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Objectives Differences in peritoneal fluid handling in the acute setting can be expected if children are converted to pH-neutral dialysis solutions because conventional acidic solutions exert toxic effects on peritoneal mesothelial cells and microcirculation. Peritoneal fluid kinetics was therefore investigated with both types of solutions in a group of children. Design Peritoneal equilibration tests (PETs) were performed in 12 patients [mean age 70 months, mean time on peritoneal dialysis (PD) 18 months] using a pH-neutral PD fluid (Physioneal 3.86%; Baxter Ltd, Castlebar, Ireland) and dextran 70 as a volume marker. The results of these PETs were compared to those of a historic group of 12 children (mean age 75 months, mean time on PD 17 months). Setting Pediatric dialysis unit in a tertiary institute. Patients Stable pediatric PD patients. Main Outcome Measures Transcapillary ultrafiltration (TCUF) and marker clearance, dialysate-to-plasma (D/P) ratios for urea and creatinine, and Dt/D0 ratio for glucose. Results TCUF and lymphatic absorption were not different between the two groups. There was also no significant difference in small solute clearance measured by D/P ratio for urea and creatinine and Dt/D0 ratio for glucose. Conclusion Peritoneal fluid kinetics is not significantly altered if pH-neutral dialysis solutions are applied compared to acidic solutions. An altered TCUF, as is hypothetically possible using an acidic solution, was not established.

ObjectivesTo establish intraperitoneal pressure (IPP) in a relatively large pediatric study group and to study the effects of a 3.86% glucose solution and a 7.5% icodextrin solution on IPP during a 4-hour dwell.DesignIPP was measured with the patient in a supine position. The intraperitoneal volume (IPV) was 1200 mL/m2with a 1.36% glucose solution. The influence of dialysis solutions was obtained by performing two 4-hour peritoneal equilibration tests (PETs) with 3.86% glucose and 7.5% icodextrin as test solution, using an IPV of 1200 mL/m2and dextran 70 as volume marker. IPP was measured at two consecutive time points ( t = 0 and t = 240 minutes). Transcapillary ultrafiltration, net ultrafiltration, and marker clearance were calculated.PatientsIPP was established in 30 patients with median age of 4.5 years (range 1.0 – 14.9 years). Influence of dialysis solutions on IPP was studied in 9 children with median age of 4.2 years (range 1.7 – 10.9 years) and median treatment period of 12 months (range 5.6 – 122.3 months).ResultsMean IPP was 12.0 ± 6.5 cm H2O. Significant relations were found between the change in IPP and transcapillary ultrafiltration and body surface area during the PET with 3.86% glucose. No relations were seen during the PET with icodextrin.ConclusionsIPP was established in a large pediatric study group and was similar to previously published values of IPP in a small number of patients. Differences in fluid kinetics have different effects on the change in IPP during a 4-hour dwell period.

Objective To provide guidelines on choosing dialysis solutions for children on chronic peritoneal dialysis (PD). Setting European Paediatric Peritoneal Dialysis Working Group. Data Source Literature on the application of PD solutions in children ( Evidence), and discussions within the group ( Opinion). Conclusions Glucose is the standard osmotic agent for PD in children ( Evidence). The lowest glucose concentration needed should be used ( Opinion). Low calcium solution (1.25 mmol/L) should be applied, wherever possible, with careful monitoring of parathyroid hormone levels ( Opinion). The use of amino acid-containing dialysis fluids can be considered in malnourished children, although aggressive enteral nutrition is preferred ( Opinion). There is insufficient evidence documenting the efficacy of intraperitoneally administered amino acids ( Evidence). When ultrafiltration and/or solute removal are insufficient, poly-glucose solutions are a welcome addition to the treatment of children on nocturnal intermittent PD ( Evidence). However, in the absence of any reported long-term experience with children, their use must be closely monitored ( Opinion). Bicarbonate would appear to be the preferred buffer for PD in children, but more in vivo studies are required before it replaces the present lactate-containing solutions ( Evidence/Opinion).

