Continuous peritoneal dialysis in pediatric patients with chronic kidney diseases: a case series and literature review

Introduction

In developing countries, the management of chronic kidney disease (CKD) remains challenging due to the absence of kidney transplantation, the scarcity of extra-renal purification, and the low level of health policy participation, especially for children. Peritoneal dialysis (PD) is still a viable option for pediatric renal replacement therapy in both acute and chronic conditions. The two PD modalities represented by these procedures are automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis (CAPD) and their variants.¹ The majority of children with CKD who require dialysis can be treated with peritoneal dialysis (PD), which is the most common type of dialysis available for children worldwide. In a country with limited resources, PD is still the treatment of choice for pediatric CKD patients.^2,3 Here, we reported a case series of six CKD patients managed with CAPD.

Case presentation

We present a case series of six children with chronic kidney diseases on continuous ambulatory peritoneal dialysis (CAPD (age range: 10–16 years old). All patients were diagnosed with CKD stage 5. Of the six patients, 3 were diagnosed with nephrotic syndrome, 1 with systemic lupus erythematosus with kidney involvement, 1 with primary glomerulopathy and 1 with congenital anomaly of the kidney (Table 1). All patients have agreed for their data to be used in research and publication. The patient has signed a written informed consent. In this study, the majority of patients experienced infection (n = 4; 66.67%) as the side effect of CAPD use, while the remainings experienced adhesion (n = 2; 33.33%) (Table 2). CAPD was effective in 4 out of the six patients who received the device (Table 3).

Discussion

The prevalence and incidence of CKD have gradually risen. CKD is the sixth fastest-growing cause of death worldwide, impacting around 10% of the population in industrialized nations.⁴ From 1997 to 2008, an estimated of 6% to 12% of the global population, or approximately 850 million individuals, suffered from CKD, and at least 2.4 million die annually. More than a million patients are on peritoneal dialysis and close to 1.6 million are on hemodialysis, a number that will likely double within the next decade.⁵ In the global pediatric population, the incidence of CKD have been steady during the past three decades.^6,7 In 2008, the incidence of CKD in children and adolescents was approximately 9 per million age-related individuals.⁷ From 2009 to 2011, the average incidence of pediatric CKD in Europe was 5.5% in children aged 0-14 years and 8.3% in those aged 0-19 years.⁸

Even though a kidney transplant is the ideal treatment for patients with CKD, the majority of patients receive dialysis while waiting for a transplant, or as the only treatment.¹ Continuous peritoneal dialysis (CAPD) should be the standard selection of renal replacement therapy (RRT) in low-to-middle-income countries (LMICs), especially in rural areas.⁹ In addition to fewer hospital visits, CAPD permits greater flexibility when performed. It is perfect for children, teenagers, and whoever need dialysis as it provides the convenience of home dialysis for those whose home is distant from dialysis centers. In addition, the evidence supports a CAPD-first policy prior to starting hemodialysis (HD) due to the established benefits for the preservation of residual renal function and protection of the vascular access sites. The survival rate of patients treated with CAPD has consistently increased over the past two decades, both in absolute terms and in contrast to those receiving HD. However, the majority of trials demonstrating a survival improvement with CAPD have been conducted in industrialized nations. In other countries, HD is still the most prevalent RRT.¹⁰

Dialysis is commenced in children when the estimated glomerular filtration rate (eGFR) is 10 ml/ml/1.73 m², or when the child with CKD exhibits uremic symptoms that are resistant to medical and/or dietary therapy. The timing of dialysis initiation is a complex decision that should be based on the eGFR, as well as the signs and symptoms of uremia, which include the inability to maintain euvolemia with the development of hypertension and/or significant peripheral edema; deterioration in nutritional status or growth failure and declining weight and/or height centiles; the presence of biochemical abnormalities such as hyperkalemia, hyperphosphatemia, or acidosis; and subjective complaints of the patient. Before beginning dialysis, it should be established that these conditions are persistent and unresponsive to medical and/or dietary management. The duration of uremic symptoms before dialysis is deemed necessary will depend on their severity as well as the child’s distress. The decision to initiate dialysis should be made in conjunction with the child (if of an appropriate age), the child’s caregivers, and the child’s healthcare providers.¹¹

The percentage of pediatric patients initiating dialysis in the United States with an eGFR >10 ml/min/1.73 m² has risen from 16.5% in 1995 to 40.8% in 2015. In a recent examination of United States Renal Data System (USRDS) data from 15,473 children initiated on dialysis between 1995 and 2015, 29% (4481) started dialysis when the eGFR was greater than 10 ml/min/1.73 m² (median 12.8 ml/min/1.73 m²). Compared to patients who began dialysis with an eGFR 10 ml/min/1.73 m² (median eGFR 6.5 ml/min/1.73 m²), the probability of death (censored at kidney transplant) was 24% higher for those who began dialysis with a higher eGFR. However, when dialysis modality was included, the higher mortality risk associated with “early” dialysis initiation did not achieve statistical significance in the PD cohort.¹² The majority of patients in this case series were starting CAPD when they already reached the end stage of kidney disease (ESKD).

