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Saudi Journal of Kidney Diseases and Transplantation
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EDITORIAL Table of Contents   
Year : 2005  |  Volume : 16  |  Issue : 1  |  Page : 1-5
Peritoneal Dialysis in Children: Consider the Membrane for Optimal Prescription


1 Pediatry 1, University Hospital, Avenue Moliere, 67098 Strasbourg Cedex, France
2 Department of Pharmacology-Physiology, EMI-U 0015, Medicine Faculty, Strasbourg, France
3 Department of Radiology, University Hospital, 67098 Strasbourg, France
4 Department of Pediatric Nephrology, Children’s Hospital, Im Neuenheimer Feld 150, 69120 Heidelberg, Germany
5 Department of Nephrology and Physiology, Goteborg University, PO Box 432, SE-40530 Goteborg, Sweden

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   Abstract 

The peritoneal dialysis prescription was, for a long time, based on clinical experience and very empirical, especially for patients on continuous ambulatory peritoneal dialysis (CAPD). Better comprehension of the peritoneal membrane as a dynamic dialysis surface allows an individualized prescription, especially for children on automated peritoneal dialysis (APD). Fill volume prescription should be scaled for body surface area (mL/m²) and not in a too low amount to avoid a hyperpermeable exchange. Fill volume enhancement should be done under clinical control and is best secured by intraperitoneal pressure measurement (IPP; cm H2O). A peak fill volume of 1400-1500 mL/m² could be prescribed both in terms of tolerance and of efficiency. The dwell times should be determined individually with respect to two opposite parameters namely: short dwell times which provide adequate small solute clearance and maintain ultrafiltration capacity and long dwell times which enhance phosphate clearance but can contribute to dialysate reabsorption. The new peritoneal dialysis fluids which are free of GPD's, have neutral pH and are not exclusively lactate buffered, appear as the best choice in the context of peritoneal exchange membrane recruitment and of peritoneal vascular hyperperfusion preservation.

Keywords: Peritoneal dialysis, Children, Fill volume, Dwell time, Peritoneal membrane.

How to cite this article:
Fischbach M, Dheu C, Michallat A C, Escande B, Laugel V, Barthelmebs M, Zoellner G, Schaefer F, Schmitt C P, Haraldsson B, Helwig J J. Peritoneal Dialysis in Children: Consider the Membrane for Optimal Prescription. Saudi J Kidney Dis Transpl 2005;16:1-5

How to cite this URL:
Fischbach M, Dheu C, Michallat A C, Escande B, Laugel V, Barthelmebs M, Zoellner G, Schaefer F, Schmitt C P, Haraldsson B, Helwig J J. Peritoneal Dialysis in Children: Consider the Membrane for Optimal Prescription. Saudi J Kidney Dis Transpl [serial online] 2005 [cited 2019 Sep 20];16:1-5. Available from: http://www.sjkdt.org/text.asp?2005/16/1/1/32944

   Introduction Top


Hemodialysis prescription is primarily based on the dialyzer choice, the dialysis membrane, its area and permeability. [1] On the contrary, peritoneal dialysis prescription [2] is primarily based on :

a) the peritoneal dialysis fluid choice, [3] especially its biocompatibility,

b) the tolerance of the prescribed fill volume, optimized and secured using the intra­peritoneal pressure measurement, [4] and,

c) the dwell time exchanges.

