fill volumes is preferred over adding additional exchanges.Pediatric Guide-SC3. • Start patients on the recommended prescription. . ADD AN ADDITIONAL EXCHANGE • A fifth exchange may be added manually during the daytime or at nighttime by the use of an exchange device. Baxter Healthcare Corporation. These options must be weighed with regard to improvements in clearance and the patient’s comfort and lifestyle.qxd 2/17/04 1:31 PM Page 36 CLINICAL PROCESS FOR OPTIMAL OUTCOMES Adjust CAPD Prescription There are two basic options for adjusting the CAPD prescription. If targets are still not met. 36 © Copyright 2004. proceed by increasing the fill volume of all four exchanges. and increase fill volumes if targets are not met. All rights reserved. The latter is feasible only with fill volumes greater than 1500 mL. You may elect to increase only two of the exchanges when first adjusting the prescription.

rgets are sting the f all four by the use 1500 mL. low-average transporters High.Pediatric Guide-SC3.0 and/or CrCl <50 L/1. high-average transporters Total weekly Kt/Vurea <2. psychomotor development? yes Continue close monitoring no Low. All rights reserved.73m2 ? Total weekly Kt/Vurea <2.qxd 2/17/04 1:31 PM Page 37 CLINICAL PROCESS FOR OPTIMAL OUTCOMES ion tions must omfort and nges. 37 . Baxter Healthcare Corporation. high-average transporters Consider APD in low-average transporter.73m2 ? yes yes no Gradually augment intraperitoneal volume to maximal tolerable volume (maximum 1400 mL/m2) Check dialytic and urinary CrCl and Kt/Vurea 1 month after intervention yes Adequacy targets met? no Assess clinical status: Adequate growth/nutrition status. Consider hemodialysis Consider APD © Copyright 2004. low-average transporters High. MAINTENANCE PD PRESCRIPTION IN CAPD Measure dialytic and urinary CrCl and Kt/Vurea every 4 months no Low.0 and/or CrCl <60 L/1.

Baxter Healthcare Corporation.Pediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 38 © Copyright 2004. All rights reserved. .

All rights reserved.qxd © Copyright 2004.2/17/04 1:31 PM Page 39 Ultrafiltration Management Ultrafiltration Management Pediatric Guide-SC3. Baxter Healthcare Corporation. .

Baxter Healthcare Corporation. • Periton that the remova • Dwell t in UF be • Tonicity increase • The use negative . Ultrafiltration is time dependent. Because the glucose osmotic gradient dissipates with time.Pediatric Guide-SC3. The two key factors to consider when adjusting the patient’s prescription for fluid removal are the nature of the osmotic agent used. Dextrose performs adequately in short dwells. but for the long nighttime dwell in CAPD and the daytime dwell in APD. due to its continuous nature. ultrafiltration is driven by the osmotic gradient between the plasma and dialysate compartments.qxd 2/17/04 1:31 PM Page 40 CLINICAL PROCESS FOR OPTIMAL OUTCOMES Ultrafiltration Management Adjusting a patient’s prescription to achieve and maintain fluid balance is an essential component of PD prescription management. MANIFESTATIONS OF INADEQUATE DIALYSIS • Peripheral edema • Systolic hypertension • Diastolic hypertension • Pulmonary congestion Ultrafiltration Management • Pleural effusions 40 © Copyright 2004. In PD. offers some distinct advantages such as avoiding fluctuating volume status and offering better homeostatic stability than an intermittent therapy. FACTO • Dietary • Inappro • Decreas • Mechan • Transpo reabsor COMPO • Determ • Dietary • Protecti • Optiona • Ultrafilt DETER TREATMENT GOAL • Adjust a patient’s prescription to achieve and maintain fluid balance • Patient edema free • Achieve normotension with minimal use of or need for antihypertensive medications. net ultrafiltration then begins to decrease. and lymphatic absorption continues. Peritoneal dialysis. concentration and dwell time. These are interrelated and need to be considered jointly. All rights reserved. The net ultrafiltration rate with dextrose-based solutions is greatest at the beginning of an exchange and peaks at about 2-3 hours. An alternate osmotic agent may be more appropriate for the long dwell. a significant proportion of patients manifest fluid retention with dextrose-based solutions.

qxd 2/17/04 1:31 PM Page 41 CLINICAL PROCESS FOR OPTIMAL OUTCOMES Ultrafiltration Management FACTORS CONTRIBUTING TO INADEQUATE FLUID BALANCE • Dietary noncompliance with salt and water • Inappropriate/noncompliance to PD prescription • Decreased residual renal function • Mechanical PD catheter issues • Transport characteristics: Reduced membrane function/high permeability/lymphatic reabsorption COMPONENTS OF FLUID BALANCE MANAGEMENT • Determination of appropriate target weight. © Copyright 2004. • Dietary counseling concerning appropriate salt and water intake. • Ultrafiltration management utilizing the appropriate PD prescription. a utions. All rights reserved. • Optional use of loop diuretics if residual function is present. Pediatric Guide-SC3. an increase in tonicity is associated with an increase in ultrafiltration. DETERMINANTS OF ULTRAFILTRATION IN PD • Peritoneal transport status: the dependence of UF on the osmotic gradient implies that the transport properties of the peritoneal membrane can significantly affect fluid removal when dextrose solutions are used • Dwell time: an increase in dwell time with dextrose-based solutions leads to a decrease in UF because of dissipation of the osmotic gradient. Baxter Healthcare Corporation. • The use of an alternate osmotic agent may allow for a long dwell without the risk of negative ultrafiltration. ately in APD. • Tonicity: with dextrose-based solutions.tial ous s and lysate ription ell time. 41 . olutions e the s. • Protection of residual renal function by avoiding nephrotoxic agents. net propriate cations.

25% dextrose preparations to protect the peritoneal membrane and avoid the metabolic complications of very hypertonic dextrose. STRATEGIES TO MAXIMIZE SHORT DWELL UF APD • Increase the number of cycles • Increase dextrose concentration • Increase overall cycler treatment time • Consider increasing the fill volume CAPD • Increase dextrose concentration • Decrease dwell time/increase number of exchanges • Consider increasing fill volume Figures: Dependence of UF on peritoneal transport status and dialysis solution tonicity for dextrose based solutions.Pediatric Guide-SC3. Ultrafiltr . All rights reserved. Baxter Healthcare Corporation.qxd 2/17/04 1:31 PM Page 42 CLINICAL PROCESS FOR OPTIMAL OUTCOMES Ultrafiltration Management STRATEGIES TO MAXIMIZE LONG DWELL UF CAPD/APD Ultrafil • If the patient manifests negative UF during the long dwell — Utilize alternate osmotic agent — Shorten dwell time — Replace single long dwell exchange with two exchanges — Increase dextrose concentration ∑ • If the patient has adequate UF during the long dwell: — Minimize use of 4. 42 © Copyright 2004.

Pediatric Guide-SC3. 43 .qxd 2/17/04 1:31 PM Page 43 CLINICAL PROCESS FOR OPTIMAL OUTCOMES Ultrafiltration Management Ultrafiltration response to 1. All rights reserved. Baxter Healthcare Corporation. © Copyright 2004.5% dextrose based on peritoneal transport type utions.5% dextrose based on peritoneal transport type embrane Ultrafiltration response to 2.

Pediatric Guide-SC3. Baxter Healthcare Corporation. .qxd 2/17/04 1:31 PM Page 44 CLINICAL PROCESS FOR OPTIMAL OUTCOMES Ultrafiltration Management Ultrafiltration response to 4. All rights reserved.25% dextrose based on peritoneal transport type 44 © Copyright 2004.

All rights reserved. 45 .ort type Pediatric Guide-SC3. Baxter Healthcare Corporation.qxd 2/17/04 1:31 PM Page 45 CLINICAL PROCESS FOR OPTIMAL OUTCOMES Ultrafiltration Management Ultrafiltration response to dextrose © Copyright 2004.