The selection of a dialysis modality in children should take into account the child’s age and size, any comorbid conditions, the existence of family support, any modality contraindications, the competence of the dialysis team, and the preferences of the child and parents/caregivers. While choosing the ideal dialysis modality for a child, access to peritoneal and vascular dialysis must be maintained.¹¹ There is no evidence to support the claims that treating children with ESKD with PD or HD is more effective. The worldwide registries show that PD is the major and most often used treatment option for younger children, in those less than 5 years in the UK renal replacement registry, in those under 9 years in the USRDS, and in those less than 5 years in the European Society for Pediatric Nephrology registry.¹³ In fact, according to the USRDS statistics, between 1996 and 2015, PD was used as the first renal replacement therapy in 64 percent of patients who weighed less than 20 kg, compared to just 31.8% of those who did.¹¹

In this study, the majority of patients experienced infection (41.66%), while the remaining experienced adhesion (8.33%), leakage (8.33%), and migration (8.33%). Several previous studies have described CAPD-related complications (Table 4), with peritonitis as the most prominent one.

Due to the emergence of complications, the lack of long-term efficacy of CAPD is the most significant factor limiting its application. The most common problems are those related to infection.¹⁴ Bacterial peritonitis is the most frequent complication that terminates the use of CAPD and is a major contributor to morbidity. An infection at the catheter exit site may be easily treatable, but a catheter tunnel infection that does not resolve may necessitate the removal of the CAPD catheter and surgical implantation of a new catheter at a different site. Problems with catheter can also include those that are non-infectious, such as catheter obstruction, kinking, malposition, and entrapment. Additionally, the infusion of dialysate increases intra-abdominal pressure, which may cause peritoneal herniation or dialysate leakage. These problems may result in localized edema and inadequate dialysate drainage, hence diminishing the efficacy of CAPD. Sclerosing encapsulating peritonitis is a severe and potentially fatal consequence that must be diagnosed early to permit the prompt discontinuation of COPD.¹⁵

There are several studies conducted in developing countries as depicted in Table 5. Bakal et al. evaluates the indications, complications, and outcomes of PD in developed countries. The document provides information on the technique of PD, the types of catheters used, and the dialysis solution. It also discusses the complications associated with PD, such as catheter occlusion and peritonitis. The study concludes that PD is a viable treatment option for pediatric patients with renal failure, with a relatively low rate of complications. In patients undergoing continuous peritoneal dialysis (CPD), complications occurred in 31.2% of the cases. The most common complication was peritonitis (14.1%), followed by catheter occlusion (4.6%) and inguinal hernia (4.6%).²⁰ Stefano et al. focuses on the experience of using peritoneal catheters in pediatric patients in developed countries over a 15-year period from 1986 to 2000. The study analyzed data on 503 chronic peritoneal dialysis (CPD) catheters implanted between 1986 and 2000 in pediatric patients enrolled in the Italian Registry of Pediatric Chronic Peritoneal Dialysis. The patients included those under 2 years of age, aged 2-5 years, and over 5 years of age, with a mean patient age at the start of CPD of 8.0 ± 5.1 years. The main complications observed were catheter infections, which accounted for 73.2% of complications and were the most common cause of catheter removal (75.4%). The reported rate of exit-site infection/tunnel infection (ESI/TI) in children varied, but in this study, the rate was 1 episode per 28.1 CPD-months overall and 1 episode per 16.2 CPD-months in the <2 years age group.²¹ In the study from Rahim et al., the mean age at the time of diagnosis with renal failure was 5.5 years, with a range of 0.1-17 years. The mean age at the time of first dialysis was 9.0 years, with a range of 0.1-19 years. Young age, specifically age <3 years at the time of first dialysis, was found to be a risk factor for infection in patients receiving peritoneal dialysis. However, there was no significant difference in complication rates based on age for dialysate leak or catheter malfunction. The study did not reflect a worse catheter survival rate in younger children, possibly due to the small number of patients in the younger age group.²²

Conclusion

The authors report a case series of successful experience with CAPD in children in Indonesia. Patiets were stabilized with the aid of this technique. In this instance, satisfaction was derived from the child’s return to their family, as well as the fact that chronic hemodialysis-related restrictions were overcome. Although this method of extrarenal purification was effective, the majority of patients in this series do not survive. Therefore, it is important to note that much work remains to reduce the risk of infection and popularize CAPD in a developing countries despite the fact that kidney transplant is still the optimum treatment for this type of patients.