All these together are implicated in the achievement of adequate ultrafiltration and blood purification. [5]

Nevertheless, it is also of importance to con­sider the impact of the peritoneal surface area on adequacy, [6] knowing more about the possibility of both the contact surface area recruitment capacity, the so called « wetted « membrane, and the vascular surface area changes with the hope of hyperperfusion preservation. [7],[8],[9],[10],[11]

Peritoneal dialysis prescription should be individualized and adapted to achieve at least two main targets: firstly adequate ultrafil­tration and thereby reducing cardiovascular morbidity or mortality, and secondly, blood purification, not limited only to the urea removal dialysis capacity. [2],[3],[4],[5]


   Fill Volume Determination Top
[Table - 1]

In adults on continuous ambulatory peritoneal dialysis (CAPD), the intraperitoneal fill volume choice is reduced to the prescription of a full dialysis bag of two or 2.5 L without adaptative consideration to the patients' differences in body weight (BW ; kg) or body surface area (BSA ; m²). In pediatric care, we have to adjust the fill volume to suit each child, considering the wide morphologic differences between babies and adolescents. The main question raised for fill volume prescription is tolerance of a child of a full abdominal cavity; which fill volume could be well tolerated? Twenty years ago, the fill volume was prescribed per kg body weight, 30 to 50 mL/kg; lower in infants that in older children, lower at the beginning of the dialysis. These factors together resulted in relatively small fill volume prescriptions. This limited fill volume concept also contributed to a false perception of differences in peritoneal permeability between children and adults, with a presumed hyper­permeable peritoneal state especially in infants. [12],[13] Scaling of the fill volume by BSA (mL/m²), particularly in infants and small children allowed to avoid such a hyperper­meable exchange as defined in a peritoneal equilibration test (PET). [2],[3],[12],[13],[14] Therefore, fill volume prescription in children should be scaled for BSA and prescribed not in a too small amount. [2],[15] In fact, a too small fill volume [2],[15],[16] is a factor of functional hyper­permeability, this state being presumably related to the ratio between the peritoneal surface area in contact with a low amount of dialysate. A hyperpermeable state is a major risk factor of ultrafiltration failure due to a too rapid loss of glucose related osmotic crystalloid gradient, [2] of impaired statural growth rate [17] and of discrepancy between urea in a normal high range and creatinine in a normal low range for the parameters of ade­quacy, [2],[18] all together contributing to an in­creased morbidity and even mortality rate. [2],[15],[16] Conversely, a too large fill volume, may con­tribute to patient morbidity by causing the following complications: [2],[15],[16] pain, dyspnea, hydrothorax, hernia formation, gastroesopha­geal reflux with anorexia and loss of ultra-filtration by enhanced lymphatic drainage. Such morbidity could also result in patient non­compliance. Also, increasing the fill volume over a so called peak volume shall not improve dialysis efficiency, and may even reduce it. [2],[3]

All together, fill volume prescription should be low enough to be clinically well tolerated, but thereafter promptly modified under the control of the intraperitoneal pressure measure­ments to achieve adequate ultrafiltration and urea purification both of which are directly related to the amount of the fill volume. In children over the age of two years, the presumed optimal fill volume should be increased step­wise, close to the upper limit of 1200 to 1500 mL/m² for a night exchange in prone position, while resting.


   Dwell Time Exchange Determination Top


[Table - 2]

In CAPD, dwell times are in fact long. Therefore, the major risk is the loss of the glucose related osmotic gradient leading to ultrafiltration failure, even more dialysate reabsorption by the child, especially in case of residual polyuric states. In order to limit such a condition, hypertonic dialysate is often prescribed despite the potentially enhanced peritoneal membrane toxicity which is related to the amount of glucose degradation end products (GPD's). [3],[11] Icodextrin fluid was proposed to limit time related dialysate reabsorption but it should be limited to one exchange per day. [2],[19]

Most of the children are treated with automatic peritoneal dialysis (APD), a choice supported both by the better tolerance of a full peri­toneal cavity in supine position and by the need for short dwell times to limit dialysate reabsorption. [2] However, short dwell time exchanges will be more appropriate for urea clearance than for phosphate clearance. [2],[18] In fact, during a PET the time needed to achieve a dialysate over plasma concentration ratio of 50 % is three to four times longer for phosphate than for urea. [2],[20] Thus, [21] short dwell time exchanges are more adapted to achieve adequate ultrafiltration and urea purification (KT/V urea ). On the contrary, long dwell time exchanges are in favor of higher creatinine and phosphate clearance, but with a risk of impaired ultrafiltration. [2],[18]

