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Chronic peritoneal dialysis in children

Chronic peritoneal dialysis in children
Literature review current through: Jan 2024.
This topic last updated: Apr 10, 2023.

INTRODUCTION — Chronic peritoneal dialysis (CPD) is the most common dialysis treatment modality used to treat pediatric patients with end-stage kidney disease (ESKD), particularly in children less than five years of age [1-3]. CPD offers several advantages over hemodialysis (HD) that are beneficial for children; however, there are clinical settings in which CPD is contraindicated or may not be the best dialytic modality. In addition, although the principles of CPD are the same for pediatric and adult patients, there are aspects of CPD that are unique to children and infants, which need to be addressed to ensure the adequacy of dialysis and to reduce complications for the pediatric patient.

The various aspects of CPD in children will be reviewed here. Overview of kidney replacement therapy (KRT) in children and hemodialysis for children with chronic kidney disease are presented separately. (See "Overview of kidney replacement therapy for children with chronic kidney disease" and "Hemodialysis for children with chronic kidney disease".)

The general mechanisms of the removal of solute and fluid during CPD are the same in the adult and pediatric patient and are also discussed separately. (See "Mechanisms of solute clearance and ultrafiltration in peritoneal dialysis".)

PERITONEAL DIALYSIS VERSUS HEMODIALYSIS — There have not been any comparative studies of peritoneal dialysis (PD) and hemodialysis (HD) outcomes in children with end-stage kidney disease (ESKD) to suggest superiority of one procedure versus the other. While the majority of pediatric patients with ESKD who require dialysis can be managed with CPD, the choice of dialysis modality is most often based on patient and family preference, center philosophy, and availability of the desired modality.

The quality of life for both patient and family assumes great importance in the selection of home dialysis therapy as a result of the "burden of care" associated with this approach to ESKD management. As such, careful evaluation of the family's social, psychological, and economic background, ideally by a multiprofessional team including the family clinician and nephrologist, dialysis nurse, psychologist, and social worker, is mandatory if a fully informed decision regarding modality selection is to be made [4-6].

Although both HD and CPD are effective in solute and fluid removal, CPD offers the following advantages over HD in children [7]:

Less restricted diet including fluid intake because CPD is performed daily. This is particularly beneficial for infants in whom nutritional intake is exclusively or mainly dependent upon a liquid diet.

Therapy is performed at home, thereby allowing for regular school attendance and participation in other normal childhood activities. For those who live a long distance from a hemodialysis center, there is no need to travel to the unit three or more times per week for dialysis treatments.

No vascular access and the associated need for repeated venipuncture (arteriovenous fistula/graft) or the risk for bacteremia (central venous catheter). In particular, vascular access for hemodialysis is challenging in patients less than two years of age. (See "Hemodialysis for children with chronic kidney disease", section on 'Vascular access'.)

Disadvantages of CPD include, but are not limited to:

Increased caregiver burden, which may lead to psychological and social stress [8,9]

Possible patient/caregiver nonadherence to prescribed therapy

Risk of CPD-related infections, such as PD catheter exit site/tunnel infections and peritonitis

Contraindications to CPD — The only absolute contraindications to CPD include conditions that affect the integrity of the abdominal cavity and peritoneum including the following:

Omphalocele

Gastroschisis

Bladder exstrophy

Diaphragmatic hernia

Obliterated peritoneal cavity and peritoneal membrane failure

Relative contraindications to CPD include:

Impending abdominal surgery.

Scheduled (<3 months) living-donor kidney transplantation, as the efforts and resources required for training may not be justified for short term provision of CPD. However, CPD might be considered if hemodialysis is not a viable option.

Lack of an appropriate caregiver for home therapy.

Patient/caregiver choice for HD, which is available and medically suitable.

Controversy exists as to whether the presence of a ventriculoperitoneal shunt constitutes a contraindication to CPD. Limited experience suggests that CPD is acceptable in this situation if no feasible alternative dialysis option exists, recognizing the potential infection-related risks [10].

On the other hand, the presence of a colostomy [11], gastrostomy, ureterostomy, and/or pyelostomy does not preclude CPD. However, data from the International Pediatric Peritoneal Dialysis Registry (IPPN) revealed an increased risk of peritonitis in patients who had a colostomy [11]. Patients with prune-belly syndrome have also been successfully managed with CPD [12].

PRESCRIBING PERITONEAL DIALYSIS — Selection of the peritoneal dialysis (PD) modality and the specific prescription components should ideally be tailored to the needs of the individual patient, with consideration of the medical needs of the child and the quality of life of the patient and family [5,13,14]. These choices are based on the child's age, body size, residual kidney function (RKF), associated nonrenal diseases, nutritional status, and transport characteristics of the peritoneal membrane, as well as the social, educational, and economic status of the family.

