Pediatric Peritoneal Dialysis Patients Research Articles

A population-based study on the incidence and aetiology of infectious complications in peritoneal dialysis in South Sweden

Background Peritonitis is a major cause of morbidity in peritoneal dialysis (PD) and an independent risk factor for elevated all-cause mortality. The aims of this study were to report the incidence, trend, aetiology, and antimicrobial susceptibility of PD-associated peritonitis and catheter-related infections in South Sweden between 2011–2020. Methods This population-based observational cohort study included all patients with PD between the years 2011–2020 in the county of Skåne. Data was accessed through the Swedish Renal Registry and the Department of Clinical Microbiology in Lund. Definitions issued by the International Society for Peritoneal Dialysis were implemented to assess PD-associated infections. Results Medical records of 675 paediatric and adult PD patients were eligible for inclusion. Of those, 208 (31%) were female and the median age was 67 years (range 0-91). The overall rate of PD-peritonitis was 0.38 episodes per year at risk. Out of 484 episodes of peritonitis, 61% (n = 295) were caused by Gram-positive bacteria. There were 289 occurrences of exit site infections, of which most (n = 152, 53%) were Gram-positive. Tunnel infections occurred in 16 episodes and were caused by S. aureus or P. aeruginosa. Among all isolates, 37 were of MRSE, four of ESBL-producing E. coli, and one of MRSA. Conclusion The crude rate of PD-peritonitis was stable during the study period. Gram-positive bacteria dominated the microbial aetiology, and antibiotic resistance was limited. It is important to monitor the aetiology, incidence, and resistance rates in PD-associated infections, to base empirical antibiotic regimens and facilitate prevention.

Cumulative Dialytic Glucose Exposure is a Risk Factor for Peritoneal Fibrosis and Angiogenesis in Pediatric Patients Undergoing Peritoneal Dialysis Using Neutral-pH Fluids

Neutral-pH dialysate has been reported to be beneficial to prevent the peritoneal pathological changes in adult peritoneal dialysis (PD) patients, but its use is controversial in pediatric PD patients. In addition, the impact of cumulative dialytic glucose exposure has not been examined. Pediatric PD patients using conventional fluids (conventional group, n= 31) or those using neutral-pH fluids (neutral-pH group, n= 33) were compared. Clinical risk factors for peritoneal pathological changes in the neutral-pH group were analyzed using generalized linear modeling. Furthermore, the mechanisms of peritoneal pathological changes were explored using immunohistochemical studies and cultured cells. The median (interquartile range) duration of dialysis was 3.2 (1.7-5.3) years in overall patients. After propensity score matching, the conventional group showed increased thickening of the submesothelial compact (SMC) zone and lower luminal-to-vessel diameter (L/V) ratio than the neutral-pH group. In the neutral-pH group, the cumulative dialytic glucose exposure was an independent risk factor for greater thickness of the SMC zone (odds ratio [OR], 1.54; 95% confidence interval [CI], 1.16-2.05) and higher submesothelial microvessel density (OR, 1.29; 95% CI, 1.01-1.64). Immunohistochemical study showed that cumulative dialytic glucose exposure correlated with the proportion of the tissue expressing hypoxia inducible factor -1α (HIF-1α) and vascular endothelial growth factor-α (VEGF-α). In human peritoneal mesothelial cells, high glucose significantly increased HIF-1α and VEGF-α expressions. Cumulative dialytic glucose exposure is an independent risk factor for peritoneal fibrosis and angiogenesis in pediatric patients undergoing PD using neutral-pH fluids, which might be associated with greater VEGF-α production by myofibroblasts implying a hypoxic response.

High C-reactive protein and number of previous episodes at diagnosis increase the risk of catheter removal in peritoneal dialysis-related peritonitis in children.

