Pediatric Peritoneal Dialysis Research Articles

Peritoneal Dialysis Access Associated Infections.

Infection is a significant driver of morbidity and mortality in patients with end-stage renal disease undergoing maintenance dialysis. In the United States, septicemia and other infections account for 8% deaths in patients undergoing dialysis. In patients undergoing peritoneal dialysis (PD), PD-related peritonitis remains the most frequent treatment-related infection and is the greatest contributor to infection-related morbidity, including risk for hospitalization, and temporary or permanent transfer to hemodialysis. In the 4 decades since the introduction of ambulatory PD in clinical practice, a large number of treatment innovations have been shown to be effective in reducing the risk for exit site infection and PD-related peritonitis. Notwithstanding the evidence for efficacy of these innovations and the numerous adverse health consequences with PD-related peritonitis, the uptake of these interventions in clinical practice around the world remains inconsistent. This article reviews current knowledge with regards to prevention of PD-associated infections, and the diagnosis and management of exit site infections and peritonitis.

Teaching Pediatric Peritoneal Dialysis Globally through Virtual Simulation.

Despite the increasing prevalence of childhood kidney disease worldwide, there is a shortage of clinicians trained to provide peritoneal dialysis (PD). E-learning technologies may provide a solution to improve knowledge in PD. We describe the development of a virtual PD simulator and report the first 22 months of online usage. The PD simulator was developed and released on OPENPediatrics in January of 2016. A prospective study of international, multidisciplinary healthcare providers was conducted from January of 2016 through October of 2017. User action data were analyzed with descriptive statistics and linear regression. Paired t tests compared user pre- and post-test scores. User satisfaction was assessed by survey. The simulator was accessed by 1066 users in 70 countries. Users spent a median of 35 minutes (interquartile range [IQR] 14-84) in the simulator. Users who completed the structured learning curriculum (n=300) spent a median of 85 minutes (IQR 46-95), and those who completed the entire simulator (n=63) spent a median of 122 minutes (IQR 69-195). Users who completed the simulator were more likely to scroll through text and access the simulator in multiple sessions. The 300 users that completed testing showed statistically significant increases in the post- versus pretest scores, with a mean increase of 36.4 of 100 points, SD 19.9 (95% confidence interval, 34.1 to 38.6, P<0.001). Eighty-seven percent (20 of 23) of survey respondents felt the simulator was relevant to their clinical practice, and 78% (18 of 23) would recommend it to others. This is the first reported virtual PD simulator. Increased test scores were observed between pre- and post-tests by clinicians who completed testing, across disciplines, training levels, and resource settings.

The Dialysis Facility Compare Five-Star Rating System at 2 Years.

The 1997 Balanced Budget Act required the Centers for Medicare and Medicaid Services (CMS) to develop and implement a method to measure and report the quality of kidney dialysis services provided by Medicare ([1][1]). As a result, CMS launched the Dialysis Facility Compare (DFC) website in 2001,

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.

Complement Activation in Peritoneal Dialysis-Induced Arteriolopathy.

Cardiovascular disease (CVD) is the leading cause of increased mortality in patients with CKD and is further aggravated by peritoneal dialysis (PD). Children are devoid of preexisting CVD and provide unique insight into specific uremia- and PD-induced pathomechanisms of CVD. We obtained peritoneal specimens from children with stage 5 CKD at time of PD catheter insertion (CKD5 group), children with established PD (PD group), and age-matched nonuremic controls (n=6/group). We microdissected omental arterioles from tissue layers not directly exposed to PD fluid and used adjacent sections of four arterioles per patient for transcriptomic and proteomic analyses. Findings were validated in omental and parietal arterioles from independent pediatric control (n=5), CKD5 (n=15), and PD (n=15) cohorts. Transcriptomic analysis revealed differential gene expression in control versus CKD5 arterioles and in CKD5 versus PD arterioles. Gene ontology analyses revealed activation of metabolic processes in CKD5 arterioles and of inflammatory, immunologic, and stress-response cascades in PD arterioles. PD arterioles exhibited particular upregulation of the complement system and respective regulatory pathways, with concordant findings at the proteomic level. In the validation cohorts, PD specimens had the highest abundance of omental and parietal arteriolar C1q, C3d, terminal complement complex, and phosphorylated SMAD2/3, a downstream effector of TGF-β Furthermore, in the PD parietal arterioles, C1q and terminal complement complex abundance correlated with the level of dialytic glucose exposure, abundance of phosphorylated SMAD2/3, and degree of vasculopathy. We conclude that PD fluids activate arteriolar complement and TGF-β signaling, which quantitatively correlate with the severity of arteriolar vasculopathy.

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).