Pediatric versus adult PD — Specific issues for children undergoing CPD that differ from the adult patient include the following:

Fill volume is based on the body surface area (BSA) of the child (calculator 1). (See 'Fill volume' below.)

Peritoneal equilibration test (PET) – PET is used to evaluate the peritoneal membrane function (see 'Peritoneal membrane function' below). When performing this test, instead of the standard 2 L fill volume used for the PET in adults, a test volume of 1100 mL/m2 based on the patient's BSA is typically used in children. However, infants and young children (below two years of age) may not tolerate a test volume of 1100 mL/m2. In these patients, the test volume generally used is the clinically prescribed fill volume. (See 'Peritoneal membrane function' below.)

PD catheter size and placement – Size of PD catheter will vary based on size of the child. In addition, attention to location of the PD catheter exit site is important in infants still wearing diapers as well as in patients who have a gastrostomy tube or some other stoma (eg, colostomy). (See 'PD catheter' below.)

Choice of modality — For both children and adults, PD modalities are divided into manual and automated options:

Continuous ambulatory peritoneal dialysis (CAPD)

Automated peritoneal dialysis (APD)

Continuous ambulatory PD — Continuous ambulatory peritoneal dialysis (CAPD) provides continuous solute and fluid removal throughout the day and night. In this manual form of CPD, the patient or caregiver attaches and instills a bag of sterile dialysis fluid into the peritoneal cavity four times per day through a surgically placed catheter, followed by drainage through the same catheter after a predetermined period of time (referred to as the dwell time). The filling and draining of fluid constitutes an exchange. Each of the three daytime exchanges lasts approximately five hours, and the nighttime exchange nine hours. The advantages of CAPD are its ease of use and the limited cost of equipment. CAPD is a modality that is often used in developing countries where there is a lack of access to automated PD and chronic HD [15].

Automated PD — APD is broadly defined as all forms of PD that employ the use of a cycler [5,13]. If it is available and there are no financial constraints, APD is the preferred modality for pediatric patients because it allows for a wide range of treatment options, which is more easily tailored than CAPD to the individual needs of the child. In addition, the risk of peritonitis may be less in patients receiving APD as compared with CAPD [16].

In general, multiple automated exchanges are performed at night while the patient is sleeping. The supine position is superior to the upright position for solute and fluid transport because there is better tolerance of large fill volumes, which increases the contact area of the peritoneal membrane and dialysate.

There are currently three APD options that include multiple nocturnal exchanges:

Nightly intermittent PD (NIPD) – In NIPD, there are a number of short automated nocturnal exchanges, but no dialysis exchange during the day. Thus, solute and fluid removal only take place at night.

Advantages of a dry peritoneal cavity during the day include normal intraperitoneal pressure (IPP) and a decreased risk for hernia formation, reduction of glucose absorption from dialysate, reduction of amino acid and protein loss, and reduction of peritoneal membrane exposure to glucose. In addition, the absence of fluid in the peritoneal cavity might result in improved appetite. (See 'Mechanical complications' below.)

The absence of a daytime dwell volume limits solute clearance; thus, NIPD is generally not a suitable choice in patients with little or no RKF.

Continuous cycling peritoneal dialysis (CCPD) – In CCPD, automated nocturnal exchanges are followed by a prolonged daytime exchange (dialysis solution volume of 50 to 100 percent of the nocturnal volume), applied at the conclusion of the nocturnal APD session and left in the peritoneal cavity until the start of the next nocturnal dialysis session.

CCPD provides continuous solute and fluid removal throughout the day and night.

CCPD is recommended when RKF becomes negligible.

Tidal peritoneal dialysis (TPD) – In TPD, an initial infusion of dialysis solution into the peritoneal cavity is followed by only partial drainage of the dialysis solution during each exchange. As a result, an intraabdominal volume of dialysate is retained at the end of each exchange, so there is constant contact between dialysis solution and the peritoneal membrane.

Partial drain volume is replaced by fresh dialysate to restore the initial fill volume with each cycle. The entire dialysate volume is drained at the end of the session.

TPD provides continuous solute and fluid removal throughout the day and night.

It is commonly used for patients with mechanical (eg, drainage of dialysate) problems and as a means of alleviating discomfort in patients experiencing drainage pain [17]. (See 'Noninfectious complications' below.)

The tidal drain volume can be adapted to the drainage profile of the patient to increase dialysis efficiency. The rate of outflow is not linear and is highest at the beginning of the drain time and then significantly drops to a breakpoint when a critical intraperitoneal volume is reached. Elimination of the time at this breakpoint necessary for complete drainage decreases the time period when solute clearance is greatly reduced.

