Pediatr Nephrol
DOI 10.1007/s00467-016-3482-6
EDUCATIONAL REVIEW
Peritoneal dialysis for the management of pediatric patients
with acute kidney injury
Anil Vasudevan 1 & Kishore Phadke 2 & Hui-Kim Yap 3,4
Received: 29 September 2015 / Revised: 2 July 2016 / Accepted: 5 July 2016
# IPNA 2016
Abstract Renal replacement therapy (RRT) is the most im-
portant supportive measure used in the management of acute
kidney injury (AKI). Peritoneal dialysis (PD) is a safe, simple
and inexpensive procedure and has been used in pediatric AKI
patients, ranging from neonates to adolescents. It is the mo-
dality of choice for RRT in developing countries with cost
constraints and limited resources. However, its use has de-
clined with the availability of newer types of extracorporeal
modalities for RRT in the developed world. Much controversy
exists regarding the dosing and adequacy of PD in the man-
agement of AKI. Data in infants and children have shown that
PD can provide adequate clearance, ultrafiltration and correc-
tion of metabolic abnormalities even in those who are critical-
ly ill. Although there are no prospective studies in children,
data from retrospective studies reveal no differences in mor-
tality rates between different modalities of RRT. In this review,
we discuss the advantages and limitations of PD, indications
for acute PD, strategies to improve the efficiency of acute PD
and outcomes of PD in children with AKI.
Keywords Peritoneal dialysis . Acute kidney injury . Renal
replacement therapy . Prescription
* Anil Vasudevan
anil.vasudevan@sjri.res.in
1
Department of Pediatric Nephrology, St. John’s Medical College
Hospital, Bengaluru, Karnataka, India 560034
2
Rainbow Children’s Hospital, Bengaluru, India
3
Department of Paediatrics, Yong Loo Lin School of Medicine,
National University of Singapore, Singapore, Singapore
4
Khoo Teck Puat-National University Children’s Medical Institute,
National University Hospital, Singapore, Singapore
Introduction
Renal replacement therapy (RRT) is often required in the man-
agement of children with acute kidney injury (AKI), especial-
ly in critically ill children [1–3]. The different options for RRT
have expanded from peritoneal dialysis (PD) and intermittent
hemodialysis (HD) to continuous RRT (CRRT; continuous
venovenous hemodialysis/hemofiltration/hemodiafiltration),
slow low-efficiency dialysis and slow continuous ultrafiltra-
tion. PD has been successfully used to treat AKI across all age
groups, including neonates following open heart surgery for
congenital heart disease, in critically ill children with multi-
organ failure and shock, infection and sepsis and following
natural disasters, particularly in regions that are remote and
have poor infrastructure [4–8]. It remains one of the most
common RRT modalities in AKI in developing countries
[9–11]. However, despite PD being a common RRT modality
in the management of children with AKI, the choices of cath-
eters, treatment regimens and dosing are not standardized due
to limited evidence. Recently, the International Society of
Peritoneal Dialysis has published guidelines to help standard-
ize clinical practice [12]. In this review we discuss the advan-
tages and limitations of PD, indications for acute PD, strate-
gies to improve the efficiency of acute PD and outcomes of
PD in children with AKI.
Advantages of acute PD
Peritoneal dialysis offers several advantages over other forms
of RRT in children. First, this RRT modality is particularly
suitable for children as the peritoneal surface area of pediatric
patients is greater than that of adults (per unit weight), leading
to more efficient solute clearance as compared to PD in adults
[13]. Second, PD is a dynamic dialysis process which is more

physiological and less pro-inflammatory than HD because the
natural biocompatible peritoneal membrane is used as the di-
alyzer [14]. Third, cardiovascular tolerance is excellent as the
gradual and continuous nature of solute and fluid removal
during PD permits large volumes of ultrafiltration without
causing hemodynamic instability [15, 16]. Finally, the perito-
neal membrane has large pores which allow clearance of
higher molecular weight substances as compared to HD; this
may provide a potential advantage over conventional HD and
filtration in patients with sepsis as it allows removal of toxic
cytokines [17].