A minority of patients with peritonitis require removal of peritoneal dialysis (PD) catheters. We examined risk factors at diagnosis that could predict the removal of PD catheter before obtaining the results of treatment success in children with peritonitis. We analyzed 156 peritonitis episodes in 57 pediatric PD patients. The peritonitis rate was 0.68 peritonitis episode per patient year. Catheter removal was required in 22 of 156. C-reactive protein (CRP) ≥ ×10 of upper limit at diagnosis and increased previous episode number were found to be associated with catheter removal (OR [95% CI] 6.4 [2.3-18.1], p= 0.001 and 3.8 [1.4-10.6], p= 0.009). These findings supported that CRP could be an early marker in predicting catheter removal even before obtaining the results of treatment success. Furthermore, it should be kept in mind that the risk of catheter removal is high in patients with high number of previous episodes especially of three or more.

Proteomics and Extracellular Vesicles as Novel Biomarker Sources in Peritoneal Dialysis in Children.

Peritoneal dialysis (PD) represents the dialysis modality of choice for pediatric patients with end-stage kidney disease. Indeed, compared with hemodialysis (HD), it offers many advantages, including more flexibility, reduction of the risk of hospital-acquired infections, preservation of residual kidney function, and a better quality of life. However, despite these positive aspects, PD may be associated with several long-term complications that may impair both patient’s general health and PD adequacy. In this view, chronic inflammation, caused by different factors, has a detrimental impact on the structure and function of the peritoneal membrane, leading to sclerosis and consequent PD failure both in adults and children. Although several studies investigated the complex pathogenic pathways underlying peritoneal membrane alterations, these processes remain still to explore. Understanding these mechanisms may provide novel approaches to improve the clinical outcome of pediatric PD patients through the identification of subjects at high risk of complications and the implementation of personalized interventions. In this review, we discuss the main experimental and clinical experiences exploring the potentiality of the proteomic analysis of peritoneal fluids and extracellular vesicles as a source of novel biomarkers in pediatric peritoneal dialysis.

Sociodemographic features and outcomes of peritonitis episodes in children on peritoneal dialysis.

Peritoneal dialysis (PD) is one of the most preferred kidney replacement therapies in children. However, it has an important complication such as peritonitis. This study was planned to investigate the causes and frequency of peritonitis in children with PD. The demographic features, peritonitis episodes, and microbiological characteristics of PD patients followed up for 5 years. Overall, 50 pediatric PD patients who met the study criteria in a 5-year period were included in the study. Consanguineous marriage was 64% and 44% of the mothers was illiterate. A total of 19 patients had no peritonitis episode, and a total of 54 peritonitis episode were experienced. The overall peritonitis rate was one episode per 24.4 patient-months. Culture negativity rate was 44%. Even though factors such as the education level of the parents, the number of people or rooms in the house, dialysis modality were thought to influence peritonitis episodes, they could not be shown statistically.

Kt/V or Bicarbonate: What Is More Important for Growth in Pediatric Peritoneal Dialysis Patients?

Introduction: Growth retardation is a common problem in pediatric patients with chronic kidney disease. It is unknown if the growth of children on peritoneal dialysis (PD) can be augmented by more dialysis. Methods: We studied the effect of various peritoneal adequacy parameters on delta height standard deviation scores (SDSs) and growth velocity z-scores in 53 children (27 males) on PD, who underwent 2 longitudinal adequacy tests at 9-month intervals. None of the patients were on growth hormone. Intraperitoneal pressure and standard KDOQI guidelines were compared to the outcome measures delta height SDS and height velocity z-scores, using univariate and multivariate tests. Results: At the time of the second PD adequacy test, their mean age was 9.2 ± 5.3 years; mean fill volume was 961 ± 254 mL/m²; and median total infused dialysate volume was 5.26 L/m²/day (range 2.03–15.32 L). The median total weekly Kt/V was 3.79 (range 0.9–9.5), and the median total creatinine clearance was 56.6 (range 7.6–133.48) L/week, higher than previous pediatric studies. The delta height SDS was a median of −0.12 (range −2 to +3.95)/year. The mean height velocity z-score was −1.6 ± 4.0. The only relationships discovered were between the delta height SDS and age, bicarbonate, and intraperitoneal pressure, but not for Kt/V or creatinine clearance. Conclusion: Our findings highlight the importance of normalization of bicarbonate concentrations to improve height z-score.

