Pediatr Nephrol (2010) 25:2141–2147
DOI 10.1007/s00467-010-1581-3
ORIGINAL ARTICLE
Specialist pediatric dialysis nursing improves outcomes
in children on chronic peritoneal dialysis
W. D. Vindya N. Gunasekara & Kar-Hui Ng & Yiong-Huak Chan & Eric Aragon &
Pei-Pei Foong & Yew-Weng Lau & Lee-Kean Lim & Chien-Wyei Liew & Wee-Song Yeo &
Hui-Kim Yap
Received: 10 February 2009 / Revised: 29 May 2010 / Accepted: 2 June 2010 / Published online: 18 June 2010
# IPNA 2010
Abstract Chronic peritoneal dialysis (PD) for children in
Singapore was instituted in 1988 at the National University
Hospital with adult nurses providing dialysis services
during the first 10 years. In 1998, a specialist pediatric
dialysis nursing team was recruited. This study was
conducted to determine the impact of dialysis nursing
service on PD-related outcomes during the two nursing
periods. Comparing the adult (group 1) and pediatric (group
2) nursing periods, the peritonitis rate was significantly
higher in group 1 (RR 1.90; 95%CI 1.27–2.84), and this
association did not weaken after adjusting for age, gender,
and exit site infections. Exit site infection rate (RR 2.16;
95%CI 1.44–3.23), risk of peritonitis during the first year
(RR 3.65; 95%CI 1.68–7.90), and multiple peritonitis
attacks (RR 2.45; 95%CI 1.32–4.55) were higher in group
1. The peritonitis rates for adult patients cared for by the
same adult nurses declined sharply from 1.05 episodes per
patient-year between 1989 and 1992 to 0.41 episodes per
patient-year between 1995 and 1997, however the
corresponding pediatric rates did not change (1.48 to 1.06
W. D. V. N. Gunasekara : K.-H. Ng : E. Aragon : P.-P. Foong :
Y.-W. Lau : L.-K. Lim : C.-W. Liew : W.-S. Yeo : H.-K. Yap
Shaw-NKF Children’s Kidney Centre, University Children’s
Medical Institute, National University Health System,
Singapore, Singapore
K.-H. Ng : H.-K. Yap (*)
Department of Pediatrics, Yong Loo Lin School of Medicine,
National University of Singapore,
5 Lower Kent Ridge Road,
Singapore 119074, Singapore
e-mail: paeyaphk@nus.edu.sg
Y.-H. Chan
Biostatistics Unit, Yong Loo Lin School of Medicine,
National University of Singapore,
Singapore, Singapore
episodes per patient-year, respectively) until the second era
when specialized pediatric nurses were available. In
conclusion, establishment of a specialist pediatric dialysis
nursing team resulted in significant improvement in
infection-related PD outcomes.
Keywords Peritoneal dialysis . Nursing service .
Peritonitis . Exit site infection . Catheter
Introduction
Peritoneal dialysis (PD) is the preferred modality of dialysis
in children with end-stage renal disease (ESRD) [1].
Children with chronic illnesses have special needs. The
child’s physiology, psychosocial make-up, and physical and
cognitive development distinguishes him or her from the
adult with similar illnesses. At each stage of a child’s
development, from infancy to childhood and then to
adolescence, there is an evolution in the child’s needs due
to growth and puberty. In addition, their primary kidney
disease also makes them unique. Unlike in adults where
diabetic nephropathy is the main cause of chronic renal
failure, in children, the physician is frequently faced with
problems of renal dysplasia associated with neuropathic
bladders. Hence the dialysis physician has to deal not only
with the dialysis catheters but also problems associated
with continent catheterizable stoma in children with
neuropathic bladders. Special problems in children include
nutrition and growth, and hence these children may have
feeding tubes or enteral stomas to enhance their nutrition,
or they may require recombinant human growth hormone
therapy.
