Elsevier

Seminars in Nephrology

Volume 31, Issue 2, March 2011, Pages 213-224
Seminars in Nephrology

Peritoneal Dialysis in Infants and Young Children

https://doi.org/10.1016/j.semnephrol.2011.01.009Get rights and content

Summary

Although end-stage renal disease is rare in infants and young children, its development can be associated with significant morbidity and mortality and only through the provision of experienced, multidisciplinary care can a favorable outcome be anticipated. Peritoneal dialysis is the renal replacement modality of choice for this age group and serves as an essential bridge until successful renal transplantation can occur. In this review, we discuss the practice of peritoneal dialysis in infants including the unique ethical and technical considerations facing pediatric nephrologists and caregivers. In addition, we review current guidelines concerning nutrition, growth, and adequacy, as well as the literature on complications and outcomes.

Section snippets

Ethical Considerations

Clearly, one of the most difficult issues that families and pediatric nephrology teams are confronted with is the decision regarding the initiation of chronic dialysis therapy for the young infant (<1 y) with ESRD. Despite the advances in dialysis technology that now make it possible to provide dialysis to this patient population safely and effectively, the concept of proceeding with a lifetime of ESRD care is unavoidably complex. Comorbidities such as neurocognitive delay, growth delay, and

PD as a Renal Replacement Modality

Although transplantation is the ideal renal replacement therapy for children, technical aspects limit the feasibility of the procedure in the first year of life. Thus, dialysis is used as a bridge to successful early transplantation with peritoneal dialysis (PD) as the modality of choice. Data from the NAPRTCS show that nearly 96% of children younger than 2 years of age who are on long-term dialysis are treated with PD.14 Similar percentages are seen in the United Kingdom.2

The dialysis access

PD Access

The most important consideration for the successful placement and function of a PD catheter in the young infant is the experience of the surgeon.19 This can be particularly problematic at centers caring for a small volume of infants overall, where the need to provide dialysis to a very young infant may be a rare event. Because of the importance of the access and the desire for the outcome of placement to be without complication, the surgical placement should be limited to only a few surgeons

Exchange Volume and Dwell Time

Historically, the prescription of PD in small children was based on the perception that the pediatric peritoneal membrane, especially in infants, had different solute transport properties than that of an adult. This was in large part based on the results of early studies in which dialysis exchange volumes were based solely on body weight. When scaled to body weight, the surface area of the infant peritoneal membrane is almost twice that of a 70-kg adult. Thus, the use of weight-based volumes

Growth and Nutrition

A particularly challenging aspect of caring for infants and young children with ESRD is achieving normal growth. Early infancy typically is characterized by a very high linear growth rate of nearly 25 cm/y, which gradually decreases to 18 cm/y over the first year of life. Maintaining optimal growth during this period is critical if a normal adult height is to be obtained because a third of final adult height normally is achieved during the initial 2 years of life.48 However, infants with ESRD

Complications and Outcome

Despite significant advances in care, morbidity remains high in infants receiving PD. Although peritonitis rates for patients ages 0 to 2 years have improved from an annualized rate of 1 to 0.85 over the past decade, they remain higher than the rate of 0.6 seen in older children.3, 69 Overall catheter survival is also suboptimal as reflected by data from the Italian PD registry, which reported a 50% 1-year catheter survival rate in patients younger than 6 months of age versus an 83.7% 1-year

Conclusions

The past 2 decades have seen tremendous advances in the care of the infant with ESRD. There have been notable improvements in overall survival, although complications remain high, especially in those infants with comorbidities. Clearly, a multifaceted approach to care is necessary to minimize or prevent complications and in turn promote growth, development, and readiness for transplant. To do so requires a multidisciplinary pediatric dialysis team consisting of physicians, nurses, dietitians,

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