TPD requires more dialysate solution and is technically more difficult to perform than CCPD or NIPD.

APD is performed through a specific pediatric mode of the cycler, which has been adapted for use in infants, children, and adolescents. In small children and infants, this allows for more accurate delivery of small dialysate volumes. As a result of technological advancements, software computer programs can record adherence to the dialysis prescription, delivered dialysate volume, the amount of fluid removed (eg, ultrafiltrate), and the drainage profile of each exchange. This information can be downloaded from the memory card of the cycler or be retrieved via a modem on a regular basis and is used to improve and update the PD prescription [18]. Remote monitoring of APD is also available and allows for more personalization of the APD prescription. In adults, remote monitoring results in more frequent modifications of the APD prescription that proactively address clinical issues and helps decrease the need for additional clinic visits [19]. The use of remote monitoring in children on APD is currently being studied.

Adapted PD, a variation of automated PD, is characterized by sequential short- and longer-dwell exchanges with small and large dwell volumes designed to enhance volume and solute removal, respectively [20]. It still requires further study in children to determine effectiveness.

PD catheter — Successful CPD is dependent on the placement of a reliable access. A two-cuffed Tenckhoff catheter is preferred because use of double cuff versus single cuff catheters is associated with a lower incidence of peritonitis and access revisions, and a longer time to first peritonitis episode [21-23]. (See "Placement of the peritoneal dialysis catheter".)

Catheters should be surgically placed in a paramedian or lateral abdominal location. The deep cuff is placed in or below the rectus muscle, and the superficial cuff is located approximately 2 cm below the skin surface. The catheter should be placed with a lateral or downward-facing exit site position to reduce the risk of peritonitis [21,22]. Other considerations include placement of the exit site away from a (or potential) gastrostomy or other ostomy site, and outside the diaper area in infants and small children. Omentectomy should be performed at time of PD catheter placement; in a multicenter retrospective study, it was strongly associated with reduced likelihood of PD catheter revision [24].

Peritoneal membrane function — The transport capacity of a patient's peritoneal membrane is one of the most important characteristics to consider when determining the dialysis prescription. The most widely used test of peritoneal membrane function is the peritoneal equilibration test (PET), which assesses the overall solute transport rates across the peritoneum. It categorizes patients based on their solute transport rates and serves as the basis for the patient's dialysis prescription. (See "Peritoneal equilibration test".)

In children, this standardized test measures small solute transport across the peritoneal membrane and net ultrafiltration during a four-hour dwell using a fill volume of 1100 mL/m2 BSA of a 2.5 percent dextrose-containing dialysate [25]. It is important to recognize that the test fill volume significantly impacts the PET results (eg, small volume associated with high measured solute transport capacity). Several studies have validated this test volume for the PET and have shown consistent results that are similar to the results in adults using the standard test fill volume of 2 L [25-28]. Using the BSA-adjusted test volume, there appears to be no difference in the peritoneal membrane transport characteristics between children and adults.

Infants and young children (below two years of age), however, may not tolerate a test volume of 1100 mL/m2. In these patients, the test volume generally used is the clinically prescribed fill volume. (See 'Fill volume' below.)

PET is used clinically as follows:

Initiation of dialysis to determine the dialysis prescription – A PET evaluation is conducted four to eight weeks following the initiation of CPD, with subsequent evaluation and possible modification of the initial PD prescription.

Monitor membrane function – Because of changes in the peritoneal membrane function that may occur, the PET is used to monitor membrane function and help guide changes in the dialysis prescription. PET should be repeated when there is concern for membrane injury or changes (eg, following repeated episodes of peritonitis) and/or clinical evidence of altered transport characteristics (eg, fluid retention with increased blood pressure or worsening symptoms of uremia).

The clinical applications of the PET are discussed in greater detail separately. (See "Peritoneal equilibration test", section on 'Clinical applications'.)

Prescription components — The following are the elements of the peritoneal dialysis prescription after selecting the CPD modality:

Selection of PD solutions

Determination of the fill volume

Determination of dwell time and number of exchanges

The prescription is based on the individual patient needs for solute transfer and removal of fluid, both of which can be increased by changes in the prescription, such as increasing the osmolality of the PD solution, fill volume, and/or number of exchanges.

Solutions — Several different solutions are available commercially for peritoneal dialysis and all include the following components:

Water

Buffers to control acidosis (eg, acetate, lactate, or bicarbonate)

Electrolytes (ie, sodium, calcium, chloride, and magnesium)

Osmotic agent; usually dextrose in varying concentrations (1.5, 2.5, and 4.25 percent solutions). Increasing the osmolality will increase net fluid removal.

