Prescribing peritoneal dialysis for high-quality care in children

Abstract

<jats:sec><jats:title>Background:</jats:title><jats:p> Peritoneal dialysis (PD) remains the most widely used modality for chronic dialysis in children, particularly in younger children and in lower and middle income countries (LMICs). We present guidelines for dialysis initiation, modality selection, small solute clearance, and fluid removal in children on PD. A review of the literature and key studies that support these statements are presented. </jats:p></jats:sec><jats:sec><jats:title>Methods:</jats:title><jats:p> An extensive Medline search for all publications on PD in children was performed using predefined search criteria. </jats:p></jats:sec><jats:sec><jats:title>Results:</jats:title><jats:p> High-quality randomized trials in children are scarce and current clinical practice largely relies on data extrapolated from adult studies or drawn from observational cohort studies in children. The evidence and strength of the recommendation is GRADE-ed, but in the absence of high-quality evidence, the opinion of the authors is provided and must be carefully considered by the treating physician, and adapted to local expertise and individual patient needs as appropriate. We discuss the timing of dialysis initiation, factors to be considered when selecting a dialysis modality, the assessment and management of volume status on PD, achieving optimal small solute clearance, and the importance of preserving residual kidney function. While optimal dialysis must remain the goal for every patient, a careful discussion with fully informed patients and caregivers is important to understand the patient and family’s expectations of dialysis and reasonable adjustments to the dialysis program may be considered in accordance with a philosophy of shared decision-making. </jats:p></jats:sec><jats:sec><jats:title>Conclusions:</jats:title><jats:p> There continues to be very poor evidence in the field of chronic PD in children and these recommendations can at best serve to guide clinical decision-making. In LMICs, every effort should be made to conform to the framework of these statements, taking into account resource limitations. </jats:p></jats:sec>

KDOQI US Commentary on the 2020 ISPD Practice Recommendations for Prescribing High-Quality Goal-Directed Peritoneal Dialysis

“…For children with kidney failure, the ISPD guideline provides guidance on the timing of initiation of longterm dialysis, selection of dialysis modality, and assessment and management of volume status and solute clearances. 107 As in adults, the timing of dialysis initiation is a complex decision that requires an assessment of uremic signs and symptoms, fluid overload, and biochemical abnormalities. 18,108 In addition, suboptimal growth and development should influence the timing of dialysis initiation in children.…”

“…The ISPD guideline also suggests that dialysis be initiated when estimated glomerular filtration rate (eGFR) decreases to <10 mL/ min/1.73 m 2 and, as written, it can be interpreted to mean that dialysis should be initiated when eGFR decreases below the threshold even in the absence of symptoms. 107 As in adults, eGFR provides contextual information for assessment but it alone is insufficient to determine when to start dialysis. 108 As such, the KDOQI work group does not support a universally applicable eGFR threshold below which dialysis should be initiated in the absence of clinical or biochemical manifestations of uremia.…”

Peritoneal dialysis in children: Reaching milestones but room for growth

“…1 Improved survival and outcomes are largely due to advances in dialysis technology, improved dialysis fluids and clinical expertise in the management of dialysis-related complications. 2 Yet, there are few high-quality randomized controlled trials (RCTs), or even large prospective studies among children on PD. This issue of Peritoneal Dialysis International (PDI) focuses on paediatric PD, presenting a guideline and several interesting reports.…”

“…These data support larger paediatric studies recommending regular and multimodality assessment of hydration status, including objective measures such as BIS. 2,6,7…”

“…These data support larger paediatric studies recommending regular and multimodality assessment of hydration status, including objective measures such as BIS. 2,6,7 Further reports within this issue of PDI address immune cell dysfunction, in particular the chemokine-receptor system on T-cells which play a role in lymphocyte migration and infiltration. Extrapolating adult PD research findings to the paediatric population may not always be appropriate.…”