The Outcome of Continuous Ambulatory Peritoneal Dialysis in Children: A Single Center Experience.
Keywords: Continuous ambulatory peritoneal dialysis; Chronic kidney disease; Complications; mortality.
Chronic peritoneal dialysis is a home-based, widely used, safe and effective modality of renal replacement therapy (RRT) mostly used in infants and small children with chronic kidney disease (CKD) in developing countries due to vascular access problems for hemodialysis. Due to increasing number of patients with end stage renal failure (ESRF) over the past decade, RRT is being offered to a large number of children in the form of hemodialysis, chronic peritoneal dialysis and renal transplantation. The decision to choose CAPD for dialysis treatment depends on the patients' lifestyle, availability of service and clinical contraindications. Moreover, it is less commonly related to hemodynamic instability and has been found to be associated with improved health related quality of life.1
Certain factors to be considered for the caregivers include (1) their capability to perform the dialysis at home (2) integration with work, school, hobbies, social and family activities (3) modifications of home if required (4) flexibility of daily treatment cycles (5) prescribed course of medication and diet and (6) alterations in body image and physical activities resulting from CAPD catheter access site. Unsuccessful CAPD is mostly the result of infections leading to death in some cases. Despite CAPD catheter related complications such as peritonitis, exitsite infection (ESI), tunnel infection, pericatheter leakage and mechanical dysfunction,2-4 this treatment modality is still commonly utilized in infants and small children and can serve as a bridge between ESRF and renal transplantation.
The paucity of data in our country regarding outcome of CAPD in pediatric age group made us report our experience from a single tertiary care center.
There were 45 patients diagnosed as ESRF who underwent CAPD between 2009 and 2018 and were selected for the study. This modality of treatment for CKD was recommended in participants below the age of 5 years or those weighing less than 15 kg and older individuals up to 15 years of age who could not visit the hemo-dialysis centers due to socioeconomic reasons. The children who survived for at least 6 months after initiation of CAPD were included in the study. The information was obtained from medical records of patients regarding clinical and laboratory data, duration of CAPD and complications encountered during the treatment. General anesthesia was administered for the surgical placement of Tenckhoff catheter in all subjects and the procedure was commenced electively after two weeks of catheter insertion. The dialysis was performed 5 - 6 times daily during the day with 40 ml/kg dialysate exchanges and dwell time being 3 - 4 hours.
The follow-up visits were advised initially monthly, then quarterly and later on 6-monthly basis. The routine hematological and biochemical laboratory tests included blood counts, serum urea, creatinine, electrolytes, calcium and iron profiles on every follow-up visit while serum Vitamin D and intact parathyroid hormone levels were prescribed annually or earlier if treatment modification was required. The outcomes were observed in the form of number of episodes of peritonitis, ESI and tunnel infection, pericatheter leakage and mechanical dysfunction. Peritonitis was defined as presence of two of the following signs - abdominal pain, fever, hazy dialysate and/or total leucocyte count > 100/mm3 showing predominance of neutrophils.5 ESI was diagnosed by occurrence of purulent discharge, edema, erythema, and/or tenderness at the catheter exit site. Tunnel infection was confirmed by ultrasonography showing signs of inflammation along the subcutaneous tunnel.
Recurrence of peritonitis was defined to occur within 4 weeks of a previous episode due to a different organism while relapsing peritonitis was due to the same organism responsible for the episode occurring within the past 4 weeks. Repeat peritonitis occurred beyond 4 weeks of the previous episode and due to the same organism whereas refractory peritonitis showed no response to 5 days of antimicrobial therapy.
Assessment of adequate peritoneal dialysis was measured by Peritoneal Equilibration Test (PET) twice a year after commencement of CAPD in all children. Subjects who switched to hemodialysis, underwent renal transplantation and expired during the study period were also included in the outcome measures. Data analysis was done by using SPSS version 20.0.
CAPD was performed in 45 patients diagnosed with CKD Stage 5 with 27 (60%) boys and 18 (40%) girls (male to female ratio = 1.5:1.0). The mean age of subjects was 37.5 months with 35 (78%) children below and 10 (22%) subjects above 5 years old. The majority of participants had congenital abnormalities of kidneys and urinary tract (CAKUT) (65%) (Figure 1) (Table 1). CAPD catheters were placed surgically in 46 children and one patient had replacement done following catheter dislodgement. Topical mupirocin application at the catheter exit site was not practiced in our center and dialysis in all cases was performed by the mothers/ caregivers at home with technical support and guidance provided by Fresenius Medical Care. The mean duration of treatment with CAPD was found to be 20.5 months.
The post-surgical complications seen were leakage and bleeding from the catheter site in 15 (33%) and incisional hernia in 3 (7%) children. The late complications included peritonitis occurring in all (100%) children followed by exit site infection in 9 (20%) participants, catheter blockade in 5 (11%) while tunnel infection developed in 2 (4.4%) subjects (Table 2).
Table 1: Etiology of Chronic Kidney Disease.