Feasibility of percutaneous endoscopic gastrostomy insertion in children receiving peritoneal dialysis.

Peritoneal dialysis (PD) is the preferred dialysis modality for paediatric patients with end-stage kidney disease. Frequently, malnutrition is encountered. Percutaneous endoscopic gastrostomy (PEG) is the preferred mode of feeding because of its minimal invasive mode of placement and easy handling in daily life. However, reports of a high risk for early post-interventional peritonitis hampered this procedure during PD and controlled studies on the benefit of peri-interventional management to prevent peritonitis are lacking. Here, we report the safety profile of PEG insertion among a cohort of children on PD by using a prophylactic antibiotic and antifungal regimen as well as modification of the PD programme. We performed a single-centre analysis of paediatric PD patients receiving PEG placement between 2015 and 2020. Demographic data, peri-interventional prophylactic antibiotic and antifungal treatment as well as modification of the PD programme were gathered and the incidence of peritonitis within a period of 28 days after PEG was calculated. Eight PD patients (median weight 6.7 kg) received PEG insertion. Antibiotic and antifungal prophylaxis were prescribed for median time of 4.0 and 5.0 days, respectively. After individual reduction of PD intensity, all patients continued their regular PD programme after a median of 6 days. One patient developed peritonitis within 24 h after PEG insertion and simultaneous surgery for hydrocele. Applying an antibiotic and antifungal prophylactic regime as well as an adapted PD programme may reduce the risk for peritonitis in paediatric PD patients who receive PEG procedure.

FC 105LITHIUM PRESERVES PERITONEAL MEMBRANE INTEGRITY BY REDUCING MESOTHELIAL CELL ΑB-CRYSTALLIN

Abstract Background and Aims Renal replacement therapy by peritoneal dialysis (PD) is limited in use and duration by progressive impairment of peritoneal membrane integrity and homeostasis. Preservation of peritoneal membrane integrity during chronic PD remains an urgent but long-unmet medical need. PD therapy failure results from peritoneal fibrosis and angiogenesis caused by hypertonic PD fluid (PDF)-induced mesothelial cytotoxicity. The incompletely defined pathophysiological mechanisms involved confound informed selection of therapeutic targets. Addition of cytoprotective agents to PDF have been shown to counteract pathophysiological mechanisms induced by current PDF. Lithium is a well described inhibitor of glycogen synthase kinase 3β and has recently been shown to also have nephroprotective effects in low doses. Here, we aim to characterize icodextrin-based, PDF-induced cellular injury with a combined omics approach and to investigate the effects of LiCl on the PD-induced observed molecular perturbations. Method To investigate mechanisms of acute cellular damage by PDF we chose an in vitro model of primary omental-derived peritoneal mesothelial cells with direct exposure to icodextrin-based PDF, followed by short-term or extended recovery for detection of short-term and long-term changes in transcriptome, proteome, and cell injury. 0, 2.5 or 10 mM LiCl were added to the PDF. In-vitro findings were validated in peritoneal biopsies (n=41) from pediatric PD and CDK5 patients or healthy controls and peritoneal effluents from adult and pediatric PD patients (n=27) or ascites samples (n=4) as control. For in-vivo experiments, healthy and uremic mice (C57/Bl6, female) were chronically exposed to PD-fluid without or with the addition of 5 mM LiCl via an implanted catheter. In-vivo overexpression of CRYAB was induced by i.p. injection of an adenoviral vector. All animal experiments and use of patient samples were approved by the local ethics committees and performed according to animal protection laws or the Declaration of Helsinki, respectively. Results LiCl significantly improved mesothelial cell survival in a dose-dependent manner. Combined transcriptomic and proteomic characterization of icodextrin-based PDF-induced mesothelial cell injury identified αB-crystallin as the mesothelial cell protein most significantly and consistently counter-regulated by LiCl. In-vitro and in-vivo overexpression of αB-crystallin triggered a fibrotic phenotype and PDF-like upregulation of vascular endothelial growth factor (VEGF), CD31-positive cells, and TGFβ-independent activation of TGFβ-regulated targets. In contrast, αB-crystallin knock-down decreased VEGF expression and early mesothelial-to-mesenchymal transition (MMT). LiCl reduced VEGF release and counteracted fibrosis- and angiogenesis-associated processes. αB-crystallin in patient-derived mesothelial cells was specifically upregulated in response to PDF and increased in peritoneal mesothelial cells from pediatric PD patient biopsies, correlating with markers of angiogenesis and fibrosis. Conclusion The cytoprotective effects of LiCl-supplemented PDF may be explained by counter-regulation of PD-induced angiogenesis via the novel target αB-crystallin. Reduction of mesothelial cell damage, peritoneal fibrosis and VEGF suggests therapeutic potential of this intervention. Repurposing LiCl as a cytoprotective PDF additive may offer a translatable therapeutic strategy to combat peritoneal membrane deterioration during PD therapy. Further study of LiCl-supplemented PDF is merited as a realistic approach to improving treatment longevity and patient outcomes during PD treatment.

