Pediatric

Peritoneal Dialysis
Indication
absolute
 GFR < 8 mL/min/1.73 m2
 Overt uremia (pericarditis, pleuritis)
 Fluid overload: edema, heart failure
 Malnutrition: clinicaly, bochemistry
 Persistent hypertension
 Repeated episode of hyperkalemia
relative
 GFR 9 – 14 mL/min/1.73m2
 Fatique
 Deteriorating school performance
 Poorly controled hyperparathyroidism
 Uncontrolled hyperphosphatemia
 Excessive serum Ca-PO4 product
PD vs HD

Favour PD Favour HD
 Very small/ very young patient  Imminent living-related transplantation
 Lack of vascular access  Impending/ recent major abdominal surgery
 Contraindication to anticoagulant  Lack of appropriate caregiver
 Cardiovascular instability
 Desire for normal school atendence
 More liberal fluid intake
Principles of PD : fluid removal

 An osmotic pressure gradient is applied by the addition

to the dialysis fluid of an osmotic agent
 In most cases glucose is used to create the osmotic
pressure.
 Fluid is removed by ultrafiltration driven by an osmotic
pressure gradient.

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Principles of PD: solute removal

 principle for solute removal in PD is diffusion, for which

the driving force is the concentration gradient between the
blood and the dialysis fluid.
 Small solutes move quickly through the membrane creating
an equilibrium during the dwell period.
 Larger solutes move slowly across the peritoneum,
reaching equilibrium point takes a long time.

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PD Fluid

 Components of PD fluid: electrolytes, buffer and osmotic agents.

 Eelctrolytes:
 The most abundant electrolyte in PD fluid is sodium. It’s hyponatremic, so it has a
concentration lower than blood to ensure sufficient removal of sodium.
 Standard PD fluid contains no potassium.
 Today, there is a tendency to use normcalcemic PD fluid as many patients receive
extra calcium from phosphate-binding drugs.
 buffer normally used in PD is lactate. Lactate is metabolised to form
bicarbonate, the most important buffer in the blood.

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Osmotic agent

 Rate of fluid transport is related to the osmotic strength of the

PD solution. The higher the glucose concentration, the larger the
osmotic pressure, resulting in a larger fluid removal.
 If PD exchanges are missed or dwell more than 6-8 hours, fluid
may be gained by the patient rather then lost.
 larger volume of dialysis solution will take longer for the
concentration gradient to decline
 Normal range of concentrations 1.5%, 2.3% & 4.25%.
Osmotic agent

 Glucose is not ideal, as it is rapidly absorbed from the PD fluid. This may lead to
problems with fluid removal, patient gains calories and can lose there appetite. Resulting
in overweight and malnourishment. Disturbances of the carbohydrate and lipid
metabolism may also occur.
 High molecular weight glucose polymer (extraneal/icodextrin) provide sustained
ultrafiltration for long overnight dwells.
 Aminoacid based osmotic agent: provide nutritional supplement. (nutrineal)

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 Treatment Modes CAPD/APD

 Advantages of APD v CAPD

 higher clearance of solutes, as higher volumes can be used
 better fluid removal, as shorter dwell time can be used
 more freedom during the daytime as no exchanges need to be made.

 Drawbacks of APD are that of a higher cost and portability.

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CAPD

 Catheter implantation
Need immediate PD
 Start supine dialysis 12- 24 exchanges; 300 ml/m2 for 7 days, increase to 1100 ml/m2 within 14 to 21 days

No need for immediate PD

 Wait 2 – 6 weeks healing period
 Start dialysis 4 – 8 exchange started with 300 ml/m2 increase to 1100/m2 within 7 – 14 days