PD is technically simple and can therefore be performed
with minimal infrastructural support and without an Bintensive
care unit (ICU) environment.^ This attribute not only makes
PD a lifesaving procedure in regions with poor infrastructure
and lack of trained staff, but also in places affected by calam-
ities where HD cannot be used due to the destruction of infra-
structure, disruption of power and limited accessibility to
clean water [18, 19]. The financial cost of providing PD
may be as much as three- to fivefold less than that of providing
HD or CRRT, making the former a more viable RRT modality
in developing countries [20, 21]. PD can be a good choice in
critically ill children with shock, multi-organ failure and co-
agulopathy. It is also a useful modality in newborns, including
babies weighing <1000 g and infants in whom obtaining a
vascular access for extracorporeal therapy can be very chal-
lenging [22, 23]. The dialysate which contains dextrose can
also act as a source of supplemental calories for the patient
undergoing PD, especially infants for whom hypoglycemia
with fluid restriction may be a problem [24]. The continuous
ultrafiltration by PD also allows for adequate nutrition by
creating more space for fluid administration.
Limitations associated with acute PD
There are several limitations associated with acute PD. PD
requires an intact peritoneal cavity and hence is relatively
contraindicated in children with recent abdominal surgeries,
abdominal cellulites, inguinal hernia, diaphragmatic hernia,
paralytic ileus and peritonitis [25]. The ultrafiltration and sol-
ute removal is unpredictable, hence controlled ultrafiltration
and precise fluid balance cannot be obtained with PD.
Consequently, PD is not an ideal choice in critically ill chil-
dren with multi-organ dysfunction who require meticulous
management of volume status in addition to the removal of
uremic toxins in order to maintain hemodynamic stability.
Poor ultrafiltration is another concern, especially in new-
borns and critically ill infants on high ventilator settings due to
inability to increase the dwell to the desired volume, as this
will increase intra-abdominal pressure and interfere with re-
spiratory mechanics, with worsening of symptoms [26, 27]. In
addition, many of these critically ill children are in severe
Pediatr Nephrol
shock and may have decreased splanchnic perfusion due to
vasoconstriction of the mesenteric vessels, which also contrib-
utes to the poor ultrafiltration. Although peritoneal access can
be obtained at the bedside percutaneously, allowing rapid ini-
tiation of therapy, the slow and gradual nature of PD with
unpredictable ultrafiltration may result in a slower correction
of life-threatening hyperkalemia or severe acute pulmonary
edema. The clearance of small solutes is slower with acute
PD as compared with a 4-h hemodialysis session or CRRT
[28, 29], with the potential to result in inadequate clearances in
hypercatabolic patients. Slow clearance of small solutes also
makes PD less effective than HD or CRRT in children with
inborn errors of metabolism (IEM), such as hyperammonemia
where the neurological outcome is correlated with the rapidity
of normalization of urea [30, 31]. In these patients, CRRT or
HD, both of which permit more efficient ammonium removal,
are recommended as the modality of choice during the acute
phase [32, 33]. The use of PD may be a reasonable option until
extracorporeal therapy can be commenced or when other
forms of RRT are not available [34]. In their analysis of 45
neonates who underwent extracorporeal dialysis (ECD) or PD
for hyperammonemia secondary to IEM, Picca et al. observed
that the initiation of PD at an average of 10 h after IEM diag-
nosis versus initiation of ECD 20 h after the onset of
hyperammonemia resulted in no difference in the short-term
outcome of these patients [35]. In certain clinical situations,
such as rapidly progressive glomerulonephritis and acute liver
failure, where dialysis is often combined with plasma ex-
change (PE) or immunoadsorption, HD is preferred over PD.
Over and above from the convenience of using the same ac-
cess, the combined procedure of HD and PE in tandem or
sequentially allows for a more efficient treatment [36, 37].
Mechanical complications associated with PD include
leaks, catheter displacement, catheter obstruction and hernias.
These complications lead to poor drainage of the dialysis fluid
which in turn impacts the overall efficiency of dialysis.
Dialysate leakage may occur around the catheter, especially
when large fill volumes are used. Peri-catheter leakage can be
prevented by using a lower dwell volume and tightly secured
purse string sutures at the site of entrance of the catheter into
the peritoneal cavity (for rigid catheters) and by precisely
placing the catheter cuffs. Fibrin glue has been successfully
used for the treatment of peritoneal dialysate leakage in infants
and small children on PD [38]. Dialysate may also leak into
the pleural space, through the pleuro-peritoneal channels,
resulting in hydrothorax. Severe cases may require cessation
of PD and surgical closure of the communication or
pleurodesis. Catheter obstruction is usually due to kinking,
omental wrapping or displacement of the catheter or to the
formation of fibrin clot. The risks of catheter displacement/
malposition, peri-catheter leakage and catheter obstruction are
much lower with the use of Tenckhoff catheters as compared
to rigid stylet catheters [39–41].