Value of accelerated peritoneal examination time in pediatric nocturnal intermittent peritoneal dialysis

Value of accelerated peritoneal examination time in pediatric nocturnal intermittent peritoneal dialysis

Peritoneal Dialysis Access Revision in Children: Causes, Interventions, and Outcomes.

Little published information is available about access failure in children undergoing chronic peritoneal dialysis. Our objectives were to evaluate frequency, risk factors, interventions, and outcome of peritoneal dialysis access revision. Data were derived from 824 incident and 1629 prevalent patients from 105 pediatric nephrology centers enrolled in the International Pediatric Peritoneal Dialysis Network Registry between 2007 and 2015. In total, 452 access revisions were recorded in 321 (13%) of 2453 patients over 3134 patient-years of follow-up, resulting in an overall access revision rate of 0.14 per treatment year. Among 824 incident patients, 186 (22.6%) underwent 188 access revisions over 1066 patient-years, yielding an access revision rate of 0.17 per treatment year; 83% of access revisions in incident patients were reported within the first year of peritoneal dialysis treatment. Catheter survival rates in incident patients were 84%, 80%, 77%, and 73% at 12, 24, 36, and 48 months, respectively. By multivariate logistic regression analysis, risk of access revision was associated with younger age (odds ratio, 0.93; 95% confidence interval, 0.92 to 0.95; P<0.001), diagnosis of congenital anomalies of the kidney and urinary tract (odds ratio, 1.28; 95% confidence interval, 1.03 to 1.59; P=0.02), coexisting ostomies (odds ratio, 1.42; 95% confidence interval, 1.07 to 1.87; P=0.01), presence of swan neck tunnel with curled intraperitoneal portion (odds ratio, 1.30; 95% confidence interval, 1.04 to 1.63; P=0.02), and high gross national income (odds ratio, 1.10; 95% confidence interval, 1.02 to 1.19; P=0.01). Main reasons for access revisions included mechanical malfunction (60%), peritonitis (16%), exit site infection (12%), and leakage (6%). Need for access revision increased the risk of peritoneal dialysis technique failure or death (hazard ratio, 1.35; 95% confidence interval, 1.10 to 1.65; P=0.003). Access dysfunction due to mechanical causes doubled the risk of technique failure compared with infectious causes (hazard ratio, 1.95; 95% confidence interval, 1.20 to 2.30; P=0.03). Peritoneal dialysis catheter revisions are common in pediatric patients on peritoneal dialysis and complicate provision of chronic peritoneal dialysis. Attention to potentially modifiable risk factors by pediatric nephrologists and pediatric surgeons should be encouraged.

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.

Peritonitis in children with automated peritoneal dialysis: a single-center study of a 10-year experience

Peritoneal dialysis (PD) constitutes the preferred dialysis modality for children requiring renal replacement therapy with peritonitis being one of the most common complications of PD. This study was performed to evaluate the epidemiology, microbiology, and outcomes of PD-associated peritonitis in Greek children for a 10-year period. A total of 27 patients (16 males) with a mean age 121.8 ± 57.2 months were retrospective analyzed. Patients were on PD therapy for a mean duration of 45.2 ± 26.1 months. We found 23 episodes of PD-associated peritonitis occurred in 9 out of 27 patients (0.23 episodes/patient-year), with four patients experienced two or more peritonitis episodes. Gram-positive bacteria were responsible for 15 (65.2%) peritonitis episodes, with Staphylococcus aureus being the predominant specie isolated in 30.4% of cases. A total of seven episodes of exit-site infections (ESIs) were identified in five patients (0.069 episodes/patient-year) with the most common bacteria isolated being S. aureus (57.4%). Initial antibiotic treatment included intraperitoneal vancomycin plus ceftazidime in the majority of cases (82.6%). At the end of study, 12 (44.4%) patients remained on PD, 11 (41.8%) underwent renal transplantation, 2 (7.4%) shifted to hemodialysis and unfortunately, two patients (7.4%) died. Conclusively, our study revealed a noticeable low peritonitis and ESIs rate as compared to international data and represents the first evaluation of the characteristics and outcomes of peritonitis in the Greek pediatric PD population.

Peritoneal Dialysis in Extremely Low Birth Weight Baby using Chronic PD Catheter

Acute kidney injury (AKI) and fluid overload are serious and common complication in premature babies and may increase morbidity and mortality. Renal replacement therapy should be considered for babies who fail medical interventions. Peritoneal dialysis (PD) is considered a safe and practical option for premature infants by producing efficient gentle removal of solutes and excessive water. There are few reports of PD done in extremely low birth weight (ELBW) infants. Acute PD catheters commonly used in children are reported to have more complications thus seldom used in premature babies. Several authors report using regular intravenous or central venous catheters to dialyze premature babies. We describe an ELBW (700g, twin A) infant born at 24 weeks gestation, who was dialyzed on the 34th day (910g) via pediatric size chronic PD catheter. Filling and drainage of PD fluid were performed manually. We encountered few complications and they were easily controlled. The dialysis resulted in normalization of serum creatinine and correction of fluid and electrolyte imbalance within 10 days. The infant continued to grow and eventually was discharged in good condition, with normal renal function at an adjusted age of 40 weeks (term).