 Prescription
 Dialysate tonicity : glucose 1.5, 2.5, 4.25
 Dialysate volume : target 1100/m2, consider patient tolerance
 Dwell time: waking hours: 4 – 6 h;
3 cycle 3-5 hours daytime + 1 cycle 9 – 12 hours
 Follow up and monitoring
monthly
• Record daily urine output and
ultrafiltration
• Growth and weight gain, head
circumference
• Blood pressure
• BUN, serum creatinine
• Acid base and electrolyte
• Hemoglobin/hematocrite, serum
albumin
3 month
• Serum iron, ferritin, TIBC
• Intact PTH
• Alkaline phosphatase
6 month
• Neurodevelopmental
assesement (<4 years old)
4 month
• 24 hr dialysate and urine
collection for CrCl, Kt/Vurea
annualy
• ABPM
• Echocardiography
• Hand and wrist X-ray
Criteria for CAPD adequacy

 Normal status for hydration, electrolyte balance, blood pressure, growth-nutriton and
psychomotor development
 Total Kt/Vurea > 2.0/week
 Total CrCl
 >60 L.1.73 m2/week in high/high avarage transporter
 >50 L.1.73 m2/week in low/low avarage transporter
Inadequate dialysis

 Overt uremia (uremic pericarditis, pleuritis)

 Fluid overload: edema, congestive heart failure
 Malnutrition: clinicaly, bochemistry, wasting
 Hypertension requiring more than 1 antihypertensive drug
 Hyperkalemic episodes
 Hyperposphatemia, excessive serum Ca-PO4 product
 Absolute BUN value
 Weekly Kt/V urea and CrCl bellow K/DOQI reccomendation
Factors contributing to inadequate dialysis

 Loss of residual renal function

 Prescription not adequate for membrane characteristics
 Reduce peritoneal surface: extensive adhesion
 Loss of membrane solute transport/ UF capacity: peritonitis
 Non compliance with PD prescription
 Poorly functioning PD catheter
Prescription adjustment

 Maximizing fill volume

Start with 2 exchange, if not met all 4 exchange
 Add an aditional exchange
1 extra exchange in night time, only feasible if fill volume > 1500 ml
(shorten dwell time)
 Change dialysate tonicity
UF failure, alternate osmotic agent other than glucose for night dwell.
minimize using 4.25 glucoes to avoid metabolic complication
 APD
COMPLICATION:
PERITONITIS
Assesment

Sign
 Cloudy effluent
 Abdominal pain AND/OR fever

Empiric diagnosis
 WBC >100/mm3 with 50% PMN cell
Management

 Obtain sample for WBC count with differential, gram stain and culture
 In the presence of cludy effluent with pain and/or fever begin 2 – 3 rapid exchange to
relieve discomfort, start empiric AB within 1 hour
 In asympomatic patient AB can be delayed 2 – 3 hour while waiting for laboratory result
 For cloudy effluent, add heparin 500 IU/L until effluent clear (48 – 72 h)
 Consider antifungal prophylaxis
 Re asses Kt/Vurea and CrCl after peritonitis resolved
Empirical antibiotic

 Cloudy effluent WITHOUT fever and/or abdominal pain-no risk factor for severe
infection
1st Generation Cephalosporin (CEFAZOLIN/CEPHALOTIN) + CEFTAZIDIME

 Cloudy effluent WITH fever and/or abdominal pain; history of MRSA infection, recent
history or current evidence of S.aureus colonization in exit site/nasal; younger than 2 yo
CEFTAZIDIME + Glycopeptide (VANCOMYCIN/ TEICOPLANIN)

 Treatment modification based on culture and sensitivity result

 DOSING: EMPIRICAL ANTIBIOTIC

Antibiotic Continous dosing Intermitent dosing

Cefzolin or Cephalotin 250mg/L load 15 mg/kg in single exchange q day
then 125mg/L in each exchange
Ceftazidime 250mg/L load 15 mg/kg in single exchange q day
then 125mg/L in each exchange
Vancomycin 500mg/L load 30 mg/kg in single exchange q 5-7
then 30mg/L in each exchange days

Teicoplanin 200mg/L load 15 mg/kg in single exchange q 5-7

then 20mg/L in each exchange days
End