However, in many countries, development of a pediatric
dialysis program often occurs within adult dialysis units,
2142
where managing the small child and infant is a major
challenge. Similarly, in Singapore, the chronic PD program
was launched at the National University Hospital in 1988,
where adult renal nurses provided the dialysis services
during the first 10 years of the program. A specialist
pediatric renal nursing team was recruited in 1998 with the
objective to provide optimal care to these children. Over the
20-year period from 1988 to 2007, a total of 90 patients
have entered the pediatric chronic renal replacement
program in Singapore. Of these patients, six received
hemodialysis as the initial dialysis modality and were not
converted to PD during the study period. Eighty-four of
them received automated PD (APD) as the primary dialysis
modality. This study aimed to analyze the impact of the
specialist pediatric renal nursing service on PD-related
outcomes and compare this with the adult dialysis nursing
period.
Patients and methods
The collective data of all 84 consecutive patients who
entered the chronic APD program between January 1988
and December 2007, at the Shaw-NKF-NUH Children’s
Kidney Center, University Children’s Medical Institute,
National University Hospital, were reviewed retrospectively.
Ethics approval for the study was granted by the National
University Hospital Institutional Review Board.
The study population was divided into two groups
according to the nursing period. Group 1 (n=23) was
comprised of patients who entered the PD program during
the adult renal nursing period, that is, from January 1988 to
December 1997. Group 2 (n=61) was comprised of patients
who entered the program during the pediatric renal nursing
period, that is, from January 1998 to December 2007. The
study end-points were either the date of kidney transplan-
tation, permanent transfer to hemodialysis, transfer to the
adult unit, death, or last date of each nursing period,
whichever occurred first. Patients subjected to acute PD
were not included in the study. Those patients who entered
the program during the adult nursing period and whose
follow-up was continued into the pediatric nursing period
were not included in the second period, that is, in group 2.
Diagnosis of peritonitis was based on the presence of at
least 2 of the following criteria [2]: (1) Cloudy peritoneal
effluent with an effluent white cell count greater than
100 mm−3, (polymorphonuclear leukocytes greater than
50%); (2) symptoms of peritonitis, such as abdominal pain
and fever; (3) positive peritoneal fluid culture. Exit site
infection and/or tunnel infection [2] were diagnosed in the
presence of purulent discharge from the sinus tract, or
marked peri-catheter swelling, redness and/or tenderness or
pain and signs of inflammation along the subcutaneous
Pediatr Nephrol (2010) 25:2141–2147
tunnel, with or without a pathogenic organism cultured
from the exit site.
The same surgical team inserted all the Tenckhoff
catheters since commencement of the program in 1988.
During the early years of the program, straight peritoneal
catheters were used. SWAN NECK™ curled catheters were
introduced only in 2001. Exit site orientation of most of the
patients in group 1 was upward-pointing whereas the
majority of the patients in group 2 had downward-
pointing exit sites. The automated cyclers used during the
first period included the PAC-X®, PAC-XTRA®, as well as
the Home Choice® (Baxter Healthcare Corporation McGaw
Park, IL, U.S.A), which was introduced only in 1995.
During the second nursing period, only the Home Choice®
cyclers were used. The connectology between cycler line
and patient line only changed from “spiking” to the “Luer
lock” system after the introduction of the Home Choice®
machine in 1995.
Screening and prophylaxis of nasal carriage of Staphy-
lococcus aureus were instituted in both eras and imple-
mented in the same way consistently. Pre-dialysis training
was provided by the adult nurses in the first era, and this
was taken over by the pediatric specialist nurses in the
second era. The duration of training was the same for the
two eras. Each patient in both eras had at least one home
visit by the nurses before they started their peritoneal
dialysis independently at home.
Because peritonitis rates may improve over time due
to other confounding factors such as catheter care and
quality of teaching, rather than type of nursing provided,
we also studied the changes in peritonitis rates over time
in the adult patients cared for in our adult unit and
compared these to the pediatric peritonitis rates during
the years when the adult peritonitis rates had reached
stability. The changes in our pediatric peritonitis rates
were also compared to published pediatric peritonitis
rates from the North American Pediatric Renal Trials and
Collaborative Studies (NAPRTCS) [3, 4].
Statistical analysis was performed using SPSS 16.0 for
Windows (StataCorp, College Station, Texas, USA). Data
were expressed as mean ± standard deviation (SD). PD-
related events were summarized as number of episodes per
patient-year. Only the absolute PD days were considered
when calculating the patient-years. Patient characteristics
and factors which may have caused changes in peritonitis
rates over time were analyzed in terms of patient-years.
