Chapter 68. Renal Replacement Therapy

Indications

• • End-stage renal disease.

  • Acute kidney failure accompanied by 1 or more of the following:

  • • Oliguria or anuria.

    • Uremia (azotemia accompanied by platelet dysfunction and bleeding, change in mental status, or other uremic symptoms).

    • Electrolyte or metabolic disturbance unresponsive to medical management (eg, hyperkalemia, hyponatremia or hypernatremia, acidosis, hypocalcemia, hyperphosphatemia).

    • Inability to provide adequate nutrition or other intravenous therapy due to fluid restriction.

  • Inborn error of metabolism: urea cycle disorders, propionic acidemia, maple syrup urine disease (hemodialysis and CRRT more effective and are preferred).

  • Dialyzable toxin (hemodialysis and CRRT more effective and are preferred).

Contraindications

Absolute

• • Lack of adequate peritoneal membrane or cavity.

  • • Omphalocele.

    • Diaphragmatic hernia.

    • Gastroschisis.

Relative

• • Recent abdominal surgery.

  • Prior extensive abdominal surgery that might have resulted in adhesions or peritoneal scarring.

  • Ventriculo-peritoneal shunt.

  • Unsuitable social situation for home dialysis.

Equipment

• • Peritoneal dialysate solutions.

  • • Lactate-buffered, electrolyte-balanced dextrose solution most often used.

    • Available as 1.5%, 2.5%, and 4.25% dextrose.

    • Bicarbonate-buffered solutions are available.

    • Icodextrin (glucose polymer) solution available; useful for patients with poor fluid removal.

  • Solution warmer (blood transfusion warmer for continuous ambulatory peritoneal dialysis [CAPD] or warming tray on cycler).

  • Automated cycler for intermittent peritoneal dialysis (IPD) or continuous cycling peritoneal dialysis (CCPD) or manual exchange set for CAPD.

  • Peritoneal dialysis catheter.

  • • Surgically placed permanent catheter preferred in most situations.

    • Temporary percutaneous catheter in unstable patients or per center preference for acute kidney failure.

Pearls and Tips

• • Peritoneal dialysis is the preferred method of chronic dialysis in children with end-stage renal disease.

  • Children receiving peritoneal dialysis have less daytime disruption of school and social activities.

  • Because peritoneal dialysis is performed every day, a more liberal fluid and dietary regimen is possible.

  • Peritoneal dialysis might be the only option available to small infants who cannot tolerate the large fluid shifts and large extracorporeal circuit volume of hemodialysis, and to those patients who do not have adequate vascular access for hemodialysis.

  • However, hemodialysis might be the only option for RRT for those children who have had extensive abdominal surgery, who have a social situation that precludes home dialysis, or in whom peritoneal dialysis has already failed due to repeated bouts of peritonitis or other complications.

  • Hemodialysis and CRRT remain the treatments of choice for inborn errors of metabolism and toxic ingestions because peritoneal dialysis does not provide efficient and rapid clearance of metabolites and toxins.