Pediatr Nephrol
Serious complications, such as bladder or bowel perfora-
tion, are rare and mostly seen with the use of a rigid catheter.
Hence it is important to ensure that the bladder is completely
drained prior to the procedure and that a good fluid reservoir is
achieved prior to insertion of the catheter. Bowel perforation is
manifested by severe abdominal pain and leak of intestinal
contents and may require surgical repair in some cases [4].
Other potential problems specific to PD include the risk of
hyperglycemia from glucose-containing dialysate and wors-
ening of nutritional status due to excessive protein loss
through the peritoneal route [42]. Hypothermia, especially in
malnourished children and small infants, may occur if pre-
warmed PD fluid is not used.
Indications for acute PD in children
In recent years, the indications for acute PD in critically ill
patients have been somewhat limited, mainly because of the
advent of newer HD techniques and the development of
CRRT. The extracorporeal modalities now incorporate several
technological advances that have successfully competed with
the traditional advantages of PD, such as the use of local
anticoagulation which minimizes bleeding risk and tighter ul-
trafiltration control with precise volumetric systems resulting
in better cardiovascular stability.
Acute PD remains the modality of choice in newborns and
infants who develop AKI following surgery for congenital
heart disease or from sepsis. Acute PD is currently the best
modality for managing Buncomplicated^ or primary renal dis-
ease causing AKI, such as glomerular diseases, acute tubular
necrosis due to ischemia and/or drugs and hemolytic-uremic
syndrome. This modality has been found to be useful in chil-
dren with AKI secondary to snake bites and infections such as
leptospirosis and malaria [43, 44]. Acute PD is also a useful
modality in critically ill children with severe hypotension who
are unable to tolerate more intensive extracorporeal therapy.
PD is the modality of choice in children with difficult vascular
access or with severe bleeding diathesis which makes vascular
access and extracorporeal therapy unsafe. The ability of PD to
achieve continuous gentle ultrafiltration with minimal impact
on hemodynamic status makes it pathophysiologically an at-
tractive therapy in patients with diuretic-resistant congestive
heart failure. Ultrafiltration using PD has shown promise in
the treatment of adult patients with decompensated or refrac-
tory congestive heart failure [45, 46]. Although controlled
trials are lacking, children with acute decompensated heart
failure constitute another patient group for whom PD for ul-
trafiltration may be preferred.
However, there is a wide variation between different coun-
tries in the choice of acute PD as the primary modality for
providing RRT in AKI [47, 48]. The use of PD in the man-
agement of AKI has declined steadily in developed regions of
the world since the 1990s, while it continues to be the modal-
ity of choice in developing countries [49, 50]. Many factors
are responsible for the dissimilar pattern in the choice of mo-
dality between countries. As mentioned earlier, with the ad-
vent of these extracorporeal dialytic therapies with better tech-
niques, improved patient safety profile and improved strate-
gies for vascular access, it is now possible to dialyze critically
ill children with unstable hemodynamic status and even new-
borns and infants with modalities other than PD [51, 52]. The
declining use of acute PD in developed regions is also due to
the notion that PD is not as efficacious as HD in AKI [53].
Growing loss of physician familiarity with PD coupled with
reduced training opportunities in PD that affect competency
and increased physician Bcomfort^ with HD and CRRT have
also contributed to the decline [54]. PD is the modality of
choice in many developing countries, especially in the man-
agement of children, because it is cheap and requires minimal
resources [55, 56]. Taking into account the importance of PD
as a lifesaving therapy for the management of AKI in these
minimally resourced countries, the International Society of
Nephrology-Global Outreach (ISN-GO), International
Society for Peritoneal Dialysis (ISPD) and International
Pediatric Nephrology Association (IPNA) in collaboration
with other organizations have developed educational pro-
grams for acute PD, as part of the global outreach and
capacity-building initiatives [57, 58].