.qxd 2/17/04 1:31 PM Page 46 Pe © Copyright 2004. All rights reserved.Pediatric Guide-SC3. Baxter Healthcare Corporation.

qxd Peritonitis Management .2/17/04 1:31 PM Page 47 Peritonitis Management Pediatric Guide-SC3.

patient factors.exit site infections.add heparin 500 U/L to new bag until effluent clears (usually 48–72 hours) • In asymptomatic patients with only cloudy effluent.Gram stain and culture prior to administration of antibiotics • In presence of cloudy effluent.tunnel infections STEP 4 CONTINUES ON THE TOP OF PAGE 49. Baxter Healthcare Corporation..begin 2–3 rapid exchanges • Add intraperitoneal antibiotics for duration of required therapy • Add heparin 500 U/L to each bag until clear • Report persistent cloudiness to PD unit • Schedule retraining for technique issues STEP 4 OUTCOMES EVALUATION • Date of culture.drug therapy • Date infection resolved • Recurrent organisms. an In pat infection omm history Cefaz Cepha Ceftaz Vanco Teico * Continue tables fo — For p (24–4 cleari needs ..date of drug therapy • Method of interim renal replacement therapy • Date of catheter removal • Date of new catheter reinsertion • Document contributing factors — Break-in technique.schedule re-evaluation of total (dialysis plus residual renal function) creatinine clearance and Kt/V urea STEP 3 Optimal long-t Prevention of most importan following the prompt interv © Copyright 2004. 48 • Date of re • Re-evalua • Enter data KEY ACTIVITIES Initiate the following (Performed by the patient or by the PD nurse in the dialysis unit): • Disconnect drained bag and send sample to laboratory for cell count with differential.qxd 2/17/04 1:31 PM Page 48 Peritonitis Management CLINICAL PROCESS FOR OPTIMAL OUTCOMES Peritonitis Management INITIAL EMPIRIC MANAGEMENT OF PERITONITIS STEP 1 STEP 4 ..initiation of therapy may be delayed 2–3 hours until laboratory results are available • In presence of cloudy effluent with pain and/or fever: — Begin 2–3 rapid exchanges to relieve discomfort — Initiate empiric antibiotic therapy within 1 hour while waiting for test results • Consider antifungal prophylaxis to accompany antibiotic therapy • After peritonitis resolved. KEY ASSESSMENTS • Cloudy effluent • Abdominal pain and/or fever An empiric diagnosis of peritonitis should be made if: • Peritoneal effluent is cloudy and • Effluent with WBC >100/mm3 of which at least 50% are polymorphonuclear neutrophils (PMN) STEP 2 PATIENT/PARENTS’ EDUCATION • Immediately report cloudy effluent.. abdominal pain and/or fever to PD unit • Obtain specimen of effluent for laboratory testing prior to administration of antibiotics • Initiate palliative steps — In presence of pain.Pediatric Guide-SC3. All rights reserved.organism.

. 49 .ent NITIS Pediatric Guide-SC3. without fever and/or severe abdominal pain. refer to subsequent tables for specific organisms cultured and antibiotic dosing recommendations. then 20 mg/L in each exchange 15 mg/kg in single exchange q 5–7 days * Continued assessment and modification of therapy are based on culture and sensitivity results. a history of MRSA infection.1 software) MN) stain and 2/17/04 THERAPEUTICS—EMPIRIC THERAPY 0 hour Initiate Empiric Therapy* with Cefazolin or Cephalothin and Ceftazidime or Glycopeptide (Vancomycin or Teicoplanin) and Ceftazidime In patients with cloudy effluent. This does not apply to asymptomatic patients or those with ultrafiltration needs requiring more frequent exchanges.qxd –72 hours) 3 hours until ) creatinine 1:31 PM Page 49 CLINICAL PROCESS FOR OPTIMAL OUTCOMES Optimal long-term management of the peritoneal dialysis patient hinges on prevention of peritonitis. © Copyright 2004. the combined intraperitoneal administration of a first-generation cephalosporin and ceftazidime is recommended. Baxter Healthcare Corporation. All rights reserved.. the patient’s adherence to aseptic technique during the exchange procedure and following the protocol for exit site care.. then 125 mg/L in each exchange 15 mg/kg in single exchange q day Vancomycin 500 mg/L load. and no risk factors for severe infection.POET 2. — For patients on automated peritoneal dialysis (APD) with short dwell times for routine therapy. use of advanced disconnect systems and most importantly. In patients with fever and/or severe abdominal pain. until there is clearing of the peritoneal effluent. the initial (24–48 hours) treatment of peritonitis should include a prolongation of dwell time to 3–6 hours. then 30 mg/L in each exchange 30 mg/kg in single exchange q 5–7 days Teicoplanin 200 mg/L load.g. OF PAGE 49. Early identification of the signs and symptoms of peritonitis and prompt intervention should be emphasized in the patient training program and follow-up care. Continuous Dosing Intermittent Dosing Cefazolin or Cephalothin 250 mg/L load.. STEP 4 . then 125 mg/L in each exchange 15 mg/kg in single exchange q day Ceftazidime 250 mg/L load.. a recent history or current evidence of an exit site/tunnel or nasal/exit site colonization with S. aureus.RenalSoft Access Management. Prevention of peritonitis includes proper catheter placement. CONTINUED • Date of re-education/training • Re-evaluation of total (dialysis plus residual renal function) creatinine clearance and Kt/V urea • Enter data into catheter management database (e. and in patients younger than 2 years. a glycopeptide combined with ceftazidime should be administered.

qxd 2/17/04 1:31 PM Page 50 CLINICAL PROCESS FOR OPTIMAL OUTCOMES Peritonitis Management GRAM POSITIVE AND GRAM NEGATIVE PERITONITIS STEP 1 STEP 4 .. C KEY ASSESSMENTS • Cloudy effluent • Abdominal pain and/or fever An empiric diagnosis of peritonitis should be made if: • Peritoneal effluent is cloudy and • Effluent with WBC >100/mm3.abdominal pain and/or fever to PD unit • Obtain specimen of effluent for laboratory testing prior to administration of antibiotics • Initiate palliative steps — In presence of pain. Gram stain and culture • In presence of cloudy effluent add heparin 500 U/L to new bag until effluent clears (usually 48 to 72 hours) • In asymptomatic patients with only cloudy effluent.begin 2–3 rapid exchanges • Add intraperitoneal antibiotics for duration of required therapy • Add heparin 500 U/L to each bag until clear • Report persistent cloudiness to PD unit • Schedule retraining for technique issues STEP 4 an E S Disconti glycope start a **A seco aminog based o p Vancom may be u OUTCOMES EVALUATION • Date of culture. *Refer to ** NOTIC on Periton tivation of antibiotics to exercise Handbook ..organism.of which at least 50% are polymorphonuclear neutrophils (PMN) STEP 2 KEY ACTIVITIES Initiate the following (Performed by the patient or by the PD nurse in the dialysis unit): • Disconnect drained bag and send sample to laboratory for cell count with differential.date of drug therapy • Method of interim renal replacement therapy • Date of catheter removal • Date of new catheter reinsertion • Document contributing factors — Break-in technique.Pediatric Guide-SC3.exit site infections.. All rights reserved. 50 • Date of re-e • Re-evaluatio • Enter data in © Copyright 2004.patient factors.. Baxter Healthcare Corporation.drug therapy • Date infection resolved • Recurrent organisms.schedule re-evaluation of total (dialysis plus residual renal function) creatinine clearance and Kt/V urea STEP 3 PATIENT/PARENTS’ EDUCATION • Immediately report cloudy effluent.tunnel infections STEP 4 CONTINUES ON THE TOP OF PAGE 51.initiation of therapy may be delayed 2 to 3 hours until laboratory results are available • In presence of cloudy effluent with pain and/or fever: — Begin 2–3 rapid exchanges to relieve discomfort — Initiate empiric antibiotic therapy within one 1 while waiting for test results • Consider antifungal prophylaxis to accompany antibiotic therapy • After peritonitis is resolved.