Although these solutions satisfactorily remove fluid and transfer solutes, and generally maintain adequate electrolyte, acid-base, and mineral homeostasis, there is increasing evidence that prolonged exposure to standard PD solutions results in membrane injury and reduced function, especially in patients who are exposed to the frequent short cycles used in APD [5,13,29]. In particular, solutions with high concentrations of glucose and lactate appear to be more injurious.

Therefore, development of more biocompatible solutions is desirable, especially for pediatric patients in whom preserving a functional membrane is important so that CPD can be maintained as a long-term dialysis modality. Amino acids and bicarbonate have been used to improve biocompatibility. A multicenter randomized controlled trial showed that a bicarbonate-based buffer improved long-term preservation of peritoneal membrane function compared with lactate-based PD fluids in children on automated PD, while still achieving equal control of acidosis [30]. However, in a study evaluating the effect of neutral pH and low-glucose degradation product dialysis fluids on the peritoneal membrane, biopsies demonstrated vascular changes with early peritoneal inflammation as early as six months after PD initiation, which may ultimately affect PD membrane transport function [31]. Higher molecular weight glucose polymers, such as icodextrin, can be used during the long dwell (during the night for patients on CAPD and during the day for patients on APD) to enhance ultrafiltration in patients with high peritoneal membrane transport capacity.

Further studies in children are warranted to see if these or other strategies improve long-term peritoneal membrane function without significant adverse effects [32-34].

The use of these biocompatible solutions is limited, however, as these solutions are not available in many parts of the world. (See "Peritoneal dialysis solutions".)

Fill volume — As noted above, an important difference in prescribing CPD for children compared with adults is that the prescribed fill volume is based on the BSA of the child. It is adjusted based on the patient's tolerance and need for solute and fluid removal. (See 'Pediatric versus adult PD' above.)

In a CAPD regimen of four exchanges per day, a fill volume of 900 to 1100 mL/m2 BSA (35 to 45 mL/kg) of 2.5 percent dextrose dialysis solution generally yields net fluid removal (ultrafiltration [UF]) volumes of up to 1100 mL/m2 with acceptable biochemical control. In patients who still have substantial RKF, dialysis solutions of 1.5 percent dextrose may provide acceptable ultrafiltration.

In patients managed by APD, the targeted individual nocturnal fill volume is 1000 to 1200 mL/m2 for patients >2 years, and 600 to 800 mL/m2 for children ≤2 years of age. The daytime fill volume is generally 50 percent of the nighttime volume. The UF using this modality is dependent on cycle frequency, fill volume, osmolality of the dialysis solution, and the transport capacity of the child's peritoneal membrane.

Too small a fill volume may lead to rapid solute equilibration and inadequate ultrafiltration [13]. In contrast, too large a volume can lead to excessive increases in intraperitoneal pressure (IPP) that reduces dialysis efficiency due to enhanced lymphatic uptake [35]. In addition, large fill volumes may not be well tolerated by the child due to discomfort/pain, dyspnea, hernia, gastroesophageal reflux, and hydrothorax. In these cases, the IPP measurement may be useful in assessing patient tolerance. In general, an IPP greater than 18 cm H20 is associated with abdominal pain and a decrease in vital capacity [36]. (See 'Noninfectious complications' below.)

Exchange dwell time — The length of the dwell times is dependent on the CPD modality selected.

In CAPD, the dwell times are long, and therefore the major risk to dialysis efficiency is loss of the glucose-related osmotic gradient due to solute equilibration that results in ineffective ultrafiltration and dialysate reabsorption by the child. Thus, the dwell time may need to be shortened (less than four hours) in children who have high solute transport rates across the peritoneum based on peritoneal equilibration testing. (See 'Peritoneal membrane function' above.)

In APD, an exchange dwell time of approximately one hour is initially selected. However, the dwell time needs to be reevaluated and possibly modified based on the needs of the individual patient, taking into consideration the patient's RKF, peritoneal membrane transport function, and the desired clinical goals. Dwell times are shortened to increase ultrafiltration and urea clearance. Long dwell time exchanges, on the other hand, favor higher creatinine and phosphate clearance, but may impair ultrafiltration. Commercially available modeling programs designed to assist in the prescription process have been validated in children [37].

INFECTIOUS COMPLICATIONS — Infection is one of the most significant complications of pediatric peritoneal dialysis (PD). The 2022 Annual Data Report from the United States Renal Data System (USRDS) reported that infection is second-most common cause of death in children receiving PD [38].

Peritonitis — Peritonitis remains the most common significant complication of CPD in the pediatric population, especially in infants [39,40]. Peritonitis contributes to major morbidity because of loss of peritoneal membrane function and technique failure, particularly in children with repeated episodes of infection [41].