How are families taught to look after their children on peritoneal dialysis?

For patients to be started on peritoneal dialysis (PD), they need to be trained on how to perform dialysis at home. Understanding how to carry out dialysis is difficult for adults, but perhaps even more challenging for parents of children. This study was performed to examine the PD teaching programs for parents of children with end-stage renal disease (ESRD) and to explore the issues related to educating parents of children with ESRD. A survey method was used to carry out the research through the distribution of self-completed questionnaires to pediatric dialysis units (ten units) in Saudi Arabia in both governmental and non-governmental hospitals. The questionnaire content was identified using information gained from other research performed in the field of home PD training. The questionnaire was piloted with experienced renal nurses. Questionnaires were distributed to 87 specialized nurses within the ten PD units. Descriptive statistical analysis SPSS (19.00) was used to analyze the data. Statistical tests were used to distinguish the relationship and the significant effects between variables. The response rate was 72% (n=63). Peritonitis rates varied in each hospital, and ranged from zero to three episodes per patient-year (median 1.17 episodes per patient-year). There was a significant association between home visits and peritonitis rates (P<0.01). This study has provided an initial overview of pediatric PD training programs in Saudi Arabia and has provided valuable data in this regard.

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.

Surgical Aspect of Pediatric Peritoneal Dialysis: A Survey of the Maghreb Pediatric Surgeon

Objective: To assess the routine surgical practices of consultant pediatric surgeon in the Maghrebian country in their management of peritoneal dialysis. Methods: During the twelve Maghrebiancongess of pediatric surgery in Tunis May. 2012, a session of quiz survey (4 Questions) about the surgical aspect of pediatric peritoneal dialysis was dedicated. 60 surgeons participate to this session. An electronic voting system was used. Results: 60% of surgeons practice a mini-laparotomy for catheter insertion. Half of the participants use a double cuff catheter while the other half uses a simple cuff catheter. 65% of participant allows initiation of dialysis within 7 days post catheter insertion. Only 13% of the pediatric surgeons perform an omentectomy at the time of the insertion of the catheter. Conclusion: The placement of a PD catheter requires an experienced surgeon and should be given appropriate priority. Adhesions to guidelines may improve outcome of patient by reducing the early peritoneal dialysis catheter failure in children in our countries.

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

Peritoneal dialysis in an extremely low-birth-weight infant with acute kidney injury.

Critically ill neonates are at high risk for acute kidney injury (AKI). Renal supportive therapy (RST) can be an important tool for supporting critically ill neonates with AKI, particularly in cases of oliguria and fluid overload. There are few reports of RST for management of oligo-anuric AKI in the extremely low-birth-weight infant weighing <1000 g. We report successful provision of peritoneal dialysis (PD) to an 830-g neonate with oligo-anuric AKI through adaptation of a standard pediatric acute PD catheter.

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.

Surgical outcomes analysis of pediatric peritoneal dialysis catheter function in a rural region

PurposeThe purpose of this study was to analyze the experience with peritoneal dialysis (PD) at a high-volume, single center institution that supports a rural population. MethodsFrom 2000 to 2010, 88 children (median age: 1.98 years, [range: 2 days–20.2 years]) received 134 PD catheters for the management of acute and chronic renal failure. The primary outcome of interest was the incidence of primary PD catheter failure (replacement or revision within 60 days). Operative technique, longitudinal outcomes, and time intervals to transplantation were analyzed. ResultsMedian time to transplant from the institution of dialysis was 1.4years [range: 0.3–6.4years]. Primary catheter failure occurred in 24.6% of cases. Infants less than 6months of age demonstrated an increased incidence of primary catheter failure (p=0.02). The operative technique for catheter placement was not associated with the incidence of primary failure. Postoperative complications included peritonitis (22.7%), omental plugging (11.9%), pericatheter drainage (9.0%), and exit site infection (3.0%). ConclusionPeritoneal dialysis provides a safe and effective renal replacement therapy for regional pediatric centers that serve a rural population. However, primary catheter failure rates remain high at 24.6%. The surgical technique for placement had no effect on this failure rate in our patient population. Infants less than 6months of age are at increased risk for primary catheter failure and warrant intensive surveillance.