1. THE CHOICE OF DIALYSIS ACCES CONTROVERSY AND EVIDENCE
PART 3 : Peritoneal Dialysis

2. Teaching point

3. EBM ?

4. What’s new ?

5. CONTROVERSY ?

6. EXPERT BASED GUIDELINES
Guidelines by an ad hoc European committe on elective chronic peritoneal dialysis in pediatric patients
Watson, on behalve of the European pediatric dialysis working group
Comprehensive pediatric nephrology Geary Schaefer

7. CONTROVERSY PRE-DIALYSIS INORMATION >POST DIALYSIS FOLLOW UP
>PERI- OPERATIVE CARE
> SURGEON
> CATHETER

8. CHOICE OF CATHETER Catheters Place left / right fossa
Length
Length between cuff’s
Place left / right fossa
Swan neck / straight
Straight / Currl

10. CONTROVERSY PRE-DIALYSIS INORMATION >POST DIALYS FOLLOW UP
>PERI- OPERATIVE CARE
> SURGEON
> CATHETER

11. Preparation of the patient and the family
1) It is essential that the child and family are prepared by a pediatric nurse experienced in chronic peritoneal dialysis with access to appropriate written information and other teaching aids such as dolls or videos.
2) If the child has phobias then a child psychologist should be consulted
3) Home visit / School visit
4) Contact with other child /parents

12. Preparation of the patient and the family
A nutritional assessment will be required for all dialysis patients. If nutritional support is required then the appropriate route for supplementation (oral. Nasogastric or gastrostomy) should ho discussed with the pediatric renal dietitian and team members.
If it is appropriate to consider a gastrostomy then this can be placed at the time of the PD catheter under the same anaesthesie with minimal additional morbidity. -

13. Use of Catheter and Surgical Procedure
The placement of a peritoneal dialysis catheter requires an experienced surgeon and should be given appropriate priority,
A dialysis-catheter is a “LIFE”-line..with only few alternative options during the life-span of the patient.
“early days” nephrologist was in the theatre..
Now???

14. Use of Catheter and Surgical Procedure
Open technique
Laparoscopic technique
Percutaneous technique

15. Use of Catheter and Surgical Procedure
2) Double cuff curled catheters are preferred in most children
pediatric size in patients 3-10 kgs body weight
and adult catheter >10 kg.
A single cuff catheter may be needed in infants <3kg.
Data from the NAPRTCS registry suggest
swan neck tunnels,
two cuff
and downward pointing exit sites.

16. Use of Catheter and Surgical Procedure
2) Presumed advantages of curled catheters
better separation between abdominal wall and bowel
More catheter holes
Less inflow pain
Less tendency for migration
Less prone for omental wrapping
Potentially less trauma to the bowel

17. Use of Catheter and Surgical Procedure
Prior to theatre the exit site for the catheter should be agreed with the child and marked on the abdomen by either the dialysis nurse or surgeon.
The exit site should avoid the belt line and be above the nappy or diaper line in infants.
In all but the smallest infants the exit site should he downward facing.
The exit site should be located as far as possible from other exits, ie gastrostomies, colostomies, urostomies to prevent infections.

18. Use of Catheter and Surgical Procedure

19. Use of Catheter and Surgical Procedure
Laxatives should be given pre-operatively to children who suffer from constipation
Empty bladder
Partial omentectomy may reduce postoperative obstruction but there are no prospective pediatric series addressing this issue.
Consider elective herniotomv if any evidence of inguinal or other hernia prior to or during catheter placement.

20. Use of Catheter and Surgical Procedure
Entry into the peritoneum should be lateral or paramedian
with the deep cuff outside the peritoneum.
The peritoneum is closed tightly around the catheter
Below the level of the deep cuff using a purse string suture.
A tunneling device with a sharp point is recommended for creating the catheter tunnel
and strict haemostasis is required.
No incision should be made at the exit site.
The subcutaneous cuff should be at least 2cms from the exit site.
A cephalosporin antibiotic should he given intravenously at the time of catheter implantation.

21. Procedure in Theatre
1) Catheter should be tested in theatre for patency and leaks with dialysis nurse or nephrologist present.
2) No suture should be placed at the exit site which should be downward facing with the possible exveption of infants.

22. The catheter will be irrigated in theatre until the dialysate is clear then capped off.
The PD fluid should contain Heparin 5OOiu/L.
Catheter must be immobilised at all times and no keyhole dressing applied.
If the catheter has to be used for immediate dialysis then use only low volumes, 10ml/kg/cycle. In this situation keeping the patient supine for the first few days and adequate analgesia will also help to avoid high intraperitoneal pressure and possible leaks.
If possible leave catheter for two weeks until the patient returns for training. This will allow initial healing to take place.

23. IMMEDIATE POST OPERATIVE CARE
Pain controle.
Multiple low volume exchanges until clear effluent.
Dry abdomen as long as possible
Dressing is remained for 5 days.
Bedrest for 7 days.

24. FIRST WEEK POST OPERATIVE CARE
Remove primary dressing at day 5
Exit site care done by an experienced nurse.
Secure normal position of the catheter.
Avoid lifting.
Allow catheter to heal as long as possible.

25. Forbidden: - to take a bath - to swim - contact sports (football…)
GENERAL INSTRUCTIONS
Forbidden: to take a bath to swim contact sports (football…)
Advice against: sand (beach) intensive sports (basket ball…)
Tollerance of: shower

26. CONCLUSIONS Catheter complications are to be expected
when dressing is not remained intact for 5 to 7 day (difficult healing - tunnelinfection)
immediate use of the catheter (leakkage)
poor fixation (difficult healing and outgrow cuff)
Catheter characteristics are to be respected:
to prevent malpositon
to prevent outgrow cuff
Exit site care is extremely important:
to prevent infection
to assure a long life of the access

27. THE CHOICE OF DIALYSIS ACCES
CONTROVERSY AND EVIDENCE

28. EVIDENCE / CONTROVERSY
SOME THINGS ARE WRONG
SOME THINGS ARE GOOD
MOST THINGS HAVE GOOD AND BAD POINTS..where the final decision balances, depending on “choices” made

29. Fistula superior to catheter ?
Yes
But if you choose for nighttime dialysis… not possible (A. Raes oral presentation ESPN)

30. Fistula superior to catheter ?
Yes
If you are going
for pre-emptive transplantation,
and waiting list is rather short..
And time to start dialysis is not predictable

31. Integrated care model (Van Biesen)
Every patient with CKD.. may need every method for renal replacement therapy such as
Peritoneal dialysis
Transplant
Hemodialysis
Retransplant …

32. Integrated care model (Van Biesen)
Peritoneal dialysis
Is probably not the best choice in adults
If there is no residual renal function
If BSA / BMI is very high
IDDM??
So PD… and PD catheter is treatment of choice in children because
you preserve vascular access for later

33. Acute dialysis Hemodialysis Catheter Single / double Lumen
Genius… then double lumen
Femoral catheter
Often the choice
To not interfere with other central catheters

34. Acute dialysis Peritoneal catheter Surgical Percutaneous Tenckhoff
Often time… to surgery is long
Percutaneous Tenckhoff
Adults good experience
In children few reports
Seldinger place acute catheter (pigtail) (Buchmann, Vande Walle adv Perit Dialysis)
Especially in small children
Cardiac surgery
To gain time when there is hyperkaliemia (Start dialysis in 10min)
Two catheter technique
Continuous flow dialysis (Vande Walle Adv Perit Dial)