Pediatric Peritoneal Dialysis

Dr. Osama El-ShahatDr. Osama El-ShahatConsultant Nephrologist

Head of Nephrology Department New Mansoura General Hospital (international)

ISN Educational Ambassador

11stst steps towards peritoneal steps towards peritoneal dialysis.dialysis.

Ancient Egypt were probably the first people to get a look at the peritoneum

The word preitoneum refers to the Greek word “peritononionperitononion” and means to stretch.

PD … the modality first used for the PD … the modality first used for the treatment of KItreatment of KI

Managing New Patient with ESRD

“Complementary Not Competitive” Coles 1998

“The right modality at the right time. Peter Blake, MD, John Burkart, MD

Early referral of patient With CKD to renal center

Pre-emptive Transplantation

PD as first option if medically suitable Allowing for patient chioce

Patient education program

HD Transplant

PDPD

Why to start with PD ?

Preservation of RRFHigher Hb concentrationLess risk of acquiring blood borne infections e.g. HCVBetter quality of lifeTravel , employment It allows expansion with limited resources Lower staff / patient ratiosaves vascular access preferred for children (APD)

Peritoneal dialysis (PD) is in general the preferred treatment modality for pediatric patients to bridge the time until transplantation.

It is easier to perform, less invasive than extracorporeal treatments and does not require anticoagulation. However, what counts most for the child and the family is that PD can be carried out at home.

PD is more compatible with a “normal” lifestyle and allows a better psychosocial integration of the little patient.

Patient selection

PositivePositive NegativeNegative

Selecting RRT modalit ies is influenced by a number of considerations such as Patient Preference . Availabi l i ty And Convenience. Underlying Medical Problems and Comorbid Conditions. Socioeconomic and Dialysis Center Factors. The Patient's Home Situation Medical staff Training.

PD-PD- Requirements Requirements

PD .PD .catheters PDPD. solution

Technique &TypesTechnique &Types of Chronic PDof Chronic PD

1.1. Fil l Phase Fil l Phase (<15 minutes)* Disconnect

2. 2. Dwell phase Dwell phase (4-8 hours)

3.3. Drain phaseDrain phase (<20 minutes )

CAPD ( ContinuousContinuous AmbulatoryAmbulatory PeritonealPeritoneal DialysisDialysis)

APD (Automated Peritoneal DialysisAutomated Peritoneal Dialysis)

CCPD ( Continuous Cycling Peritoneal DialysisContinuous Cycling Peritoneal Dialysis )

IPD ( Intermittent Peritoneal DialysisIntermittent Peritoneal Dialysis)

NIPD ( Nocturnal Intermittent Peritoneal DialysisNocturnal Intermittent Peritoneal Dialysis ) TPD ( Tidal Peritoneal DialysisTidal Peritoneal Dialysis)

Automated Peritoneal Dialysis(Automated Peritoneal Dialysis(APDAPD))

IndicationsIndications1. Children2. Inadequate solute or fluid removal3. High intraperitoneal pressure Hernia4. Polycystic disease5. (Recurrent) dialysate leaks6. Loss of appetite7. Lifestyle

DisadvantagesDisadvantagesMore difficult to learn Disturbed sleep

Attached to machine Sexual problems

More expensive

ESNT-CNE 1st Course Cairo Sept 10-14, 2012

Optimizing PD prescription for volume control: the importance of varying dwell time and dwell volume. M

Fischbach et al.Pediatr Nephrol 2014

Easy-to-use preassembled system◦ PD-Paed Plus is designed to perform PD manually in

premature babies, neonates and infants. It is an easy-to-use preassembled system for in-center use.

Flexible treatment adaptation◦ Capacity for inflow volumes of up to 240 mL◦ Option to connect two fluid bags at the same time

Safety features give confidence◦ An integrated ball valve in the inflow burette ensures that only

the prescribed volume is given to the patient◦ Improved therapeutic efficiency with a low recirculation

volume of only 2 mlOur patented PIN technology reduces the number of risk steps associated with disconnection and reconnection◦ DEHP-free materials ensure biocompatibility

Sleep safe is a reliable and popular device to treat children on automated PD, in general during the night time at home. It stands out for its flexibility to tailor a treatment according to the individual needs of the patient:

Adjustable flow rates for low volume treatments Special pediatric disposable set for low volumes Option to perform ‘Adapted APD (aAPD)’ to improve

patient outcome by varying dwell time, and fill volume and glucose concentration in one treatment3

Giving parents the confidence in the treatment and its comfort

Integrated continuous pressure monitoring helps to prevent outflow pain

Quiet operation Automatic bag connection and PIN technology reduce

contamination risk steps to one per day

Complications of PD therapy

infectious Non infectious

Peritonitis

Acute Chronic

Catheter MalfunctionCatheter Malfunction

.

Hyperglycaemia

Hyperlipidemia

Malnutrition

Hypokalemia

Hypermagnesaemia

Such variation from 2% to 80% !Can not be for medical reasons?

PD utilization in various countries worldwide (from USRDS data 1999(.

ConclusionsIn conclusion, PD continues to be underutilized in many

countries, including the United States. There are many

factors that contribute to this underutilization (e.ge.g.,

modality, system, and patient-related factors).

Clin J Am Soc Nephrol 6: 447–456, 2011Clin J Am Soc Nephrol 6: 447–456, 2011

Damanhor

PD program in PD program in EgyptEgypt

Transports

Hospitalisation

Pharmaceuticals )e.g. EPO(

Equipment costs )Lease, depreciation,

maintenance(

Disposables

Labor

Water Treatment

Infrastructure

Transports

Hospitalisation

Pharmaceuticals )e.g. EPO(

Equipment costs

Disposables

Labor

Infrastructure

Hemo

PD

Schematic Schematic RRT Cost RRT Cost Comparison Comparison Available ModalitiesAvailable Modalities

PD in Mansoura PD in Mansoura

PD in Mansoura PD in Mansoura

ConclusionConclusion

Thank YOUThank YOU