Chapter 478

Chronic dialysis therapy should be initiated for children with chronic kidney disease (CKD) who are unable to maintain safe electrolyte homeostasis, blood pressure control, fluid balance, and/or energy level with appropriate dietary restriction and medication management. Although no absolute serum creatinine or blood urea nitrogen concentration serves as an absolute indication for dialysis initiation, a creatinine clearance of ⩽ 15 mL/min/1.73 m2 should also prompt consideration of dialysis initiation for children who do not expect to receive expeditious renal transplantation.1 In addition, dietary restriction should not be made so severe as to prevent growth in an effort to forestall dialysis initiation.

The need for dialysis should be anticipated in order to allow for proper patient and family education on treatment modalities, patient and parent training, and creation of a functioning vascular or peritoneal access even before dialysis is required. Whenever possible, dialysis should not be initiated as an emergency procedure because this usually necessitates placement of a temporary vascular access for hemodialysis (HD). Precautions such as avoidance of cephalic vein intravenous lines, subclavian catheter placement, and salvaging of nondominant arm vessels should be taken to preserve these vessels for future vascular access.1

Peritoneal dialysis (PD) and hemodialysis (HD) have both become standard maintenance treatments for children with end-stage renal disease (ESRD). Either modality provides effective treatment for children with ESRD, although each modality may have advantages for certain pediatric subpopulations.

Peritoneal dialysis (PD) is preferred for smaller patients because it is provided without an extracorporeal blood circuit. The advantages of PD include relatively stable serum biochemistries and blood pressure and fewer restrictions on dietary and fluid intake because dialysis is performed daily; simplicity of the procedure permits dialysis to be done at home, thus allowing greater flexibility of the dialysis regimen, infrequent interruptions of the school schedule, and decreased reliance on the dialysis center. Thus, PD is most suited for infants and young children, patients with severe cardiovascular disease or with vascular access difficulties, and those who live far from the dialysis center.

### Contraindications

Absolute contraindications for peritoneal dialysis (PD) include peritoneal membrane failure, presence of extensive abdominal adhesions that obstruct dialysate flow, surgically uncorrectable mechanical defects that prevent effective PD or increase the risk of infection (omphalocele, gastroschisis, diaphragmatic hernia, bladder extrophy), and inability to identify a person (usually a parent) who can be trained for PD if the patient is incapable of performing PD. Relative contraindications for PD include newly placed abdominal foreign bodies (ventriculoperitoneal shunt), peritoneal leaks, body size limitations, inability to tolerate exchange volumes required to achieve adequate clearance or fluid removal, inflammatory or ischemic bowel disease, morbid obesity, and severe malnutrition. In addition, the parental and familial stress incurred from providing in-home life-saving medical treatment can lead to stress.2,3 Thus, adequate support systems must be established so that home-based dialysis care can be provided without compromising the family integrity.

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