Dialysis machine and connectology between cycler line and
patient line were coded as one variable since the changes
occurred simultaneously. There were nine patients who had
both straight and coiled catheters inserted at some point
during the study period, and these were coded as
“combined” catheter type. Similarly, the nine patients who
had more than one type of exit site configuration were also
Pediatr Nephrol (2010) 25:2141–2147
coded as “combined” type. Patient characteristics in terms
of patient-years were compared using a general linear
method analysis. One-way ANOVA test and Chi-square test
were performed to compare the mean age at initiation of
dialysis, the mean duration of dialysis, the number of
patients with peritonitis during the first year of dialysis, and
the number of patients with multiple attacks of peritonitis
between the two periods. Multivariate Poisson regression
analysis was performed to compare peritonitis rates in the
two periods, adjusting for age, gender, and exit site
infections. We also compared the change in the peritonitis
rates between the adult patients cared for in our adult unit
versus the pediatric peritonitis rates over the years using a
general linear model. A p value less than 0.05 was
considered statistically significant.
Results
Over the 20-year study period, a total of 84 consecutive
patients were included in the study, of which 23 were seen
during the adult nursing period (group 1), and 61 in the
pediatric nursing period (group 2). There were 40.6 patient-
years in group 1 and 189.0 patient-years in group 2. There
was no significant difference in the mean ages at the start of
dialysis between group 1 (10.8±5.1 years) and group 2
(12.7±5.3 years). Patients in group 2 were dialyzed for a
significantly longer duration (mean 37.18±29.66 months)
compared to patients in group 1 (mean 21.20±9.86 months)
(p=0.014). There was no significant difference in the
number of patient-years contributed by male versus female
patients, transplanted versus non-transplanted patients,
different exit site orientations, presence of exit site
infections and types of machine and connection (Table 1).
“Combined” catheter type was significantly different
(p<0.005). The etiology of ESRD in children in group 1
was primarily glomerular disease (58.4% of patient-years),
whereas in group 2, the etiology was mainly congenital
abnormalities (59.0% of patient-years) (Table 1).
PD-related outcomes during the two periods are sum-
marized in Table 2. The peritonitis rate was significantly
higher in group 1 (1.08 episodes per patient-year) compared
to group 2 (0.27 episodes per patient-year) [relative risk
(RR) 1.90; 95% confidence intervals (CI) 1.27–2.84].
Furthermore, the relative risk for group 1 of having
peritonitis within 1 year of commencement of dialysis was
3.65 (95% CI 1.68–7.90), and for multiple attacks (≥2
episodes) of peritonitis was 2.45 (95% CI 1.32–4.55). The
exit site infection rate per patient-year was also worse in
group 1 (1.16 episodes per patient-year) compared to group
2 (0.25 episodes per patient-year) (RR 2.16; 95% CI 1.44–
3.23). Although 38% of children in group 1 had a modality
change due to peritonitis as compared to 28% in group 2,
2143
this was not statistically significant. There was no signif-
icant difference in mortality per patient-year dialyzed
between the two groups.
Multivariate Poisson regression analysis was performed
to compare peritonitis rates in the two periods, adjusting for
age, gender, and exit site infections, and this showed
that the adult nursing period was a significant risk factor
for peritonitis with a RR of 3.31 (95% CI 1.26–8.72)
(p=0.016).
Since there may be other aspects of care which differ in
unquantifiable ways that were not accounted for by the
Poisson regression model, we examined the trends in the
pediatric peritonitis rates and compared these with the adult
peritonitis rates. As shown in Table 3, the adult rates
declined sharply from 1.05 episodes per patient-year
between 1989 and 1992 to a low of 0.41 episodes per
patient-year between the years 1995 to 1997. This did not
decline substantially thereafter, as the rates remained stable
at 0.36 episodes per patient-year even in the later part of the
second era between 2003 and 2007. On the other hand, the
pediatric peritonitis rates improved only slightly from 1.48
episodes per patient-year between 1989 and 1992 to 1.06
episodes per patient-year between 1995 and 1997, despite
being cared for by the same adult dialysis nurses. The
pediatric peritonitis rates only reached a similar low rate of
0.35 episodes per patient-year as the adult PD patients
between 2003 and 2007. The change in peritonitis rate for
the pediatric patients from 1995–1997 to 2003–2007 was
0.71 episodes per patient-year whereas in the adult patients,
the corresponding change was 0.05 episodes per patient-
year (p<0.001).