In the 2011 annual report, the North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) reported on 4248 episodes of peritonitis in 6658 years of follow-up for an annualized rate of 0.64 (one episode every 18.8 months) [21]. As seen in earlier reports, the data also revealed an inverse relationship between the age of the patient and peritonitis rate, with the youngest patients (<1 year) having an annualized rate of 0.79 (one infection every 15.3 months), while the adolescents (>12 years) had a rate of 0.57 (one infection every 21.2 months).

Although the microbiology, diagnosis, and management of peritonitis in children undergoing CPD are similar to those of adult patients, there are some issues that are unique or more common in pediatric CPD. These include:

Fungal peritonitis is an infrequent complication in pediatric patients undergoing CPD, accounting for up to 8 percent of peritonitis episodes [42]. Children with fungal peritonitis are more likely to be less than two years of age. Successful therapy is the same as in adults with fungal peritonitis and consists of combination therapy of antifungal medication and dialysis catheter removal. The outcome of fungal peritonitis in children, however, is more favorable than in adults, with a lower mortality rate [22,43]. (See "Fungal peritonitis in peritoneal dialysis".)

There is global variation in causative microbial agents in peritonitis in children receiving CPD [44]. As an example, the rate of Pseudomonas-based peritonitis is eight times greater in the United States than in Europe. In addition, there are significant differences in antibiotic susceptibility, particularly with first generation cephalosporins and aminoglycosides. These issues need to be considered when choosing empiric antibiotic coverage while awaiting results from peritoneal fluid cultures.

Predisposing factors in children that may contribute to peritonitis include early use of PD catheter (within 14 days of PD catheter insertion), peritoneal catheter exit-site infection, the higher incidence of gastrostomy feeds, the use of diapers in infants and young children who are not yet toilet trained, and surgical procedures performed around the time of PD catheter placement [11,45]. For example, in a study of infants, nephrectomy at or prior to PD catheter placement and G-tube insertion after catheter placement were associated with nearly six-fold and nearly three-fold increased risk of peritonitis, respectively [40].

The microbiology, presentation, diagnosis, and management of peritonitis in patients undergoing CPD are discussed separately. (See "Microbiology and therapy of peritonitis in peritoneal dialysis" and "Clinical manifestations and diagnosis of peritonitis in peritoneal dialysis".)

Exit site and tunnel infections — Peritoneal dialysis catheter exit site/tunnel infections are a significant cause of peritonitis and catheter failure [46-48]. A multicenter quality improvement study conducted from 2011 to 2014 reported a rate of exit site and tunnel infections of 0.25 per dialysis year [46]. In this study, peritonitis developed in 6 percent of the cohort, and catheter removal was required in 9 percent of the cases.

Treatment of catheter exit site infections routinely consists of oral antibiotics according to culture/susceptibility results [49]. Intraperitoneal antibiotics are added only if improvement is not seen promptly. (See "Peritoneal catheter exit-site and tunnel infections in peritoneal dialysis in adults".)

Prevention — Prevention of exit site infections (ESIs) is the primary goal of exit site care, which consists of aseptic care, daily assessment and cleansing of the exit site, immobilization of the catheter, and protection of the exit site and subcutaneous catheter tunnel from trauma. Proper handwashing technique is of utmost importance and should be practiced by the individual conducting exit site care [50]. Cleansing should be performed with a noncytotoxic and nonalcoholic antiseptic agent, such as sodium hypochlorite or chlorhexidine, as opposed to soap and water. In addition, many centers use topical antibiotic prophylaxis to prevent bacterial infection. As an example, topical mupirocin has been used to decrease S. aureus colonization because of the recognized risk of S. aureus peritonitis in patients with S. aureus nasal carriage.

The effect of preventive measures to reduce exit site infections and peritonitis was shown in a retrospective review from a single center that reported a reduction in catheter-related infections and prolonged catheter survival with the introduction of daily cleansing with sodium hypochlorite and application of topical mupirocin [51]. However, the association between mupirocin usage and pseudomonas infections has prompted the use of topical gentamicin cream in many centers, as it covers potential gram-positive and the gram-negative pathogens [52]. (See "Peritoneal catheter exit-site and tunnel infections in peritoneal dialysis in adults", section on 'Prevention'.)

Infection prevention can also be achieved through quality improvement initiatives. The SCOPE (Standardizing Care to Improve Outcomes in Pediatric ESKD) collaborative is one such quality improvement initiative that has successfully reduced peritonitis rates from 0.53 episodes per patient year prelaunch to 0.3 at 84 months postlaunch by increasing implementation of standardized care practices [53,54].

NONINFECTIOUS COMPLICATIONS — Peritoneal dialysis (PD) noninfectious complications can be divided into mechanical, technique-related, and catheter-related complications [55].

Mechanical complications — Mechanical complications of CPD related to increased intraabdominal pressure include hernias, fluid leaks, and hydrothorax [56].