ObjectiveTo evaluate the use of the combination of cefazolin and ceftazidime for initial treatment of peritoneal dialysis (PD)-related peritonitis in pediatric patients.DesignRetrospective nonrandomized study.SettingPediatric dialysis units of the University Medical Center of Utrecht and Nijmegen, The Netherlands.Patients40 children (median age 5.4 years) who were treated with PD during the study period of 4.5 years.InterventionsAll 50 episodes of peritonitis that occurred during the study period were evaluated by review of medical records. Patients were given intraperitoneal ceftazidime 500 mg/L dialysis fluid, and cefazolin 500 mg/L as a loading dose, followed by a maintenance dose of ceftazidime 125 mg/L and cefazolin 100 mg/L, intraperitoneally, 4 times daily. Antibiotics were continued for 14 days.ResultsAfter identification of the causative microorganism, one of the antibiotics was discontinued in 34 cases, and the antibiotic schedule was adapted in 2 cases. All cases were initially cured within 3 days. In 5 cases (10%), there was a peritonitis with the same organism recurring within 2 weeks after completion of treatment. There were 4 cases of PD-related peritonitis caused by pseudomonas, all of which were cured.ConclusionsThe antibiotic combination of cefazolin and ceftazidime is effective for the initial therapy of PD-related peritonitis in children. The toxic complications of aminoglycosides are avoided with this combination.

ObjectiveTo explore further the mechanisms leading to immune deficiency in chronic renal failure and the role of dialysis treatment in these mechanisms.DesignCross-sectional and longitudinal analysis.PatientsWe studied 39 children treated with peritoneal dialysis (PD), 23 children treated with hemodialysis (HD), 33 children not yet dialyzed [chronic renal failure (CRF)], and 27 healthy children. Peritoneal cells were also obtained from PD children for analysis.MethodsWhite blood cells (WBCs) were isolated from blood and peritoneal dialysis effluent by centrifugation. The number of CD2+, CD4+, and CD8+T cells, B cells, and natural killer cells were measured by flow cytometry.ResultsThe total peripheral blood lymphocyte count was lower in PD children (2.6 x 109/L), HD children (2.1 x 109/L), and CRF children (2.0 x 109/L) compared with healthy children (3.1 x 109/L, p < 0.05). The B lymphocyte count was also lower in PD children (0.34x109/L), HD children (0.22 x 109/L), and CRF children (0.33 x 109/L) compared with healthy children (0.52 x 109/L, p < 0.01). Numbers of CD4+T cells were not different, but numbers of CD8+T cells were lower in PD children (0.56 x 109/L), HD children (0.63 x 109/L), and CRF children (0.53 x 109/L) compared with healthy children (0.77 x 109/L, p < 0.05). The count of natural killer cells was lower in PD children (0.21 x 109/L), HD children (0.17 x 109/L), and CRF children (0.18 x 109/L) compared with healthy children (0.50 x 109/L, p < 0.0001). The CD4/CD8 ratio of lymphocytes in peritoneal effluent was 0.8 versus 1.9 in peripheral blood ( p < 0.001). The CD2/CD19 ratio was not different. The cell subsets remained stable during the first year of PD treatment. The CD2/CD19 ratio in peritoneal effluent was higher in children with a peritonitis incidence ≥ 1 per year.ConclusionsThe reduced numbers of B lymphocytes, CD8+T cells, and natural killer cells found in CRF children, dialyzed or not, may favor the frequent occurrence of infections.

