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doi: 10.3747/pdi.2013.00222 Copyright 2014 International Society for Peritoneal Dialysis
ispd guidelineS/RECOMMENDATIONS
Brett Cullis,1,2 Mohamed Abdelraheem,3 Georgi Abrahams,4 Andre Balbi,5 Dinna N. Cruz,6
Yaacov Frishberg,7 Vera Koch,8 Mignon McCulloch,9 Alp Numanoglu,10 Peter Nourse,9
Roberto Pecoits-Filho,11 Daniela Ponce,5 Bradley Warady,12
Renal Unit,1 Greys Hospital, Pietermaritzburg, South Africa; Renal and Intensive Care Units,2 Royal Devon and
Exeter Hospital, Exeter, United Kingdom; Pediatric Nephrology Unit,3 Soba University Hospital, University of
Khartoum, Sudan; Pondicherry Institute of Medical Sciences and Madras Medical Mission,4 Chennai,
India; Department of Medicine,5 Botucatu School of Medicine, Sao Paulo, Brazil; Division of
Nephrology-Hypertension,6 University of California, San Diego, USA; Division of Pediatric
Nephrology,7 Shaare Zedek Medical Center, Jerusalem, Israel; Pediatric Nephrology Unit,8
Instituto da Criana of the Hospital das Clinicas of theUniversity of Sao Paulo Medical
School, Sao Paulo, Brazil; Pediatric Nephrology Department,9 Red Cross War Memorial
Childrens Hospital, University of Cape Town, Cape Town, South Africa; Department
of Surgery,10 Red Cross War Memorial Childrens Hospital, University of Cape Town,
Cape Town, South Africa; School of Medicine,11 Pontificia Universidade Catolica
do Parana, Curitiba, Brazil; Division of Pediatric Nephrology,12 University
of Missouri-Kansas City School of Medicine, Kansas City, USA;
Division of Nephrology,13 Queens University, Kingston,
Canada; and Yale University,14 New Haven, USA
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same study, acute PD was far more likely to be practiced which matches the strength of the recommendation to the
by physicians from Asia compared to those from Europe level of evidence (12), where Grade 1 is a strong and 2 is a
and North America (8). The reasons for this are not weak recommendation. The letters (AD) indicate the level
certain, but likely include the fact that PD is a modality of evidence used to make the recommendations. Where no
now most often used in the developing world, where evidence exists, but there is enough clinical experience
cost and available resources are major issues. In these for the committee to make a recommendation, this will be
countries, it offers significant cost and infrastructural categorized as opinion (level D).
benefits over HD/hemofiltration because it does not These guidelines have been developed for practitio-
require electricity nor does it use expensive machinery ners working in very different conditions. In some cases
or consumables (6,9). Kilonzo et al. showed that it costs what is felt to be optimal care may not be practical due
approximately $370 to save the life of one patient with to resource limitations. It is, therefore, important to
AKI with PD and George et al. noted that acute PD costs define a minimum standard which needs to be achieved to
half that of hemofiltration (6,9). ensure that the benefits of PD treatment for AKI outweigh
As PD for AKI is predominantly practiced in developing the risks; this minimum standard may not, however, be
countries where the infrastructure for quality research deemed optimal treatment. There will, therefore, be rec-
is often lacking, the result has been limited evidence on ommendations made for minimum standard or opti-
which to base clinical decisions in areas such as dosing, mum, but practitioners should always strive to achieve
volumes etc. There is also a lack of standardized treat- the latter. There is no validated method of defining these
These guidelines have been developed under the aus- A1.1 Peritoneal dialysis should be considered as a suit-
pices of the International Society of Peritoneal Dialysis to able method of continuous renal replacement
help standardize practice, based on the available evidence, therapy in patients with acute kidney injury (1B).