The Prevalence of Peritonitis among Pediatric Peritoneal Dialysis Patients at Large Saudi Center.

Peritonitis is a common and serious complication of peritoneal dialysis (PD) and it is a direct or major contributing cause of death in around 16% of PD patients. Severe or prolonged peritonitis leads to structural and functional alterations of the peritoneal membrane, eventually leading to membrane failure, PD technique failure, and conversion to long-term hemodialysis (HD). This is cross-sectional record-based study in which the records of all children aged <14 years with end-stage renal disease on PD either on coiled or straight PD catheter had been reviewed at pediatric nephrology department in a tertiary care hospital, Riyadh, over the period of three years from 2017 to 2019. All information was collected using a structured data collection form. Our study had 30 patients on automated PD with 10 females (33.3%) and 20 males (66.7%) during the study period. The age ranged from 11 months to 14 years with a median 5.5 years, all of them were new to dialysis. A total of 11 out of 30 patients had multiple episodes of PD-associated peritonitis and the prevalence of peritonitis among the 30 patients was 37%. Peritoneal fluid cultures were positive in 100% episodes. Gram-positive, Gram-negative, and fungal organisms were identified in 72.7%, 18.1%, and 9.0% episodes, respectively. The analysis showed the exit-site infection (ESI) to be a risk factor to develop peritonitis, where 21 patients out of 30 had at least one ESI, 52% end by peritonitis in coiled catheter group. No mortality among our cohort of patients was noted, even removal of or changing PD catheter and transfer to HD. Our data showed that the prevalence of peritonitis secondary to ESI with Gram-positive organisms was significantly high, especially in coiled catheter group.

