1. Acute peritoneal dialysis (PD) in the PICU
Constantinos J. Stefanidis
“P. & A. Kyriakou” Children's Hospital, Athens, Greece

2. Choice of dialysis in ARF
Late referral
life-threatening hyperkalemia or severe volume overload HD
CRRT or
ARF
Early referral
Neonates and infants PD
C J Stefanidis 2002

3. Choice of dialysis in ARFPD HD
CRRT
Were used as the primary means of acute renal replacement therapy in a nearly equal percentage of centers
Warady BA, Bunchman T. Dialysis therapy for children with acute renal failure: survey results. Pediatr Nephrol 2000;15(1-2):11-3
C J Stefanidis 2002

4. Preferential use of PD and CRRT
Warady BA, Bunchman T. Dialysis therapy for children with acute renal failure: survey results. Pediatr Nephrol 2000;15(1-2):11-3
C J Stefanidis 2002

5. When to start PD in ARF ? Symptomatic uraemia Hyperkalaemia
Volume overload
Severe metabolic acidosis
( refractory to medical treatment)
Conger J. Dialysis and related therapies. Semin Nephrol 1998; 54:
C J Stefanidis 2002

6. When to start PD in ARF ?
S. creatinine and blood urea are not primary indications for dialysis unless they relate to mental status changes
Conger J. Dialysis and related therapies. Semin Nephrol 1998; 54:
C J Stefanidis 2002

7. There are essentially no data
When to start PD in ARF ?
There are essentially no data
In the absence of data it is advisable to start dialysis at the earliest sign that it may be needed
Flynn JT. Pediatr Nephrol 2002;17(1):61-9
C J Stefanidis 2002

8. 2. it is fairly inexpensive compared with other modalities
Benefits of PD
PD still remains the modality of renal replacement therapy of choice in many pediatric nephrology centers, because:
1. it requires minimal equipment and infrastructure
2. it is fairly inexpensive compared with other modalities
3. it is relatively easy to perform and
does not require additional nursing personnel.
Flynn JT. Choice of dialysis modality for management of pediatric acute renal failure. Pediatr Nephrol 2002;17(1):61-9
C J Stefanidis 2002

9. 2. Avoidance of systemic anticoagulation
Benefits of PD
1. Less haemodynamic instability
Children with ARF who are hypotensive, requiring vasopressor support and children with multiple organ failure are successfully managed with PD
2. Avoidance of systemic anticoagulation
3. Avoidance of angioaccess
Flynn JT. Choice of dialysis modality for management of pediatric acute renal failure. Pediatr Nephrol 2002;17(1):61-9
C J Stefanidis 2002

10. 2. Lower ultrafiltration
Disadvantages of PD
1. Slower correction of metabolic parameters
lower urea clearances
2. Lower ultrafiltration
3. Risk of peritonitis
Flynn JT. Choice of dialysis modality for management of pediatric acute renal failure. Pediatr Nephrol 2002;17(1):61-9
C J Stefanidis 2002

11. Choice of dialysis in ARF
Complexity
Efficiency
Moderate
control
Volume
Moderate
Anticoa-
gulation No
Use in hy-
potension
Yes PD
Low HD
Moderate
CAVH
CVVH
High
Intermittent
Yes No
Low and
variable
Good
Yes
CVVHD
High
Thadhani R et al Acute renal failure. N Engl J Med 1996; 334:
C J Stefanidis 2002

12. Acute PD in the PICU PD catheters for ARF Choice of dialysis treatment
Prescription of PD in ARF
C J Stefanidis 2002

13. Trocath catheters In our days very few centers use these catheters
Their prolonged use (> 3 days) was associated with a significant risk of:
leakage
malfunction
peritonitis
A major complication was viscus perforation.
In our days very few centers use these catheters
C J Stefanidis 2002