Comparing our pediatric peritonitis rates with reported
pediatric peritonitis rates from other countries like North
America, our pediatric peritonitis rate (1.16 episodes per
patient-year) was comparable to the North American rate
(0.98 episodes per patient-year) in the earlier adult nursing
period between 1992 and 1996 (Table 4). The North
American peritonitis rates declined steadily from 0.98
episodes per patient-year between 1992 and 1996 to a low
of 0.70 episodes per patient-year between 2003 and 2007.
On the other hand, our pediatric peritonitis rates decreased
only slightly from 1.16 episodes per patient-year between
1992 and 1996 to 1.09 episodes per patient-year between
1997 and 2000. Subsequently, there was a dramatic decline
in the peritonitis rates, such that by 2003 to 2007, the
peritonitis rate reached 0.35 episodes per patient-year.
Discussion
Historically, the development of chronic pediatric dialysis
units often started within adult dialysis units. This practice
is still prevalent in many countries [5] as the sharing of
2144 Pediatr Nephrol (2010) 25:2141–2147

Table 1 Patient characteristics

of the two dialysis nursing peri- Group 1 Group 2 p value
ods: group 1 (adult nursing Patient-years (%) Patient-years (%)
period) and group 2 (pediatric (Total=40.6 patient-years) (Total=189.0 patient-years)
nursing period)
Age at start of dialysis 0.359
0–5 years 6.6 (16.2) 18.7 (9.9)
5–12 years 13.2 (32.4) 54.8 (29.0)
>12 years 20.9 (51.4) 115.5 (61.1)
Gender 0.556
Female 17.8 (43.8) 110.2 (58.3)
Male 22.9 (56.3) 78.8 (41.7)
Primary renal disease 0.635
Congenital abnormalities 6.6 (16.2) 111.6 (59.0)
Glomerulopathies 23.7 (58.4) 41.5 (22.0)
Others 10.3 (25.4) 35.1 (18.6)
Transplanted 0.953
Yes 17.7 (43.6) 44.7 (23.7)
No 21.9 (53.9) 144.3 (76.3)
Catheter type <0.005
“Combined”a 0 54.4 (28.8)
Straight 40.6 (100.0) 56.5 (29.9)
Coiled 0 78.0 (41.3)
ES orientation 0.295
“Combined”b 0 46.1 (24.4)
a Up 39.1 (96.1) 38.6 (20.4)
Includes patients who had both
straight and coiled catheters during Lateral 0 1.4 (0.7)
the study period
Down 1.6 (3.9) 102.8 (54.4)
b
Includes patients who had more
ESI 0.242
than one type of exit site configu-
ration during the study period Yes 7.5 (18.5) 20.7 (11.0)
c
Connection between cycler line No 33.1 (81.5) 168.3 (89.0)
and patient line Machine/connectionc 0.089
ES exit site, ESI exit site infec- Non HC/spike 27.1 (66.7) 0
tion, HC home choice, LL Luer HC /LL 13.5 (33.3) 189.0 (100.0)
lock

dialysis facilities for a small number of children makes
economic sense in terms of health care resources. In our
dialysis center, the first 10 years of service was provided
within an adult unit, before the establishment of a
specialized pediatric dialysis center.
