The Other CRRT:
Peritoneal Dialysis
Mignon McCulloch
Associate Professor
Paediatric Nephrology/Critical Care
Acknowledgements
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Thanks to Stuart and Tim
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Including all forms of CRRT
Disclosures
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Passionate about PD
Access for children with AKI in poorly
resourced areas
London
Evelina Children’s Hospital
London UK
Evelina Children’s Hospital
Andrew Durward Personal Communication
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PICU
8818 Admissions
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413 deaths
Mortality 4.7%
20 Beds
Staffing:
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7 Consultants
20 Fellows
150 Nurses
Training in nurses:
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CVVH 30% trained
PD in 100% nurses
Evelina Children’s Hospital PICU
2002 – 2009
Nos of Cases
CVVH
PD
119
188
139 Cardiac
Age in months
30
7.8
Med 0.22
Weight in kg
--
5.3
Med 3.3
Mortality
30%
17%
Red Cross Children’s Hospital
Cape Town SA
Red Cross Children’s Hospital(RXH)
University of Cape Town Experience
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Increasing incidence in association with multiorgan failure in paediatric ICU’s
1 200 – 1 400 admissions per year
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Acute medical cases
Cardiac cases
Burns
Head injuries
Other
Mortality 8%
Dialysis 3.5%
AKI ???
600/yr
250/yr
50/yr
50/yr
Rest
Causes of Acute Renal Failure
Sepsis
46(22%)
Post-cardiac surgery
36(17%)
Undiagnosed chronic renal
disease
Gastroenteritis
21(10%)
Haemolytic uraemic
syndrome
19(9%)
Necrotizing enterocolitis
15(7%)
19(9%)
Causes of Acute Renal Failure
Leukaemia/Lymphoma
14(6%)
Myocarditis
11(5%)
Rapidly progressive nephritis
10(5%)
Trauma/Burns
8(4%)
Toxin ingestion
7(3%)
Kwashiorkor**
6(3%)
Practicalities of PD
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Quick – really quick – 20 mins K+ 9!
Bed-side insertion by Paeds
Nephrologist/Intensivist/Surgeons
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(Surgeons as backup)
Cook/Peel Away Tenckhoff/Formal Tenckhoff
Empty Bladder
Sedation + Local Anaesthetic
Practicalities of PD
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Prescription
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Dialysis fluid
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Dianeal(Lactate buffered) or Bicarb based
Cycles
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10-20ml/kg increase as tolerated
10/30-90/20mins
Manual or Cycling Home choice > 3kg
Adapted to ventilatory requirements
Manual Dialysis with Fluid Warmer
Perit Dial Int 2001
Flynn et al (Brophy & Bunchman)
Time period
Nos of patients
Complication Rate
Commonest
problem
Survival
RXH
Flynn (USA)
2 yrs
10 yrs
68
63
25%
25%
Catheter
blockage
61%
Catheter
malfunction
51%
Acute Peritoneal Dialysis
January 1999 to January 2004
TOTAL NUMBER OF PATIENTS
Male: Female
Age at dialysis:
< 3 months
3 months - 1yr
1 – 6 years
6 – 12 years
> 12 years
212
102:110
79(38%)
45(21%)
38(18%)
30(14%)
20(9%)
Acute PD
Long term outcome
Survival following Acute PD
130(61% )
Chronic PD required following
Acute PD
26(12%)
Total nos of patients requiring
CVVHD (PD not possible)
20(9%)
Survival following CVVHD
11(55%)
Peritoneal Dialysis as a Form of CRRT for
Infants in a Developing Country
McCulloch M, Argent A.
Red Cross Children’s Hospital
University of Cape Town
Specific Paeds Management Issues
Very Low Birth Weight Infants
Koralkar R et al. Ped Research 2011;69:4:354-8
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AKI reduces survival in infants <1500g
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Very low glomerular filtration rate
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Independent risk factor
Mild exposure – high degree of injury
High rates of infection
Nephrotoxic drugs
Premature infants <1000g
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Increase SCr of 1.0mg/dL(88.5umol/l)
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Doubles the odds of death
Small infants < 5kg
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25 of these patients were < 5kg
15/25 Infants (60%) survived
Age range from 2 - 138 days
Male:Female 2:1
Diagnosis of Infants Surviving Dialysis
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INFECTIVE CAUSES
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Septicaemia
Diarrhoea
Fungal sepsis
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SURGICAL CAUSES
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Necrotising Enterocolitis
Cardiac Surgery - TGA’s
Abdominal Surgery
DRUGS
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13/15 patients received large doses of Furosemide
e.g. 5mg/kg/dose pre-dialysis
10/13 patients were on Dopamine infusions at
time of dialysis
2 patients received Adrenaline infusions in addition
7/14 patients were on an Aminoglycoside antibiotic
(amikacin/gentamicin) pre - dialysis
Weight of Infants surviving
Dialysis
7
6
5
4
3
2
1
0
<1kg
1-2kg
2-3kg
3-4kg
4-5kg
Advantages of Acute PD
Catheters
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No bleeding complications
2/15 catheters blocked - day 3 & 4 on
dialysis
Replaced 1 catheter by “re-wiring”
Duration Of Dialysis
120-144hrs
96-120hrs
72-96hrs
48-72hrs
24-48hrs
0-24hrs
0
1
2
3
4
OUTCOME
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15/25(60%) Infants survived to come off dialysis
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Nil required long term dialysis
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3 Subsequently demised - not related to dialysis:
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1 Accidental extubation
1 Cerebral Palsy and developed septicaemia 1 year later
1 Shock & Dehydration due to excessive colostomy
losses 3 months later
Acute PD in PICU 1999-2009
Presented IPNA Aug 2010 New York
Red Cross Children’s Hospital, Cape Town SA
 Total 406 cases/10years
 Wt range 900g – 70kg
 Age 1 day – 16yrs
 Diphtheria – Liver Transplant
PD IN PICU
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Total Nos
Neonates(<1mth)
Infants(<1yr)
Cardiac
406
85(21%)
221(54%)
95(23%)
Overall Mortality Rate
70
60
50
30
Overall 42%
20
2009
2008
2007
2006
2005
2004
2003
2002
0
2001
10
2000
Rate %
40
Specific Mortality Rate
2009
2008
2007
2006
2005
2004
2003
2002
2001
Neonatal 53%
Infant 53%
Overall 42%
2000
80
70
60
50
40
30
20
10
0
Peritoneal Dialysis in neonates with
inborn errors of metabolism:
Is it really out of date?