Objectives To study longitudinal changes in trans-capillary ultrafiltration (TCUF) and marker clearance (MC), as a reflection of lymphatic absorption, in children on peritoneal dialysis (PD). To present data on fluid kinetics in infants younger than 2.5 years, using an intraperitoneal volume of 1200 mL/m2 body surface area (BSA). Design The study involved a 4-hour dwell of 1200 mL/m2 BSA of dialysis fluid containing 3.86% glucose with Dextran 70 as volume marker. Cumulative TCUF and cumulative MC were measured. Setting A tertiary-care university hospital. Patients A follow-up period of 33 months of serial (1 – 4) peritoneal equilibration tests (PETs) was studied in 20 children with a median age of 6.4 years (range 2.1 – 15.4 years). Fluid kinetics in 5 additional infants with a median age of 1.4 years (range 0.5 – 2.5 years) was measured. Results Cumulative TCUF was 1041 mL/1.73 m2 at 1 – 3 months after start of PD, 1026 mL/1.73 m2 at 7 – 9 months, 1021 mL/1.73 m2 at 11 – 13 months, and 756 mL/ 1.73 m2 at 26 – 33 months (NS). Cumulative MC was 235 mL/1.73 m2 at 1 – 3 months after start of PD, 311 mL/ 1.73 m2 at 7 – 9 months, 395 mL/1.73 m2 at 11 – 13 months, and 509 mL/1.73 m2 at 26 – 33 months (NS). In infants, cumulative TCUF was 755 ± 237 mL/1.73 m2; cumulative MC was 400 ± 214 mL/1.73 m2. Conclusions Transcapillary ultrafiltration and marker clearance do not change in children > 2.5 years during the period studied. Fluid kinetics does not differ between infants < 2.5 years and older children when intraperitoneal volumes of 1200 mL/m2 BSA are used.

ObjectiveTo measure the urea and creatinine kinetics in a pediatric populationPatients and MethodsIn 19 children treated with peritoneal dialysis (PD) KT/V, urea and creatinine clearances (Ccr) were measured. Thirteen children were on continuous ambulatory peritoneal dialysis (CAPD) and 6 on nightly intermittent peritoneal dialysis (NIPD).ResultsMean KT/V per week was 2.31 ±0.78 and mean creatinine clearance 74 ±47 L/week/1. 73 m2. There was no difference in dialytic KT/V between patients treated with CAPD and NIPD (1.75 ±0.21 vs 1.76 ±0.50). The correlation between KT/V urea and creatinine clearance was 0.9 (pConclusionsMean KT/V in this patient group was higher than the values reported for most adult patient groups. Residual renal function considerably contributes to this high KT/V. It is not clearly defined which KT/ V should be aimed for, since criteria for adequate dialysis are multifactorially determined and therefore difficult to interpret.

Cardiovascular complications are emerging as the primary cause of death for patients with childhood end-stage renal disease. Children with end-stage renal failure are subjected to many of the risk factors for cardiovascular disease identified in adult patients. Dysfunction of the endothelium is presently regarded as a first but reversible step in the development of atherosclerosis. Noninvasive techniques to assess endothelial function have been recently developed and have been proven to predict future mortality in adult patients. These techniques are readily applicable to pediatric patients. Endothelial dysfunction has been demonstrated in children in all stages of renal failure. Data on pediatric patients treated with peritoneal dialysis are currently lacking, however. Considering the abundance of cardiovascular risk factors specific to treatment with peritoneal dialysis, such studies should be initiated.

Background Acute renal failure in infants and small children is generally treated with peritoneal dialysis (PD). Dialysis has to be started immediately after catheter implantation. Early dialysate leakage can complicate the effectiveness of dialysis. Fibrin glue applied to the external part of the tunnel may stop dialysate leakage and eliminate the need for surgical intervention. The use of fibrin glue in the treatment of PD catheter leakage in children was studied. Methods Fibrin glue was used in 8 children (age 0.8 – 57 months) on PD in whom dialysate leakage was seen during the first 24 to 48 hours after catheter insertion. The dialysis volume initially administered was 20 mL/kg body weight. Fibrin glue (1 mL) was applied to the external part of the subcutaneous catheter tunnel through the exit site, as close to the cuff as possible. The occurrence of dialysate leakage and complications such as exit-site or tunnel infection and peritonitis were evaluated. Results Nine single-cuff straight Tenckhoff catheters were implanted in 8 children. In 5 cases, no subcutaneous tunnel was created. One child had catheter replacement due to obstruction of the catheter; on both occasions, catheter leakage was seen and treated with fibrin glue. In all 8 patients, no relapse of dialysate leakage was seen after application of the fibrin glue. During the time of PD, exit-site infections, tunnel infections, and peritonitis did not occur. Conclusion Fibrin glue is a successful, simple, and safe substance for the treatment of peritoneal dialysate leakage in infants and small children with acute renal failure treated with PD.