Hernias are commonly incisional, umbilical, or inguinal, occurring with a reported frequency of 11.8 to 53 percent in children undergoing CPD [57-59]. The incidence is inversely proportional to age, with the highest frequency occurring within the first year of life [57]. (See "Abdominal wall hernia and dialysate leak in peritoneal dialysis patients".)

Fluid leaks may occur early (defined as occurring less than 30 days after catheter insertion) or late. Early leaks often occur at the PD catheter exit site, while late leaks more commonly occur into the abdominal wall, leading to abdominal wall or genital edema, and are more likely to be associated with hernias [60]. Leakage is more common in children who weigh less than 10 kg. (See "Noninfectious complications of peritoneal dialysis catheters", section on 'Pericatheter leakage'.)

Hydrothorax, which may present as an incidental finding on chest x-ray, as respiratory distress without volume overload, or as ultrafiltration failure, is an uncommon but potentially serious complication of CPD. It may result in PD technique failure and the need for transfer to hemodialysis if recurrent. Successful continuation of PD has been reported using reduced fill volumes or following surgical correction of an identified pleuroperitoneal connection; resolution of the hydrothorax may also occasionally occur with temporary cessation of PD. (See "Noninfectious complications of continuous peritoneal dialysis", section on 'Pleural effusion due to pleuroperitoneal leak'.)

Technique related complications — Ultrafiltration (UF) failure can lead to symptomatic volume overload and PD technique failure, especially in patients who are anephric or oliguric. Decreased ultrafiltration can occur as a result of the following [55]:

High peritoneal membrane solute transport capacity, with rapid dissipation of the glucose-based osmotic gradient for UF. While this may be a chronic issue, it can also arise acutely in patients with peritonitis, which resolves with treatment of the infection.

Repeated episodes of peritonitis.

Prolonged exposure to glucose degradation products (GDPs) present in conventional PD solutions in patients on long-term PD [13].

Iatrogenic due to the use of a small fill volume relative to the peritoneal surface area.

Increased peritoneal lymphatic absorption secondary to elevated intraperitoneal pressure.

Rarely, aquaporin (ultrasmall pore water channels in the peritoneum) deficiency (see "Mechanisms of solute clearance and ultrafiltration in peritoneal dialysis", section on 'Aquaporin-1 and water transport').

Sclerosing encapsulating peritonitis, an outcome that can arise following a prolonged period (years) of PD [61,62] (see 'Other complications' below).

Performing a peritoneal equilibration test (PET) in patients with UF failure can help better characterize the membrane transport capacity, which will guide PD prescription modifications. (See "Peritoneal equilibration test".)

Catheter-related complications — Catheter-related complications can occur in the immediate postoperative period or later, and include [63,64]:

Leakage of dialysate around the catheter – Delaying catheter usage for one to two weeks following catheter placement or initial use of a small fill volume can decrease the risk of leakage [65]. Two case series from tertiary centers reported that the risk of PD catheter leak was greatest in children who weighed less than 10 to 12.4 kg [60,66]. (See "Noninfectious complications of peritoneal dialysis catheters", section on 'Pericatheter leakage'.)

Catheter migration – May occur less commonly with a PD catheter with a curled intraperitoneal segment, swan neck catheter, and a downward-facing exit site [67-69].

Extrusion of catheter cuff at exit site with subsequent increased risk for infection, which can be prevented by placement of external cuff approximately 2 cm from the exit site [23,70,71]. (See "Noninfectious complications of peritoneal dialysis catheters", section on 'Superficial catheter cuff extrusion'.)

Catheter outflow occlusion, usually caused by omentum, or adhesions to mesentery or other intraabdominal structures. Partial omentectomy is often performed at time of placement in an attempt to prevent catheter outflow occlusion and has been strongly associated with reduced likelihood of PD catheter revision [24,69,72-74]. (See "Noninfectious complications of peritoneal dialysis catheters", section on 'Impaired catheter flow'.)

Peritoneal dialysis catheter failure can result in the need for access revision. Based on data from the International Pediatric Peritoneal Dialysis Network registry, mechanical dysfunction was the most common indication for access revision within the first year of PD, whereas infectious complications were the predominant cause for revision at >1 year after PD initiation [75].

Other complications

Hemoperitoneum –The incidence of hemoperitoneum as a complication of PD in children is reported to be 1.7 percent [76]. Conventional treatment of hemoperitoneum includes the addition of heparin to the dialysis fluid to prevent catheter occlusion from clots; however, management depends on the severity and underlying cause. The etiology, evaluation, and management of hemoperitoneum in patients undergoing CPD are discussed separately. (See "Bloody peritoneal dialysate (hemoperitoneum)".)