Efficiency of acute PD
The most appropriate dose for PD in the management of pa-
tients with AKI is poorly defined. In addition to solute clear-
ance, factors such as fluid balance, acid–base and electrolyte
disturbances and nutritional factors also have to be considered
while dialyzing a child with AKI. A recent guideline recom-
mends that a targeted dose of a weekly Kt/V urea of 2.1 with
PD may represent a reasonable goal [12]. There is limited data
to determine the minimum PD dose in AKI in children and
adults. In a prospective study involving five patients aged 6–
839 days who underwent cardiopulmonary by-pass and devel-
oped AKI requiring PD, a Kt/V of >2.1 (median 4.84, range
2.12–5.59) was achieved in all patients [59]. In another study
involving 20 neonates requiring postoperative PD following
cardiopulmonary bypass, the PD creatinine clearance and ul-
trafiltration rate was 3.4 ml/min/1.73 m2 and 9.75 ml/h, re-
spectively, independent of hemodynamic status or vasopressor
support [60]. Similarly, in a study that used dialysate volumes
of <20 ml/kg in 12 critically ill infants and children with
hypervolemia, the average ultrafiltration obtained was 3.0
± 0.3 ml/kg/h [61]. Fleming et al. compared PD and CRRT
in a small cohort of children (n = 42) who underwent RRT
after repair of congenital heart disease [62]. These authors
observed that ultrafiltration rate and solute clearance as

measured by percentage reduction in urea and creatinine was
higher with CRRT than with PD. Controversy exists regarding
the efficacy of PD in critically ill patients with AKI, who are
often severely hypercatabolic [63].
Strategies to improve dialysis efficiency in acute PD
The efficiency of PD is influenced by choice of peritoneal
catheters, method of fluid delivery, the choice of regimen
and prescription of PD. Figure 1 describes the setting-up of
acute PD and the practical aspects of prescribing, delivering
and monitoring PD in patients with AKI.
Choice of catheter for peritoneal access, PD fluid and
method of fluid delivery Safe and efficient access to the
peritoneal cavity is a key factor for PD success. In order to
ensure an effective dialysis, it is important to insert a catheter
that provides a good dialysate flow with minimal mechanical
problems. The common types of catheters used in acute PD
are the rigid stylet catheter, Tenckhoff catheter and Cook
(Cook Medical Inc., Bloomington, IN) Teflon rigid catheter
[64–66]. The flexible Cook Mac-Loc Multipurpose Drainage
catheter (Cook Medical Inc.) is an alternative to the Tenckhoff
and Cook catheters [67]. The type of catheter used varies
widely between countries as it depends on the availability of
catheters, cost and expertise for insertion. A percutaneous or
surgically placed Tenckhoff catheter is the catheter of choice
for acute PD in children as continuous PD can be performed
for a long period of time. ATenckhoff catheter provides higher
dialysate flow rates, and the risks of catheter displacement,
peri-catheter leakage, organ injury and mechanical complica-
tions are much lower than with other catheter types [64, 66].
Rigid catheters should only be used if Tenckhoff or Cook
catheters are not available or if the expertise and/or requisite
infrastructure to place the Tenckhoff catheter is not available.
Recent guidelines from the ISPD suggest that if Tenchkoff
catheters are unavailable, catheters using the Seldinger tech-
nique for insertion, such as the Cook catheters, are preferred to
rigid catheters [12]. However, the reality in many emerging
economies is that the rigid catheters are the only available
catheters for acute PD [9, 48, 68].
Although the natural biocompatible peritoneal membrane
is used as the dialyzer, the conventional dextrose-containing
PD fluids may alter the functional and anatomical integrity of
the peritoneal membrane over time due to presence of glucose
degradation products (GDPs), high lactate and low pH levels.
In children on long-term dialysis, the use of pH-neutral solu-
tions with a low concentration of GDPs and bicarbonate or a
bicarbonate/lactate mixture as buffer has been associated with
better membrane preservation, less pain at peritoneal filling
and a smaller increase in intraperitoneal pressure (IPP) for the
same amount of fill volume [69, 70]. Several new PD
Pediatr Nephrol
solutions with low GDPs have been introduced, but these
are more expensive than the conventional dextrose/lactate-
containing solutions. Little information exists on the impact
of the use of these more physiological PD fluids in AKI. The
decision to use biocompatible PD solutions needs to be indi-
vidualized in AKI as there are clinically relevant benefits with-
out added risks of harm, as well as potential limitations.
