Peritoneal Dialysis International | 2021
Peritoneal dialysis in children: Reaching milestones but room for growth
Abstract
Peritoneal dialysis (PD) is the most common chronic dialysis modality in children, particularly for younger children, given its almost universal applicability, costeffectiveness and quality-of-life advantages of a homebased treatment. Improved survival and outcomes are largely due to advances in dialysis technology, improved dialysis fluids and clinical expertise in the management of dialysis-related complications. Yet, there are few highquality randomized controlled trials (RCTs), or even large prospective studies among children on PD. This issue of Peritoneal Dialysis International (PDI) focuses on paediatric PD, presenting a guideline and several interesting reports. Although PD is frequently utilized in the management of acute kidney injury (AKI), unlike the adult literature, there are no RCTs comparing the effectiveness or outcomes of different renal replacement modalities for the treatment of AKI in children. Nourse and colleagues present clinical practice recommendations on the use of PD for the treatment of AKI in children. In the absence of an evidencebase, recommendations are largely based on observational studies and expert opinion. Very practically, the guideline differentiates between minimum standards and optimal care, empowering colleagues in lower and middle-income countries to consider and perform PD even in resourcelimited settings. The prodigious experience of the authors provides the reader with several clearly defined and comprehensive practice points from catheter insertion and PD fluid selection to adapting the PD prescription for fluid and solute clearance. Topics for future research are clearly outlined, stressing that we have a long way to go in our understanding of optimal care for these children. Accurate assessment of volume status continues to be challenging in children on maintenance PD. Routine and frequent evaluation is needed to distinguish weight increases that are due to volume overload from physiological growth-related changes. Hypertension, although largely volume-related in paediatric dialysis patients, may be multifactorial. Karava et al. present a prospective longitudinal study measuring bioimpedance spectroscopy (BIS), blood pressure and serum albumin at multiple time points over 6 months in children with a median age of 12.6 years. They demonstrate the advantage of BIS over blood pressure or weight monitoring to assess volume status; BIS was particularly useful when serial changes in the relative overhydration status were assessed rather than a single measure. These data support larger paediatric studies recommending regular and multimodality assessment of hydration status, including objective measures such as BIS. Further reports within this issue of PDI address immune cell dysfunction, in particular the chemokine-receptor system on T-cells which play a role in lymphocyte migration and infiltration. Using flow-cytometric analysis of the absolute numbers and percentage of T-cell subsets with surface chemokine receptors or receptor combinations in children on maintenance PD, SzczepaĆska et al. could not confirm premature T-cell senescence in this cohort. Further research on immune disorders, including gene polymorphisms in chemokine receptors, and the effect of anti-inflammatory treatment or chemokine receptor antagonists, is required. Extrapolating adult PD research findings to the paediatric population may not always be appropriate. As an example, in this issue of PDI, Hennessy et al. discuss dosing recommendations for the use of intraperitoneal vancomycin based on pharmacokinetic modelling, pointing out that current dosing recommendations that are based on adult practice may lead to toxic vancomycin levels among children. Although much has been achieved, as a paediatric nephrology community we have a long way to go in providing high-quality PD for children that is informed by evidence-based practice. Given the rarity of maintenance