Peritoneal dialysis (PD) may be a feasible, safe, and complementary alternative to hemodialysis not only in the chronic setting, but also in the acute setting. It previously was widely accepted for ...acute kidney injury (AKI) treatment, but its practice decreased in favor of other types of extracorporeal therapies. The interest in PD to manage AKI patients has been reignited and PD now frequently is used in developing countries because of its lower cost and minimal infrastructural requirements. Studies from these countries have shown that, with careful thought and planning, critically ill patients can be treated successfully using PD. Some of the classic limitations of PD use in AKI, such as a high chance of infectious and mechanical complications and poor metabolic control, have been overcome with the use of cyclers, flexible catheters, and a high volume of dialysis fluid. However, in developing countries the infrastructure for quality research often is lacking and the result has been limited evidence on standardized treatment regimens such as indications, dosing, and technical failure and mortality. The recent publication of the International Society for Peritoneal Dialysis guidelines for PD in AKI have tried to address these issues and provide an evidence-based standard by which to initiate therapy. In this article, advances in technical aspects and the advantages and limitations of PD are discussed, and recent literature on clinical experience with PD for the treatment of AKI patients is reviewed.
Peritoneal dialysis (PD) for acute kidney injury (AKI) has been available for nearly 80 years and has been through periods of use and disuse largely determined by availability of other modalities of ...kidney replacement therapy and the relative enthusiasm of clinicians. In the past 10 years there has been a resurgence in the use of acute PD globally, facilitated by promotion of PD for AKI in lower resource countries by nephrology organizations effected through the Saving Young Lives program and collaborations with the World Health Organisation, the development of guidelines standardizing prescribing practices and finally the COVID-19 pandemic. This review highlights the history of PD for AKI and looks at misconceptions about efficacy as well as the available evidence demonstrating that acute PD is a safe and lifesaving therapy with comparable outcomes to other modalities of treatment.
Posttransplantation lymphoproliferative disorder (PTLD) is one of the most serious complications of solid-organ transplantation. It potentially is treatable in most cases, but current methods involve ...withdrawal or reduction of immunosuppression and the consequent risk for graft rejection. Sirolimus was shown in vivo and in vitro to limit proliferation of a number of malignant cell lines, including those of PTLD-derived cells. We present a case of disseminated PTLD in a patient with a renal transplant that resolved completely with conversion of immunosuppression to sirolimus. Graft function was maintained and improved with treatment. This offers a novel means of treating these patients and minimizing transplant loss.
It is estimated that >50% of patients with end-stage kidney disease (ESKD) in low-resource countries are unable to access dialysis. When hemodialysis is available, it often has high out-of-pocket ...expenditure and is seldom delivered to the standard recommended by international guidelines. Hemodialysis is a high-cost intervention with significant negative effects on environmental sustainability, especially in resource-poor countries (the ones most likely to be affected by resultant climate change). This review discusses the rationale for peritoneal dialysis (PD) as a more resource and environmentally efficient treatment with the potential to improve dialysis access, especially to vulnerable populations, including women and children, in lower-resource countries. Successful initiatives such as the Saving Young Lives program have demonstrated the benefit of PD for acute kidney injury. This can then serve as a foundation for later development of PD services for end-stage kidney disease programs in these countries. Expansion of PD programs in resource-poor countries has proven to be challenging for various reasons. It is hoped that if some of these issues can be addressed, PD will be able to permit an expansion of end-stage kidney disease care in these countries.
Peritoneal dialysis (PD) is a modality frequently preferred by patients for the management of their end-stage kidney disease; however, a major factor in its success is PD catheter placement and ...subsequent function. Optimal placement of PD catheters is generally accepted to be in the true pelvis, for this reason, many patients who are found to have a pelvic cavity obliterated by adhesions are often denied the opportunity to do PD. We report on four cases of an alternative advanced laparoscopic technique used in patients with inaccessible pelvic cavities, with three catheter placements in the intraperitoneal left iliac fossa/paracolic gutter and one case in the right paracolic gutter with subsequent good outcomes. This report suggests that a ‘frozen pelvis’ is not a contraindication to successful PD, with alternative catheter tip placement in the iliac fossa.
Peritoneal dialysis (PD) for acute kidney injury (AKI) in children has a long track record and shows similar outcomes when compared to extracorporeal therapies. It is still used extensively in low ...resource settings as well as in some high resource regions especially in Europe. In these regions, there is particular interest in the use of PD for AKI in post cardiac surgery neonates and low birthweight neonates. Here, we present the update of the International Society for Peritoneal Dialysis guidelines for PD in AKI in paediatrics. These guidelines extensively review the available literature and present updated recommendations regarding peritoneal access, dialysis solutions and prescription of dialysis.