and enable those practicing PD for AKI to achieve optimal
results. It is hoped that this will facilitate increased access RATIONALE
to renal replacement therapy (RRT) in developing coun-
tries, and by standardizing practice, act as a platform Guideline A1.1: Peritoneal dialysis has many potential
for future research. The committee has been carefully advantages over extracorporeal RRT (13). It is technically
selected to include adult and pediatric nephrologists as simple, with minimal infrastructure requirements, and,
well as intensive care specialists from around the world therefore, lower cost. It may be the preferred option
with a bias towards including practitioners from those for the patient with difficult vascular access or those
countries where PD for AKI is practiced as a routine. Each at risk of bleeding as there is no need for anticoagula-
section was written by at least two authors who performed tion. Solute removal is gradual, with less potential for
a review of the literature in that area. The section was disequilibrium syndrome and intracranial fluid shifts,
reviewed by the co-chairs (BC, FF) and finally the recom- making it perhaps a better modality among patients at
mendations and their grading were made by consensus. risk of increased intracranial pressure. Since no extra-
The final guidelines were then subsequently reviewed by corporeal circulation is required, there is relatively good
all authors. The authors of each section can be found in hemodynamic tolerance, and local renal hemodynamics
online supplementary material. The recommendations may be better preserved. It has also been postulated that
are based on the GRADE system, a well validated structure PD may be more physiologic and less inflammatory than
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e xtracorporeal therapies which involve the exposure of criteria, and not being powered to detect a mortality
blood to synthetic membranes. These factors together difference (7). The other 2 studies were stopped early
could potentially contribute to earlier recovery of renal and were of suboptimal methodological quality, with
function (7). In sepsis there is considerable interest in unclear randomization process, lack of intention-to-treat
the use of high cut-off membranes for hemofiltration to analysis, modest sample sizes, and single-center design.
allow removal of toxic cytokines. These have been shown Peritoneal dialysis techniques also varied among these
to reduce the need for vasopressors (14). As the perito- 3 studies. Two of these studies compared continuous PD
neal membrane has pores large enough to allow clear- with continuous RRT (6,17), while the third compared PD
ance of these molecules, PD may provide a significant with daily intermittent HD (7). The fourth RCT random-
advantage over conventional HD and filtration. ized 40 acute or chronic renal failure patients to either
There are nevertheless important concerns regard- intermittent PD or HD; only 8 (4 PD, 4 HD, 7/8 sepsis)
ing PD in AKI, primarily involving the risk of peritoni- had AKI (18). In the 7 cohort studies, there was no
tis, potentially unpredictable fluid removal rates and difference in mortality between PD and extracorporeal
possible inadequate solute clearances, particularly in RRT (OR 0.96; 95% CI, 0.531.71). Although pooled
hypercatabolic patients or those with splanchnic hypop- results of the 4 RCTs also suggested no difference in
erfusion or who are on vasopressors. In contrast, modern mortality (OR 1.50; 95% CI, 0.464.86), the results
HD and continuous veno-venous hemofiltration (CVVH) were heterogeneous.
machines have precise volumetric systems that guide Peritoneal dialysis was significantly inferior to CVVH
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i ntermittent PD, survived (18). Gabriel et al. were the areas spiking of bags and makeshift connections
only investigators who used a cycler, allowing higher may be necessary (2D) (Minimum standard). It
exchange volumes compared to the other trials (7). is imperative that strict asepsis be maintained
In terms of recovery of renal function, results are also throughout.
conflicting. One study (7) demonstrated shorter time
to renal recovery with PD compared with daily HD. Two RATIONALE
other studies noted that patients on PD required more
or longer dialysis sessions which, although not spe- Guideline A2.1 Catheter Type:
cifically reported, may indicate a longer time to recover
function (6,17). Flexible Catheter: The Tenckhoff catheter remains the
Overall there is enough evidence to base the recom- gold standard for PD access and is the most widely used
mendation that PD is a suitable method of renal replace- in chronic dialysis (21). These catheters are preferable
ment therapy in AKI. to those mentioned below as they have a larger diameter
lumen and side holes resulting in better dialysate flow
GUIDELINE A2: Access and fluid delivery for acute PD rates and less obstruction which is imperative in acute
in adults PD to achieve adequate clearances. They are also less
prone to leakage and have a lower incidence of peritonitis
A2.1 Flexible peritoneal catheters should be used for (22). If the patient does not recover renal function, the
A2.6 Insertion of the Tenckhoff catheter should take Improvised Catheters Nasogastric Tube, Rubber Catheter
place in the most sterile environment available, and Intercostal Drainage Catheter: These improvised
using sterile technique with the operator using catheters have been used for access in resource-poor
gloves, gown and mask (1D). settings. They need to be surgically implanted and have
the disadvantages of few side holes and are less suitable
A2.7 We recommend the use of prophylactic antibiotics for tunneling, with a resultant higher risk of dialysate
prior to insertion of the Tenckhoff Catheter (1C). leakage. They may be lifesaving, though, and therefore
may be used when no other alternative is available.