A dwell time for APD exchanges close to one hour appears to be a usual initial choice pres­cription in children, but needs to be adapted to the patients' condition, the residual renal function, and to the desired main goal: [2] ultra­filtration using short dwell times, phosphate clearance using longer dwell times. It is of importance to note that the kinetics of an exchange are also influenced by the compo­sition of the PDF [2],[3] and the amount of the prescribed fill volume. [22]


   Influence of the Dialysis Prescription on the Peritoneal Dialysis Membrane Top
[Figure - 1]

The peritoneal membrane is a dynamic dialysis membrane. [6],[8] The surface area in contact with the dialysate is only a fraction of the anatomic area, i.e. 30 to 60 % in humans as measured by computed tomography. This contact area is dependent on different factors such as posture, i.e. positive recruitment in supine position, and fill volume, i.e. progressive recruitment until a peak fill volume close to 1400 mL/m² BSA in children. [22] The peritoneal vascular perfusion and the density of the functional pores of the perfused capillaries determine the vascular exchange area. This vascular surface area is dynamically affected by different factors, such as the PDF compo­sition, the amount of fill volume, and possible inflammatory agents. [8] All together, it appears that the new, more physiological PDF's i.e. GPD's free, not exclusively lactate buffered, with neutral pH, offer the best combination in terms of both peritoneal exchange membrane recruitment and peritoneal vascular hyper­perfusion preservation. [6],[7],[9],[10] However, it is not clear whether the best choice is mixed lactate/bicarbonate PDF [7] impacting on peri­toneal hyperperfusion preservation and fill volume enhancement due to lower induced IPP's, or pure bicarbonate PDF [9],[10] potentially impacting on contact area recruitment and limiting peritoneal hyperperfusion.