Objective During continuous ambulatory peritoneal dialysis (CAPD), activation of complement in the peritoneal cavity may theoretically occur, with inappropriately high or low levels of certain complement factors in dialysate as a consequence. In a group of children on CAPD, it was tested whether levels of a number of complement factors in dialysate were in the range that was predicted on the basis of their molecular weight. Design Serum and dialysate levels of C1 q, C3, C4, C3d, B, D, and P were measured after a night dwell in children on CAPD. Simultaneously, four non-complement proteins (β2-microglobulin, albumin, IgG, and α2macroglobulin) were also measured in dialysate and serum. Assuming a linear relationship between the log base 10 of the dialysate/serum ratio of these non-complement proteins and the log base 10 of their molecular weight, the expected ratios of all complement factors were determined. The differences between actual and predicted ratios were tested using a modified t-test, taking into account the inaccuracy of the estimate. Setting University hospital. Patients A group of 14 children on CAPD, with a median age of 7.8 years (range 2.1–13.2). These children had been on CAPD for a median period of 42.4 months (range 0.4 89.1). Results The ratios of factor D (p < 0.001) and C3d (p = 0.035) were elevated, whereas those of C3 (p < 0.001), C4 (p < 0.001), and factor P (p = 0.012) were decreased. Conclusions Relatively low dialysate/serum ratios of C4, C3, and factor P could be caused by intraperitoneal consumption of complement. High levels of C3d are compatible with this. High dialysate/serum ratios of factor D indicate intraperitoneal production of factor D. These results provide evidence for activation of complement in the peritoneal cavity in children on CAPD. A further reduction of already low levels of complement factors in dialysate as a result of this may impair host defense.

Objective Previous measurements of peritoneal fluid handling in children treated by continuous ambulatory peritoneal dialysis (CAPD) were performed with human albumin as a fluid marker. A major disadvantage of this substance is that endogenous patient albumin enters the peritoneal cavity during the dwell period. For this reason perito neal fluid kinetics were measured in a group of children on CAPD, using autologous hemoglobin as a volume marker. Design Autologous hemoglobin was added to dialysate containing 1.36% glucose as a volume marker. Marker clearance (MC), which is presently the best available approximation of lymphatic absorption in the clinical setting, and transcapillary ultrafiltration (TCUF) were measured during a 4-hour dwell. Setting University hospital. Patients Children on CAPD (N=9), with a median age of 8.1 years (range 2.1–13.2 years). Results MC was 521±166 mL/4 hour/1.73 m2, which is high compared to the literature data on adult CAPD patients. TCUF was 519±92 mL/4 hour/1.73 m2, which is similar to data concerning adult patients. TCUF reached no maximum during the 4-hour dwell, and the deviation of the TCUF curve from linear was markedly less than usually seen in adult patients. Conclusions MC in children treated with CAPD is higher when compared to the literature data on adults. Difficulties to achieve sufficient ultrafiltration in children could be caused by relatively small differences between MC and TCUF from the beginning to the end of the dwell.

ObjectiveDuring continuous ambulatory peritoneal dialysis (CAPD), the loss of complement factors via the dialysate may cause complement deficiencies. This hypothesis was tested in a group of children treated with CAPD.DesignClassical (CH50) and alternative (AP50) complement activity and serum levels of factors C1 q, C3, C4, C3d, B, D, and P in CAPD patients were compared to normal controls and to children with preterminal renal failure.SettingPatients were seen in a university hospital; normal controls were seen in an outpatient clinic of a general hospital.PatientsA group of 22 children on CAPD was compared to a normal control group of 44 children and to a group of 12 children with preterminal renal failure with a creatinine clearance below 25 mL/min/1.73 m2.ResultsCH50, AP50, C3, and B were not significantly different from the control group in both the CAPD and preterminal groups. Factors C1q (p=0.01) and C4, C3d, D, and P (pConclusionsThere is no deficiency of complement in children treated with CAPD. High levels of C3d and D can be explained by the reduction of their elimination by the kidney. The increased levels of the other factors are presumably due to increased synthesis in renal failure. This does not seem to be caused by CAPD.