reculture and evaluate • Consider ultrasound evaluating for occult tunnel infection • For peritonitis with exit site or tunnel infection. THERAPEUTICS — GRAM POSITIVE PERITONITIS 0 hour Initiate Empiric Therapy* with Cefazolin or Cephalothin and Ceftazidime or Glycopeptide (Vancomycin or Teicoplanin) and Ceftazidime 24–48 hours Gram Positive Organism on Culture (Choice of therapy guided by sensitivity patterns) Enterococcus Streptococcus Staphylococcus aureus Other Gram Positive Organisms Discontinue cephalosporin or glycopeptide and ceftazidime. CONTINUED • Date of re-education/training • Re-evaluation of total (dialysis plus residual renal function) creatinine clearance and Kt/V urea • Enter data into catheter management database (e. Ref.g. Baxter Healthcare urges physicians to exercise good medical judgment in selecting antibiotic combinations in the treatment of peritonitis... 58th ed. 51 . Baxter Healthcare Corporation. continue cephalosporin **A second antibiotic such as an aminoglycoside may be added based on sensitivity results and patient response Vancomycin or clindamycin may be used in case of ampicillin resistance Methicillin resistant: Discontinue ceftazidime Continue or substitute glycopeptide or clindamycin 96 hours • If no improvement. 2002.. ASHP...RenalSoft Access Management. Baxter Healthcare is aware of literature which documents the potential inactivation of aminoglycosides by ampicillin in parenteral solution. 12th ed. The manufacturer’s precaution labeling states that these antibiotics should not be mixed together in the same solution container (see references).POET 2. Physician’s Desk Reference. Trissel. Macmillan Publishers LTD. All rights reserved. start ampicillin 125 mg/L Methicillin sensitive: Continue cephalosporin Discontinue ceftazidime and glycopeptide.1 software) PMN) to 72 hours) o 3 hours until on) creatinine OF PAGE 51. consider catheter removal Duration of Therapy 14 Days 21 Days 14 Days *Refer to Initial Empiric Management of Peritonitis and antibiotic dosing recommendations (page 49) ** NOTICE: The therapeutic recommendations provided above are those recommended by the ISPD Advisory Committee on Peritonitis Management in Pediatric Patients.qxd 2/17/04 1:31 PM Page 51 CLINICAL PROCESS FOR OPTIMAL OUTCOMES ent ONITIS STEP 4 . © Copyright 2004. LA. consider addition of rifampin 20 mg/kg/day PO in divided doses (maximum 600 mg/day) Methicillin sensitive: Discontinue ceftazidime and glycopeptide.Pediatric Guide-SC3. Handbook on Injectable Drugs.

ciprofloxacin. . add agent with activity against this pseudomonas/ stenotrophomonas** Consider surgical intervention and add metronidazole 15 mg/kg/day in divided doses every 8 hours (maximum dose 1.qxd 2/17/04 1:31 PM Page 52 CLINICAL PROCESS FOR OPTIMAL OUTCOMES Peritonitis Management GRAM NEGATIVE PERITONITIS THERAPEUTICS — GRAM NEGATIVE PERITONITIS 0 hour Initiate Empiric Therapy* with Cefazolin or Cephalothin and Ceftazidime or Glycopeptide (Vancomycin or Teicoplanin) and Ceftazidime 24–48 hours Gram Negative Organism on Culture (Choice of therapy guided by sensitivity patterns) Single Gram Negative Organism (Non-Stenotrophomonas) Adjust antibiotics to sensitivity patterns. ** Additional agents may include piperacillin. remove catheter • If no clinical improvement and exit site infection present.Pediatric Guide-SC3. *** Duration may need to be adjusted on clinical grounds but never shorter than recommended. IV or rectally 96 hours • Clinical improvement: continue above therapy • No clinical improvement: repeat cell count.5 gm/day). aminoglycoside or aztreonam as susceptibility indicates. Baxter Healthcare Corporation. remove catheter Duration of Therapy*** 14 Days 21 Days 21 Days * Refer to Initial Empiric Management of Peritonitis and Antibiotic Dosing Recommendations (page 49). PO. culture and Gram stain • If culture remains positive. 52 © Copyright 2004. All rights reserved. continue ceftazidime. May continue ceftazidime Pseudomonas/ Stenotrophomonas Multiple Organisms and/or Anaerobes Discontinue cephalosporin or glycopeptide.

y Management of Growth Failure er .Pediatric Guide-SC3. Baxter Healthcare Corporation. ity © Copyright 2004. . All rights reserved.qxd 2/17/04 1:31 PM Page 53 Management of Growth Failure ent n) ms es l dd ded rs m/day).

88 SDS) • Goal while still growing: target height standard deviation score (SDS) (= midparental height SDS) Heigh Check PATTERNS OF GROWTH FAILURE • Loss of relative height (downward crossing of percentiles) • Percentile-parallel growth below third percentile • Subnormal pubertal growth spurt acid-bas FACTORS CONTRIBUTING TO UREMIC GROWTH FAILURE • Malnutrition (most important factor in infants) Evide • Electrolyte imbalance (sodium. > –1.5 cm for boys. –6. All rights reserved.e. S (g .5 cm for girls) • Minimal: final adult height above third percentile (i.qxd 2/17/04 1:31 PM Page 54 CLINICAL PROCESS FOR OPTIMAL OUTCOMES Management of Growth Failure Management of Growth Failure TREATMENT GOAL • Optimal: final adult height = midparental height (i.. potassium deficiency. Baxter Healthcare Corporation. mean of parents’ heights +6.e.Pediatric Guide-SC3.. metabolic acidosis) • Impaired growth hormone/IGF-1 action (most important factor beyond infancy) • In adolescents: delayed onset of puberty • Infection/inflammation (occult or overt) Ina • Medications (glucocorticoids) • Complete loss of residual renal function • Inadequate dialysis • Excessive dialytic protein losses Excessiv or low- • Low-turnover bone disease/severe secondary hyperparathyroidism • Severe psychosocial stress/depression/anorexia Si infec OUTCOME EVALUATION • Monthly measurement of supine length/standing height • Annual bone age assessment 54 © Copyright 2004.

Pediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 55 CLINICAL PROCESS FOR OPTIMAL OUTCOMES MANAGEMENT OF GROWTH FAILURE DURING DIALYSIS Height <3rd percentile for age and deviating Height <3rd percentile but growing along percentiles Height still normal but losing percentiles Check anthropometric status Check nutritional intake Check labs arental y) Evidence of acid-base/electrolyte imbalance? yes Correct by supplementation to total CO2 22mEq/L yes Go to malnutrition algorithm yes Go to NIPD/CCPD/CAPD maintenance prescription algorithms yes Go to uremic hyperparathyroidism algorithm yes Find and treat underlying cause no Evidence of malnutrition? no Inadequate dialysis? Monitor growth for 3 months after correction of problem no Excessive renal osteodystrophy or low-turnover bone disease? Growth rate improved? no Signs of subclinical infection/inflammation? no yes no Start rGH treatment (go to rGH algorithm) © Copyright 2004. Baxter Healthcare Corporation. All rights reserved. Continue current management 55 .

