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research letter

Indian Pediatr 2015;52: 531-532

Continuous Ambulatory Peritoneal Dialysis in Children – Experience from Eastern India


Rajiv Sinha and *Subhashis Saha

Department of Pediatrics, Institute of Child Health; and *AMRI group of Hospitals and Fortis Hospital;
Kolkata, West Bengal, India.
Email: [email protected]

  


Twenty-three children (
£18 years) have been initiated on continuous ambulatory peritoneal dialysis at our center over the last 32 months. Ten (43%) went on to have successful transplantation proving the viability of pediatric continuous ambulatory peritoneal dialysis in our scenario. Major concern identified was a relatively high peritonitis rate of 0.85 per year of peritoneal dialysis usage.

As per Western data, pediatric End Stage Renal Disease (pESRD) has an incidence of 9.4 per million age related population (pmarp) and prevalence of 56.8 pmarp [1]. Although no such reports are available from India, with a pediatric population of over 400 million [2] the numbers are likely to be significant. In children, peritoneal dialysis is usually preferred over hemodialysis with the significant advantage of it being conducted at home [3]. Unfortunately Indian data on chronic pediatric perfitoneal dialysis is limited [4]. We retrospectively reviewed all children £18 years initiated on continuous ambulatory peritoneal dialysis (CAPD) between January 2011 and August 2014 at our centre.

Twenty-three children were identified with median age at last follow-up of 10.3 (range 5.1 -17.4) years (74% male). Underlying etiologies were : congenital anomalies of kidney and urinary tract (n=6), focal segmental glomerulosclerosis (n=4), autosomal recessive polycystic kidney disease (n=3), nephronopthisis (n=3), atypical Haemolytic Uremic Syndrome (n=2) and unknown etiology (n=5). 35% (n=8) needed urgent dialysis, whereas the rest were known to be suffering from chronic kidney disease for median 4.1 (range 0.4 to 10.8) years. Median age at onset of CAPD was 9.2 (range 3-16.5) years and median duration of CAPD was 15 (range 3- 48) months. Only 6 (23%) were local city residents and for the rest median distance from nearest pediatric dialysis centre was 102 (range 17 to 689) kilometre. Post initiation, four (17%) children required catheter reposition because of poor fluid drain, but of these, only one needed catheter change. Usual CAPD prescription was 3 to 4 exchanges of 4 to 6 hours duration with dwell volume of 1L/ m2 of body surface area. Twelve (52%) children developed peritonitis as per standard definition [5]. Overall, peritonitis rate was 0.85/year of peritoneal dialysis use. E. coli was the commonest organism (82%). None had exit-site infection. Only a single episode of fungal peritonitis was reported. Culture negative peritonitis was seen in 5 (21 %) cases. Duration of CAPD significantly correlated with peritonitis (P=0.006). Significant improvements were seen in various laboratory parameters except serum albumin and creatinine (Table I). One child was lost to follow up at 1 month. Of the rest, 8 (35%) underwent successful transplantation while on CAPD, 5 (22%) were switched to hemodialysis for recurrent peritonitis (2 subsequently underwent transplantation), 4 (17%) died on CAPD and 5 (22%) are still on CAPD for median duration of 9 (range 3 -14) months. Of the 4 deaths, three were associated with peritonitis and all of them had compliance issues due to financial constraints.

TABLE I Biochemical Parameters 
Biochemical parameters At initiation At last follow up
Albumin (g/dL) 2.8 (0.6) 3.3 (0.6)
Hemoglobin# (g/dL) 7.1 (0.8) 9.2 (1.5)
Urea (mg/dL)* 147.6 (43.2) 105.1 (39.3)
Creatinine (mg/dL) 7.5 (3.3) 6.2 (2.5)
Phosphate# (mg/dL) 6.9 (1.6) 4.8 (1.3)
Values in mean (SD); # P<0.001; *P<0.01.

In conclusion, pediatric CAPD is a viable option in India as 43% of children finally progressed to transplantation. Although the results are better than previous Indian reports, peritonitis and mortality continue to be a major concern when compared to international reports [4,6]. A likely solution might be better training for the caregivers by institution- based peritoneal dialysis nurses and consideration for financial support for these families [6,7].

References

1. Pruthi R, O’Brien C, Casula A, Braddon F, Lewis M, Maxwell H, et al. UK Renal Registry 15th Annual Report: Demography of the UK Paediatric Renal Replacement Therapy Population in 2011. Nephron Clin Pract. 2013;123:81-92.

2. Child Rights and You (CRY). Available from: http://www.cry.org/resources/pdf/types_of_corp_parts_sep11. pdf . Accessed October 20, 2014).

3. Just PM, de Charro FT, Tschosik EA, Noe LL, Bhattacharyya SK, Riella MC. Reimbursement and economic factors influ­encing dialysis modality choice around the world. Nephrol Dial Transplant 2008;23:2365-73.

4. Prasad N, Gulati S, Gupta A, Sharma RK, Kumar A, Kumar R, et al. Continuous peritoneal dialysis in children: a single-centre experience in a developing country. Pediatr Nephrol. 2006;21:403-7.

5. Piraino B, Bernardini J, Brown E, Figueiredo A, Johnson DW, Lye WC, et al. ISPD position statement on reducing the risks of peritoneal dialysis-related infections. Perit Dial Int. 2011;31:614-30.

6. Schaefer F, Borzych-Duzalka D, Azocar M, Munarriz RL, Sever L, Aksu N, et al; IPPN Investigators. Impact of global economic disparities on practices and outcomes of chronic peritoneal dialysis in children: insights from the International Pediatric Peritoneal Dialysis Network Registry. Perit Dial Int. 2012;32:399-409.

7. Ramachandran R, Jha V. Kidney transplantation is associated with catastrophic out of pocket expenditure in India. PLoS One. 2013;8:e67812.

 

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