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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.
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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
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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.
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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.
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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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