A2.8 A closed fluid delivery system with a Y connection A comparison of flexible Tenckhoff catheters and rigid
should be used (1A) (Optimal). In resource-poor stylet catheters in 64 children who underwent acute PD
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reported fewer complications with Tenckhoff catheters reduces the risk of catheter displacement and leak of
and significantly longer catheter survival (22). dialysate; but this is not feasible in most patients with
In conclusion, although there is little published evi- AKI. Nevertheless, these studies offer insight into the
dence that flexible catheters are superior to these other risks and benefits of each method and will be discussed
catheters apart from a small study in children, it is the briefly. Henderson et al. compared 283 percutaneous
authors experience and opinion that better flow rates and with 104 surgically inserted catheters. The incidence of
fewer complications occur when using a flexible catheter. leak (6% vs 10% p = 0.18) and poor drainage (21% vs
This is the basis for this recommendation. The advantages 23% non significant) were similar between both meth-
and disadvantages of each are summarized in Table 1. ods. However, peritonitis within the first month was
significantly higher in the surgical group (4% vs 13%
Guidelines A2.2 A2.6 Method of Insertion: The key p = 0.009) (24). Perakis et al. reported 170 PD catheter
to effective PD is a catheter which allows rapid inflow and insertions (86 percutaneous) where a higher incidence
outflow of fluid to maximize the dialysate dwell time and of leak occurred in the percutaneous group (10% vs
contact of the dialysate with the peritoneal membrane. 2%). However, infectious complications were higher in
This is predominantly dependent on the catheter used the surgical group (25). A trial from Iran randomized
(see above), but will be influenced by the position of 64 patients to surgical or percutaneous insertion and
the catheter and any interference from the omentum or found a higher incidence of outflow failure and hemo-
adhesions. Leakage of fluid through the surgical wound peritoneum in the surgical group. However, the number
TABLE 1
Advantages and Disadvantages of Flexible, Rigid, and Other Peritoneal Access
Advantages Disadvantages
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TABLE 2
Advantages and Disadvantages Different Catheter Implantation Techniques
Advantages Disadvantages
Percutaneous (bedside) Can be performed at bedside allowing Risk of bowel or bladder injury
rapid initiation of dialysis Not suitable in patients with
Physician or nurse can be trained to previous midline surgical scars or
perform the procedure risk of adhesions
Open surgical Available in most centers Needs surgical scheduling, where
Cost of consumables lower than available theatre time at a
laparoscopy premium
Laparoscopy Lower incidence of leak Skilled personnel necessary
Ability to perform adjunctive procedures High cost of consumables
such as rectus sheath tunneling and
omentopexy, etc.
Ability to place the catheter in the pelvis
under vision
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are gentamicin and a combination of gentamicin and We recommend that, where possible, a closed system
cefazolin (35,36). A Cochrane meta-analysis in 2004 be used. There is no evidence that automated PD is any
showed that there was a significant reduction in the safer than manual exchanges.
incidence of peritonitis with the use of prophylactic
antibiotics (37). GUIDELINE A3: Peritoneal dialysis solutions for acute
PD
Guideline A2.8 Fluid Delivery: Collapsible bags of
varying sizes and glucose concentrations can be used A3.1 In patients with shock or liver failure, bicarbonate-
for acute PD (38). Rigid glass bottles and non-collapsible containing solutions should be used (1B) (Optimal).
plastic containers may also be available (10,17). The Where these solutions are not available, the use of
collapsible bags may have integral transfer tubing which lactate-containing solutions is an alternative (1D)
allows a closed system once connected to the patient. (Minimum standard).