Pain – Abdominal pain can be observed, even in the absence of peritonitis. Causes of abdominal pain include:

Jet of dialysis fluid or catheter irritation in the dry peritoneal cavity. The use of a PD catheter with a curled intraperitoneal segment has been associated with a decreased incidence of jet-related pain.

Overdistention of the peritoneal cavity with excessive dialysis fluid due to cycler malfunction or catheter malfunction, and incomplete drainage prior to subsequent filling.

Intraabdominal processes unrelated to the dialysis procedure such as peptic ulcer disease, pancreatitis, appendicitis, or diffuse peritoneal calcification. In a case report, tidal peritoneal dialysis effectively provided symptomatic relief of pain in a child with peritoneal calcifications [77].

Other causes of pain during dialysate infusion include acidic dialysate fluid, malposition of the catheter, and high glucose concentration of hypertonic dialysis solutions. In addition, referred shoulder pain may occur due to air introduced into the peritoneum during the infusion of dialysis fluid or at the end of draining. (See "Noninfectious complications of continuous peritoneal dialysis", section on 'Pain with dialysate infusion or drainage'.)

Encapsulating peritoneal sclerosis– Encapsulating peritoneal sclerosis (EPS) is a rare, potentially devastating complication of CPD, which leads to progressive loss of UF capacity and can result in abdominal pain, ascites, intestinal obstruction, and death [78,79]. Risk factors implicated in the development of EPS include prolonged duration of peritoneal dialysis, recurrent bacterial peritonitis, and prolonged exposure to hypertonic dialysis solutions [61,62,80-88]. This devastating complication should be suspected when the PET and clinical care shows decreased solute and fluid removal (type II membrane failure). (See "Encapsulating peritoneal sclerosis in patients on peritoneal dialysis" and "Peritoneal equilibration test".)

Nutritional and metabolic issues ‒ Nutritional and metabolic issues associated with CPD include:

Protein loss. (See "Nutritional status and protein intake in patients on peritoneal dialysis".)

Hyponatremia due to sodium loss, which may result in significant hypovolemia and hypotension. Case reports in infants and young children undergoing CPD suggest that hypovolemia and hypotension may contribute to developing anterior ischemic optic neuropathy [89,90]. (See "Mechanisms of solute clearance and ultrafiltration in peritoneal dialysis", section on 'Electrolytes'.)

Hypothyroidism has been reported as a complication of chronic exposure to povidone-iodine-impregnated gauze from the transfer set [91]. (See "Thyroid function in chronic kidney disease", section on 'Thyroid hormone metabolism'.)

OUTCOME

Patient survival — Patient mortality rates in children receiving CPD are significantly greater than the rates in transplanted children or the healthy population. Among nearly 3000 patients from the International Pediatric Peritoneal Dialysis Network (IPPN) cohort between 1996 and 2017, the mortality rate globally was 5 percent over three years follow-up [92]. The lowest rate was in North America (2 percent) and the highest in Eastern Europe (9 percent); the difference was largely related to disparate resources.

The most common causes of death for pediatric CPD patients of all ages are cardiovascular disease and infection [93-96]. Pulmonary disease and severe oliguria/anuria appear to be significant risk factors for mortality in young children and infants.

Young children — Survival rate is lowest in children below five years of age as noted by the following:

In the United States Renal Data System (USRDS) 2022 Annual Data Report, five-year survival was reported to be lowest in the <1 year age group, at approximately 79 percent, followed by children aged one to five years old, at approximately 89 percent [38]. In contrast, survival in the ≥6-year age group was 96 percent.

Data from the Italian dialysis registry has also documented the highest mortality rates in the youngest patients (<5 years of age) [97].

Infants — Data from the USRDS showed a mortality of 21 percent while on dialysis for infants who initiated chronic PD at ≤12 months of age from 1990 to 2014 [98]. For infants who started PD as neonates, survival improved during the period between 2000 to 2014 compared with the earlier time period 1990 to 1999 for both one-year survival (87 versus 77 percent) and five-year survival (75 versus 64 percent). Similar results were reported for older infants who initiated PD at 1 to <12 months for one-year survival (90 versus 81 percent) and five-year survival (79 versus 62 percent). The two most common causes of death based on reports of 273 of the 360 patient deaths were cardiorespiratory failure (26 percent) and infection (23 percent).

Data from the North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) also showed that the three-year patient survival improved from 79 to 85 percent for infants initiating CPD during the first year of life in 1992 to 1999 and 2000 to 2012 [99].

The European Registry for Paediatric Nephrology also reported increasing mortality for infants with decreasing age with a 5 percent increased risk of death per month of earlier initiation during the first year of life [100].

