1. ACUTE PERITONEAL DIALYSIS ALTERNATIVE FORM OF CRRT
Mignon McCulloch
Departments of Paediatric Nephrology & PICU Red Cross Children’s Hospital & University of Cape Town

3. Paediatric Modified RIFLE (pRIFLE) Criteria
eCreatinine clearance
(eCCL)*
Urine output 1
 eCCL by 25 %
<0.5 ml/kg/hr for 8 hrs 2
 eCCL by 50 %
<0.5 ml/kg/hr for > 16hrs 3
 eCCL by 75 %
<0.3 ml/kg/hr for > 24 hr or anuria for 12 hr
*eCCL = 40 x height (cm) / s-creatinine (μmol/L)
Akcan-Arikan A et al Kidney Int 2007; 71:

4. AKI: Treatment Modality Selection
Ashita Tolwani, M.D., M.Sc.
University of Alabama at Birmingham
Critical Care Nephrology – Vicenza June 2015

5. Which mode of RRT is ‘best’ in the ICU?
MODALITIES
Intermittent
IHD
PIRRT
Continuous
CRRT
SCUF
CVVH
CVVHD
CVVHDF PD
Ashita Tolwani,
Which mode of RRT is ‘best’ in the ICU?

6. Use of Peritoneal Dialysis in AKI: A Systematic Review Ashita Tolwani
24 studies identified
19/24 from Asia, Africa, and South America
13 studies with PD only
11 studies with PD and EBP
7 observational
4 randomized
Eleven studies (total
n=959, median sample size=60) were included, of which four studies were conducted only in the ICU (15,30,33,37) and four studies were RCTs (10,33,34,37) (Table 2). In total,
392 patients underwent PD, whereas 567 patients underwent EBP. For PD patients, reported mortality rates ranged from 25.0% to 75.8%, except for two studies with
0% mortality on PD (31,34). In comparison, mortality for EBP patients ranged from 15.0% to 84.0% in individual studies.
Pooled mortality was 58.0% for PD and 56.1% for EBP. Among the observational studies, there was no significant difference in mortality between PD and EBP (odds ratio, 0.96; 95% confidence nterval, 0.53 to 1.71) (Figure 3).
Among the RCTs, there was significant intertrial heterogeneity (I2=73%, P=0.03) (Figure 3). PD was inferior to continuous venovenous hemofiltration in one study (33),
whereas mortality rates were comparable for the other three studies (10,34,37). Of note, the first study enrolled patients with severe falciparum malaria (68.6% of cases)
(33) in contrast to the other studies with AKI, which were mainly caused by sepsis or hemodynamic disturbances. These factors likely contribute to the heterogeneity among
these studies. Because of the small number of RCTs, there was insufficient data to conduct a sensitivity analysis to determine the cause of heterogeneity.
Chionh CY et al. Clin J Am Soc Nephrol 8: 1649–1660, 2013

7. Clinical Problems Produced By AKI

9. PD as CRRT Alternative to Extracorporeal systems
Difficult Venous access
Small infants
“Challenged” resources
No equipment
No surgical back-up appropriate
Not about Chronic PD

10. Peritoneal Dialysis in PICU RRT in PICU
London
Peritoneal Dialysis in PICU RRT in PICU
Dr Mignon McCulloch
Evelina Children’s Hospital, Guy’s & St Thomas’ NHS Trust

11. 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

12. 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%

13. 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 6% predicted 10-12%
Dialysis 3.5%

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

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

16. 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

17. Practicalities of PD Prescription Dialysis fluid
10-20ml/kg increase as tolerated to 50ml/kg
Dialysis fluid
1.5%/2.5%/4.25%
Dianeal(Lactate buffered) or Bicarb based
Cycles: Fill/Dwell/Drain
10/30-90/20mins
Manual or Cycling Home choice > 3kg
Adapted to ventilatory requirements