This is safer compared to rubber stopper bottles and bags
which require spiking. A3.2 Once potassium levels in the serum fall below 4
Disconnecting systems with Y-set and double bag are mmol/L, potassium should be added to dialysate
associated with lower peritonitis rates compared to the using sterile technique (see below) (1D).
standard spiking system in chronic patients and there is
no reason to suspect this would not be the case in acute A3.3 Potassium levels should be measured daily (1D)
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with bicarbonate-buffered solution, there was a more potassium was lower than 4 mmol/L, K 3.5 to 5 mmol/L
rapid increase in serum bicarbonate (21.2 1.8 mmol/L was added to dialysis solutions to avoid hypokalemia
vs 13.4 1.3 mmol/L) and blood pH (7.3 0.03 vs 7.05 (7,11,51,52). It is important that sterile technique be
0.04, p < 0.05). These improvements remained statisti- maintained when potassium is added and that nurses be
cally significant between the 2 groups through cycle carefully instructed to make certain the amount added
36. Overall, lactate levels were significantly lower in the is appropriate.
groups receiving the bicarbonate-buffered solution in
both the patients with shock (3.6 0.4 mmol/L vs 5.2 Guideline A3.4 Commercial vs Locally Mixed Solu
1.3 mmol/L) and without shock (2.9 0.2 mmol/L vs tions: Commercially produced solutions are produced
3.4 0.2 mmol/L). Of note, patients without shock had to high standards with strict asepsis and careful monitor-
comparable improvements in both blood pH and serum ing for bacterial and endotoxin contamination. Locally
bicarbonate with either solution. Other outcomes, such prepared solutions carry the potential risks of contami-
as hemodynamic stability, could not be analyzed because nation and mixing errors which may be life-threatening.
of the limited data available. Results of this study suggest Commercial solutions often have closed drainage systems
that AKI associated with poor perfusion states should be to prevent accidental contamination. However, the disad-
managed with the use of bicarbonate-buffered solutions vantage of commercial solutions involves the costs, which
rather than lactate solutions (45,46). may limit utilization in low-resource settings, particularly
if patients are paying for their own care. The costs include
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TABLE 3
Commercially Available Intravenous Fluids
TABLE 4
Typical Composition of Commercially Available PD Fluid
present. In general, this is not a problem for acute PD, A4.2 During the initial 24 hours of therapy, the duration
which is usually of short duration. If calcium or magne- of cycle times needs to be dictated by the clini-
sium supplementation needs to be given, this can be done cal circumstances. Short cycle times (every 1 2
by giving oral or intravenous supplementation. Many of hours) may be necessary in the first 24 hours to
the plasma expanders contain potassium and, although correct hyperkalemia, fluid overload, and/or meta-
after the first 24 hours this may be beneficial, it may be bolic acidosis. Thereafter, the cycle time may be
counter-productive initially. increased to 4 6 hours depending on the clinical
General rules when preparing dialysis solutions: circumstances (1D).
The concentrations of the well-known IV solutions may
vary from country to country so check concentrations A4.3 Avoiding fluid overload is extremely important
before mixing and ultrafiltration can be increased by raising
Maintain absolute strict sterile technique when mixing the concentration of dextrose and/or shorten-
solutions ing the cycle duration. When the patient is euv-
The fewer components added to the solution, the lower olemic, the dextrose concentration and cycle
the risk of infection and error time should be adjusted to ensure a neutral fluid
Avoid mixing bicarbonate and calcium as they will balance (1B).
precipitate
In cases of severe hypernatremia, add concentrated A4.4 There may be enhanced clearance of medica-
NaCl to increase Na to within about 15 mmol of tion (e.g., antibiotics) in acute PD and it is
patients sodium to allow a gradual reduction in the recommended that doses be adjusted accord-
serum sodium. ingly and, where possible, levels should be
monitored (1D).