Transition to hemodialysis — The need to terminate CPD for reasons other than transplantation is most commonly the result of infectious complications. A North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) study found that 20 percent of patients transitioned from CPD to hemodialysis (HD) over a six-year period, most commonly (43 percent) due to infection, followed by ultrafiltration failure, patient/family choice, and access failure [21].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Chronic kidney disease in children".)

SUMMARY AND RECOMMENDATIONS

Advantages and disadvantages of chronic peritoneal dialysis – Chronic peritoneal dialysis (CPD) is the most common dialysis treatment modality used to treat pediatric patients with end-stage kidney disease (ESKD), particularly in children less than six years of age. There are no comparative studies of chronic peritoneal dialysis (CPD) and hemodialysis (HD) outcomes in children with ESKD to suggest superiority of one procedure versus the other. Advantages associated with CPD include a less restricted diet, ability to perform dialysis treatments at home, and no need for vascular access and repeated venipuncture. Disadvantages of CPD include increased caregiver burden and risks of potential nonadherence, and CPD related infections. Contraindications to CPD include specific conditions that affect the integrity of the abdominal cavity and peritoneum. (See 'Peritoneal dialysis versus hemodialysis' above.)

CPD prescription – Selection of the CPD modality and the specific prescription should ideally be tailored to the needs of the individual patient, with consideration of the medical needs of the child and the quality of life of the patient and family. These choices are based on the child's age, body size, associated nonrenal diseases, nutritional status, and transport characteristics of the peritoneal membrane, as well as the social, educational, and economic status of the family. (See 'Prescribing peritoneal dialysis' above.)

The elements of the CPD prescription include selection of PD solutions and determination of the fill volume, dwell time, and the number of exchanges. The prescription is based on the individual patient needs for solute transport and removal of fluid, both of which can be increased by changes in the prescription, such as increasing the osmolality of the solution, fill volume, and/or number of exchanges. (See 'Prescription components' above.)

CPD modalities – These are divided into manual and automated options:

Continuous ambulatory PD (CAPD) is the manual form of CPD that provides continuous solute and fluid removal throughout the day and night. It is easier to use and less costly than the automated PD options. (See 'Continuous ambulatory PD' above.)

Automated PD (APD) uses a cycler that performs multiple exchanges at night. It allows for a wide range of treatment options, which can be more easily tailored to the patient's needs than CAPD. The three options of APD are nightly intermittent PD, continuous cycling PD, and tidal peritoneal dialysis. (See 'Automated PD' above.)

Catheter placement – Successful CPD is dependent on the placement of a reliable access. In the pediatric patient, we suggest using a two-cuffed Tenckhoff catheter rather than a single-cuffed catheter to reduce the risk of peritonitis (Grade 2B). Placement of the catheter with a lateral or downward-pointed exit site position also reduces the risk of peritonitis. (See 'PD catheter' above.)

Assessing peritoneal membrane function – We suggest that a peritoneal equilibration test (PET) be performed in all children undergoing CPD to determine the solute transport characteristics of the peritoneal membrane, which can assist in developing an adequate dialysis prescription (Grade 2C). Test fill volume is determined by the body surface area of the child. (See 'Peritoneal membrane function' above.)

Infectious complications – These include peritonitis and catheter exit site/tunnel infections. We recommend daily care of the exit site and catheter that reduces the risk of exit site and tunnel infections (Grade 1C). This includes proper handwashing by the care provider, daily assessment and cleansing of the exit site with antiseptic agents, catheter immobilization, trauma avoidance to the exit site and subcutaneous catheter, and the use of topical antibiotic prophylaxis. (See 'Infectious complications' above.)

Noninfectious complications – These include:

Mechanical complications due to increased intraperitoneal pressure include hernia, fluid leak, and hydrothorax. (See 'Mechanical complications' above.)

Technique-related complications include ultrafiltration failure, which may be due to rapid solute transport, increased lymphatic flow, or aquaporin deficiency. (See 'Technique related complications' above.)

Catheter-related complications include dialysate leakage, catheter migration, cuff extrusion, and outflow occlusion. (See 'Catheter-related complications' above.)

Other complications include hemoperitoneum, pain, sclerosing encapsulating peritonitis, and nutritional and metabolic problems. (See 'Other complications' above.)

Prognosis – Patient mortality rates in children receiving CPD are significantly greater than the rates in transplanted children or the healthy population. The most common causes of death for pediatric CPD patients of all ages are cardiovascular disease and infection. Mortality is highest in young children (below five years of age) and infants. Pulmonary disease and severe oliguria/anuria appear to be significant risk factors for mortality in infants and young children. (See 'Patient survival' above.)

The need to terminate CPD and transition to HD is most commonly the result of infectious complications. (See 'Transition to hemodialysis' above.)

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Topic 16400 Version 27.0

References

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