All rights reserved.5 cm for girls) • Minimal: final adult height above third percentile (i.. mean of parents’ heights +6.Pediatric Guide-SC3.88) • At least ev • Before and funduscop rGH DOSE • 0.c.05 mg/kg/day by once daily subcutaneous injection Ad • Consider dose doubling in primary or secondary nonresponders STRATEGIES FOR OPTIMIZED USE OF rGH • Correct/treat causes of growth failure before start of rGH: — Electrolyte imbalance (sodium.. injections • Continue therapy until transplantation or attainment of target height SDS • Be alert to possibility of catch-down growth after discontinuation • Discontinue rGH if persistently ineffective (height velocity <2 cm/year above pretreatment level).e.5 cm for boys. Cont Perform r Transplantat Discontinue rG Re-evaluate growth after months Catch yes Resume rGH treatment . particularly in patients with syndromal growth failure 56 © Copyright 2004.qxd 2/17/04 1:31 PM Page 56 CLINICAL PROCESS FOR OPTIMAL OUTCOMES Recombinant Growth Hormone Therapy TREATMENT GOAL BASELIN • Optimal: final adult height = midparental height • Monthly: m (i. Baxter Healthcare Corporation. systemic causes) — Glucocorticoid medication — Inadequate dialysis — Inadequate treatment of renal osteodystrophy • Start early in the course of chronic renal failure • Start before growth retardation is severe • Never use less than standard dose • Regularly adjust dose to body weight • Assure compliance with daily s. >–1. metabolic acidosis) — Hypothyroidism (frequent in patients with cystinosis!) — Latent or overt inflammation (consider focal.1 SDS /treatment year in subsequent years (as long as height SDS < –1. –6.88 SDS) • Goal while still growing: target height SDS (= midparental height SDS) • Every 3 mo • Every 12 m SAFETY RESPONSE CRITERIA • Baseline: h • Increase in annual height velocity by >2 cm/year above baseline height velocity in first 2 • Initial 1–2 treatment years • Change in standardized height by >0. potassium deficiency.e.

increase within 4 weeks to 0. Perform regular safety checks Transplantation Target height SDS exceeded Discontinue rGH. All rights reserved. alkaline phosphatase ars (as long • Before and at least every 12 months after start of treatment: glycosylated hemoglobin.Pediatric Guide-SC3. Baxter Healthcare Corporation.05 mg/kg/day Monitor growth monthly for 6 months no Annualized height velocity increased by >2 cm/year? ) Continue treatment. 57 .025 mg/kg/day. start with 0. funduscopy (exclude benign intracranial hypertension) MANAGEMENT OF rGH THERAPY Administer rGH once daily. Re-evaluate growth after 12 months Discontinue rGH. Evaluate height velocity every 3–4 months yes Continue treatment. Perform regular safety checks Secondary nonresponsiveness (drop of 6-month height velocity to pretreatment level) Signs of subclinical inflammation ? yes Find and treat underlying disorder yes Improve nutritional status yes Increase dialysis dose no Catch-down growth? New evidence of malnutrition? no yes Resume rGH treatment no Continue monitoring Rapid loss of residual GFR/signs of inadequate dialysis? yes no Consider doubling rGH dose no Annualized height velocity increased by >2 cm/year 3 months after intervention? © Copyright 2004.qxd 2/17/04 1:31 PM Page 57 CLINICAL PROCESS FOR OPTIMAL OUTCOMES h BASELINE/OUTCOME EVALUATION • Monthly: measurement of supine length/standing height • Every 3 months: puberty staging in peripubertal patients • Every 12 months: hand and wrist X-ray SAFETY EVALUATION • Baseline: hip X-rays y in first 2 • Initial 1–2 months: intensified monitoring of blood pressure and fluid status • At least every 3 months: intact PTH.

qxd 2/17/04 1:31 PM Page 58 © Copyright 2004. All rights reserved.Pediatric Guide-SC3. . Baxter Healthcare Corporation.

qxd .2/17/04 1:31 PM Page 59 Management of Malnutrition Management of Malnutrition Pediatric Guide-SC3.

qxd 2/17/04 1:31 PM Page 60 CLINICAL PROCESS FOR OPTIMAL OUTCOMES Management of Malnutrition TREATMENT GOAL RESPONS • Energy intake — 100% RDA • Percentile- • Protein intake — 120% RDA height per • Energy int dietary ass • Water soluble vitamin intake — 100% RDA • BMI. skinfolds within normal range for height age • Linear growth at target height SDS STRATEG Management of Malnutrition MANIFESTATIONS • Suppleme • Poor weight gain • Institute co • Poor growth • Consider c • Poor brain growth during infancy • Maintain r • Poor school performance • Impaired exercise activity • Impaired wound healing • Impaired sense of well-being/quality of life CONTRIBUTING FACTORS • Anorexia • Emesis • Food refusal • Food preference • Peritonitis • Inadequate dialysis • Constipation • Gastroesophageal reflux • Pica • Economic factors • Impaired physical eating skills 60 © Copyright 2004.Pediatric Guide-SC3. OUTCOM • Monthly: m and skinfo • Every 3 mo . Baxter Healthcare Corporation. All rights reserved.

All rights reserved. 61 . head circumference and skinfolds (if available). Baxter Healthcare Corporation.qxd 2/17/04 1:31 PM Page 61 CLINICAL PROCESS FOR OPTIMAL OUTCOMES RESPONSE CRITERIA • Percentile-parallel growth and weight gain (catch-up pattern if below target height percentile) • Energy intake = 100%. protein intake 120% of individual requirement (RDA) by dietary assessment STRATEGIES FOR ENTERAL TUBE SUPPORT • Supplement may be provided by bolus or continuous infusion • Institute continuous feedings at rate of approximately 1–2 mL/kg/hr • Consider concomitant use of antiemetic/motility agents if emesis present • Maintain regular oral stimulation during infancy to enhance oral-motor development OUTCOMES EVALUATION • Monthly: measurement of supine length/standing height.Pediatric Guide-SC3. weight. biochemical assessment • Every 3 months: head circumference until age 36 months © Copyright 2004. calculation of BMI.

. All rights reserved. infection. fundoplication. anthropometric status and biochemistry Review dietary (formula) prescription.qxd 2/17/04 1:31 PM Page 62 CLINICAL PROCESS FOR OPTIMAL OUTCOMES Management of Malnutrition MANAGEMENT OF MALNUTRITION WITH GROWTH FAILURE IN INFANTS Evidence of malnutrition based on dietary history. Consider rGH treatment *Malnourished infants/small children should receive NG feeds for 3–4 months prior to PEG placement to decrease risk of leak.Pediatric Guide-SC3. Consider jejunal PEG. 62 © Copyright 2004. frequent small-volume feeding) no Nutritional status improved? yes Psychosocial assessment and intervention if necessary. Baxter Healthcare Corporation. Monitor nutritional status for 1–2 months Nutritional status improved? GR Apply K/DOQI Pediatric Nutritional Guidelines yes no Start PEG/NG tube feeding.* Monitor nutritional status for 1–2 months Nutritional status improved? yes no Frequent vomiting? no yes Growth rate improved? no yes Start rGH treatment (see growth hormone algorithm) Continue current management Modify feeding patterns (continuous nocturnal pump.

All rights reserved.qxd 2/17/04 1:31 PM Page 63 CLINICAL PROCESS FOR OPTIMAL OUTCOMES MANAGEMENT OF MALNUTRITION WITH GROWTH FAILURE IN SCHOOLCHILDREN AND ADOLESCENTS Evidence of malnutrition based on dietary history. Increase energy intake if insufficient. consider psychosocial assessment Apply K/DOQI Pediatric Nutritional Guidelines Monitor nutritional status for 2–3 months Nutritional status improved? yes no Consider PEG/NG tube feeding. © Copyright 2004. 63 . Baxter Healthcare Corporation. anthropometric status and biochemistry Intensify dietary counseling.Pediatric Guide-SC3. Consider psychosocial intervention Growth rate improved? no yes Start rGH treatment (see growth hormone algorithm) Continue current management Monitor nutritional status for 2–3 months Nutritional status improved? no yes Consider rGH treatment .

Pediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 64 M © Copyright 2004. Baxter Healthcare Corporation. . All rights reserved.

qxd 2/17/04 1:31 PM Page 65 Mineral Metabolism Mineral Metabolism © Copyright 2004. All rights reserved.Pediatric Guide-SC3. . Baxter Healthcare Corporation.

qxd 2/17/04 1:31 PM Page 66 CLINICAL PROCESS FOR OPTIMAL OUTCOMES Management of Calciumphosphate Metabolism TREATMENT GOAL • Normal bone turnover • Prevention of vascular and soft tissue calcifications • Control of hyperparathyroidism • Normal growth • Prevention of skeletal deformities (rickets) Hyperphosphatemia MANIFESTATIONS • Hyperparathyroidism • Soft tissue and vascular calcifications H MANIFES • Uremic os — gro — bon — ske — abn — den — red • Myocardia • Myopathy • Vascular a • Hypercalce CONTRIB • Hyperpho CONTRIBUTING FACTORS Mineral Metabolism • Impaired renal phosphate excretion • Dietary phosphorus intake (meat. milk products) • Inadequate dialysis: — low fill volume.75 mM/3.Pediatric Guide-SC3. — lack of daytime dwell(s) in APD • Insufficient dietary phosphate binder therapy or • Nonadherence to phosphate binder prescription TREATM • Dietary ph • Phosphate Hypercalcemia MANIFESTATIONS • Low-turnover bone disease • Soft tissue and vascular calcifications CONTRIBUTING FACTORS • Severe hyperparathyroidism • Vitamin D toxicity • Low turnover bone disease • Use of calcium containing phosphate binders • Use of high calcium PD fluid (1. — calc — sev • Oral calcit — com hyp RESPONS • Serum pho • Serum inta OUTCOM • Serum calc • Serum inta • Serum alk . All rights reserved.5 mEq/L Ca2+) 66 — ina -— ina • Decreased • Hypocalce — hyp — dec — ske © Copyright 2004. Baxter Healthcare Corporation.

All rights reserved. 67 . phosphorus every 4 weeks • Serum intact PTH at least every 2–3 months • Serum alkaline phosphatase activity every 6 months © Copyright 2004. neuropathy • Vascular and soft tissue calcifications • Hypercalcemia CONTRIBUTING FACTORS • Hyperphosphatemia due to: — inadequate dietary phosphorus restriction -— inadequate oral phosphate binder therapy • Decreased levels of calcitriol due to impaired renal calcitriol synthesis • Hypocalcemia due to: — hyperphosphatemia. Baxter Healthcare Corporation. calcium and calcium-phosphorus ion product in normal range for age • Serum intact PTH 150–300 pg/mL (normal 10–65 pg/mL) OUTCOMES EVALUATION • Serum calcium.qxd 2/17/04 1:31 PM Page 67 CLINICAL PROCESS FOR OPTIMAL OUTCOMES Hyperparathyroidism MANIFESTATIONS • Uremic osteodystrophy — growth failure — bone pain — skeletal deformities — abnormal gait — dental abnormalities — red eye syndrome • Myocardial fibrosis • Myopathy.mm Pediatric Guide-SC3. — decreased GI calcium absorption — skeletal resistance to PTH TREATMENT STRATEGIES • Dietary phosphorus restriction • Phosphate binder therapy — calcium carbonate/acetate if serum calcium low or normal — sevelamer if hypercalcemia present or Ca intake with binders >200% RDA • Oral calcitriol therapy — combined with low-calcium PD fluid and/or sevelamer in the presence of hypercalcemia RESPONSE CRITERIA • Serum phosphorus.

Ma .5 mmol/L Pi normal or elevated Reduce calcitriol dose by 50% PTH 150–300 pg/mL Ca <2.5 mmol/L Pi elevated Hold calcitriol and consider calcitriol analogue. Increase dialytic phosphate clearance (dialysate quantity/daytime dwell). Continue phosphate binders PTH >300 pg/mL Ca <2. If persistent: consider subtotal parathyroidectomy © Copyright 2004. All rights reserved.Pediatric Guide-SC3. Reduce or hold calcium carbonate/acetate. Use low-calcium PD fluid.5 mmol/L (10mg/dl) Pi normal or elevated Discontinue calcitriol.5 mmol/L Pi in normal range Start/increase calcitriol PTH >300 pg/mL Ca <2. Reduce or hold calcium carbonate/acetate and add calcium/aluminum-free phosphate binder PTH <150 pg/mL Ca <2. Start/increase calcium carbonate/acetate PTH >500 pg/mL Ca >2. Baxter Healthcare Corporation.qxd 2/17/04 1:31 PM Page 68 CLINICAL PROCESS FOR OPTIMAL OUTCOMES MANAGEMENT OF UREMIC HYPERPARATHYROIDISM IN CHILDREN ON PD PTH <150 pg/mL Ca >2. and add calcium/aluminum-free phosphate binder.5 mmol/L Pi elevated Intensify dietary counseling. Use low-calcium PD fluid.5 mmol/L Pi in normal range Continue/reinstitute calcitriol.

Pediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 69 Management of Anemia Management of Anemia © Copyright 2004. All rights reserved. . Baxter Healthcare Corporation.

sickle cell anemia) • Malnutrition • Inadequate dialysis • Aluminum toxicity OUTCOME EVALUATION • Hemoglobin/hematocrit at least monthly • Serum ferritin/TSAT monthly until stable. All rights reserved. elixir. If using d . B6 and folate deficiency • Carnitine deficiency • Secondary hyperparathyroidism • Infection/inflammation • Surgery • Trauma • Hemolysis • Medications (e. tablets) 33% elemental iron — Polysaccharide iron complex (capsules. tablets) • Intravenous — Iron dextran — Ferric gluconate — Iron sucrose 70 © Copyright 2004.Pediatric Guide-SC3.. functional) • Blood loss • Vitamin B12. dried 30% elemental iron — Ferrous fumarate (drops. tablets.qxd 2/17/04 1:31 PM Page 70 CLINICAL PROCESS FOR OPTIMAL OUTCOMES Management of Anemia TREATMENT GOAL • Hemoglobin 11–12 g/dL • Hematocrit 33–36% MANIFESTATIONS • Anorexia • Fatigue • Decreased exercise capacity • Increased risk for patient mortality • Left ventricular hypertrophy • Poor cardiac function • Impaired school performance CONTRIBUTING FACTORS Management of Anemia • Iron deficiency (absolute. ACE inhibitors) • Hemoglobinopathies (alpha & beta thalassemia. drops. suspension.g. capsules) powder 20% elemental iron. then every 3 months IRON PREPARATIONS • Oral iron (3–5 mg/kg/day elemental iron) — Ferrous gluconate (tablets) 12% elemental iron — Ferrous sulfate (syrup. Baxter Healthcare Corporation. elixir.

All rights reserved. Repeat Hgb in 1–2 weeks Monitor Hgb every 1–2 weeks following initiation and monthly during maintenance therapy.5 µg darbepoetin alfa]. 71 .Pediatric Guide-SC3. if epoetin dosing once weekly.75 g/dL weekly up to target Hgb of 11–12 g/dL? no Factors present that decrease EPO effect? Continue current therapy yes no Identify and correct factors Increase EPO dosage 25%. convert to darbepoetin alfa dosing once weekly. convert to darbepoetin alfa dosing every other week [100 IU epoetin = 0. provide weekly equivalent epoetin dose. INITIATION OF ERYTHROPOIETIN (EPO) THERAPY Hgb <11 gm/dL and/or presence of anemia-related symptoms Iron replete or receiving iron therapy? no yes See iron administration algorithm Initiate subcutaneous EPO therapy at 50 u/kg/dose twice weekly (>5 yrs) or 100 u/kg/dose twice weekly (<5 yrs) yes Hgb increase 0.5–0. © Copyright 2004. If using darbepoetin alfa. if epoetin dosing 2–3 times weekly. Baxter Healthcare Corporation.qxd 2/17/04 1:31 PM Page 71 CLINICAL PROCESS FOR OPTIMAL OUTCOMES mia mental iron.

convert to darbepoetin alfa dosing every other week [100 IU epoetin = 0. if epoetin dosing once weekly.Pediatric Guide-SC3. Repeat Hgb in 1–2 weeks yes Factors pres that decrea EPO effec no See iron management algorithm yes Identify and correct other factors Monitor Hgb every 1–2 weeks following initiation and monthly during maintenance therapy.qxd 2/17/04 1:31 PM Page 72 CLINICAL PROCESS FOR OPTIMAL OUTCOMES Management of Anemia MAINTENANCE ERYTHROPOIETIN (EPO) THERAPY Receiving Maintenance EPO Hgb 11–12 g/dL Hgb <11 g/dL Factors present that decrease EPO effect? yes Iron replete? Continue current therapy Hgb >12 g/dL and increasing Patient undergoing surgery or with significant infection Decrease dosage by 25%. 72 © Copyright 2004. Baxter Healthcare Corporation.5 µg darbepoetin alfa]. Repeat Hgb in 1–2 weeks TSAT >20 ser >100 ng/m no Hgb <1 large Increase EPO dosage by 25%. if epoetin dosing 2–3 times weekly. Repeat Hgb in 1–2 weeks Increase dosage by 25–50%. All rights reserved. If using darbepoetin alfa. convert to darbepoetin alfa dosing once weekly. provide weekly equivalent epoetin dose. .

