1. The Other CRRT: Peritoneal Dialysis
Mignon McCulloch
Associate Professor
Paediatric Nephrology/Critical Care

2. Acknowledgements Thanks to Stuart and Tim Disclosures
Including all forms of CRRT
Disclosures
Passionate about PD
Access for children with AKI in poorly resourced areas

3. Evelina Children’s Hospital London UK

4. Evelina Children’s Hospital Andrew Durward Personal Communication
PICU
8818 Admissions
413 deaths
Mortality 4.7%
20 Beds
Staffing:
7 Consultants
20 Fellows
150 Nurses
Training in nurses:
CVVH 30% trained
PD in 100% nurses

5. Evelina Children’s Hospital PICU 2002 – 2009
CVVH PD
Nos of Cases
119
188
139 Cardiac
Age in months 30
7.8
Med 0.22
Weight in kg --
5.3
Med 3.3
Mortality
30%
17%

7. Red Cross Children’s Hospital Cape Town SA

8. Red Cross Children’s Hospital(RXH) University of Cape Town Experience
Increasing incidence in association with multi-organ failure in paediatric ICU’s
1 200 – admissions per year
Acute medical cases 600/yr
Cardiac cases 250/yr
Burns 50/yr
Head injuries 50/yr
Other Rest
Mortality 8%
Dialysis 3.5%
AKI ???

10. Causes of Acute Renal Failure
Sepsis
46(22%)
Post-cardiac surgery
36(17%)
Undiagnosed chronic renal disease
21(10%)
Gastroenteritis
19(9%)
Haemolytic uraemic syndrome
Necrotizing enterocolitis
15(7%)

11. Causes of Acute Renal Failure
Leukaemia/Lymphoma
14(6%)
Myocarditis
11(5%)
Rapidly progressive nephritis
10(5%)
Trauma/Burns
8(4%)
Toxin ingestion
7(3%)
Kwashiorkor**
6(3%)

12. Practicalities of PD Quick – really quick – 20 mins K+ 9!
Bed-side insertion by Paeds Nephrologist/Intensivist/Surgeons
(Surgeons as backup)
Cook/Peel Away Tenckhoff/Formal Tenckhoff
Empty Bladder
Sedation + Local Anaesthetic

13. Practicalities of PD Prescription Dialysis fluid Cycles
10-20ml/kg increase as tolerated
Dialysis fluid
Dianeal(Lactate buffered) or Bicarb based
Cycles
10/30-90/20mins
Manual or Cycling Home choice > 3kg
Adapted to ventilatory requirements

16. Manual Dialysis with Fluid Warmer

17. Perit Dial Int 2001 Flynn et al (Brophy & Bunchman)
RXH
Flynn (USA)
Time period
2 yrs
10 yrs
Nos of patients 68 63
Complication Rate
25%
Commonest problem
Catheter blockage
Catheter malfunction
Survival
61%
51%

18. Acute Peritoneal Dialysis January 1999 to January 2004
TOTAL NUMBER OF PATIENTS
212
Male: Female
102:110
Age at dialysis:
< 3 months
3 months - 1yr
1 – 6 years
6 – 12 years
> 12 years
79(38%)
45(21%)
38(18%)
30(14%)
20(9%)

19. Acute PD Long term outcome
Survival following Acute PD
130(61% )
Chronic PD required following Acute PD
26(12%)
Total nos of patients requiring CVVHD (PD not possible)
Survival following CVVHD
20(9%)
11(55%)

20. Peritoneal Dialysis as a Form of CRRT for Infants in a Developing Country
McCulloch M, Argent A.
Red Cross Children’s Hospital
University of Cape Town

21. Specific Paeds Management Issues Very Low Birth Weight Infants Koralkar R et al. Ped Research 2011;69:4:354-8
AKI reduces survival in infants <1500g
Independent risk factor
Very low glomerular filtration rate
Mild exposure – high degree of injury
High rates of infection
Nephrotoxic drugs
Premature infants <1000g
Increase SCr of 1.0mg/dL(88.5umol/l)
Doubles the odds of death

22. Small infants < 5kg 25 of these patients were < 5kg
15/25 Infants (60%) survived
Age range from days
Male:Female 2:1

23. Diagnosis of Infants Surviving Dialysis
INFECTIVE CAUSES
Septicaemia
Diarrhoea
Fungal sepsis
SURGICAL CAUSES
Necrotising Enterocolitis
Cardiac Surgery - TGA’s
Abdominal Surgery

24. DRUGS
13/15 patients received large doses of Furosemide e.g. 5mg/kg/dose pre-dialysis
10/13 patients were on Dopamine infusions at time of dialysis
2 patients received Adrenaline infusions in addition
7/14 patients were on an Aminoglycoside antibiotic (amikacin/gentamicin) pre - dialysis

25. Weight of Infants surviving Dialysis

26. Advantages of Acute PD Catheters
No bleeding complications
2/15 catheters blocked - day 3 & 4 on dialysis
Replaced 1 catheter by “re-wiring”