 
   References Top

1.Fischbach M, Terzic J, Menouer S, Provot E, Bergere V. Hemodialysis in children: principles and practice. Semi Nephrol 2001;21:470-9.  Back to cited text no. 1    
2.Fischbach M, Stefanidis CJ, Watson AR (European Pediatric Peritoneal Dialysis Working Group). Guidelines by an ad hoc European committee on adequacy of the pediatric peritonial dialysis prescription. Nephrol Dial Transplant 2002; 17(3):380-5.  Back to cited text no. 2    
3.Schroder CH. Optimal peritoneal dialysis: choice of volume and solution. Nephrol Dial Transplant 2004;19:782-4.  Back to cited text no. 3    
4.Fischbach M, Terzic J, Laugel V, Escande B, Dangelser CL, Helmstetter A. Measurement of hydrostatic intraperitoneal pressure: a useful tool for the improvement of dialysis dose prescription. Pediatr Nephrol 2003;18:976-80.  Back to cited text no. 4    
5.Goldstein SL. Adequacy of dialysis in children: does small solute clearance really matter? Pediatr Nephrol 2004;19:1-5.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Fischbach M, Dheu C, Helms P, Terzic J, Michallat AC, Laugel V, Wolff-Danner S, Haraldsson B. The influence of peritoneal surface area on adequacy. Perit Dial Int 2004 (submitted).  Back to cited text no. 6    
7.Fischbach M, Terzic J, Chauve S, Laugel V, Muller A, Haraldsson B. Effect of peritoneal dialysis fluid composition on peritoneal area available for exchange in children. Nephrol Dial Transplant 2004;19:925-32.  Back to cited text no. 7    
8.Fischbach M, Haraldsson B, Helms P, Danner S, Laugel V, Terzic J. The peritoneal membrane: a dynamic dialysis membrane in children. Adv Perit Dial 2003;19:265-8.  Back to cited text no. 8  [PUBMED]  
9.Schmitt CP, Haraldsson B, Doetsschmann R, et al. Effects of pH neutral, bicarbonate - buffered dialysis fluid on peritoneal transport kinetics in children. Kidney Int 2002;61: 1527-36.  Back to cited text no. 9    
10.Haas S, Schmitt CP, Arbeiter K, et al. Improved acidosis correction and recovery of mesothelial cell mass with neutral-pH bicarbonate dialysis solution among children undergoing automated peritoneal dialysis. J Am Soc Nephrol 2003;14:2632-8.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]
11.Mortier S, De Vriese AS, Van de Voorde I, Schaub TP, Passlick Deetjen IJ, Lameire NH. Hemodynamic effects of peritoneal dialysis solutions on the rat peritoneal membrane: role of acidity buffer choice, glucose concen­tration, and glucose degradation products. J Am Soc Nephrol 2002;13:480-9.  Back to cited text no. 11    
12.Kohaut EC, Waldo FB, Bienfield M. The effects of changes in dialysate volume on glucose and urea equilibration. Perit Dial Int 1994;14:236-9.  Back to cited text no. 12    
13.Warady BA, Alexander S, Hossli S, Vonesh E, Geary D, Kohaut E. The relationship between intraperitoneal volume and solute transport in pediatric patients. Pediatric Peritoneal Dialysis Study Consortium. J Am Soc Nephrol 1995;5:1935-9.  Back to cited text no. 13    
14.Bouts AH, Davin JC, Groothoff JW, Van Amstel SP, Zweers MM, Krediet RT. Standard peritoneal permeability analysis in children. J Am Soc Nephrol 2000;11:943-50.  Back to cited text no. 14  [PUBMED]  [FULLTEXT]
15.Fischbach M, Terzic J, Menouer S, Haraldsson B. Optimal volume prescription for children on peritoneal dialysis. Perit Dial Int 2000;20:603-6.  Back to cited text no. 15  [PUBMED]  [FULLTEXT]
16.Durand PY. Optimization of fill volumes in automated peritoneal dialysis. Perit Dial Int 2000;20:601-2.  Back to cited text no. 16  [PUBMED]  [FULLTEXT]
17.Schaefer F, Klaus G, Mehls O. Mid European Pediatric Peritoneal Dialysis Study Group. Peritoneal transport properties and dialysis dose affect growth and nutritional status in children on peritoneal dialysis. J Am Soc Nephrol 1999;10:1786-92.  Back to cited text no. 17    
18.Malhotra D, Murata GH, Tzamaloukas AH. Creatinine clearance and urea clearance in peritoneal dialysis: what to do in case of discrepancy? Perit Dial Int 1997;17:532-5.  Back to cited text no. 18  [PUBMED]  [FULLTEXT]
19.Schroder CH. New peritoneal dialysis fluids: practical use for children. Pediatr Nephrol 2003;18:1085-8.  Back to cited text no. 19    
20.Fischbach M, Lahlou A, Eyer D, Desprez P, Geisert J. Determination of individual ultra­filtration time (APEX) and purification phosphate time by peritoneal equilibration test. Application to individual peritoneal dialysis modality prescription in children. Perit Dial Int 1996;16 (Suppl 1):19-22.  Back to cited text no. 20    
21.Fischbach M, Desprez P, Terzic J, Lahlou A, Mengus L, Geisert J. Use of intraperitoneal pressure, ultrafiltration and purification dwell times for individual peritoneal dialysis pre­scription in children. Clin Nephrol 1996; 46,1:14-6.  Back to cited text no. 21    
22.Fischbach M, Haraldsson B. Dynamic changes of the total pore area available for peritoneal exchange in children. J Am Soc Nephrol 2001;12:1524-9.  Back to cited text no. 22  [PUBMED]  [FULLTEXT]

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Correspondence Address:
M Fischbach
Pediatry 1, University Hospital, Avenue Moliere, 67098 Strasbourg Cedex
France
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PMID: 18209452

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