18. PD Catheters Art of Medicine? Innovative and Creative Cannulaes
Naso-gastric tubes/Chest Drains
Venous Central lines
Rigid ‘Stick’ catheters
‘Peel away’ Tenckhoff
Flexible Multi-purpose drainage catheters
Auron A et al Am J Kidney Dis 2007

19. New Generation Cook Catheters

20. Kimal ‘Peel-away’ Tenckhoff

21. Complications of PD Dysequilibration Syndrome (rare in acute)
Hypotension
Infection
Blocked / Displaced catheter
Respiratory difficulties
Diaphragmatic leak
Hyperglycaemia

22. Equipment – Audit at RXH
Total catheters used
260
Cook
- 5 Fr Neonatal
- 8 Fr Paediatric
- 11 Fr Adult
(62%) 53
106 4
Kimal “peel away” Percutaneous Tenckhoff 46
(18%)
Surgical inserted Tenckhoff 51
(20%)

23. Automated Dialysis
Home choice machine

25. Manual Dialysis with Fluid Warmer

26. 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%)

27. 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%)

28. 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

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

30. Overall Mortality Rate

31. Peritoneal Dialysis in NICU
Vesna Stojanović, MD, PhD
Institute for Child and Youth Health Care of Vojvodina, Intensive Care Unit
Novi Sad, Serbia

32. Peritoneal Dialysis as a Form of CRRT for Infants in a Developing Country

33. 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

34. Duration Of Dialysis

35. OUTCOME 15/25(60%) Infants survived to come off dialysis
No bleeding complications
2/15 catheters blocked - day 3 & 4 on dialysis
Nil required long term dialysis

37. Manual Dialysis with Fluid Warmer

38. PD Paed system

39. Quick and Easy

40. Post Cardiac Surgery Nitric Oxide, Oscillator & PD

43. Contra-indication? Post Abdominal Surgery
8Fr Cook
Pigtail multi-purpose
drainage device
8Fr Cook PD
Catheter

44. Improvised equipment and solution used in the procedure
4/24/2017
Dr S. Antwi: Paediatric Nephrologist -KNUST-SMA/KATH 44

45. CFPD Performed with two bedside placed catheters:
the first conventionally placed in the midline below the umbilicus
the second one placed midway between the superior iliac crest and the umbilicus

46. 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

47. Schematic drawing of CFPD
Patient
PD Solution
Blue pump BM 14
Fluid Heater
Venous bubble trap transducer to BM 11
Air detector
Pressure transducer to BM 11
Yellow pump
BM 14
BM 14
Waste Bag

48. Overall recommendations: Critically ill patient with AKI
Early fluid resuscitation in acute hypovolaemia + septic shock states
Early consultation and assessment of %FO
Early initiation of CRRT + Inotropes over fluid administration to maintain BP
Appropriate expertise in management of RRT
DO what you are good at!
Do not delay
Call a friend

49. Take Home Message PD is available in resource poor environment
PD is appropriate in acute setting in PICU
Not dependant on large nos and well trained staff members
Certain patient groups more suitable for PD
Practical for small infants – access + stability
Even in ‘resource rich’ hospital settings, there is a role for acute PD

50. 

51. CLINICAL SKILLS COURSE
In conjunction with Saving Young Lives (SYL)
Including Airway & Resuscitation, Vascular Access, Acute Peritoneal Dialysis
Aimed at Pairs of Doctor and Nurse Team
9 – 12 March 2015
Registration:
Surgical Skills Training Centre
University of Cape Town
Red Cross War Memorial Children’s Hospital
Departments of Paediatrics, Anaesthetics & Paediatric Surgery

53. 2015

54. Surgical Support

55. Learning is fun !

56. Doctor Nurse Teams
Bloemfontein, SA
Malawi + Zambia
Ghana
Nigeria
Kenya

57. Foreign Faculty

58. Nursing Training

59. Tim Bunchman pic
IMG_5847.JPG

60. Thank you to all my colleagues @ RXH

61. 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