qxd 2/17/04 1:31 PM Page 73 CLINICAL PROCESS FOR OPTIMAL OUTCOMES mia IRON ADMINISTRATION Baseline TSAT* and serum ferritin Initiate oral iron therapy 3–5 mg/kg/day elemental iron g surgery infection 1 month TSAT and serum ferritin ge by . Consider course of IV iron Consider change of oral iron preparation or course of IV iron 1 month Repeat TSAT and serum ferritin Within therapeutic range? no yes Consider course of IV iron yes no Resume iron at 33%–50% lower dose Continue to hold iron therapy and monitor TSAT and serum ferritin monthly Identify and correct weekly.Pediatric Guide-SC3. 73 . –2 weeks TSAT >20% to <50% and serum ferritin >100 ng/mL to <800 ng/mL TSAT <20% and serum ferritin >100 ng/mL TSAT <20% and serum ferritin <100 ng/mL TSAT >50% and/or serum ferritin >800 ng/mL Hgb <11 g/dL and/or large EPO dose? ** Inflammatory block? Compliant with oral iron? Hold iron therapy yes no yes no Functional Treat source of Factors present Continue inflammation iron deficiency that decrease current therapy likely. and re-evaluate EPO effect? Consider course of IV iron yes no Evaluate for blood loss. Baxter Healthcare Corporation. *TSAT = serum FE/TIBC **Large EPO dose is 2–3 x typical age-related dose © Copyright 2004. All rights reserved.

.Pediatric Guide-SC3. Baxter Healthcare Corporation. All rights reserved.qxd 2/17/04 1:31 PM Page 74 © Copyright 2004.

Baxter Healthcare Corporation. . All rights reserved.qxd © Copyright 2004.2/17/04 1:31 PM Page 75 Preparation for Transplantation Preparation for Transplantation Pediatric Guide-SC3.

COMPON Physical Exam • Height. GGTP Serology Stu • Serology f Immunizatio • DPT. All rights reserved. Hep A months of Histocompat • Blood type Radiologic • In infants patency of Consultation • Urology ev obstructive . crea ALT. irreversible neurologic impairment/persistent vegetative state 76 © Copyright 2004. we evaluation Medical Histo • Detailed p Laboratory S • BUN.qxd 2/17/04 1:31 PM Page 76 CLINICAL PROCESS FOR OPTIMAL OUTCOMES Preparation for Transplantation TREATMENT GOALS • Thorough evaluation to determine patient suitability/readiness for transplantation • Detect and treat reversible medical conditions that may influence transplant outcome • Complete all live attenuated viral vaccinations (if possible) 6–12 weeks prior to transplant TIMING OF EVALUATION • When progression toward end stage renal disease becomes evident • When patient/family is medically/psychologically prepared for evaluation and subsequent transplant INDICATION FOR TRANSPLANTATION • Symptoms of uremia not responsive to standard medical therapies • Failure to thrive due to limitations in total caloric intake • Delayed psychomotor development • Hypervolemia • Hyperkalemia • Metabolic bone disease due to renal osteodystrophy not responsive to standard medical therapies CONTRAINDICATION FOR TRANSPLANTATION • Active or untreated malignancy • HIV infection • Chronic active infection with Hepatitis B • Severe multiorgan failure that precludes a combined transplant with a kidney Preparation for Transplantation • Severe.Pediatric Guide-SC3. Baxter Healthcare Corporation.

ophthalmologic evaluation Medical History • Detailed patient and family medical history. dental evaluation. AST. glucose. pelvic examination (if applicable). influenza. record of all blood transfusions Laboratory Studies • BUN. HZV. cross-match Radiologic • In infants and small children with history of central venous access. Hep A and B.ion utcome transplant ubsequent d medical Pediatric Guide-SC3. HIV and Hepatitis A. HIB. monthly PRA Serology Studies • Serology for CMV.C Immunizations • DPT. IPV. phosphorus. weight. PTT. albumin.B. 77 . CBC with differential/platelets. creatinine. PT. Baxter Healthcare Corporation. EBV. magnesium. ALT. All rights reserved. electrolytes. calcium. HLA. obstructive uropathy © Copyright 2004. VZV. CT/MRI evaluation for patency of abdominal and pelvic vasculature Consultation • Urology evaluation for assessment of children with history of bladder dysfunction. PRA. pneumococcal.qxd 2/17/04 1:31 PM Page 77 CLINICAL PROCESS FOR OPTIMAL OUTCOMES COMPONENTS OF EVALUATION Physical Exam • Height. VZV and MMR (not within 2 months of transplant) Histocompatibility • Blood type. GGTP.

Delay transplant following live virus vaccines no Complete testing yes Psychosocial assessment of patient and family complete? yes Laboratory and serologic evaluation completed and satisfactory? yes Genitourinary evaluation completed and satisfactory? yes Immunizations up-to-date? yes Histocompatibility testing completed? yes 78 Recipient Preparation Complete © Copyright 2004.Pediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 78 CLINICAL PROCESS FOR OPTIMAL OUTCOMES Preparation for Transplantation Preparation for Transplant Recipient Evaluation Medical/nutritional history and physical examination completed? no Complete assessment. . Dietary consult if indicated no Refer to Psychologist/Social Worker no Obtain outstanding laboratory data no Refer to pediatric urologist. Review GU history and radiologic/urodynamic results no Provide immunizations. Baxter Healthcare Corporation. All rights reserved.

Baxter Healthcare Corporation.qxd 2/17/04 1:31 PM Page 79 CLINICAL PROCESS FOR OPTIMAL OUTCOMES Donor selection Donor options discussed with patient/family? no Conference with patient/family and transplant personnel yes Decision made? yes no Proceed with LD transplant evaluation or list for cadaveric donation Continue decision process © Copyright 2004. 79 .Pediatric Guide-SC3. All rights reserved.

Pediatric Guide-SC3. Baxter Healthcare Corporation. . All rights reserved.qxd 2/17/04 1:31 PM Page 80 © Copyright 2004.

All rights reserved.qxd Appendix © Copyright 2004. .2/17/04 1:31 PM Page 81 Appendix Pediatric Guide-SC3. Baxter Healthcare Corporation.

G Twenty-four collection (th the growth o its protocol.e. dialysate volume. If a daytime exchange is performed. • Instruct the patient to mix the solution thoroughly and obtain a sample. To perform t • First.. Baxter Healthcare Corporation. Note: When performing 24-hr. Send blood sample to lab for creatinine and urea nitrogen (BUN) measurement. — Measure the 24-hr. or Aliquot Method — Empty each dialysate bag into a measuring container.qxd 2/17/04 1:31 PM Page 82 CLINICAL PROCESS FOR OPTIMAL OUTCOMES Guidelines for 24-Hr Dialysate Collection Appendix CAPD • Have the patient drain and discard dialysate. have • Collect all bacterial b • End the te complete • Draw a blo to lab for c • Measure 2 • Send urine Note: For pat recommended by 2 to create . • Two methods are common for dialysate collection: Batch method — Pool the entire volume of dialysate and mix thoroughly. — Mix all dialysate samples in single container. — Move the decimal point 3 places to the left. — Record the individual bag volume. — Send dialysate sample to lab for creatinine and urea nitrogen (DUN) measurement. • Draw a blood sample in close proximity to the 24-hr collection period.35 mL are placed in the test tube). if effluent volume is 2350 mL. (i. — Repeat the process for all bags. it must be included in the total collection. • Record the total volume drained. collections. standard precautions should be taken when handling blood or drained dialysate. APD • Begin the cycler treatment by draining the patient and saving the drained volume. 2. All rights reserved. Dialysate does not require refrigeration OR a preservative. — Send dialysate sample to lab for creatinine and urea nitrogen (DUN). • Send dialysate sample to lab for creatinine and urea nitrogen (DUN) measurement. • Collect all dialysate during the cycler treatment using a 15-liter drain bag.Pediatric Guide-SC3. • Draw a blood sample in close proximity to the 24-hr collection period. • Collect all dialysate for the next 24 hours. Send to lab for creatinine and urea nitrogen (BUN) measurement. — Draw a final sample of mixed dialysate. 82 © Copyright 2004. Draw this amount in mL from that sample of effluent and place in a red top test tube.