Summary of recommendations
1.1 Peritoneal dialysis is a suitable renal replacement therapy modality for treatment of acute kidney injury in children. (1C)
2. Access and fluid delivery for acute PD in children.
2.1 We recommend a Tenckhoff catheter inserted by a surgeon in the operating theatre as the optimal choice for PD access. (1B) (optimal)
2.2 Insertion of a PD catheter with an insertion kit and using Seldinger technique is an acceptable alternative. (1C) (optimal)
2.3 Interventional radiological placement of PD catheters combining ultrasound and fluoroscopy is an acceptable alternative. (1D) (optimal)
2.4 Rigid catheters placed using a stylet should only be used when soft Seldinger catheters are not available, with the duration of use limited to <3 days to minimize the risk of complications. (1C) (minimum standard)
2.5 Improvised PD catheters should only be used when no standard PD access is available. (practice point) (minimum standard)
2.6 We recommend the use of prophylactic antibiotics prior to PD catheter insertion. (1B) (optimal)
2.7 A closed delivery system with a Y connection should be used. (1A) (optimal) A system utilizing buretrols to measure fill and drainage volumes should be used when performing manual PD in small children. (practice point) (optimal)
2.8 In resource limited settings, an open system with spiking of bags may be used; however, this should be designed to limit the number of potential sites for contamination and ensure precise measurement of fill and drainage volumes. (practice point) (minimum standard)
2.9 Automated peritoneal dialysis is suitable for the management of paediatric AKI, except in neonates for whom fill volumes are too small for currently available machines. (1D)
3. Peritoneal dialysis solutions for acute PD in children
3.1 The composition of the acute peritoneal dialysis solution should include dextrose in a concentration designed to achieve the target ultrafiltration. (practice point)
3.2 Once potassium levels in the serum fall below 4 mmol/l, potassium should be added to dialysate using sterile technique. (practice point) (optimal) If no facilities exist to measure the serum potassium, consideration should be given for the empiric addition of potassium to the dialysis solution after 12 h of continuous PD to achieve a dialysate concentration of 3–4 mmol/l. (practice point) (minimum standard)
3.3 Serum concentrations of electrolytes should be measured 12 hourly for the first 24 h and daily once stable. (practice point) (optimal) In resource poor settings, sodium and potassium should be measured daily, if practical. (practice point) (minimum standard)
3.4 In the setting of hepatic dysfunction, hemodynamic instability and persistent/worsening metabolic acidosis, it is preferable to use bicarbonate containing solutions. (1D) (optimal) Where these solutions are not available, the use of lactate containing solutions is an alternative. (2D) (minimum standard)
3.5 Commercially prepared dialysis solutions should be used. (1C) (optimal) However, where resources do not permit this, locally prepared fluids may be used with careful observation of sterile preparation procedures and patient outcomes (e.g. rate of peritonitis). (1C) (minimum standard)
4. Prescription of acute PD in paediatric patients
4.1 The initial fill volume should be limited to 10–20 ml/kg to minimize the risk of dialysate leakage; a gradual increase in the volume to approximately 30–40 ml/kg (800–1100 ml/m2) may occur as tolerated by the patient. (practice point)
4.2 The initial exchange duration, including inflow, dwell and drain times, should generally be every 60–90 min; gradual prolongation of the dwell time can occur as fluid and solute removal targets are achieved. In neonates and small infants, the cycle duration may need to be reduced to achieve adequate ultrafiltration. (practice point)
4.3 Close monitoring of total fluid intake and output is mandatory with a goal to achieve and maintain normotension and euvolemia. (1B)
4.4 Acute PD should be continuous throughout the full 24-h period for the initial 1–3 days of therapy. (1C)
4.5 Close monitoring of drug dosages and levels, where available, should be conducted when providing acute PD. (practice point)
5. Continuous flow peritoneal dialysis (CFPD)
5.1 Continuous flow peritoneal dialysis can be considered as a PD treatment option when an increase in solute clearance and ultrafiltration is desired but cannot be achieved with standard acute PD. Therapy with this technique should be considered experimental since experience with the therapy is limited. (practice point)
5.2 Continuous flow peritoneal dialysis can be considered for dialysis therapy in children with AKI when the use of only very small fill volumes is preferred (e.g. children with high ventilator pressures). (practice point)
Saving more young lives in Africa Cullis, Brett; Lalya, Francis; Smoyer, William E
Peritoneal dialysis international,
09/2020, Letnik:
40, Številka:
5
Journal Article
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