Commercial or pharmacy-prepared bicarbonate-based solu-
tions may be used in critically ill children with shock, liver
dysfunction and metabolic disorders who have impaired con-
version of lactate to bicarbonate [71, 72]. Amino acid-based
PD solutions contain very low amounts of GDPs [70]. In a
retrospective study in children with AKI, Vande Walle et al.
observed lower glucose reabsorption and protein loss but no
significant difference in plasma albumin levels with use of PD
solutions containing amino acids as compared to only
glucose-based solutions [73]. Icodextrin is a less toxic osmotic
agent than glucose. However, the slow ultrafiltration process
with icodextrin-containing solutions limits its use in those
who require rapid fluid or solute removal [72].
Unfortunately, these newer biocompatible fluids are not avail-
able in many countries.
A manual, gravity-based closed system or automated sys-
tem using a cycler may be used for delivering and draining
dialysis fluid from the abdominal cavity. In neonates and
smaller children, buretrols, which permit the precise measure-
ment of in- and outflow is recommended for optimal dialysis
and fluid removal. Automated PD reduces the nursing burden
but adds to the cost; in addition, a trained nurse is required for
the smooth operation of the cycler which is not easily avail-
able in resource-poor settings.
Regimen of PD Peritoneal dialysis can be performed inter-
mittently or continuously with either manual or automated
exchanges using a cycler. The various regimens that have
been described are acute intermittent PD, continuous PD
(CPD), tidal PD (TPD), high-volume PD (HVPD) and
continuous flow PD (CFPD) (Fig. 2). These regimens
have been adapted from chronic PD to achieve adequate
solute clearances. Data comparing different regimens of
acute PD in children are not yet available. Acute intermit-
tent PD with a stiff catheter is used in children in coun-
tries with limited resources and cost constraints [9, 48].
The catheter needs to be removed after 3–5 days due to
increased risk of peritonitis and the mechanical complica-
tions associated with stiff catheters [74]. Hence, the small
solute clearance may not be sustained as it is an intermit-
tent process. CPD is similar to continuous ambulatory
peritoneal dialysis (CAPD) wherein PD is continued until
indicated. CPD may control azotemia and provide good
ultrafiltration but being a continuous system with a low
dialysate flow rate, it may provide inadequate nitrogen
balance in severe hypercatabolic patients [75]; however,
Pediatr Nephrol
Fig. 1 Flow diagram of the acute peritoneal dialysis (PD) set-up and the
associated practical aspects of prescribing, delivering and monitoring PD
in patients with acute kidney injury (AKI). Asterisk Catheter change every
3–5 days, @@Delivered Kt/V (the dose target for PD in AKI has not been
dialysate urea nitrogenðmg=dlÞ
well studied) ¼ Mean mean serum urea nitrogenðmg=dlÞ before and after dialysis 
the middle molecular weight solute clearance may be
higher as the dwell time is longer [76]. TPD is a modality
wherein only a portion of dialysate (25–50 % of dwell
volume) is drained, giving a tidal volume of 50–75 %
[77]. TPD always requires a cycler. The clearance of
small and middle molecules is better in TPD than in
CPD, possibly because of a high dialysate flow rate
and shortened inflow and outflow times which increase
dialysate contact time [77, 78]. The disadvantage of
drained 24−hour volumeðmlÞ
RRT Renal replacement therapy, CPD
patient urea distribution volumeðmlÞ
continuous peritoneal dialysis, HD hemodialysis, CRRT, continuous
renal replacement therapy, ABG arterial blood gas, BUN blood urea
nitrogen
TPD is that the protein loss may be higher than with
CPD. Chitalia et al. performed a randomized crossover
trial in adults and obtained a weekly Kt/V of 2.43 and
1.80 for TPD and CPD, respectively, leading them to con-
clude that both TPD and CPD are reasonable options for
the management of mild-to-moderate hypercatabolic AKI
[77]. HVPD is another continuous modality in which each
session lasts 24 h and is repeated daily, with a dwell time
of 30–50 min, dwell volume of 1200 ml/m2 and 18–22

Urea Clearance
(ml/min)
15
Tidal PD
V Connuous 30-50
Flow PD
O
L 12- 15
Connuous PD
U children with Tenckhoff catheters without the risk of leak-
M age. The recommendation for children under 2 years old
E
8-12
Intermient
PD
TIME
Fig. 2 Diagrammatic representation of PD regimens with respect to urea
clearance. Adapted from: Ansari N [97] (open access)
exchanges/24 h [79]. The use of a high volume has not
been shown to interfere with oxygenation in ventilated