GUIDELINE A4: Prescription of Acute PD
RATIONALE
A4.1 Where resources permit, targeting a weekly Kt/V
urea of 3.5 provides outcomes comparable to that of The treatment of AKI involves general supportive
daily HD; targeting higher doses does not improve therapy and dialytic support when significant meta-
outcomes (1B). This dose may not be necessary for bolic or fluid status derangements related to the kid-
many patients with AKI and targeting a weekly Kt/V ney injury develop. Where resources exist to provide
of 2.1 may be acceptable (2D). higher intensity protocols, PD has been shown to
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provide comparable outcomes to HD in appropriately molecules (15). If we are to concentrate on larger mol-
selected patients. ecule clearance in PD, then we need to remember that
The dose and/or efficacy of PD is often assessed with the clearance of larger molecules is both time- and
a Kt/V urea measurement (urea clearance over time), convection-dependent and the dialysis prescription will
where: need to be adjusted accordingly. Another problem is that
although we use AKI as a generic term, it comprises a vast
K = volume of dialysate drained multiplied by
array of conditions, and the dialysis clearances necessary
dialysate/plasma urea concentration
for the catabolic, septic patient may be very different
t = the duration of the dialysis
than those clearances for the patient with acute tubular
V = the volume of distribution of urea (Total Body
necrosis secondary to a tubular toxin. We urge readers to
Water ~ 0.5 [female] or 0.6 [male]
bear this in mind when using these guidelines.
multiplied by body weight).
Prescribing dialysis in acute PD requires that a number
The most appropriate dose for PD in the management of assumptions be made about peritoneal transport, as
of patients with AKI is poorly defined. This lack of clear there is little data on the peritoneal transport charac-
definition has occurred because there are only a limited teristics in patients who are acutely unwell. The potential
number of trials available to compare treatment modali- variation in rates of solute transport with different acute
ties, the studies that have been done have methodological illnesses is not well studied. However, splanchnic blood
flaws, and the dose of dialysis used has varied widely. The flow rates and the presence of various cytokines could
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resulted in our recommendation that acute PD can be the achieved Kt/V was 3.6 (7). As noted above, however,
utilized to treat AKI (6,9,18,51,55,56). A pilot study of a follow-up study by the same Brazilian group suggested
acute PD in adults and children conducted in Tanzania that lower doses of PD achieved the same results as the
between July 2009 and June 2011 included 20 patients higher dose of PD.
and had good outcomes (9). Sixteen of 20 patients sur- George et al. also compared PD and CVVHDF in a ran-
vived and were discharged from the hospital. Sixteen domized trial (25 patients in each group); the outcomes
patients were adults. Technique survival was good using were similar in the 2 groups, but the mortality rates were
a closed twin-bag system with initial 2-hourly cycles in extremely high (84% for the CVVHDF group and 72% for
adults and 2-liter dialysate fill volumes (1 liter on the first the PD group) (6). The dose of PD used in this study is not
day). Low infection rates were achieved, with peritonitis clear and rigid, non-cuffed PD catheters were used.
being suspected in only 2 patients (11). Chitalia et al. As the only randomized controlled trial comparing PD
compared two modalities for treating AKI in moderately (with an achieved weekly Kt/V of 3.5) with dHD showed
catabolic patients in a crossover study using rigid, non- comparable mortality, we have used a Kt/V of 3.5 as the
cuffed catheters. Patients either received manual PD optimal dose. If one extrapolates from extracorporeal
with 4-hour cycles using 2 liters of fluid over 48 hours studies the minimum optimal dose would be a weekly
or automated tidal PD with an initial fill of 2 liters fol- Kt/V of 2.1 (16). Until these 2 doses have been com-
lowed by a tidal volume of 675 mL and 20-minute cycles pared head to head, the former should be considered
for 12 hours. Manual PD achieved weekly Kt/V of 1.8 and optimal but the latter is the minimum standard. The
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in many countries. Therefore, in these settings, ade- 500 1000 units of heparin may be added to each liter
quacy will have to be assessed by clinical signs of fluid of PD fluid.
balance, normalization of potassium levels and acid Methods for manipulating displaced PD catheters
base improvement. could include the use of laxatives and guidewire (blind
or flouroscopic) manipulation. If these methods fail, the
Complications of PD for AKI catheter should be replaced using the original catheter
track into the peritoneum, to reduce leakage.