Peritoneal handling of glucose and metabolites is reported to be higher in young children treated with CAPD than in older children. Reference curves for the standardized peritoneal equilibration test (PET) are not available for younger ages. The present study describes the results of the PET in 19 children (mean age 5.0 years, ranging from 0.3–15) during the first month of CAPD treatment. No age dependency for the handling of glucose, urea, and creatinine could be established when the group was subdivided into 1. children below the age of 3 years, and 2. children above that age. There was, however, a significant correlation between equilibration of creatinine and age, indicating more rapid equilibration at younger ages.

ObjectiveChronic tunnel infections often necessitate the removal of the continuous ambulatory peritoneal dialysis (CAPD) catheter. Most published studies advocate postponing the insertion of a new catheter for several weeks. For young children it will be particularly difficult to wait this length of time, since vascular access may be cumbersome, and hemodialysis may not be well tolerated. The present study describes the results of the simultaneous removal and replacement of the CAPD catheter. .Design: Twenty-three Toronto Western Hospital II catheters were inserted in 17 children because of infectious complications (21 chronic tunnel infections; 2 recurrent peritonitis) in a single operation under appropriate antibiotic prophylaxis. The new catheter was inserted at the contralateral side of the abdomen with the deep cuff in the midline, using the same entrance to the peritoneal cavity. Dialysis was resumed immediately after the operation.SettingA university pediatric dialysis unit.PatientsSeventeen children (mean age 3.7 years; range 1.0–8.5 years) were studied. In this group 23 catheters were replaced.ResultsIn four cases a relapse of the tunnel infection was observed within 3 months. All other cases remained free of infection for a period of at least 6 months. The main causative microorganism was Staphylococcus aureus (15 occurrences).ConclusionIt is not necessary to interrupt peritoneal dialysis for the replacement of a CAPD catheter because of infectious complications.

The influence of peritoneal dialysate exchange on the ventricular function in 11 children on continuous ambulatory peritoneal dialysis (CAPD) therapy was studied before and after instillation dialysate. Systolic blood pressure, pulse rate, and echocardiographical data (shortening fraction and pre-ejection period/left ventricle ejection time-ratio) were obtained before and after instillation. There were no differences present with respect to the measured parameters after the abdomen was filled. It is concluded that in children treated with CAPD the exchange of normal volumes of dialysate has no influence on the function of the left ventricle.

Sodium sieving is a consequence of dissociation between the amount of water and sodium transported over the peritoneal membrane. This dissociation occurs in the presence of aquaporin-mediated water transport. Sieving of sodium can be used as a rough measure for aquaporin-mediated water transport. Icodextrin contains glucose polymers, inducing ultrafiltration by colloid osmosis. Therefore, aquaporins play a minor role in ultrafiltration, which is confirmed by the absence of sodium sieving. Icodextrin is very suitable for the daytime dwell in children on a nightly intermittent peritoneal dialysis regimen. Ultrafiltration obtained with icodextrin is similar to ultrafiltration obtained with 3.86% glucose after a 12-hour dwell. When using icodextrin in children, it is also confirmed by the absence of sodium sieving that the aquaporins play a minor role in ultrafiltration.

In most series of children treated with continuous ambulatory peritoneal dialysis (CAPO), the incidence of peritonitis is higher than in adults. This phenomenon has been insufficiently explained. In the serum of 12 young children treated with CAPO, the serum immunoglobulins IgA, IgM, and IgG, as well as the IgG subclasses, were evaluated. In 11 of them, IgG2 was not detectable. Total IgG was also slightly decreased in these patients. In control groups, consisting of children before CAPO was started, children treated with hemodialysis, and adult CAPO patients, no clear abnormalities were found. It is concluded that in young patients peritoneal dialysis causes IgG loss leading to IgG2 deficiency.