P1176DECLINING PERITONEAL HOST DEFENCES REVEALED BY EX-VIVO CYTOKINE RELEASE ASSAY OF PERITONEAL DIALYSIS EFFLUENT CELLS

Abstract Background and Aims Infectious complications occur in a significant proportion of patients treated with peritoneal dialysis (PD), limiting its long-term applicability. Reduced peritoneal immune-competence, caused by the continuous exposure to PD-fluids, has been described as a therapy-related pathomechanisms, prompting the need for a tool to assess the functional peritoneal immune status. We established an ex-vivo stimulation assay to test host defence mechanisms in only 9ml of crude PD-effluent. The assay was used in two randomized clinical trials investigating immune-modulatory effects of a novel additive (alanyl-glutamine) to PD-fluid. Here we aimed to evaluate the assay as a method to assess peritoneal immune-competence in the general PD-population and linking it to PD vintage and outcome parameters. Method 462 PD-effluent samples, originating from 148 adult and paediatric PD patients, were stimulated ex-vivo (24h, 37°C) with toll-like receptor (TLR)-agonists lipopolysaccharide (LPS) and Pam3Cys. Unstimulated samples of each effluent were used as controls. Interleukin 6 (IL-6) and tumor necrosis factor α (TNF-α) concentrations and the predictive value of the assay for clinical outcome parameters were analyzed using Wilcoxon matched-pairs signed rank test and a mixed model logistic regression analysis. Results Ex-vivo stimulation of peritoneal cells resulted in a dwell-time dependent increase of cytokine release, with a significant lower cytokine released at the 1h PET time point (normalized to unstimulated controls). Ratios between stimulated PDE-samples and unstimulated controls, accounting for a potential increase in basal inflammation, significantly declined with PD therapy duration. Correlation of the cytokine levels with the predefined clinical parameters revealed predictive potential of the assay for the occurrence of infectious complications, as well as of ultrafiltration and technique failure. Conclusion In summary, the current study provides evidence of a correlation of declining local host defence and duration of PD-therapy. These data support the hypothesis of PD-duration dependent progressive impairment of the ability of the peritoneal immune cells to secrete cytokines in response to a pathogenic stimulus and thereby dampening the global peritoneal immuno-competence. The results suggest the utility of this clinically feasible ex-vivo induced cytokine-release assay in crude peritoneal effluent as a surrogate of the functional peritoneal immune competence. Future analyses will have to evaluate the assay as a tool to predict common clinical outcomes and define reference values to facilitate stratification of patient populations, clinical staging and to guide novel therapeutic interventions.

Evaluation of T2Candida Panel for detection of Candida in peritoneal dialysates.

Fungal peritonitis in the peritoneal dialysis population is difficult to diagnose promptly due to the inherently slow cultivation-based methods currently required for identification of peritonitis pathogens. Because of the moderate risk for severe complications, the need for rapid diagnostics is considerable. One possible solution to this unmet need is the T2Candida Panel, a new technology designed to detect the most common pathogenic Candida spp. directly from whole blood specimens in as little as a few hours. We hypothesized that this technology could be applied to the detection of Candida in peritoneal dialysate, a matrix not currently approved by the Food and Drug Administration for testing by this system. Remnant dialysate samples from three healthy (noninfected) pediatric peritoneal dialysis patients were spiked with Candida glabrata, serially diluted, and tested in triplicate with unaltered dialysate specimens. The assay detected C. glabrata in 100% of spiked dialysate samples across the full spectrum of dilutions tested, and no assay inhibition or cross-reactivity was noted. These findings suggest one of possibly more applications of this technology. The positive clinical implications of this test will continue to be realized as its use is validated in peritoneal dialysate and other patient specimen types.

Long-Term Survival of Peritoneal Dialysis in Children: A Cohort Study

Background: There is little information about the survival rate of pediatric peritoneal dialysis (PD) patients and its risk factors. Therefore, the aim of the present study was to assess survival rate and its risk factors in Iranian children undergoing PD. Materials and Methods: Demographic and laboratory data of 407 Iranian children (up to 19 years old) undergoing PD, from 20 centers in Iran were included. The outcome of interest in our study was survival rate and determination of its risk factors in PD children. The joint models of longitudinal and time-to-event data analysis was used. Results: The median duration of follow-up was 537 (interquartile range: 146 to 1,177) days. Finally, 72 (17.7%) patients died during a period of 23 years. Our results showed that one-year survival rate of PD patients was 93.6% and five-year survival rate was 76.9%. In addition, the most important risk factors for the PD all-cause mortality were age (HR=0.9301; 95% CI: 0.9031 to 0.9587), serum creatinine (HR=0.8907; 95% CI: 0.8138 to 0.9750), platelet count (HR=0.9999; 95% CI: 0.99995 to 0.99999), aspartate aminotransferase level (HR=1.0001; 95% CI: 0.9999, 1.0002), alkaline phosphatase (HR=0.9989; 95% CI: 0.9982 to 0.9997), renal solute clearance rate (HR=0.9839; 95% CI: 0.9700 to 0.9981), and normalized protein catabolic rate (HR=0.4031; 95% CI: 0.1879, 0.8648). Conclusion: The survival rate of Iranian pediatric PD patients is similar to other countries. It is suggested that laboratory assessment be continually

Peritonitis in Children on Chronic Peritoneal Dialysis: The Experience of a Large National Pediatric Cohort