Posterior urethral valves###11###46
Congenital renal hypoplasia###1###4
Primary hyperoxaluria I
Polycystic kidney disease###1###33.3
Multicystic dysplastic kidney###1###33.3
Distal renal tubular acidosis
Table 2: Complications of CAPD.
Exit site infection###9###20
31 (68.9%) cases experienced more than one episode of peritonitis with the first one occurring within the first 6 months of initiation of CAPD in 28 (62%) children. The causative pathogens responsible for peritonitis episodes were mostly not isolated (41%) while Gram negative and positive organisms accounted for 33.3% and 25.7% respectively - Klebsiella, Pseudomonas and Coagulase-negative Staphylococcus being most common. The outcome measures analyzed are shown in Figure 2. The most common causes of death were infection (55%), volume overload (13%), and bowel perforation (5%) while cause was undetermined in 27%.
The study performed on 45 children with ESRF in a single tertiary care center reports that in our country there is preference for CAPD over hemodialysis mostly in cases below 5 years of age/weighing less than 15 kg (78%) as also seen in other studies.6-8 The common causes of ESRF in our patients were seen to be CAKUT (54%) followed by glomerular diseases (20%) which was similar to the results presented by Sinha and colleagues.9 In contrast Lee K et al observed chronic glomerulonephritis in majority of patients (87.7%) followed by CAKUT (8.8%).10 According to the annual report of North American Pediatric Renal Trials Collaborative Studies (2011)11 and Gonzalez et al,12 CAKUT was the leading cause of ESRF in 35.2% and 28.3% subjects respectively.
Peritonitis has been found to be more common in our setup as compared to the developed world which can be related to the poor socioeconomic status of our children. All our subjects experienced peritonitis with 68.9% cases having more than one episode with the first one occurring within the first 6 months of CAPD initiation in 62%. Although the number of episodes of peritonitis was observed to be low in older children, there was no difference in the incidence of peritonitis seen among children below and above 5 years of age (p = 0.31). The low incidence of peritonitis is associated with automated peritoneal dialysis (APD) as compared to CAPD.13 The frequency of relapse in our study was more (35%) than the previously reported rates of relapsing peritonitis which was seen in up to 21% of patients.14
The etiology of peritonitis revealed no isolation of micro-organisms in majority of our participants (41%) followed by growth of Gram negative pathogens in 33.3% which was different from other data published in the literature which shows Gram positive organisms (58.2%) to be responsible for majority of episodes.15,16
Mekki et al concluded that the noninfectious complications of CAPD including catheter blockade were found to be significantly prevalent in children as compared to adults17 (22.5% versus 9.3%; P = 0.006). Esposito et al also identified catheter obstruction in almost similar number of subjects (21%) which was confirmed by ultrasonography.18 Comparatively, leakage and bleeding from the catheter site was seen in 33%, incisional hernia in 7% and catheter blockade in 11% of our patients.
Our mortality was found to be much higher (33.3%) in contrast to 17% pediatric patients receiving CAPD in a trial by Tsai HL et al19 in whom hypoalbuminemia had a significant association with death. Our data revealed the high mortality to be associated with repeated episodes of peritonitis leading to septicemia. Honda M and his coworkers20 determined the association of mortality with sclerosing encapsulating peritonitis following repeated episodes of peritonitis which was also observed by Maruyama Y21 and Levy et al.22 A study by Sethna CB et al revealed that poor conformity with follow-up of peritoneal dialysis care was associated with an elevated hazard of peritonitis.23
It is concluded that Congenital anomalies of kidney and urinary tract (CAKUT) was found to be the underlying etiology of chronic kidney disease in majority of our children who underwent CAPD. The outcome depends on infectious and non-infectious complications associated with the dialysis modality and included peritonitis which was seen in more than 50% patients during the first six months of initiation of dialysis followed by leakage and hemorrhage occurring in about one-third cases. Despite the high rate of mortality CAPD still remains the treatment modality in small children with ESRF.
The authors acknowledge (1) the Social Welfare department of The Children's Hospital and Institute of Child Health Lahore for financial assistance and (2) Fresenius Medical Care for providing their technical support to the patients at home.
Conflict of Interest
NA: Conceived the idea, design and writing of manuscript. SI: Critical review and suggestions. AC: Data collection and statistical analysis.
1. Harshman LA, Neuberger ML, Brophy PD. Chronic hemodialysis in pediatric patients: technical and practical aspects of use. Minerva Pediatr. 2012; 64 (2): 159-69.
2. Szeto C-C, Li PK-T, Johnson DW, Bernardini J, Dong J, Figueiredo AE et al. ISPD Catheter-Related Infection Recommendations: 2017 Update. Perit Dial Int. 2017; 37 (2): 141-154.
3. Li PK-T, Szeto C-C, Piraino B, Arteaga J, Fan S, Figueiredo AE et al. ISPD Peritonitis Recommendations: 2016 Update on Prevention and Treatment. Perit Dial Int 2016; 36 (5): 481-508.