Neonatal Inborn Error of Metabolism
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If response to dietary and pharmacologic treatment
poor or severe hyperammonemic coma
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Require rapid removal of neurotoxic metabolites
Risk:
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Ammonia > 1355ug/dl(800umol/l) – 34% survival rate
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Coma > 2 - 3days
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Enns et al NEJM 2007 256:2282-92
Msall et al. N Eng J Med 310:1500-5
Extra-corporeal dialysis more effective >> PD
Outcome primarily related to duration of neonatal
hyperammonemic coma
PD in IOM
Ped Nephrol(2008) 23:163-8
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7 Neonates ammonia > 1000ug/dL(588umol/l)
Bed-side surgically inserted PD catheter
No difficulties – mild leakage in 2 patients
Baxter closed system
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1.36% lactate buffered
Added K+ and Antibiotics
Fill volumes – 10-15ml/kg incr to 30ml/kg
Dwell times 30-45mins
PD in IOM
Ped Nephrol(2008) 23:163-8
4 organic aciduria pts ammonia < 200umol/l
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1 propionic aciduria ammonia < 362umol/l
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Average after 20hrs of PD + medical rx
Catheter out day 5 – sepsis day 19 - death
Mean time coma 14.5hrs
4/7 Survivors – 3 normal outcome + 1 delay
Death 3/7
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1 OTC – death after few hrs on dialysis
1 Sepsis after recovery of acute metabolic
decompensation
1 survived acute neonatal hyperammonia
PD in IOM
Ped Nephrol(2008) 23:163-8
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CVVH/D
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Vascular access – difficult in neonates
Anti-coagulation
PD maintains some effectiveness
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Applied in ALL neonatal units
Less efficacious than extra-corporeal dialysis
But can improve prognosis
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Rapid access – bridging procedure
Small patient size
Less severe hyperammonemia
Quick and Easy
Continuous Flow Peritoneal Dialysis
Clin J Am Soc Nephrol. 2011 Feb;6(2):311-8
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PD useful in hypotension, disturbed
coagulation or difficult venous access
Disadvantage – limited efficacy
CFPD – 2 bed-side catheters + adapted
CVVHF machine
CFPD vs Conventional PD for 8-16 hours
First report of CFPD in Paeds practice
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Clearances and UF significantly higher than PD
Continuous Flow Peritoneal Dialysis
Clin J Am Soc Nephrol. 2011 Feb;6(2):311-8
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Mean UF
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Creatinine clearance
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PD 0.20ml/min/1.73m2 vs
CFPD 1.8ml/min/1.73m2
PD 7.6ml/1.73m2 vs 28.8ml/1.73m2
2 Catheters vs Double lumen catheters
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Urea clearances 44-58ml/min(2xC) vs 14-20(DL)
DL not available in paeds
Continuous Flow Peritoneal Dialysis
Clin J Am Soc Nephrol. 2011 Feb;6(2):311-8
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Complications
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Catheter related – major complication rate <2%
Pederson KR KI Supp 108:S81-86, 2008
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Infection – closed system
Intra-abdominal pressure – carefully monitored
Clearances + UF Lower values than predicted adults:
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Low flow rate 100ml/1.73m2/min
Re-circulation due to small patient
Continuous Flow Peritoneal Dialysis
Clin J Am Soc Nephrol. 2011 Feb;6(2):311-8
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CFPD useful for ARF Ronco C Perit Dial Int 27:251-3, 2007
Especially in children
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Especially if small haemodynamically infant
Developing and Developed countries
Future
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Larger studies in Paeds
Higher flow volumes
Improved catheter technology
Acute Kidney Injury:The Future is now
The past of acute kidney injury was
observation,
and the present is intervention with renal
replacement therapy,
but perhaps the future is the use of
biomarkers to identify AKI sooner and
intervene early.
Bunchman TE. Oct 2009. Nephrology Times 15-16.
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Thank you for your attention !