Check with your laboratory for its protocol. have the patient empty his/her bladder and discard urine.r ion OR a Pediatric Guide-SC3. Refrigerate urine OR add thymol to prevent bacterial breakdown of urea • End the test by having the patient empty his/her bladder.qxd 2/17/04 1:31 PM Page 83 CLINICAL PROCESS FOR OPTIMAL OUTCOMES Guidelines for 24-Hr Urine Collection Twenty-four-hour urine collection requires either a preservative be added to the collection (thymol is the recommended preservative) or refrigeration to inhibit the growth of bacteria that can break down urea. daytime o lab for ment. If the sample is a 48-hr collection. Baxter Healthcare Corporation. Send blood sample to lab for creatinine and urea nitrogen (BUN) measurement • Measure 24-hr urine volume • Send urine sample to lab for creatinine and urea nitrogen (UUN) measurement Note: For patients who void infrequently (less than 3 times per 24 hours). All rights reserved. Save the urine to complete the 24-hr collection • Draw a blood sample in close proximity to the 24-hr collection period. a 48-hr collection is recommended. ). when handling © Copyright 2004. the total volume collected should be divided by 2 to create a 24-hr volume result. 83 . ood ) L from that olume is To perform the 24-hr collection: • First. me. • Collect all urine for the next 24 hours.

and V is the distribution volume of urea. Schaefer F and Warady BA.) Dialysis CrCl L/week = 24-Hr D/P Cr x 24-Hr Drained Volume x 7 x 1. and using a different equation may give different values. (Refer to the Body Surface Area chart on pages 18–19. A simple method for determining the volume of urea distribution is to estimate the patient’s total body water. Kt is the urea clearance during the sampling period.098 x ( Ht x Wt )0. Renal Kt/V = mL/min Urea clearance x 1440 min/day x 7 ––––––––––––––––––––––––––––––––––––––– 1000 mL x V *Morgenstern BZ. clearance from their residual function is added to the calculated dialysate clearance for a total combined clearance. Cl Residual rena clearance.63 Dialysis Kt/V = 24-Hr D/P Urea x 24-Hr Drained Volume x 7 –––––––––––––––––––––––––––––––––––––––– V For those patients with renal function.73m2 BSA –––––––––––––––––––––––––––––––––––––––––––––––––– Patient’s BSA *D/P = Dialysate concentration/Plasma concentration Kt/Vurea is the urea clearance normalized for the urea distribution space. The following are simplified formulas to calculate patient clearance.qxd 2/17/04 1:31 PM Page 84 CLINICAL PROCESS FOR OPTIMAL OUTCOMES Clearance Calculations It is important to measure achieved clearances to document the actual dialysis dose received. It is important to note that different equations exist for estimating total body water.Pediatric Guide-SC3. Mahoney DW. J Am Soc Nephrol (abst) 2002. All rights reserved. V can be estimated by the following pediatric total body water prediction equation (Morgenstern et al. Creatinine Clearance (CrCl) calculation is normalized to BSA. Ca Renal Clearan Urea Clearan Creatinine Cle . Baxter Healthcare Corporation.*): TBW ( V ) = 0. Wuhl E. 13: 2A 84 © Copyright 2004. Total Body Water (TBW) in Children on Peritoneal Dialysis.

Renal Clearance: Urea Clearance mL/min = Volume of 24-Hr Urine in mL x Urine Urea Nitrogen Concentration ––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1440 min/day x Blood Urea Nitrogen Concentration Creatinine Clearance mL/min = Volume of 24-Hr Urine in mL x Urine Creatinine Concentration ––––––––––––––––––––––––––––––––––––––––––––––––––– 1440 min/day x Serum Creatinine Concentration is the urea rea. m2 BSA ––––––– Pediatric Guide-SC3. 85 .ns ysis dose ce. Calculate residual renal clearance using the following formulas. All rights reserved. Baxter Healthcare Corporation.qxd 2/17/04 1:31 PM Page 85 CLINICAL PROCESS FOR OPTIMAL OUTCOMES Residual Renal Clearance Calculations Residual renal clearance is calculated as the average of creatinine clearance and urea clearance. A simple patient’s stimating quation s added to on Peritoneal © Copyright 2004.

Pediatric Guide-SC3.7 0. if occurs. Japan) • Test exchange after prolonged (8 hours) dwell. volume may not be tolerable.6 0.5 0.3–2. note infusion time — Keep patient in supine position — Drain <10% of dialysate solution into the drain bag at 0. Also note the dextrose and volume infused — Infuse the calculated fill volume.5% dextrose dialysis solution (North America. Source: Wa Journal of t 86 © Copyright 2004.1 0 Source: War Journal of th D/D0 Glucose *In early infancy.4% anhydrous glucose dialysis solution (Europe) 0.3 0.8 • 2.2 0.4 0. Reinfuse any remaining effluent — Obtain blood sample after 120 minutes • Measure creatinine and glucose in each sample • Calculate dialysate to plasma (D/P) creatinine and dialysate glucose to baseline dialysate glucose (D/DO) concentration ratios • Determine transporter state by comparing creatinine and glucose equilibration curves with pediatric reference percentiles (see next page) D/P Creatinine 0. 120 and 240 minutes — Invert bag for mixing and obtain sample. . Baxter Healthcare Corporation. if possible as follows: — Drain the overnight dwell — Record the length of the dwell and the volume drained. conduct PET with regular daily exchange volume for evaluation.qxd 2/17/04 1:31 PM Page 86 CLINICAL PROCESS FOR OPTIMAL OUTCOMES Method of Performing a PET in Children Me • Dwell period: 4 hours • Fill volume: 1100 mL/m2 BSA* • 2. All rights reserved.

.qxd 2/17/04 1:31 PM Page 87 CLINICAL PROCESS FOR OPTIMAL OUTCOMES g Method of Performing a PET in Children PEDIATRIC CREATININE PET CURVE 0.7.1 Time in Hours minutes nt 0 0 2 ■ High ■ High Average ■ Low Average 4 ■ Low Source: Warady.8 dextrose D/P Creatinine 0.5 0.3 0. 1996 p. Vol.5 0. 1 0.Pediatric Guide-SC3.2385-2391 © Copyright 2004.7 0. Vol. et al.6 0. Number 11.6 0. Peritoneal Membrane Transport Function in Children Receiving Long-Term Dialysis Journal of the American Society of Nephrology.7 0. All rights reserved.8 0. Peritoneal Membrane Transport Function in Children Receiving Long-Term Dialysis Journal of the American Society of Nephrology. 1996 p.1 Time in Hours 0 0 2 ■ High ■ High Average ■ Low Average 4 ■ Low Source: Warady..4 0.7. Number 11.2 0.4 0.2 0.9 D/D0 Glucose 0.2385-2391 dialysate curves PEDIATRIC GLUCOSE PET CURVE evaluation. Baxter Healthcare Corporation. 87 . et al.3 0.