14. Acute PD catheters Percutaneus guidewire inserted catheters
Trocath catheters
Percutaneus guidewire inserted catheters
Tenckhoff catheters implanted under general anesthesia
C J Stefanidis 2002

15. Percutaneus guidewire inserted catheters
Site of introduction: Level of umbilicus lateral to the rectus sheath (newborns)
or any where along a line parallel to the rectus sheath.
Local anesthetic
C J Stefanidis 2002

16. Percutaneus guidewire inserted catheters
Angiocath
Insertion of Angiocath 18 G
Flushed with 5 ml of N/S and aspirated to ensure bowel content is not retrieved
C J Stefanidis 2002

17. Percutaneus guidewire inserted catheters
The wire is advanced through the needle in the peritoneal cavity (3-4 cm)
The Angiocath 18 G is removed
Priming of the abdomen is not essential
Seldinger (Acta Radiologica, 38, [1953], )
C J Stefanidis 2002

18. Percutaneus guidewire inserted catheters
3-4 mm incision around the wire.
In newborns is not recommended `
The catheter is threaded around the wire and is forced in the peritoneal cavity with a «screwing action»
The wire is removed
The catheter is taped to the skin
Seldinger (Acta Radiologica, 38, [1953], )
C J Stefanidis 2002

19. Femoral vein catheter for neonates
Guide wire-inserted femoral vein
polyurethane catheter
(Medcomp-pediatric)
14 G cm
3 sideports
Kohli HS et al Acute peritoneal dialysis in neonates: comparison of two types of peritoneal access. Pediatr Nephrol 1999 Apr;13(3):241-4
It was used in 10 neonates.
Intraperitoneal bleed : 1 neonate
Dialysate leak: 1
Catheter blockade: 4
Incidence of peritonitis: 1
C J Stefanidis 2002

20. Percutaneus guidewire inserted catheter
Cook catheter
8.5 French 8 cm
44 sideports
C J Stefanidis 2002

21. 5 French Cook PD catheter
29 infants
age 4.5 +/- 1.3 months
weight 4.8 +/- 0.5 kg
Complications:
inadequate inflow in one case
bleeding in one case
accidental removal in one case
5 French 5.5 cm
Duration of the placed catheters was 9.9 +/- 2.7 days, without the problems associated with the use of a stiff catheter
Bunchman TE. Acute peritoneal dialysis access in infant renal failure
Perit Dial Int 1996;16 Suppl 1:S
C J Stefanidis 2002

22. Cook (pleuropericardial) pig tail catheter
8.5 French 15 cm 6 sideports
C J Stefanidis 2002

23. Cook (pleuropericardial) pig tail catheter
Retrospective study ( ) in 46 patients Complications of the Seldinger-placed Cook (pleuropericard) catheter were limited:
leakage (1/44)
bleeding: n = 0
obstruction or dislocation: n = 4
peritonitis: n = 1 (Candida)
Vande Walle J et al New perspectives for PD in acute renal failure related to new catheter techniques and introduction of APD. Adv Perit Dial 1997;13:190-4
C J Stefanidis 2002

24. Tenckhoff catheters 9.5 French Introducer 11 French
Lewis MA, Nycyk JA.Practical peritoneal dialysis--the Tenckhoff catheter in acute renal failure. Pediatr Nephrol 1992 Sep;6(5):470-5
C J Stefanidis 2002

25. Tenckhoff catheters implanted under general anesthesia
16 French
C J Stefanidis 2002

26. Tenckhoff catheters (TC) implanted under general anesthesia compaired with Cook catheters (CC)
TC in 22 patients and a CC in 37 patients
The duration of use of TCs (16 days) was significantly greater than the duration of CC use (5 days; P < 0.001).
By day 6 of dialysis, 90% of TCs were functioning without complications compared with 46% of CCs
Only 2 patients with a TC (9%) developed complications, whereas 18 patients with a CC (49%).
Chadha V et al. Tenckhoff catheters prove superior to Cook catheters in pediatric acute peritoneal dialysis. Am J Kidney Dis. 2000;35(6):
C J Stefanidis 2002