Comparing the patient characteristics in the two eras,
there were some notable differences. Glomerular disease
was the commonest primary cause of ESRD in the earlier
adult nursing period (group 1), whereas in the pediatric
nursing period (group 2), congenital renal malformations

Table 2 Comparison of dialysis-related events between adult nursing period (group 1) and pediatric nursing period (group 2)

Parameters Total (n=84) Group 1 (n=23) Group 2 (n=61) RRa (95% CI) p value

Peritonitis rate per patient-year 0.41 1.08 0.27 1.90 (1.27–2.84) 0.002
Number of patients with peritonitis within 1 year 19 11 8 3.65 (1.68–7.9) 0.001
Number of patients with multiple attacks of peritonitis 25 12 13 2.45 (1.32–4.55) 0.006
Exit site/tunnel infection rate per patient-year 0.41 1.16 0.25 2.16 (1.44–3.23) <0.001
Modality change rate per patient-year 0.11 0.22 0.09 1.36 (0.62–2.99) 0.45
Mortality per patient-year 0.035 0.025 0.037 0.48 (0.15–1.56) 0.22
a
RR relative risk for adult nursing vs. pediatric nursing
CI confidence interval
Pediatr Nephrol (2010) 25:2141–2147
Table 3 Peritonitis rates expressed as episodes per patient-year for
pediatric patients and adult patients (95% CI)
Years Pediatric patients Adult patients
1989–1992 1.48a (0.80–2.16) 1.05a (0.60–1.50)
1995–1997 1.06a (0.46–1.66) 0.41a (0.10–0.86)
2003–2007 0.35b (0.17–0.53) 0.36a (0.29–0.42)
a straight catheters whereas the majority of patients starting
Cared for by adult dialysis nurses
b dialysis after the year 2000 had coiled catheter. During the
Cared for by pediatric dialysis nurses
were predominant. The most probable reason for this is that
in the earlier period, most parents of young children with
congenital malformations refused dialysis as pediatric
dialysis service was relatively new at that time. The
duration of dialysis was significantly longer for patients in
group 2, with a lower proportion of patients being
transplanted during this later period. This was likely a
reflection of the kidney transplant policies in our country.
The deceased donor program for the pediatric population
was only approved in 1995, resulting in a greater
proportion of patients in the second 10-year period being
on the deceased donor transplant waiting list. In contrast,
the majority of patients who entered the dialysis program in
the earlier years had plans for living-related transplantation,
and therefore remained on dialysis for a shorter duration.
There was a significant improvement in the PD out-
comes as measured by the decrease in technique-related
complications during the pediatric nursing period compared
to the adult nursing period. The peritonitis rate, risk of
peritonitis during the first year, risk of having multiple
attacks of peritonitis, exit site and tunnel infection rates
were significantly less during the pediatric nursing period.
Many factors, other than the type of nursing, could have
accounted for this improvement in PD outcomes.
The nurse-to-patient ratio in the second era was 0.057
and this was only slightly higher than that in the first era.
Therefore, this was unlikely to be the main contributory
factor to the improvement in outcomes in the second era.
We also considered improvement in catheter types as a
possible contributor to the improvement in PD outcomes.
The International Pediatric Peritonitis Registry (IPPR) data
suggested that straight catheters may be associated with
higher post-peritonitis sequelae [3], however, well-designed
Table 4 Comparison of pediatric peritonitis rates (episodes per
patient-year) with data from North America
Years North America Pediatric patients in this study
1992–1996 0.98 [3] 1.16
1997–2000 0.80 [3] 1.09
2003–2007 0.70 [4] 0.35
2145
trials in adult patients on chronic ambulatory peritoneal
dialysis (CAPD) failed to demonstrate a significant differ-
ence in peritonitis rates between straight and coiled
catheters [6]. Similar results were shown by the Japanese
Study Group of Peritoneal Dialysis [7] as well as in adult
CAPD patients in Singapore [8]. In our study, all the
patients in the adult renal nursing period, before 1998, had
pediatric nursing period, there were nine patients who had
their straight catheters changed to coiled catheters (“com-
bined” catheter type), 44% of whom did not have any
peritonitis at all. This could be because the catheters were
electively changed after an exit site infection, reducing the
risk of peritonitis, thus accounting for the finding that a
“combined” catheter type predicts a low risk for peritonitis.
Improvement in exit site care and changes in exit site
orientations over time may also have led to the improve-
ment in infection-related outcomes. However, while exit
site infections and upward pointing exit sites have been
shown in previous studies to be independent risk factors for
peritonitis [9, 10], the Japanese Study Group of Pediatric
Peritoneal Dialysis failed to demonstrate any association
between infections and exit site orientation and exit site
care [7]. In our cohort, the exit site infection rate per
patient-year was at least four times greater during the adult
nursing period, however, this was not significantly associ-
ated with peritonitis.