adult patients [80]. In single-center studies comparing
CPD or HVPD with HD in adults, although daily solute
clearances achieved with PD were lower than those
achieved with daily intermittent or extended HD, PD pro-
vided adequate ultrafiltration rates and control of bio-
chemical derangements in most patients [79–81]. CFPD
uses a fixed intraperitoneal volume and fast, continuous
movement of dialysate into and out of the peritoneal cav-
ity at a high flow rate using two peritoneal catheters
(Cook or Tenckhoff dialysis catheters) or one double lu-
men catheter [82]. In this modality, there is continuous
flow of the PD solution, unlike in CPD where the perito-
neal fluid is allowed to remain in the peritoneal cavity for
1–4 h. CFPD provides higher solute clearance and ultra-
filtration rates than the regimens due to maintenance of
the highest possible plasma to dialysate concentration and
minimal exchanges during the procedure, both of which
maximize the dialysis time. In the first reported study on
the use of CFPD in children with AKI admitted to the
ICU, CFPD was shown to be ninefold more effective than
conventional PD for ultrafiltration and at least three- to
fivefold more effective for urea and creatinine clearance
[83]. CFPD is technically complex and more costly than
the other modalities of PD which may preclude its routine
use in AKI, particularly at centers with limited resources.
Prescription of PD There are no standardized prescription
of dose, volume and duration of PD. The PD prescription
needs to be individualized according to patient size, clin-
ical condition and volume status with a goal to achieve
adequate ultrafiltration and biochemical control (Table 1).
The choice of dextrose concentration is based on volume
Pediatr Nephrol
status of the child. It is recommended that dialysis fill
volumes of 10–20 ml/kg (300 to 600 ml/m 2) be used
initially, especially in younger children who are at greater
risk of leaks, with increasing dwell times and cycle fill
volume (if no leakage problems or respiratory compro-
mise) until the desired fill volume of 30 ml/kg (800 ml/
m2), as tolerated by the child, is achieved. Larger volumes
of 40–50 ml/kg (1100–1400 ml/m2) may be achievable in
is not to exceed fill volumes of >800 ml/m2 due to prob-
lems related to increased interperitoneal pressure (IPP)
[84]. Whenever possible, the fill volume—especially in
infants and smaller children—may be scaled to body sur-
face area (in m2) rather that body weight (per kg) in order
to ensure an adequate fill volume. This step will prevent
the development of functional hyperpermeability, a major
risk factor for ultrafiltration failure [85].
An optimal dwell volume that is well tolerated by the
child is an important factor that enhances the adequacy of
PD. Bedside measurement of IPP in children on chronic
dialysis has been shown to be helpful in scaling the dwell
volume to prevent poor clearance secondary to inappro-
priately low fill volume and at the same time avoid com-
plications associated with large fill volumes, such as poor
ultrafiltration due to increased lymphatic absorption and
risks related to high IPP (leaks, hernia, pain and pleural
effusion) [86]. The upper level Bof tolerable^ IPP is 8–
10 cm H2O (800 ml/m2) and 13–14 cm H2O (1400 ml/m2)
in children aged <2 years and >2 years, respectively [59].
Since intra-abdominal hypertension due to increased intra-
abdominal pressure is an adverse complication seen in a
number of critically ill children, further studies are re-
quired to assess the appropriate upper level Bof tolerable^
IPP in children with AKI receiving PD [87].
The initial exchange time (combined time for inflow,
dwell and drain) suggested is 60–90 min, with a dwell
time of 30–40 min [12]. Current practice in many parts
of the world suggests that 1-h dwells may also be used
initially, especially in CPD, which can be gradually in-
creased to ensure adequate dialysis [9, 12, 72]. Shorter
dwells can be considered initially in the presence of life-
threatening hyperkalemia, hypercatabolic states or fluid
overload, especially in neonates and infants, as reducing
the dwell time increases the dialysate flow rate resulting
in more efficient dialysis. In CPD, the dwell time can be
gradually prolonged after 24 h to that used for chronic
dialysis based on patient tolerance, adequacy of fluid re-
moval and normalization of metabolic parameters. The
duration of PD depends on the dose of PD that needs to
be delivered. Fluid balance, metabolic control and renal
recovery are factors which determine the length of a dial-
ysis session.
