Neobook — clinical reference

Assessment of membrane function

Knowledge of the transport capacity of the patient’s peritoneal membrane is required to be able to write an optimal dialysis prescription. For this purpose a peritoneal equilibration test should be done with an exchange volume scaled to the body surface area and peritoneal membrane surface area of the child.^4,5

PD solutions

Should meet the requirements of the European good manufacturing practice and the European Pharmacopoeia Monograph “Solutions for Peritoneal Dialysis”. Manufacturing facilities are required to meet the relevant standards (ISO 9001/2 and EN 46001/2)
Glucose is the standard osmotic agent in most dialysis solutions e.g. Dianeal 1.5 % and 2.5 %
Higher glucose concentrations should be avoided as it results in more damage to the peritoneal membrane and eventually membrane failure and failure of the technique
Glucose degradation products in dialysis solutions damage the peritoneal membrane in the long term
High glucose concentrations are also associated with increased absorption of glucose which results in the development of obesity, hyperinsulinism and dyslipidaemia
The rate of absorption of glucose from the peritoneum varies and affects the length of time for which the gradient remains effective
To improve ultrafiltration, dialysis fluid with higher glucose concentrations or shorter dwell times are used
Standard dialysis solutions contain lactate which contributes to peritoneal fibrosis
Newer solutions contain bicarbonate in a separate bag which can be mixed into the main solution just before instilling into the peritoneum. It is associated with less pain during filling and less injury to the peritoneal membrane
The sodium concentration in dialysis fluid is usually 132 - 134 mmol/L. Children may need sodium supplementation particular those with ongoing renal tubular salt losses or diarrhoea
Dialysis fluids with two different calcium concentrations are available i.e. 1.75 mmol/L and 1.25 mmol/L
The latter is mostly used in children who receive large doses of calcium-containing phosphate binders or in those with increased levels of blood ionised calcium.

Determination of exchange volume

The fill volume in children should be scaled to body surface area
In children >2 years the target volume should be 1000- 1200 ml/m² body surface area
In patients receiving automated PD the exchange volume can be gradually increased to the upper limit of 1200-1400 ml/m²
In children <2 years an initial dwell volume of 600-800 ml/ m² should be used
Maximal volume is determined by intraperitoneal pressure.

Assessment of PD adequacy

Dialysis prescription should be individualised for each patient
Treatment goals are aimed at improving the overall clinical status of the patient
Consider ultrafiltration, water and sodium balance, and blood purification of components including urea and phosphate
Current recommendations are a combined peritoneal and kidney Kt/Vurea of ≥ 1.8
When calculating V, sex-specific nomograms should be used
Clinical indications of inadequate dialysis include congestive heart failure, hyperphosphataemia, excessive calcium-phosphate product, overt uraemia (pericarditis or pleuritis) and clinical and biochemical signs of malnutrition or wasting.

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Van Biljon I, Bhimma R, Gajjar P, McCulloch M, Nourse P. Guideline for Chronic Dialysis in Children in South Africa. South African Renal Society; 2015.