We performed multivariate Poisson regression analysis
and showed that the adult nursing period was a significant
risk factor for peritonitis after adjusting for age, gender, and
exit site infections. We have excluded factors that had little
or no variability between the two nursing periods in the
Poisson regression model. These factors were catheter type,
exit site orientation and type of machine and connection
(Table 1). There may also be other unquantifiable aspects of
dialysis care such as catheter care recommendations and
quality of teaching that might have caused the improvement
in PD-related outcomes over time. The Poisson regression
model therefore could not have answered the important
question of whether the improvement in PD outcomes was
indeed related to the setting up of specialized pediatric
dialysis nursing, or due to improvement in dialysis
techniques over time. Hence we compared the peritonitis
rates in our pediatric patients to those in the adult patients
dialyzed by the same cohort of adult dialysis nurses. There
was an overall general decline in the peritonitis rates over
the 20 years, but the rates of decline were different. The
peritonitis rates in the adult patients declined steeply from
1.05 episodes per patient-year between 1989 and 1992 to
0.41 episodes per patient-year between 1995 and 1997
(Table 3). However, this sharp decline was not seen in the
pediatric patients over the same period even though they
2146
were looked after by the same adult dialysis nurses. Any
factor that might have driven the improvement in the adult
peritonitis rates from 1.05 to 0.41 episodes per patient-year
should also have led to a similar improvement in the
pediatric peritonitis rates. The most likely reason for this
was the lack of priority of care for the pediatric patients,
possibly as the adult-trained nurses were unfamiliar and
therefore uncomfortable with dealing with children. The
dramatic decline in our pediatric peritonitis rates only
occurred after the pediatric specialist nurses took over, at
the time when the adult peritonitis rates had already reached
stability, with rates ranging between 0.36 to 0.41 episodes
per patient-year. A limitation in this study was that adult
data on the variables that might have caused the improve-
ment in peritonitis rates over time were not available.
Hence, comparison of these variables with those in the
pediatric patients was not possible. Nevertheless, any
changes or improvement in dialysis techniques that have
occurred in our adult units also occurred at the same time in
our pediatric unit.
To further substantiate the point that the improvement in
peritonitis rates was due to the difference in nursing rather
than advances in dialysis care per se, we compared our
pediatric peritonitis rates with those reported in the
NAPRTCS registry, which by far, has one of the most
extensive longitudinal published data on pediatric dialysis
patients. The North American pediatric peritonitis rates
steadily improved from 0.98 episodes per patient-year
between 1992 and 1996 to 0.70 episodes per patient-year
between 2003 and 2007 [3, 4]. In comparison, our pediatric
peritonitis rates were rather static from 1992 to 2000 at 1.09
to 1.16 episodes per patient-year. In fact, our pediatric
peritonitis rates during this period were worse than that in
other countries as well, such as Italy (0.60 episodes per
patient-year) [11, 12], Turkey (0.78 episodes per patient-
year) [13], and Japan (0.41 episodes per patient-year) [14].
It was only after pediatric nursing was established in our
unit that we saw a steep decline in the peritonitis rates to
0.35 episodes per patient-year between 2003 and 2007.
Our study concluded that specialist pediatric dialysis
nursing for children with ESRD resulted in better
outcomes compared to dialysis within adult units. A
previous multi-center survey conducted by the Interna-
tional Society of Peritoneal Dialysis Advisory Committee
for Peritonitis showed that there was no significant
difference in peritonitis rates between children who were
dialyzed in adult and pediatric centers [15]. However,
this study considered only the characteristics of the
training program and staffing as contributory factors to
peritonitis, and did not take into account patient demo-
graphics and technique differences. Children on PD have
fundamentally different problems from adults on PD.
Specialist pediatric nurses are trained to understand the
Pediatr Nephrol (2010) 25:2141–2147
specific emotional, psychosocial, and behavioral changes
that occur in the patients, families, and caregivers at
various stages of development from infancy to adoles-
cence. This understanding is crucial in successful training
and follow-up of these patients. Moreover, pediatric-
trained nurses will also be more sensitive to medical
issues peculiar to children, such as nutrition, growth, and
care of gastrostomy tubes. They are therefore essential if
holistic care is to be given to these patients.
Acknowledgements W.D. Vindya N. Gunasekara, Kar-Hui Ng,
Yiong-Huak Chan, and Hui-Kim Yap contributed equally to this
work. This paper was presented in part at the 12th Annual Pediatric
Dialysis Symposium and 21st Annual Dialysis Conference, New
Orleans, Louisiana, 2001.
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