Thematic Area: Peritoneal Dialysis in Children

Solutions for Peritoneal Dialysis in Children: Recommendations by the European Paediatric Dialysis Working Group

Reference: Schmitt CP, Bakkaloglu SA, Klaus G, Schröder C, Fischbach M; European Pediatric Dialysis Working Group. Pediatr Nephrol. (2011).doi: 10.1007/s00467-011-1863-4

Core Recommendations:

1. The EPDWG suggests using neutral pH PD solutions with low glucose degradation product content
2. Icodextrin based solutions are recommended for the long daytime fill.
3. Bicarbonate-based PD fluids are recommended in children with AKI when liver function is severely compromised.
4. Dialytic glucose exposure to the peritoneum and patient should be minimzed, but euvolemia maintained.
5. The dialysate calcium concentration must be adapted to the individual needs of the growing child.
6. No evidence to recommend amino acid-based PD solutions in malnourished children on PD.
7. General recommendations with regard to the combination of the different types of PD solutions available cannot be given; the PD Regime must be adapted for each individual.

Comments by evaluators:

• The Guideline development process does not meet several criteria as proposed by GRADE and AGREE. 
• No external experts included.
• Preferences of patients and their parents are not considered and they are not included as stakeholders.
• The evidence review process is not described.
• Most guidelines were largely based on studies in adults and have been extrapolated to children; many recommendations need down-graded.
• Transparency and Editorial independence may be questioned since there is no mention of external funding for the group and the authors do not provide disclosures.

Clinical practice guidelines for pediatric peritoneal dialysis. Canadian Association of Pediatric Nephrologists (CAPN); Peritoneal Dialysis Working Group

Reference: White CT, Gowrishankar M, Feber J, Yiu V; Canadian Association of Pediatric Nephrologists (CAPN); Pediatr Nephrol. (2006). doi: 10.1007/s00467-006-0099-1

Core Recommendations:

1. Peritoneal dialysis in children should be initiated when CrCl is <10 ml/min per 1.73 m² and/or when there are symptoms and signs of uremia and/or growth failure.
2. Double-cuff catheters can be used in children heavier than 3 kg where the external cuff can be placed 2–3 cm from the exit site.
3. Exit sites should be oriented either downward (preferred) or laterally in children.
4. Use of a swan neck catheter in children should be left to the discretion of the individual PD center.
5. Children should have a PD catheter which has a curled intraperitoneal segment.
6. The tip of the PD catheter should be placed, whenever possible, in the pelvis.
7. The decision to perform an omentectomy (or omentopexy if a laparoscopic insertion is contemplated) in a pediatric patient should be left to the discretion of the surgeon.
8. All children should receive preoperative and, when appropriate, postoperative antibiotics with the insertion of a PD catheter.
9. Timing for the initiation of dialysis post catheter insertion should be left to the discretion of the center recognizing the need for wound healing. If initiation of dialysis is required within 7 days post-catheter insertion, low volumes should be commenced (500 ml/m² body surface area).  
10. Membrane characteristics should be determined by the PET with a test exchange volume scaled to body surface area (1,100 ml/m², 2.5% dialysate) and this should then determine a dialysis regimen with optimization of dwell time and exchange volumes. 
11. Delivered PD dose and residual renal function should be measured 1 month after reaching maximum dwell volume and a minimum of two times over the subsequent 6 months. After 6 months, total solute clearance should be measured every 3 months and/or if there have been significant changes in the dialysis prescription and/or in the setting of a recent bout of peritonitis (must wait minimum 4 weeks from peritonitis).