Peritoneal dialysis for Acute Renal Failure (ARF)
The exact incidence of ARF in children is unknown, and estimates vary from 20 cases per year per 100,000 population in neonates to as low as 2 cases per year per 100,000 population in adolescents21. Etiology of ARF in neonates and older children shows wide variability. Common causes of ARF in the neonate are anatomic malformations such as renal malformations and bladder outlet obstruction leading to oliguria; hemodynamic events secondary to birth events or critical illness such as birth asphyxia, sepsis, hemorrhage or respiratory distress syndrome; and metabolic defects which lead to accumulation of toxins17,22. Common causes of ARF in older children are primarily attributed to acute glomerulonephritis and hemolytic-uremic syndrome. Children may also have an acute episode of renal failure related to underlying renal disease or GU tract malformation. Additionally, several cases of ARF in this age group have been reported during hospitalization due to sepsis, nephrotoxic drugs, or congestive heart failure post cardiac surgery17, 22.
The decision to initiate dialysis in a pediatric patient is complex and multi-factorial. Typical indications related to acute kidney injury are associated with minimal urine output that clinically does not respond to increased fluid administration23. The child might present with signs of fluid overload such as congestive heart failure (CHF), pulmonary edema, or severe hypertension. Common electrolyte imbalances that may require dialysis are hyperkalemia or severe acidosis that does not respond to medical management. Rare indications are toxicities associated with external therapeutic agents or poisons, or related to inborn errors of metabolism causing hyperammonemia. Severe symptoms related to uremia may also be a reason for dialysis initiation, the most common symptoms being nausea, vomiting, and malaise24.
PD offers several advantages for pediatric renal replacement therapy compared to HD or continuous renal replacement therapy (CRRT). In most instances, PD can be initiated more efficiently than HD, in part because PD catheter placement is generally less complex than obtaining vascular access. In addition, the smaller the child, the more technically difficult HD becomes. PD is also very well suited for the hemodynamically unstable patient. In comparison to HD or CRRT, the equipment and nursing requirements for PD are relatively less labor intensive23,25. Disadvantages of PD in the ARF environment include decreased efficiency in rapid solute removal, as required in drug poisoning or inborn errors of metabolism23 and the therapy is contraindicated when severe abdominal wall defects are present. When initiating pediatric PD for ARF, the risk of complications must not be overlooked. Peritonitis, bleeding, bladder perforation, dialysate leakage (which can occur when initial exchange volumes are too large), and poor dialysate flow (frequently associated with omental trapping of the catheter) have been observed. .
Peritoneal dialysis for ESRD:
Unlike adults, in which 80% of ESRD is related to acquired disorders26, the majority of renal disease in children is related to congenital disorders (~32%) or glomerulonephritis (~25%)5.
Similar to ARF, neonates with CKD generally are diagnosed with ESRD secondary to congenital abnormalities whereas adolescents are frequently noted to have glomerular abnormalities26, 27. However, renal damage can occasionally be avoided or delayed when conditions such as obstructive uropathy and reflux nephropathy are discovered and treated early28. The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI™) and the International Society for Peritoneal Dialysis (www.ispd.org) provide guidelines for initiation of chronic PD in children. A triad of assessments, clinical, biochemical and psychosocial, are recommended: specifically: creatinine clearance less than 8 milliliters per minute per 1.73 meters squared [KDOQI]; evidence of uremia, fluid overload, electrolyte disturbances not controlled by medical interventions, and failure to thrive. It is important to note that a small child may not have elevated blood urea nitrogen but can become symptomatic and anorectic quickly. Loss of sucking ability and depressed appetite may be the catalyst to start dialysis in a small child29, 30 and warrants further clinical investigation.
PD, in both adult and pediatric populations, empowers the patient and their caregivers. There is no immediate need for vascular access, fluid and dietary restrictions are generally less due to the daily treatment regimen and prescriptions may be more flexible30. The chosen dialysis modality should support as normal a life style as possible for the child and aid with normal growth and development. Regular evaluation for transplant is recommended.
References:
5. United States Renal Data System. Retrieved from www.usrds.org on October 5, 2009
17. Daschner M, Schaefer F: Emergency dialysis in neonatal metabolic crises. Adv Ren Repla Thera 9:63-69, 2002
21. Moghal NE et al. (1998) A review of acute renal failure in children: Incidence, etiology and outcome. Clin Nephrol 49: 91–95 cited in Bucnhman TE. Treatment of acute kidney injury in children: From conservative management to renal replacement therapy. Nat Clin Pract Nephrol 4:510-514, 2008
22. Mendley SR, Langman CR. Acute renal failure in the pediatric patient. Adv Ren Repla Ther 4:93-101, 1997
23. Parekh RS, Bunchman TE. Dialysis support in the pediatric intensive care unit. Adv Ren Repla Ther 3:326-336, 1996
24. Vanholder R, De Smet R, Glorieux G, Argiles A, Baurmeister U, Brunet P, Clark W, Cohen G, De Deyn PP, Deppisch R, Descamps-Latscha B, Henle T, Jorres A, Lemke HD, Massy ZA, Passlick-Deetjen J, Rodriguez M, Stegmayr B, Stenvinkel P, Tetta C, Wanner C, Zidek W: Review on uremic toxins: classification, concentration, and interindividual variability. Kidney Int 63:1934–1943, 2003
25. Warady BA, Bunchman TE. Dialysis therapy for children with acute renal failure: survey results. Pediatr Nephrol 15:11-13, 2000
26. Alexander SR, Warady BA: The demographics of dialysis in children, in Warady BA, Schaefer F, Fine RN, Alexander S (eds): Pediatric Dialysis. Dordrecht, The Netherlands, Kluwer, 2004, pp 35-45
27. Ferris, ME, Gipson DS, Kimmel PL, Eggers PW. Trends in treatment and outcomes of survival of adolescents initiating end-stage renal disease care in the United States of America. Pediatr Nephrol 21:1020-1026, 2006
28. Miller D, Macdonald D, Kolnacki K, Simek T: Challenges for nephrology nurses in the management of children with chronic kidney disease. Neph Nursing J 31:287-296, 2004
29. Warady BA, Alexander SR, Watkins S, Kohaut E, Harmon WE: Optimal care of the pediatric end-stage renal disease patient . Am J Kidney Dis 33:567-583, 1999
30. Avner ED, Harmon WE, Niaudet P. Section XI: Chronic Renal Failure. Chapter 70: Peritoneal Dialysis. In Pediatric Nephrology. 5th Ed. Philadelphia:Lippincott Williams & Wilkins, 2004:1375-1394
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