There are a number of potential complications associ- Loss of protein from the peritoneum in patients on
ated with the use of acute PD. Although an in-depth dis- chronic PD varies in different studies from 6.2 to 12.8 g
cussion of these is beyond the scope of these guidelines per 24 hours. However this has been known to increase to
the following will be discussed briefly: as high as 48 g during episodes of peritonitis (10,61,62).
A study from Brazil measured protein loss in 31 patients
Peritonitis
on high-volume acute PD over 208 sessions. They showed
Mechanical complications
that protein loss was 4.2 ( 6.1) g/24 h and there was
Protein loss
no correlation with albumin levels. Peritonitis did how-
Hyperglycemia
ever increase protein loss (63). Care should be taken to
The diagnosis of peritonitis may be challenging, ensure that adequate protein intake occurs aiming for
but should be based on the recommendations from the approximately 1.2 g/kg of protein per 24 hours. There is
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The etiology of AKI is different between children from GUIDELINE P1: Suitability of PD for AKI in children
developed and developing countries. Whereas isch-
emic/hypoxic and nephrotoxic injury secondary to P1.1 Peritoneal dialysis is a suitable modality for RRT in
prematurity, post-cardiac surgery, or bone marrow AKI in children (1C).
transplantation are common in the former, infection-
related causes (especially malaria), gastroenteritis RATIONALE
and primary renal diseases are common in the latter
(6870). Renal replacement therapy in the form of PD, Guideline P1.1: There have been no randomized clinical
HD or continuous renal replacement therapy (CRRT) is trials comparing different RRT modalities (PD, HD and
frequently needed and the decision to use any of these CVVH) for the treatment of children with AKI. Observational
modalities should not be delayed; higher survival rates studies have shown no difference in mortality between chil-
in neonates and infants have been associated with early dren treated with PD and those receiving CVVH (68,7779).
initiation of PD (71,72). However, in 1 study, CVVH was associated with better fluid
Peritoneal dialysis was the first RRT modality used control and was superior to PD in the management of hyper-
for the management of AKI in children of all ages, and catabolic AKI due to sepsis (79). In another study, CVVH was
remains the preferred method in younger children. associated with better ultrafiltration, solute removal and
However, its practice has declined in favor of the new nutritional support (77). However, in none of these stud-
extracorporeal blood purifying technologies (73). The ies was there a survival benefit associated with the use of
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performing manual PD (1C) (Optimal). In resource- in children can be the greatest hazard in this situation
limited settings, an open system with spiking of and it is imperative that facilities and staff be available
bags may be used; however, this should be designed to administer and deal with the consequences of these
to limit the number of potential sites for contamina- agents. The procedure needs to be performed in the most
tion (2D) (Minimum standard). sterile environment available, and operators must wear
hats, masks, gowns, and gloves.
P2.3 Automated PD (APD) is suitable for management A study of 108 cases of bedside catheters inserted by
of pediatric AKI with the exception of low birth pediatric nephrologists showed this to a be a safe and
weight neonates where fill volumes are too small cost-effective method of insertion. Of particular note,
for currently available machines (1D). there were no cases of bowel perforation despite using
both blind and Seldinger techniques (85).