27. Laparoscopic Tenckhoff catheter implantation
In 25 children laparoscopic TCIs and in 23 conventional TCIs
The inner cuff was placed adjacent to the peritoneum, without sutures
leakage: n =1, bleeding: n = 0 ,obstruction : n = 2
Laparoscopic TCI is feasible in children of all age groups, with equivalent functional results compared to conventional TCI
An additional advantage is the option to identify and eliminate anatomical risk factors, such as intra-abdominal adhesions or preformed inguinal hernias in male infants
Daschner M et al Perit Dial Int 2002 Jan-Feb;22(1):22-6
C J Stefanidis 2002

28. Acute PD catheters
A Tenckhoff catheter implanted under general anesthesia is recommended
If the patient can not undergo surgery, a percutaneus guidewire inserted PD catheter should be placed
C J Stefanidis 2002

29. Acute PD in the PICU PD catheters for ARF Prescription of PD in ARF
Choice of dialysis treatment
PD catheters for ARF
Prescription of PD in ARF
C J Stefanidis 2002

30. Prescription of acute PD
The patient should be connected and start automated PD immediately after surgical catheter implantation.
Complications (peritonitis and hypothermia) are significantly reduced with the use of a cycler compared with the manual method.
Kohli HS et al Ren Fail 1995
If APD is not available a closed-drainage system PD system with disconnection should be used.
The use of a closed-drainage system
reduced the incidence of system-related peritonitis
Valeri A et al Am J Kidney Dis 1993
C J Stefanidis 2002

31. Initial prescription of acute PD
Cefazoline (250 mg/liter) and Heparin 500 U/liter should be added to the dialysis solution for first two days
Dialysate with a glucose concentration of 1.36% for volume of urine > 1.5 ml/kg/hr and UF is not required
Otherwise a dialysate with a higher glucose concentration 2.27% (or even higher) should be prescribed
For children with severe lactic acidosis or hepatic failure a bicarbonate-based dialysate can be prepared in the hospital pharmacy
C J Stefanidis 2002

32. Initial prescription of acute PD
Initially the exchange volume is kept low (20 ml/kg,
ml/m²) to reduce the risk of dialysate leakage
After 24 hours the volume is increased by ml/m²/day up to ml/m² as tolerated by the patient
The first day one-hour dwells are prescribed and usually two-hour dwells are recommended on the second day
C J Stefanidis 2002

33. Adapted prescription of acute PD
Prescription of PD should be individually adjusted in the next days according to the needs of ultrafiltration and the parameters of adequacy (bl. urea and s. creatinine levels)
Usually after the stabilization period 5 to 8 exchanges daily are effective in most children with ARF. The aim is to deliver a maximum clearance to compensate the catabolic stress
C J Stefanidis 2002

34. Messages to take home
1. Early referral and early initiation of PD is very important for the outcome of children with ARF
2. PD should not be used in children with severe life-threatening hyperkalemia or with severe volume overload
C J Stefanidis 2002

35. Messages to take home
3. Access to the peritoneal cavity using a Tenckhoff catheter implanted under general anesthesia is at present one of the key factors determining long-term success of acute PD
4. If the patient is not fit for surgery, a percutaneus guidewire inserted PD catheter can be placed at the bedside in a short period of time
C J Stefanidis 2002

36. Messages to take home
3. Access to the peritoneal cavity using a Tenckhoff catheter implanted under general anesthesia is at present one of the key factors determining long-term success of acute PD
4. If the patient is not fit for surgery, a percutaneus guidewire inserted PD catheter can be placed at the bedside in a short period of time
C J Stefanidis 2002

37. Messages to take home
5. The perscription of PD treatment should be optimized in critically ill children with ARF in order to achieve the goal of controlling uremia and fluid overload, and giving appropriate nutritional support
C J Stefanidis 2002