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Perit Dial Int. 2012 Jul-Aug; 32(4): 393–394.
PMCID: PMC3524849
Peritoneal Dialysis and the Pediatric Patient
Bradley A. Warady
Children’s Mercy Hospitals and Clinics Kansas City, Missouri, USA
bwarady/at/cmh.edu
Of pediatric patients who require chronic dialysis worldwide, most are managed with peritoneal dialysis (PD). This treatment option is particularly attractive for children in need of renal replacement therapy because the simplicity of the procedure allows for performance at home in all but the most exceptional circumstances, thereby returning the child with end-stage renal disease (ESRD) to regular school attendance and facilitating normal family and childhood activities. Peritoneal dialysis also avoids the challenges associated with vascular access in children, which can be particularly problematic. As a result, of children with ESRD and on dialysis, the proportion receiving PD is estimated to be 50% - 70% in developed countries and likely considerably higher in developing countries. In fact, the only absolute contraindications to chronic PD hinge on the lack of availability of a functional peritoneal membrane, as might occur in children with uniquely pediatric disorders such as diaphragmatic hernia or gastroschisis.
Despite the substantial percentage of dialysis patients who receive PD, the absolute numbers of pediatric patients pale in comparison to those of adults because of the low incidence of ESRD in the pediatric population and the preferential selection of transplantation as a treatment modality. In the United States alone, pediatric patients represent about 1% of the total incident dialysis population (1). It is for that reason that the development of pediatric dialysis registries has been crucial to the generation of important clinical outcomes data in pediatric PD.
The dialysis registry of the North American Pediatric Renal Trials and Collaborative Studies was established in 1992, and it was the first to provide evidence pertaining to the high peritonitis rate in children (2). After publication of the initial pediatric-specific peritonitis treatment guidelines in 2000, the International Pediatric Peritonitis Registry (IPPR) was established as a means of tracking the impact of guideline implementation around the globe (3). In turn, the IPPR provided crucial data that has been incorporated into the Consensus Guidelines for the Prevention and Treatment of Catheter-Related Infections and Peritonitis in Pediatric Patients Receiving Peritoneal Dialysis: 2012 Update (4). The present issue of Peritoneal Dialysis International includes two important publications from yet another informative registry—that established by the International Pediatric Peritoneal Dialysis Network (IPPN). The IPPN registry currently collects data from 86 pediatric dialysis centers in 33 countries from around the globe, creating the opportunity not only to document geographically related similarities and differences in treatment and outcomes, but also to delineate the factors that influence whatever variability is noted between regions. In the first of the two IPPN publications, Schaefer et al. (5) provide new and enlightening information on the practice of chronic PD in the developing world, and of the association between national wealth, patient selection, and patient outcomes. In the accompanying IPPN article, Neu et al. (6) describe the frequent presence of significant comorbidities in the PD population and the impact that those comorbidities have on both hospitalization and patient survival. Registry data like these are exceedingly important to the global pediatric dialysis community and help to make possible the ultimate development of evidence-based best practices.
Of course, single-center reports provide valuable complementary data, as reflected by the additional manuscripts published in the present issue. Aksu et al. (7) describe their experience with patient comorbidities and the strategies used to provide effective therapy in this complicated group of patients. Ellis et al. (8) emphasize the value of home visits as a means of uncovering previously undetected aspects of the home environment that may affect the clinical care and outcome of the child on dialysis. In the last manuscript addressing chronic therapy, Azocar et al. (9) hypothesize that patients with focal segmental glomerulosclerosis, the most frequent acquired cause of ESRD in children, may exhibit enhanced loss of protein across the peritoneal membrane as a result of an as-yet-undefined permeability factor.
Finally, acute kidney injury in children also often necessitates the introduction of renal replacement therapy, and PD remains the predominant acute dialytic modality in developing countries. Mishra et al. (10) present their single-center experience with acute PD, adding to the limited literature on the subject and providing guidance to the many centers in which more advanced techniques such as hemodialysis and continuous renal replacement therapy are not available to support the pediatric patient.
Speaking on behalf of the pediatric dialysis community, we are grateful that Peritoneal Dialysis International has seen fit to publish this issue highlighting the pediatric peritoneal dialysis patient, and we are hopeful that attention to the information contained in this issue will result in improved care for this vulnerable and very special patient population.
1. United States Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, U.S. Renal Data System (USRDS) 2011 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. Bethesda, MD: USRDS; 2011. [Available online at: http://www.usrds.org/atlas.aspx; accessed 10 May 2012]
2. North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) 2011 Annual Dialysis Report. Rockville, MD: EMMES Corporation; 2011. [Available online at: https://web.emmes.com/study/ped/annlrept/annualrept2011.pdf; accessed 10 May 2012]
3. Warady BA, Schaefer F, Holloway M, Alexander S, Kandert M, Piraino B, et al. Consensus guidelines for the treatment of peritonitis in pediatric patients receiving peritoneal dialysis. Perit Dial Int 2000; 20:610–24 [Erratum in: Perit Dial Int 2001; 21:6] [PubMed]
4. Warady BA, Bakkaloglu S, Newland J, Cantwell M, Verrina E, Neu A, et al. Consensus guidelines for the prevention and treatment of catheter-related infections and peritonitis in pediatric patients receiving peritoneal dialysis: 2012 update. Perit Dial Int 2012; 32(Suppl 2):S29–86 . [PMC free article] [PubMed]
5. Schaefer F, Borzych-Duzalka D, Azocar M, Munarriz RL, Sever L, Aksu N, et al. on behalf of the IPPN investigators Impact of global economic disparities on practices and outcomes of chronic peritoneal dialysis in children: insights from the International Pediatric Peritoneal Dialysis Network (IPPN) registry. Perit Dial Int 2012; 32:399–409. [PMC free article] [PubMed]
6. Neu AM, Sander A, Borzych-Duzalka D, Watson AR, Valles PG, Ha IS, et al. on behalf of the IPPN investigators Comorbidities in chronic pediatric peritoneal dialysis patients: a report of the International Pediatric Peritoneal Dialysis Network. Perit Dial Int 2012; 32:410–418. [PMC free article] [PubMed]
7. Aksu N, Yavascan O, Anil M, Kara OD, Bal A, Anil AB. Chronic peritoneal dialysis in children with special needs or social disadvantage or both: contraindications are not always contraindications. Perit Dial Int 2012; 32:424–430. [PMC free article] [PubMed]
8. Ellis EN, Blaszak C, Van Lierop A, Wright S. Effectiveness of home visits to pediatric peritoneal dialysis patients. Perit Dial Int 2012; 32:419–423. [PMC free article] [PubMed]
9. Azocar M, Quiroz L, Delucchi A, Dinamarca H, Emilfork M, Cano FJ. The plasma permeability factor in nephrotic syndrome: indirect evidence in pediatric peritoneal dialysis. Perit Dial Int 2012; 32:437–443. [PMC free article] [PubMed]
10. Mishra OP, Gupta AK, Pooniya V, Prasad R, Tiwary NK, Schaefer F. Peritoneal dialysis in children with acute kidney injury: a developing country experience. Perit Dial Int 2012; 32:431–436. [PMC free article] [PubMed]
Articles from Peritoneal Dialysis International : Journal of the International Society for Peritoneal Dialysis are provided here courtesy of
Multimed Inc.