RATIONALE An alternative to the Tenckhoff catheter which can
be inserted at the bedside in children of all sizes is the
Guideline P2.1 Catheter Design and Insertion Tech flexible Cook Mac-Loc (Cook Medical Inc, Bloomington,
niques: The provision of acute dialysis in children can IN, USA) Multi-purpose Drainage Catheters (CMMDCs).
be challenging due to many factors including a lack of These were used in 21 infants and children with a mean
equipment suitable for use in small children and babies age of 6.9 months. There were only 3 complications in 2
including PD catheters, circuits and fluid bags, as well patients precluding continuation of PDthe remainder
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first 24 48 hours of dialysis, fibrin glue was applied cycler then automatically performs the treatment. As is
(1 mL) to the external part of the catheter at the exit the case with manual PD, the APD exchange has 3 phases:
site. No recurrence of dialysate leakage was seen in any fill, dwell, and drain.
of the 8 children (86). Components of the APD prescription:
Type of dialysis solutions
Guideline P2.2 Manual PD Delivery Systems: Peri
Total volume of dialysis solution
toneal dialysis for infants and children with AKI may be
Total therapy time: Total time starting with the initial
implemented with a manual and gravity-based system.
drain. Maximum setting is 48 hours, minimal setting
The circuit should consist of a closed system which reduces
10 minutes, and setting increments are 10 minutes
the risk of infection (87). Strict fluid balance, which is of
Intraperitoneal fill volume
utmost importance in the very young, is assisted by the
use of buretrols, which permit the precise measurement of APD options for treatment of AKI include the follow-
in- and outflow. This technique also minimizes the number ing: Continuous Cycling Peritoneal Dialysis (CCPD)/
of connections and, therefore, the risk of touch con- Intermittent Peritoneal Dialysis (IPD): Total volume of
tamination. Systems are now available commerciallythe PD solution used for the therapy includes the total fill
PD-Paed system (Fresenius Medical Care, BadHomburg, volume for all cycles and the last fill volume. The last
Germany) and the Dialy-Nate system/Gesco Dialy-nate fill volume has to be prescribed in this mode of APD;
(Utah Medical Products, Midvale, UT, USA). In older chil- it is delivered at the end of the therapy and left in the
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GUIDELINE P3: Peritoneal dialysis solutions for acute commercially prepared solutions for acute PD are lactate
PD in children based with a concentration of 35 40 mmol/L, more
biocompatible solutions (e.g. bicarbonate- or lactate/
P3.1 The composition of the acute PD solution should bicarbonate-based) are available in countries other
include dextrose in a concentration designed to than the United States and have been used for acute PD
achieve the target ultrafiltration (1D). (9193). On occasion, infants and young children do not
tolerate the lactate absorbed from the dialysis solution
P3.2 Serum concentrations of electrolytes should be in the setting of hepatic dysfunction, hemodynamic
measured 12-hourly for the first 24 hours and daily instability, and persistent/worsening metabolic acidosis.
once stable (1D) (Optimal). In resource-poor set- In these situations, use of a commercial or pharmacy-
tings, sodium and potassium should be measured prepared bicarbonate-based solution is preferable. If
daily if practical (2D) (Minimum standard). calcium is needed (see below) it must be given by a route
other than in the PD solution to prevent precipitation.
RATIONALE
Serum ionized calcium levels must be closely monitored
when the dialysate contains a high concentration of
Guideline P3.1: Peritoneal dialysis solutions for acute
bicarbonate to prevent the risk of tetany. It should also
PD are generally commercially available with dextrose
be noted that bicarbonate loss from dialysate is increased
concentrations of 1.5%, 2.5%, and 4.25% (1.36%, 2.27%
in association with high ultrafiltration rates as a result
GUIDELINE P4: Prescription of acute PD in pediatric and dialysate are preserved. Although even shorter
patients (< 60-minute) exchange times have been used on occa-
sion, solute removal is often compromised because of
P4.1 The initial fill volume should be limited to 10 the substantial period of time that is spent filling and
20 mL/kg to minimize the risk of dialysate leakage; draining the patient (98). In general, the inflow time
a gradual increase in the volume to approximately is 5 10 minutes (or less), and depends on the amount
30 40 mL/kg (800 1,100 mL/m2) may occur as of fluid to be infused, the height of the bag of dialysis
tolerated by the patient (1D). solution relative to the patient, and the resistance
created by the PD catheter and the associated tubing.