Background: We performed this study to evaluate the incidence, risk factors, microbiology, treatment, and outcome of peritonitis in pediatric Peritoneal dialysis (PD) patients at a nationwide prospective study. Methodology: Patients younger than 18 years recruited in the BRAZPD II study from 2004 to 2011, who presented their first peritonitis episode, were included in the study. Results: We found 125 first episodes of peritonitis in 491 children PD patients (0.43 episodes/patient-year). Patients free of peritonitis episode constituted 75.6% in 1 year. Culture-negative episodes were very high (59.2%) and gram-positive (GP) bacteria were the most commonly found organisms (58.8%). First-generation cephalosporin was the initial choice to cover GP (40.5%) and aminoglycosides was the most prescribed antibiotics used for gram-negative agents (27.5%). Treatment failure was 26.4%. Technique failure (TF) occurred in 12.1% and peritonitis was the main cause (65.1%). Pseudomonas (p = 0.04) and negative cultures (p < 0.001) were identified as predictors of TF. Conclusion: Peritonitis remains a common complication of PD in children and negative cultures and pseudomonas had a negative impact on TF.

ISPD Catheter-Related Infection Recommendations: 2017 Update.

Peritoneal dialysis (PD) catheter-related infections are a major predisposing factor to PD-related peritonitis (1–3). The primary objective of preventing and treating catheter-related infections is to prevent peritonitis.Recommendations on the prevention and treatment of catheter-related infections were published previously together with recommendations on PD peritonitis under the auspices of the International Society for Peritoneal Dialysis (ISPD) in 1983 and revised in 1989, 1993, 1996, 2000, 2005, and 2010 (4–9). The present recommendations, however, focus on catheter-related infections, while peritonitis will be covered in a separate guideline.These recommendations are evidence-based where such evidence exists. The bibliography is not intended to be comprehensive. When there are many similar reports on the same area, the committee prefers to refer to the more recent publications. In general, these recommendations follow the Grades of Recommendation Assessment, Development and Evaluation (GRADE) system for classification of the level of evidence and grade of recommendations in clinical guideline reports (10). Within each recommendation, the strength of recommendation is indicated as Level 1 (We recommend), Level 2 (We suggest), or Not Graded, and the quality of the supporting evidence is shown as A (high quality), B (moderate quality), C (low quality), or D (very low quality). The recommendations are not meant to be implemented in every situation indiscriminately. Each PD unit should examine its own pattern of infection, causative organisms, and sensitivities and adapt the protocols according to local conditions as necessary. Although many of the general principles presented here could be applied to pediatric patients, we focus on catheter-related infections in adult patients. Clinicians who take care of pediatric PD patients should refer to the latest consensus guideline in this area for detailed treatment regimen and dosage (11).

Serum albumin and von Willebrand factor: possible markers for early detection of vascular damage in children undergoing peritoneal dialysis.

Cardiovascular diseases are the main causes of morbidity and mortality in children with end-stage renal disease and the relationships among several relevant potential biomarkers were investigated in pediatric peritoneal dialysis patients. Serum homocysteine, von Willebrand factor (vWF), apolipoproteins A and B, lipoprotein-a, high sensitive-CRP, hemoglobin, phosphorus and parathyroid hormone (PTH) levels, systolic (SBP) and diastolic (DBP) blood pressure, carotid intima-media thickness (cIMT) and left ventricular mass index (LVMI) were measured in 21 pediatric peritoneal dialysis patients and control subjects. All risk factors were higher in patients than controls. LVMI values were negatively correlated with hemoglobin and positively correlated with PTH and phosphorus levels (p=0.007, r= - 0.573; p=0.013, r= 0.532 and p=0.035, r= 0.461, respectively). cIMT was negatively associated with serum albumin and positively correlated with vWF levels and with SBP and DBP (p=0.006, r= - 0.578; p=0.039, r= 0.453; p=0.02, r= 0.503; p=0.024, r= 0.491, respectively). Robust regression analyses showed that hemoglobin was an independent predictor of LVMI and serum albumin was an independent predictor of cIMT. Only uremia-related factors were independent risk factors for predicting LVMI and cIMT. Hemoglobin level may be a critical factor in the development of left ventricular hypertrophy; therefore, effective treatment of anemia is crucial. Low serum albumin and high hsCRP and vWF levels, and their correlations with cIMT, indicate these patients could be at risk of developing malnutrition-inflammation-atherosclerosis syndrome and suggest that serum albumin and vWF levels may be useful markers for early detection of vascular damage.

