Acute peritoneal dialysis for children
Indications
- Acute kidney injury
- No obvious signs of chronic kidney disease (poor growth, LVH, small kidneys,
anemia without other causes, severe hypertension)
- Fluid overload
- Hyperkalemia
- Acidosis
- Uremic symptoms (nausea, vomiting, confusion, low level of consciousness,
convulsions)
Management
- involve pediatric surgeons, contact early (send a catheter + a transfer set to
theatre)
- Give Ceftriaxone IV stat 1/2-1 hour before the procedure
PD
- start with 10-20ml/kg exchanges
- In the beginning frequent exchanges, usually 1,5-2 hours
- More frequent if severe hyperkalemia
- If the catheter is not leaking, the exchange volume can be increased up to
30ml/kg next day
- Fluid: use
- 1.5% (blue), if mild or no fluid overload
- 2.5% (green), if fluid overload
- 4.25% (red), if pulmonary edema
- Take K, Na daily, if possible
- If K < 4.0, add potassium to PD fluids, 3-4 mmol/l
- If Ca result available, correct severe, symptomatic Hypocalcemia
- Give fluids po/iv to keep the patient euvolemic/slightly fluid overloaded, usually need fluid restriction
- After 2-3 days of treatment, if patient euvolemic, acidosis and hyperkalemia resolved
- Decrease the dose of PD: longer dwell times 3-4 hours or do dialysis only 10-12 hours per day with frequent 2h exchanges (at night the abdomen can be empty or fluid can stay in the whole night)
- HAND DESINFECTION!
- Involve Umodzi early if no prompt improvement
Possible problems
Catheter not draining out
- Most common cause is constipation - give bisacodyl, enema etc
- May be fibrin clotting the catheter (especially if severe inflammation) -
add heparin 500-1000 IU/1000ml of PD fluids
- May be omentum blocking the catheter or wrong position - catheter
needs to be changed
- Abdominal X-ray for position of the catheter (supposed to be behind
the urinary bladder)
Poor ultrafiltration
- Check catheter's position and that the catheter is draining well
- Use stronger fluids
- Rule out hyperglycemia
Fever
- Likely cause is PD peritonitis
- Symptoms: abdominal pain, vomiting, but often only fever
- On examination abdomen is usually not peritonistic, PD fluid is cloudy
- Take WBC + culture from the PD fluid
- Give ceftriaxone (+/- ciprofloxacin)
- Commonest causes: Staphylococcus species, enterococcus
Stop PD
- When patient has been passing good amounts of urine 1-2 days, doesn't have uremic symptoms and creatinine is decreasing (if possible to measure)
- If no improvement in 3-4 weeks (discuss with seniors)