10: 17 IPV mL/m 2 IPP cm of water 88 990 ± 160 8. Normal level for children greater than 2 years of age 10. 17.g.. Haffner D. Wuhl E. Schroder CH peritoneal d Supplies • Metric measurement of the height of the dialysis fluid column in the PD tube. Perit D • The zero level of the column is set at the center of the abdominal cavity. on the midaxillary line • The peritoneal cavity is emptied after taking the IPP reading. Kidney Int S 12. V 13. Fischbach M European co 18. Gu 5. correlated to the measured mean IPP • IPP is measured at atmospheric pressure without any counterpressure in the distal part of the measurement tubing. Schroder CH patients.1 ± 3.Pediatric Guide-SC3. for Elective C . Abu-Alfa A. directly connected to the peritoneal cavity (like a central venous pressure) • A rule (scale graduated in centimeters) on a bracket • CAPD connecting system. In Patients. lying in a supine position • Connection with the peritoneal system is made (as usual). Sanchez CP disease. and the patient’s peritoneal cavity is filled • The PD line is fixed vertically on the bracket. so an air inlet is needed. and the volume of the drained dialysis fluid is measured. Baxter Healthcare Corporation. In disconnect systems. determination of mean IPP: 2. Schaefer F.2 ± 3. Y-system) or nondisconnect system Procedure • Patient is at rest. Warady BA. Holloway M rates. Wit Reusz GS. R children nor 8. Am 11. either a disconnect system (e. 15.6 © Copyright 2004. and there is no counterpressure in the distal part of the measurement tubing • The level of the column of dialysis fluid in the PD line is read with a scale graduated in centimeters after the height of the column stabilizes. Bu transplantat of Transplan 6. Sem 4. NKF-K/DOQ pp132-180. All rights reserved. 20(6) 9. S with chronic 343(13):923 7. there is almost always a moderate counterpressure. S. dialysis. K practice of p 16. The technique used depends upon the geometry of the PD system. Verrina E. Watson AR. Co IPP insp + IPP exp –––––––––––––––– 2 2000. Mujais. Fischbach M a useful too 3. NKF-K/DOQ 14. Warady BA. first after deep inspiration (IPP insp) and second after expiration (IPP exp). K properties a 1999.qxd 2/17/04 1:31 PM Page 88 CLINICAL PROCESS FOR OPTIMAL OUTCOMES Measurement of Intraperitoneal Pressure (IPP) 1. Schaefer F. Davis ID. In nondisconnect systems. there is no counterpressure in the line or in the empty drainage bag after the line has been connected.8 1400 ± 50 14. accomplished before the readings are made by introducing a trocar at the injection site of the bag.

Haffner D. Warady BA.17:380-5. Semin Nephrol 2001. Measurement of hydrostatic intraperitoneal pressure: e. Warady BA. Müller-Wiefel DE. Dangelser C. Effect of growth hormone treatment on the adult height of children with chronic renal failure. 33(3):567-583. Grimm PC.s8 12. Benfield MR. Pediatric peritoneal dialysis training: characteristics and impact on peritonitis rates. Klaus G. German Study Group for Growth Hormone Treatment in Chronic Renal Failure. Klaus G. Pediatric renal transplantation: indications and special considerations. 14. 18(10):976-980. J Hypertens 2002. Stefanidis CJ. Optimal care of the pediatric end-stage renal disease patient on dialysis. Mehls O. Kandert M. Watson AR. 4. 3. Danne T. The management of anemia in pediatric peritoneal dialysis patients. S. 20(6):610-624. Perit Dial Int 2001. e of the distal part try of the PD he empty there is plished the bag. Bunchman TE. Peritoneal transport properties and dialysis dose affect growth and nutritional status in children on chronic peritoneal dialysis. Soergel M. 9. Gellermann J. Krull F.qxd 2/17/04 oneal 1:31 PM Page 89 References 1. References the 15. European Paediatric Peritoneal Dialysis Working Group. 19 (Suppl. Nephrol Dial Transplant 2002. Warady BA. Alexander SR.2): S445-S449. Holloway M. pp132-180. Kohaut E. Verrina E.21:240-4. Burkart J. Mehls O. Laugel V. 21(4):401-404. 10. Schaefer F. Alexander S. 8.S17-S22. Divino J. Mujais. Schaefer F. Piraino B. Briscoe DM. N Engl J Med 2000. A position paper from the Pediatric Committee of the American Society of Transplant Physicians. The choice of dialysis solutions in pediatric chronic peritoneal diaysis: guidelines by an ad hoc European committee. Am J Kidney Dis 1999. Alexander SR. Harmon WE. Escande B. Vonesh E. Reusz GS. Guidelines by an ad hoc European committee on adequacy of the paediatric peritoneal dialysis prescription. 20(10):1995-2007. Consensus guidelines for the treatment of peritonitis in pediatric patients receiving peritoneal dialysis. Holl R. Perit Dial Int 2000. International Society for Peritoneal Dialysis *ISPD) Advisory Committee on Peritonitis Management in Pediatric Patients. Perit Dial Int. Schroder CH. Guidelines by an ad hoc European committee. Schaefer F. 2001. 21(1):6.Pediatric Guide-SC3. Wuhl E. Sanchez CP. and Mid European Pediatric Peritoneal Dialysis Study Group (MEPPS). Avner ED. 2001. NKF-K/DOQI Clinical Practice Guidelines for Anemia of Chronic Kidney Disease. European Paediatric Peritoneal Dialysis Working Group. 7. 10: 1786-1792. Mujais S. J Am Soc Nephrol 1999. peritoneal e in the distal aduated in tion (IPP insp) 6. 5. Pulliam J. Wuhl E. Pediatr Nephrol 2003. 20(6):607 and (Erratum) Perit Dial Int Dial 2001. Nissel R. 89 . 21(5):441-450. Rascher W. Fischbach M. Schaefer F. 2001. Perit Dial Int 2001.62. 17. Witte K. Reichert H. 16. Watkins S. Guidelines by an Ad Hoc European Committee for Elective Chronic Peritoneal Dialysis in Pediatric Patients. Profiling of peritoneal ultrafiltration. Approach to fluid management in peritoneal dialysis: A practical algorithm. Pediatr Nephrol 2003. directly a useful tool for the improvement of dialysis dose prescription. Tranaeus A. Terzic J. Salusky I. New York. 2. Holloway M. Helmstetter A.62. 343(13):923-930. 2(2):117-129. NKF-K/DOQI Clinical Practice Guidelines for Nutrition in Chronic Renal Failure. Davis ID. Periton Dial Int 1999. Gartland C. German Working Group on Pediatric Hypertension. Harmon WE. Kirschstein M. Watson AR. Fischbach M. Kidney Int 2002. New York. Piraino B. Mujais S. 18. Tonshoff B. (Comment) Perit Dial Int 2000. Current practice of peritoneal dialysis in children: Results of a longitudinal survey. Prevention and treatment of renal osteodystrophy in children with chronic renal insufficiency and end-stage renal disease. Abu-Alfa A. European Paediatric Peritoneal Dialysis Working Group. Pediatr Transplant 1998. European Pediatric Peritoneal Dialysis Working Group. Schroder CH. National Kidney Foundation. National Kidney Foundation. Mehls O and Mid European Pediatric Peritoneal Dialysis Study Group (MEPPS). Kidney Int Suppl 2002. Distribution of 24-h ambulatory blood pressure in children normalized reference values and role of body dimensions. Mehls O. 21(6):568-574. 13. Busel C. Schaefer F. 18(8):805-809. Kandert M. Honda M. Mujais S. 11.

PediatricCovers. Baxter Healthcare Corporation. PD Adequest. All rights reserved. RenalSoft.QX 2/17/04 1:55 PM Page 3 This information does not reflect the opinions of BAXTER HEALTHCARE CORPORATION. Readers must evaluate this information and make changes in their own patient management practices only if it seems prudent. Baxter assumes no liability for any practice changes that centers make as a result of reading this material. and HomeChoice are trademarks of Baxter Healthcare Corporation © Copyright 2004. . but is that of the authors of the “Care of the Pediatric Patient on Peritoneal Dialysis”.

AL03482 . 5L0476.PediatricCovers. Baxter Healthcare Corporation.QX 2/17/04 1:55 PM Page 4 Care of the Pediatric Patient on Peritoneal Dialysis Clinical Process for Optimal Outcomes © Copyright 2004. All rights reserved.