Peritoneal dialysis tailored to pediatric needs

C P Schmitt, A Zaloszyc, B Schaefer, M Fischbach, C P Schmitt, A Zaloszyc, B Schaefer, M Fischbach

Abstract

Consideration of specific pediatric aspects is essential to achieve adequate peritoneal dialysis (PD) treatment in children. These are first of all the rapid growth, in particular during infancy and puberty, which must be accompanied by a positive calcium balance, and the age dependent changes in body composition. The high total body water content and the high ultrafiltration rates required in anuric infants for adequate nutrition predispose to overshooting convective sodium losses and severe hypotension. Tissue fragility and rapid increases in intraabdominal fat mass predispose to hernia and dialysate leaks. Peritoneal equilibration tests should repeatedly been performed to optimize individual dwell time. Intraperitoneal pressure measurements give an objective measure of intraperitoneal filling, which allow for an optimized dwell volume, that is, increased dialysis efficiency without increasing the risk of hernias, leaks, and retrofiltration. We present the concept of adapted PD, that is, the combination of short dwells with low fill volume to promote ultrafiltration and long dwells with a high fill volume to improve purification within one PD session. The use of PD solutions with low glucose degradation product content is recommended in children, but unfortunately still not feasible in many countries.

Figures

Figure 1
Figure 1
IPP is an individual patient characteristic, determined by BMI and dwell volume. The intraperitoneal pressure (IPP, y-axis) is positively correlated with the normalized body mass index (x-axis) within the general population. This correlation is even stronger than the correlation between dwell volume to IPP [5].
Figure 2
Figure 2
Intraperitoneal pressure (mean/SD) according to dwell volume in children on PD above two years of age [7, 26]. In infants IPP should be below 8–10 cm, in children below 13-14 cm H2O. The red arrows give an example of how dwell volumes can be increased in patients with low IPP.
Figure 3
Figure 3
Illustration of APEX time, the crossing point of dialytic urea appearance, and glucose disappearance curve. APEX time indicates the optimal dwell time for ultrafiltration (normal range: 18 to 71 minutes).
Figure 4
Figure 4
Example of an adapted PD session. Short dwells of 45 minutes of dwell time (i.e., individual APEX time) with a small fill volume (800 mL/m2) favoring ultrafiltration by a high osmotic gradient at a low IPP are followed by long dwells (150 minutes; 3-4 times the APEX time) with a large fill volume (1500 mL/m2), to promote uremic toxin removal.

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