27. Duration Of Dialysis

28. OUTCOME 15/25(60%) Infants survived to come off dialysis
Nil required long term dialysis
3 Subsequently demised - not related to dialysis:
1 Accidental extubation
1 Cerebral Palsy and developed septicaemia 1 year later
1 Shock & Dehydration due to excessive colostomy losses 3 months later

29. Acute PD in PICU 1999-2009 Presented IPNA Aug 2010 New York
Red Cross Children’s Hospital, Cape Town SA
Total 406 cases/10years
Wt range 900g – 70kg
Age 1 day – 16yrs
Diphtheria – Liver Transplant

30. PD IN PICU Total Nos 406 Neonates(<1mth) 85(21%)
Infants(<1yr) 221(54%)
Cardiac 95(23%)

31. Overall Mortality Rate

32. Specific Mortality Rate

33. Peritoneal Dialysis in neonates with inborn errors of metabolism:
Is it really out of date?

34. Neonatal Inborn Error of Metabolism
If response to dietary and pharmacologic treatment poor or severe hyperammonemic coma
Require rapid removal of neurotoxic metabolites
Risk:
Ammonia > 1355ug/dl(800umol/l) – 34% survival rate
Enns et al NEJM :
Coma > 2 - 3days
Msall et al. N Eng J Med 310:1500-5
Extra-corporeal dialysis more effective >> PD
Outcome primarily related to duration of neonatal hyperammonemic coma

35. PD in IOM Ped Nephrol(2008) 23:163-8
7 Neonates ammonia > 1000ug/dL(588umol/l)
Bed-side surgically inserted PD catheter
No difficulties – mild leakage in 2 patients
Baxter closed system
1.36% lactate buffered
Added K+ and Antibiotics
Fill volumes – 10-15ml/kg incr to 30ml/kg
Dwell times 30-45mins

36. PD in IOM Ped Nephrol(2008) 23:163-8
4 organic aciduria pts ammonia < 200umol/l
Average after 20hrs of PD + medical rx
1 propionic aciduria ammonia < 362umol/l
Catheter out day 5 – sepsis day 19 - death
Mean time coma 14.5hrs
4/7 Survivors – 3 normal outcome + 1 delay
Death 3/7
1 OTC – death after few hrs on dialysis
1 Sepsis after recovery of acute metabolic decompensation
1 survived acute neonatal hyperammonia

37. PD in IOM Ped Nephrol(2008) 23:163-8
CVVH/D
Vascular access – difficult in neonates
Anti-coagulation
PD maintains some effectiveness
Applied in ALL neonatal units
Less efficacious than extra-corporeal dialysis
But can improve prognosis
Rapid access – bridging procedure
Small patient size
Less severe hyperammonemia

38. Quick and Easy

39. Continuous Flow Peritoneal Dialysis Clin J Am Soc Nephrol
Continuous Flow Peritoneal Dialysis Clin J Am Soc Nephrol Feb;6(2):311-8
PD useful in hypotension, disturbed coagulation or difficult venous access
Disadvantage – limited efficacy
CFPD – 2 bed-side catheters + adapted CVVHF machine
CFPD vs Conventional PD for 8-16 hours
First report of CFPD in Paeds practice
Clearances and UF significantly higher than PD

40. Continuous Flow Peritoneal Dialysis Clin J Am Soc Nephrol
Continuous Flow Peritoneal Dialysis Clin J Am Soc Nephrol Feb;6(2):311-8
Mean UF
PD 0.20ml/min/1.73m2 vs
CFPD 1.8ml/min/1.73m2
Creatinine clearance
PD 7.6ml/1.73m2 vs 28.8ml/1.73m2
2 Catheters vs Double lumen catheters
Urea clearances 44-58ml/min(2xC) vs 14-20(DL)
DL not available in paeds

41. Continuous Flow Peritoneal Dialysis Clin J Am Soc Nephrol
Continuous Flow Peritoneal Dialysis Clin J Am Soc Nephrol Feb;6(2):311-8
Complications
Catheter related – major complication rate <2% Pederson KR KI Supp 108:S81-86, 2008
Infection – closed system
Intra-abdominal pressure – carefully monitored
Clearances + UF Lower values than predicted adults:
Low flow rate 100ml/1.73m2/min
Re-circulation due to small patient

42. Continuous Flow Peritoneal Dialysis Clin J Am Soc Nephrol
Continuous Flow Peritoneal Dialysis Clin J Am Soc Nephrol Feb;6(2):311-8
CFPD useful for ARF Ronco C Perit Dial Int 27:251-3, 2007
Especially in children
Especially if small haemodynamically infant
Developing and Developed countries
Future
Larger studies in Paeds
Higher flow volumes
Improved catheter technology

46. Acute Kidney Injury:The Future is now
The past of acute kidney injury was observation,
and the present is intervention with renal replacement therapy,
but perhaps the future is the use of biomarkers to identify AKI sooner and intervene early.
Bunchman TE. Oct Nephrology Times 

47. Thank you for your attention !