The importance of ultrasonographic measurement of peritoneal wall thickness in pediatric chronic peritoneal dialysis patients

Loss of peritoneal function due to peritoneal fibrosing syndrome (PFS) is a major factor leading to treatment failure in chronic peritoneal dialysis (PD) patients. Although the precise biologic mechanisms responsible for these changes have not been defined, the general assumption is that alterations in peritoneal function are related to structural changes in the peritoneal membrane. Studies of the peritoneal membrane by non-invasive ultrasonography (US) in chronic PD patients are limited. The aim of the present study is to assess the relationship between functional parameters of peritoneum and peritoneal thickness measured by US in children treated by chronic PD. We recruited two groups of patients: 23 subjects (13 females, 10 males) on chronic PD (patient group) and 26 (7 females, 19 males) on predialysis out-patient follow-up (creatinine clearance: 20–60 mL/min/1.73 m2) (control group). Age, sex, weight, height, body mass index (BMI), chronic PD duration, episodes of peritonitis and the results of peritoneal equilibration test (PET) were recorded. Hemoglobin (Hb), blood pressure (BP), left ventricular mass index (LVMI) and renal osteodystrophy (ROD) parameters were also obtained. The thickness of the parietal peritoneum was measured by trans-abdominal US in all children. Statistical analyses were performed by using Student's t and Pearson's correlation tests. Mean peritoneal thickness in chronic PD patients (1028.26 ± 157.26 μm) was significantly higher than control patients (786.52 ± 132.33). Mean peritoneal thickness was significantly correlated with mean body height (R2 = 0.93, p < 0.05), BMI (R2 = 0.25, p < 0.05), chronic PD duration (R2 = 0.64, p < 0.05), episodes of peritonitis (R2 = 0.93, p < 0.05), D/Pcreatinine (R2 = 0.76, p < 0.05) and D4/D0glucose (R2 = 0.81, p < 0.05). No correlation was found between peritoneal thickness and Hb, BP, LVMI and ROD parameters. In conclusion, ultrasonographic measurement of peritoneal membrane thickness is a simple and non-invasive method in chronic PD children. This diagnostic tool likely enables to assess peritoneal structure and function in these patients.

Guidelines for laparoscopic peritoneal dialysis access surgery.

The use of peritoneal dialysis (PD) as a primary mode of renal replacement therapy has been increasing around the world. The surgeon’s role in caring for these patients is to provide access to the peritoneal cavity via a PD catheter and to diagnose and treat catheter complications. Since the early 1990s, laparoscopy has been applied by many adult and pediatric surgeons for insertion of PD catheters as well as for salvage of malfunctioning catheters. This document is an evidence-based guideline based on a review of current literature and the opinions of experts in the field. It provides specific recommendations to assist surgeons who take care of adult and pediatric PD patients. Disclaimer

A single-center experience on percutaneously performed partial omentectomy in pediatric peritoneal dialysis patients