Pediatr Nephrol
Table 1 Components of acute
peritoneal dialysis prescription Components
Length of the dialysis session
Composition of dialysate (%
dextrose)
Exchange volume
Exchange time—inflow, dwell,
outflow time
Additives to dialysate
Monitoring
PD, Peritoneal dialysis
Timing of initiation of PD
One of the important questions to address in the manage-
ment of children with AKI is when to initiate RRT in pa-
tients with AKI. The optimal timing for RRT initiation is
not determined. Most of the studies on the timing of RRT
in AKI in children involve children receiving CRRT.
Analysis of 116 pediatric patients with multiple organ dys-
function syndrome (MODS) and AKI who received CRRT
showed that children with patient fluid overload of >20 %
at the time of CRRT initiation had decreased survival com-
pared to those with fluid overload of <20 % [88]. In anoth-
er retrospective cohort study of critically ill children who
received CRRT for management of AKI and/or fluid over-
load (n = 190; 380 treatments), timing of initiation was
identified as an independent predictor of mortality with
modest effect (adjusted odds ratio 1.05; 95 % confidence
interval 1.01–1.11) [89]. Similarly, results from a meta-
analysis based on heterogeneous studies of variable quality
suggest that outcomes of RRT in critically ill patients with
AKI are superior with early institution of RRT, but no clear
definition of Bearly^ was provided [90]. In the only study
which has examined the timing of PD in AKI, Bojan et al.
observed that in their retrospective cohort of 146 neonates
and infants who received PD for the treatment of AKI
following cardiac surgery, initiation of PD on the first
day following surgery was associated with a significant
decrease in mortality compared with delayed dialysis [91].
Comments
Length of dialysis session determined by fluid balance, biochemical
abnormalities and urine output
Ultrafiltration rate of 1.5 % dextrose and 2.5 % dextrose (40 ml/kg dwell) is
50–150 and 200–400 ml/h, respectively. A higher concentration of dextrose
solution may be used for initial cycles in children with severe fluid
overload.
Initial fill volume: 10–20 ml/kg; maximum fill volume: 30 ml/kg or 1100 ml/
m2, but <800 ml/m2 if age <2 years. The higher the fill volume, the greater
the clearance and ultrafiltration.
Initial exchange time is 1 h—inflow 10 min, dwell 30–40 min, outflow
20 min. Dwell time pf 1–4 h in continuous PD using a flexible catheter.
Shorter dwell time for rapid fluid, urea and potassium clearance (e.g. severe
hyperkalemia or pulmonary edema).
If hypernatremia develops, extend the dwell time if feasible or lower glucose
concentration in dialysis solution.
Potassium 3–4 mmol/l
Heparin 250–1000 U/l
Fluid balance q 4–6 h
Serum electrolytes per 6–12 h
Blood sugar per 6–12 h (more frequently if using 2.5 or 4.25 % dextrose based
dialysis fluid)
Blood urea and serum creatinine per 24 h
Impact of PD on outcomes in children with AKI
No prospective studies in children have evaluated the ef-
fect of dialysis modality on the outcome of children with
AKI. The outcomes by various modalities of RRT for
AKI are summarized in Table 2; all these studies are ret-
rospective in nature and have patient selection bias. A
retrospective analysis of 118 infants and children treated
either with PD (n = 82) or CRRT (n = 36) demonstrated
that there was no difference in mortality rates between
modalities, although CRRT provided better fluid control
[92]. Fleming et al. reported similar findings in their ret-
rospective study comparing PD (n = 21) and CRRT
(n = 21) in 42 children with AKI who underwent surgery
for repair of congenital heart disease [62]. Although a
higher proportion of children in the CRRT group obtained
negative fluid balance and better solute clearance as com-
pared to the PD group, the mortality rates were similar in
the two groups. In a large retrospective analysis of 226
children comparing CRRT (n = 106), HD (n = 61) or PD
(n = 59), survival rates between PD and CRRT were sim-
ilar, but higher survival rates were seen with intermittent
HD than with PD or CRRT (89.9 % vs. 49 % and 40 %,
respectively) [93]. In another retrospective study of 115