P4.2 The initial exchange duration, including inflow, The dwell time, that period of the exchange when the
dwell, and drain times, should generally be every dialysis solution remains in the peritoneal cavity, is
60 90 minutes; gradual prolongation of the approximately 30 40 minutes. The drain time is typically
dwell time can occur as fluid and solute removal 10 20 minutes and is dependent on the volume of fluid
targets are achieved (1D). In neonates and small to be drained, the resistance of the catheter and tubing,
infants, the cycle may need to be reduced to achieve and the height difference between the patient and the
adequate ultrafiltration. drainage bag. As noted previously, frequent exchanges
increase the risk for hypernatremia and mandate close
P4.3 Close monitoring of total fluid intake and output monitoring for these laboratory abnormalities. Finally,
RATIONALE
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Guideline P4.3: Pediatric patients with AKI are fre- the achievement of solute/fluid stability, the provision
quently hypervolemic and substantial fluid overload has of dialysis during only a portion of each 24 hours using
been associated with an increased risk for morbidity and an increased exchange volume is usually sufficient. It
mortality (99). Fluid removal is, in turn, an important should be emphasized that the use of PD continuously
treatment goal for many patients. Ideally, the successful does not inhibit the resolution of AKI.
generation of ultrafiltrate with each exchange (plus any
urine output that might exist) will result in resolution Guideline P4.5: Clearance of many drugs may be altered
of the fluid overloaded state, while permitting the fluid once the patient transitions between AKI with oliguria to
needs of the patient for medications, blood products, PD. This may result in inadequate serum levels especially
nutrition and maintenance of hemodynamic stabil- with agents such as antibiotics and anticonvulsants and
ity to be met. The ability to regularly achieve positive dosing should be adjusted accordingly.
ultrafiltration and meet the patients needs will often
require hypertonic dialysis solutions (2.5%/4.25%) GUIDELINE P5: Continuous flow peritoneal dialysis
and frequent exchanges early in the course of acute PD (CFPD)
when the exchange volumes are small; modification of
the ultrafiltration needs will mandate adjustment of the P5.1 Continuous flow peritoneal dialysis could be con-
dialysis prescription. Ideally, once the patient is euv- sidered as a PD treatment option when an increase
olemic, the dextrose concentration of the dialysate and in solute clearance and ultrafiltration is desired
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rate of between 100 300 mL/min and a glucose concen- Single-pass CFPD circuits have been described in adult
tration of 1.5%. With this prescription, greatly improved patients using only an inflow pump and partially occlud-
ultrafiltration and clearances were obtained (100103). ing outflow to maintain satisfactory flow (102,103).
However, these studies were conducted with stable Purely gravity-assisted CFPD has also been described
chronic PD patients. As noted in section P5.1, it is custom- in children, but without a fixed intraperitoneal volume
ary to initially prescribe small fill volumes (10 20 mL/ (104). Single-pass CFPD is the use of dialysate which
kg) in children on acute PD because of concerns regarding is discarded and not regenerated after it has passed
raised IPP and its effect on ventilation (80). Raaijmakers through the abdomen. As such small volumes of fluid are
et al. were able to achieve greatly enhanced small-solute used in pediatric patients, this is felt to be reasonable. It
clearance and ultrafiltration with CFPD using a fill volume is important to note that experience with CFPD is limited
of 20 mL/kg, a peritoneal flow rate of 100 mL/1.73m2/ and although the technique is potentially useful, its use
min and a dialysate glucose concentration of mostly should be considered experimental.
1.5% (105). Thus, CFPD could be useful in situations
where standard acute PD does not achieve adequate Dialysis Prescription for CFPD:
clearance or ultrafiltration because of the requirement
Fill volume of 10 20 mL/kg
for small fill volumes. As is the case with all approaches
Dialysate flow rate of 100 mL/1.73m2/min
to acute PD, careful and frequent monitoring of the
Ultrafiltration flow: This can initially be set at 2.5 mL/
patient is essential and ultrafiltration rates need to be
CONCLUSION
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Appendix 1:
Local Preparation of Solutions
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