4. Li PK-T, Szeto C-C, Piraino B, Bernardini J, Figueiredo AE, Gupta A, et al. Peritoneal dialysis-related infections recommendations: 2010 update. Perit Dial Int. 2010; 30 (4): 393-423.
5. Lopez-GD, Garduno J, Reyes LA, Partida GA, Medeiros M. Risk Factors Associated with Nosocomial Peritonitis in Children on Peritoneal Dialysis. Rev Invest Clin. 2015; 67 (3): 170-6.
6. Hooman N, Esfehani ST, Mohkam M, Derakhshan A, Gheissari A, Vazirian S et al. The Outcome of Iranian Children on Continuous Ambulatory Peritoneal Dialysis: The First Report of Iranian National Registry. Arch Iranian Med. 2009; 12 (1): 24 - 28
7. Cerda J, Bagga A, Kher V, Chakravarthi RM. The contrasting characteristics of acute kidney injury in developed and developing countries. Nat Clin Pract Nephrol 2008; 4 (3): 138-53.
8. Nikibakhsh A-A, Mahmoodzadeh H, Vali M, Enashaei A, Asem A, Yekta Z. Outcome of Immediate Use of the Permanent Peritoneal Dialysis Catheter in Children with Acute and Chronic Renal Failure. Iran J Pediatr. 2013; 23 (2): 171-176.
9. Sinha R, Saha S. Continuous Ambulatory Peritoneal Dialysis in Children, Experience from Eastern India. Indian Pediatr. 2015; 52 (6): 531-2.
10. Lee KO, Park SJ, Kim JH, Lee JS, Kim PK, Shin J II. Outcomes of Peritonitis in Children on Peritoneal Dialysis: A 25-Year Experience at Severance Hospital. Yonsei Med J. 2013; 54 (4): 983-989.
11. Novak TE, Mathews R, Martz K, Neu A. Progression of chronic kidney disease in children with vesicoureteral reflux: the North American Pediatric Renal Trials and Collaborative Studies Database. J Urol. 2009; 182 (4 Suppl.): 1678-81.
12. Gonzalez DL, Garduno J, Reyes-Lopez A, Gaytan AP, Medeiros M. Risk Factors Associated with Nosocomial Peritonitis in Children on Peritoneal Dialysis. Rev Inves Clin. 2015; 67: 170-6.
13. Chadha V, Schaefer FS, Warady BA. Dialysis-associated peritonitis in children. Pediatr Nephrol. 2010; 25 (3): 425-40.
14. Lane JC, Warady BA, Feneberg R, Majkowski NL, Watson AR, Fischbach M et al. Relapsing peritonitis in children who undergo chronic peritoneal dialysis: a prospective study of the international pediatric peritonitis registry. Clin J of Am Soc of Nephrol. 2010; 5: 1041-6.
15. Fahim M, Hawley CM, McDonald SP, Ghali JR, Bannister KM, Brown FG et al. Culture-negative peritonitis in peritoneal dialysis patients in Australia: predictors, treatment, and outcomes in 435 cases. Amer J of Kid Dis. 2010; 55: 690-7.
16. Peng W, Zhou Q, Ao X, Tang R, Li X. Pathogenic bacteria and drug resistance in peritoneal dialysis related peritonitis Zhong Nan Da Xue Xue Bao Yi Xue Ban. 2012; 37 (12): 1205-9.
17. Mekki MO, Fedail HM, Ali EM, Abdelraheem MB, AlSanousi H, Elamin S, et al. Non-infectious complications of peritoneal dialysis among Sudanese patients: five years experience. Arab J Nephrol Transplant. 2011; 4 (1): 27-30.
18. Esposito F, Di Serafino M, Ambrosio C, Panico MR, Malacario F, Mercogliano C, et al. Chronic peritoneal dialysis in children: the role of ultrasound in the diagnosis of peritoneal catheter obstruction. J Ultrasound, 2016; 19 (3): 191-6.
19. Tsai HL1, Yang LY, Chin TW, Wang HH, Liu CS, Wei CF, Chang JW. Outcome and risk factors for mortality in pediatric peritoneal dialysis. Perit Dial Int. 2010; 30 (2): 233-9.
20. Honda M, Warady BA. Long-term peritoneal dialysis and encapsulating peritoneal sclerosis in children. Pediatr Nephrol. 2010; 25 (1): 75-81.
21. Maruyama Y, Nakayama M. Encapsulating peritoneal sclerosis in Japan. Perit Dial Int. 2008; 28 Suppl. 3: S201-4.
22. Levy CS, Mudi A, Venter B, Geel J. Challenges Facing Children on Chronic Peritoneal Dialysis in South Africa. Perit Dial Int. 2018; 38 (6): 402-404.
23. Sethna CB, Bryant K, Munshi R, Warady BA, Richardson T, Lawlor J et al. Risk Factors for and Outcomes of Catheter-Associated Peritonitis in Children: The SCOPE Collaborative. CJASN. 2016; 11 (9): 1590-1596.
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|Date:||Dec 31, 2018|
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