Objective: This study describes a single-center experience on percutaneously performed partial omentectomy procedure in pediatric peritoneal dialysis (PD) patients who showed early catheter dysfunction and required catheter replacement due to catheter flow obstruction. Materials and methods: We performed a retrospective review of clinical outcomes from pediatric PD patients who underwent percutaneous catheter replacement by pediatric nephrologists between November 1995 and December 2012. Partial omentectomy was performed in those patients in whom omental or adhesion trapping to the catheter tip was seen. Results: During the study period, catheter dysfunction that eventually required percutaneous catheter replacement occurred in 32 (23.7%) children. Of these, 9 patients were performed partial omentectomy. Mean age at initiation of PD and time of omentectomy was 97.48 ± 46.06 and 98.53 ± 45.55 months, respectively. Catheter dysfunction appeared after a mean 1.20 ± 1.0 months. The causes of catheter dysfunction were omental wrapping and malposition. No peritonitis occurred before omentectomy. Mean total operation time was 60 ± 8.83 min. No complications were encountered during the procedure. After omentectomy, mean catheter survival period was 5.92 ± 6.88 months. A total of five peritonitis episodes occurred. Three patients were transferred to hemodialysis. Six patients were on PD treatment without any problem at the end of the first year of their follow-up. Two patients underwent kidney transplantation. Four patients were still on chronic PD treatment at the end of the study period. Conclusion: When performed by an experienced nephrologist, the performance of partial omentectomy by percutaneous route, when required, is an easy, safe and efficient therapeutic procedure in children on chronic PD treatment.

“Qualcosa è cambiato”: il bambino e la dialisi peritoneale, oggi

Nell'ultimo decennio, si è verificato un importante cambiamento della situazione culturale e socio-economica delle famiglie che assistono i bambini che necessitano di dialisi (aumento del numero delle famiglie monoparentali o con genitori separati e delle famiglie di immigrati e incremento della povertà e, quindi, della necessità di lavoro per entrambi i genitori). Vi è stato, inoltre, un aumento dei pazienti con comorbidità severe correlate a prematurità o a sindromi genetiche, ora avviati alla dialisi, contrariamente a quanto si faceva in passato. Si è palesato con maggiore chiarezza il rischio di peritonite sclerosante con un'importante quota di decessi, in parte, ma non completamente, correlata al numero di peritoniti e alla durata della dialisi peritoneale. Nello stesso tempo, si è assistito a un sostanziale miglioramento delle tecniche dialitiche, peraltro maggiormente evidente per le metodiche extracorporee. Per tutti questi motivi, l'assioma degli anni '90 “bambino in dialisi = bambino in dialisi peritoneale” non è più da considerarsi del tutto valido. La scelta della metodica più consona al singolo paziente e alla sua famiglia dipende, quindi, dal lavoro di valutazione di un team multidisciplinare, che consideri attentamente sia gli aspetti clinici del bambino con insufficienza renale cronica terminale sia i fattori psico-sociali ed economici relativi ai vari tipi di trattamento, nello specifico di una determinata famiglia. Solo in questo modo si possono prevenire gli insuccessi terapeutici (dropouts), spesso riportati per alcune categorie di bambini in dialisi peritoneale. La conseguenza di quanto detto, dal punto di vista epidemiologico, è stata, in questi ultimi anni, nel nostro centro, la ridistribuzione della prima scelta di trattamento a favore dell'emodialisi.

“Something has changed”: Peritoneal dialysis in children, today

In the last decade a change in the cultural and socio-economic attitude of the caregivers of children in dialysis has been observed. This includes an increase in the number of mono-parental or split families, an increase in the number of immigrant families, as well as an increase of poverty conditions and need for working for both parents. A higher number of patients with severe comorbidities, related to extreme prematurity or genetic syndromes, are now considered for dialysis treatment, while this was not the case in the past. Encapsulating peritoneal sclerosis with a high fatality rate, only partially related to a high incidence of peritonitis or long duration of peritoneal dialysis, has become a clear, though rare, risk for those who start peritoneal dialysis. Finally, a substantial improvement in dialysis technology has been observed, particularly in the field of extracorporeal dialysis. On the basis of all the above mentioned factors, the equation “children on dialysis = children on peritoneal dialysis” does not seem so completely valid today. The choice of the best dialysis treatment for the child with ESRD and his family depends on the evaluation of a multidisciplinary team, which considers not only the clinical aspects of the child but also the psycho-social and economic factors related to the treatment and the family. This way, the frequent dropouts of some categories of pediatric peritoneal dialysis patients can be prevented. As a consequence of the previous considerations, especially from the epidemiological point of view, in our center we observed a decrease in the number of children treated with peritoneal dialysis and an increase of those on hemodialysis over the last 10 years.