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CAPD is the best modality for children.

Health care professionals agree that transplantation is the best renal replacement therapy for children. For those who cannot receive a transplant immediately, peritoneal dialysis (PD) offers the most normal, child-friendly, and family-friendly therapy. There are two ways to perform PD in children: Continuous cycling peritoneal dialysis (CCPD), also known as automated peritoneal dialysis (APD), and continuous ambulatory peritoneal dialysis (CAPD).

CAPD Is the Best Modality for Children

CAPD permits a very normal lifestyle. Three to four CAPD exchanges are done during normal waking hours. The relatively longer times between CAPD exchanges makes it the best modality for those who are low transporters on PET tests. High average to low average transporters can be treated successfully with CAPD as well (Harmon, Jabs & Alexander, 2000).

Although an exchange every 6 to 8 hours would be ideal (Warady, Schaefer, Alexander, Firanek, & Mujais, 2004), the timing of exchanges need not be rigid. CAPD generally can be adjusted as needed around school, sports, and family schedules. Our unit recommends exchanges before school, after school, mid-evening, and before bed during the week, and at breakfast, lunch, dinner, and bedtime on the weekends. Adolescents, particularly, enjoy being able to work exchanges around after-school or evening social activities. Most teens are not at all interested in going to bed between 6-8 p.m. With CAPD, there is no need for the young person to go to bed or be shut in their room early in the evening as may happen with CCPD in order to get enough time on the cycler. If all is going well, the child and family need to come to the dialysis facility only once a month for clinic. Thus, children on CAPD are free to attend school full time.

CAPD is low tech. There is no need for high-tech skills or even electricity, which is valuable for those families, such as the Amish, who do not have access to this amenity. There is no beeping, so there are not frequent interruptions of parents' or the child's sleep for dialysis issues. Some family members, especially older adults, may find it difficult to return to sleep if awakened in the middle of the night. CCPD becomes a prescription for sleep deprivation in that event. In our unit, even families who choose CCPD as their primary modality are required to learn CAPD. This provides them with a manual backup for times of machine breakage or of prolonged power failure due to bad weather.

Vacations and travel are part of a normal life. It is fairly easy to travel on CAPD; one just needs to take disposables. Most vendors will deliver supplies to vacation locations with just a couple of weeks' notice. Furthermore, most pediatric facilities are easily able to provide backup support for a traveling patient on PD.

Because it is must be done 7 days a week, CAPD does create a high parental burden. However, families who view PD as just another body maintenance procedure are most successful. Those who perceive it as the mountain they must climb every day are less likely to thrive in the long term.

Peritonitis rates are generally higher in pediatric patients on PD than in adult patients on PD (Harmon et al., 2000). Although many have postulated that the eight connections/disconnections a day required for CAPD present an increased risk for infection, no studies have been published showing higher rates of peritonitis in patients on CAPD than in patients on CCPD.

Certainly cost is the least desirable reason for picking a dialysis modality. However, financial reality does need to factor in to some choices. The total volume of dialysate used per day for CAPD is smaller than that used for CCPD, which makes it more economical. Either Method I or Method II can be cost-effective for children using 2000 ml or larger CAPD exchanges. Small volume (< 1000 ml) PD solution bags have become less available over the past few years. This requires parents to measure smaller exchange volumes with a gram scale or an additional buretrol spiked into the PD system. The smaller dialysate bags that are available are significantly more expensive per ml of dialysis than "adult size" PD bags. However, Method II can help a dialysis facility deal with the high cost of small PD bags, if a child is eligible for Renal Medicare.

Summary

In our center, we believe that a PD modality should not be arbitrarily assigned by the dialysis facility. Rather, the choice of PD modality should be made based on the individual child's treatment requirements and PET results as well as the family's strengths, challenges, and desires (Harmon et al., 2000). The family has the choice whether to use CCPD or CAPD. Families and children who are able to switch back and forth between the two modalities as needed are the most flexible and most successful because they can build their therapy around their lifestyle and not the other way around (Hislop & Lansing, 1983).

References

Harmon, W.E., Jabs, K.L., & Alexander, S.R. (2000). Pediatric dialysis. In W.F. Owen, B.J.G. Pereira, & M.H. Sayegh (Eds.), Dialysis and Transplantation (pp. 319-336). Philadelphia: W.B. Saunders Company.

Hislop, S., & Lansing, L. (1983). A comparison of pediatric home peritoneal dialysis modalities: The family point of view. AANNT Journal, 71, 22-23, 53.

Warady, B.A., Schaefer, F., Alexander, S.R., Firanek, C., & Mujais. S. (2004). Care of the pediatric patient on peritoneal dialysis--Clinical process for optimal outcomes. [Brochure]. Baxter Healthcare Corporation.

Cyrena Gilman, MN, RN, CNN

Manager, Clinical Operations, Kidney/MSA Pediatric Dialysis Indianapolis, IN

Chairperson, Pediatric SIG 1998-2000

Member, ANNA's Hoosier Hills Chapter
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Title Annotation:continuous ambulatory peritoneal dialysis
Author:Gilman, Cyrena
Publication:Nephrology Nursing Journal
Geographic Code:1USA
Date:Mar 1, 2006
Words:932
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