While children approaching end-stage kidney disease (ESKD) are considered at risk of uremic anorexia and underweight they are also exposed to the global obesity epidemic. We sought to investigate the variation of nutritional status in children undergoing chronic peritoneal dialysis (CPD) around the globe. The distribution and course of body mass index (BMI) standard deviation score over time was examined prospectively in 1001 children and adolescents from 35 countries starting CPD who were followed in the International Pediatric PD Network (IPPN) Registry. The overall prevalence of underweight, and overweight/obesity at start of CPD was 8.9% and 19.7%, respectively. Underweight was most prevalent in South and Southeast Asia (20%), Central Europe (16.7%) and Turkey (15.2%), whereas overweight and obesity were most common in the Middle East (40%) and the US (33%). BMI SDS at PD initiation was associated positively with current eGFR and gastrostomy feeding prior to PD start. Over the course of PD BMI SDS tended to increase on CPD in underweight and normal weight children, whereas it decreased in initially overweight patients. In infancy, mortality risk was amplified by obesity, whereas in older children mortality was markedly increased in association with underweight. Both underweight and overweight are prevalent in pediatric ESKD, with the prevalence varying across the globe. Late dialysis start is associated with underweight, while enteral feeding can lead to obesity. Nutritional abnormalities tend to attenuate with time on dialysis. Mortality risk appears increased with obesity in infants and with underweight in older children.

This study was designed to compare chronic peritoneal dialysis (CPD) long-term outcomes (patient and technique survival, incidence of peritonitis, and overall average death outcomes) between seven patients with lumbar spina bifida (SB) and 20 controls without SB. Both groups were matched for potentially outcome-confounding factors: gender, and socioeconomic status (SES). SES was established using modified Graffar's method. No significant differences were found in CPD outcomes. The incidence of peritonitis was one episode per 17.6 and 10.3 months in SB patients and controls, respectively (p = 0.5). Overall patient survival at 5 years was 86% and 73% in SB patients and controls, respectively (p = 0.55). Overall average death rate between SB and control patients was 47.6/1,000 and 79.4/1,000 patient years, respectively (p = 0.63). Overall technique survival at 5 years was 83% and 73% in SB patients and controls, respectively (p = 0.84). There were no cases of retrograde brain ventricular infection secondary to PD-related peritonitis. We conclude that SB is not a risk factor for CPD, and therefore, it is an effective renal replacement alternative in children with SB.

The peritoneal equilibration test (PET) is the gold standard method for defining peritoneal membrane permeability and for prescribing peritoneal dialysis (PD) therapy on an individual basis. However, it is laborious, consumes nursing time, and requires many hours to be performed. Therefore, several authors have attempted to validate a short PET protocol, with controversial results. To evaluate the concordance between the 2-h (short) and 4-h (classical) peritoneal equilibrium test, a prospective observational protocol was applied in three PD centers (Mexico, Chile, and Uruguay) between July 1, 2008 and July 31 2009. PET protocol: the night prior to the test, each patient received five exchanges, 1 h each, at the same glucose concentration as previously used. Afterwards, a 2.5% glucose dialysis solution was used for a dwell time of 4 h. Exchange fill volume was 1,100 ml/m2 body surface area. The next morning, the 4-h dwell was drained, and Dianeal 2.5% was infused. Three dialysate samples at 0, 2, and 4 h were obtained. A single blood sample was obtained at 120 min. Creatinine D/P and glucose D/D0 ratios were calculated at hours 0, 2, and 4. Patients were categorized as low, low average, high average, or high transporters according creat D/P and gluc D/D0 results. Pearson and Kappa test were used for numerical and categorical correlations, respectively, and p<0.05 was considered significant. Eighty-seven PET studies were evaluated in 74 patients, 33 males, age 11.1+/-5.05 years old. A positive linear correlation of 92% between 2 and 4-h creat D/P and 80% between 2 and 4-h gluc D/D0 (p<0.001) was founded. The Kappa test showed a significant concordance between creat D/P and gluc D/D0 categories at 2 and 4 h (p<0.001). When analyzing cut-off-value categories, creat D/P was founded to be lower and gluc D/D0 higher than other experiences. This multicentric prospective study strongly suggests that PET obtained at 2 h and 4 h, based on either creatinine or glucose transport, provides identical characterization of peritoneal membrane transport capacity in PD children.

In this study we analyze the impact of the patient's socioeconomic status (SES) and the distance from the patient's home to the dialysis center (DPH-DC), classified as < or =300 km or >300 km, on the patient and technique survival of 59 patients starting chronic peritoneal dialysis (CPD) between May 1983 and January 2004 at a single center in Uruguay. SES was established using Graffar's method. Mean duration of CPD was 38.1+/-26.0 months. Mean age at the start of CPD was 8.4+/-5.2 years. Overall patient and technique survival at 5 years were 86.4% and 77.9%, respectively. Twenty (33.8%) patients were transferred to hemodialysis. Eight (13.5%) patients died. The incidence of peritonitis was one episode every 9.1 months. There was no statistically significant difference in patient and technique survival between the patients in the low and high SES groups (p=0.72 and 0.99, respectively), and between those in the two DPH-DC groups, (p=0.22 and p=0.99, respectively). Logistic regression analysis confirmed low SES and DPH-DC >300 km are not predictors of patient death (p=0.79 and p=0.09, respectively) or technical failure (p=0.35 and p=0.15, respectively). No SES- and DPH-DC-related statistically significant differences were found in patient and technique survival.

Objective The goal of this paper was to review the viability of peritoneal dialysis (PD) in patients with spina bifida and/or ventriculoperitoneal shunt (VPS). Setting Pediatric dialysis unit in a tertiary-care hospital. Data Source The course and outcome in 9 children, 5 from the authors’ experience and 4 from reported experience, are analyzed. Results One patient died of a cause unrelated to PD or VPS, 2 were transferred to hemodialysis because of recurrent peritonitis, 1 discontinued PD transiently, 2 were transplanted, and 3 continue on PD. Six of these 9 children had a functioning VPS, and none presented evidence of ventriculitis or VPS dysfunction, even though 4 had PD-related peritonitis. One child presented with a massive PD-related hydrothorax. Conclusions ( 1 ) Having a VPS is not an absolute contraindication to PD; the available data support the viability of PD in patients with spina bifida and/or a VPS. ( 2 ) If cerebrospinal fluid diversion is needed simultaneously or after starting PD, an extraperitoneal site should be a better choice than VPS. This should avoid the risk of intra- and postoperative infection in the PD catheter secondary to surgical intervention for VPS insertion. ( 3 ) Loss of peritoneal function is a potential late risk related to cerebrospinal fluid and PD. ( 4 ) Spina bifida patients on PD present specific diagnostic challenges due to overlapping symptoms ( e.g., vomiting, abdominal tenderness, fever) secondary to PD- or VPS-related complications ( e.g., peritonitis, visceral injury by devices) or primary disease ( e.g., neurogenic bladder, pyelonephritis), with inherent risks of delaying adequate treatment. Cloudy peritoneal effluent is an early indication of peritonitis, although it is not specific. ( 5 ) Early evaluation by a pediatric surgeon and a neurosurgeon is required for effective management of complications and selection of more efficient individualized therapeutic alternatives. Prompt treatment of complications is crucial. A registry of children with spina bifida on PD and the accumulation of a large population followed up for longer periods will provide an objective assessment of their problems and management.