children with AKI requiring RRT, a similar trend of fa-
vorable outcome with HD as compared to PD or
hemodiafiltration was observed [94]. The better survival
rate seen with HD in both of these studies is due to fewer
 Pediatr Nephrol

Table 2 Comparison of outcome

by renal replacement therapy Study/Sample size Age (range) Modality of Complications Survival
modality in acute kidney injury RRT
(no. of subjects)

Bunchman et al. 0 days– PD (59) PD: PD 49 %

[93] 18 years HD (61) -Mechanical (<5 %) HD 81 %*
( n = 226)
HF (106) -HD/HF HF 40 %
-Bleeding (5 %)
-Clotting of access (6 %)
Fleming et al. [62] 1 week– PD (21) PD: PD 38 %
(n = 42) 11 years HF (21) -Hypokalemia (76 %) HF 38 %
-Mechanical (14 %)
-Peritonitis (9.5 %)
HF:
-Hypokalemia (57 %)
-Hypothermia (19 %)
-Bleeding (9.5 %)
Krause et al. [94] 0 days– PD (81) PD: PD 48.8 %
(n = 115) 16.5 years HD (18) -Access failure (8.7 %) HD
HF (31) -Peritonitis (4.3 %) 91.7 %**
-Hemodynamic instability (2.6 %) HF 16.7 %
HD/HF:
-Hemodynamic instability (30.
5 %)
-Bleeding (5.6 %)

*p < 0.01 HD vs. HF or PD; **p < 0.001 HD vs. HF or PD

The studies are retrospective in nature and have patient selection bias
RRT, Renal replacement therapy; HD, intermittent hemodialysis; HF, hemofiltration

sick children and older children being preferentially dia-
lyzed using HD. A systematic review of 11 studies in
adults (7 cohort studies, 4 randomized trials) looking at
outcomes in patients with AKI treated with PD found no
significant differences in mortality between PD and extra-
corporeal therapies [95]. However, a significant heteroge-
neity (I2 = 73 %, p = 0.03) between studies was noted. Two
studies in adults from the same center that compared
HVPD with HD or extended HD noted shorter time to
renal recovery with PD, possibly due to the absence of
extracorporeal circulation resulting in a reduced risk for
worsening of renal ischemia [81, 96].
is a viable alternative to HD and CRRT in AKI, particularly in
children with hemodynamic instability, severe coagulopathy
and mild-to-moderate catabolic conditions. It is the modality
of choice in settings that do not have access to extracorporeal
therapies or if there are cost constraints. The minimum dose of
PD in AKI has not been well studied. Various techniques of PD
are available to achieve a high small solute clearance. To date,
data do not suggest any inferiority of PD over other modalities.
Multicentric, randomized studies in children are required to
compare adequacy between different RRT modalities and to
evaluate the impact of modality on outcomes.

Key summary points

Conclusion
Peritoneal dialysis is a simple, safe and inexpensive procedure
and is an option for the supportive management of AKI. In the
absence of evidence-based guidelines for the selection of mo-
dality of RRT for AKI, the choice of PD is based on local
expertise, available resources and the patient’s clinical status.
PD performed with a flexible catheter ensuring efficient dialysis
1. PD is a technically simple and inexpensive form of mo-
dality used as RRT in children with AKI although its use
has declined considerably in developed countries.
2. Using the appropriate catheter and technique, adequate
solute clearances, ultrafiltration and metabolic control
can be achieved even in critically ill infants and children,
although fluid removal may be unpredictable.
Pediatr Nephrol
3. Currently there is no evidence to suggest significant dif-
ferences in mortality between PD and extracorporeal dia-
lytic modalities in AKI.
Key research points
1. There is a need for multicentric randomized controlled
trials to evaluate the impact of modality of RRT in the
outcome of children with AKI and also to identify the
group of children who would benefit the most from PD.
2. Evaluation of the delivery of doses and clearance using
novel regimens of PD (continuous flow PD, tidal PD,
high-volume PD) in various settings of AKI in infants
and children is needed.
3. Studies assessing the transport characteristics in acute PD
are needed in order to determine the most appropriate PD
regimen in children.
Questions (answers are provided following
the reference list)
1. Which of the following statement is true:
a) Peritoneal surface area in infants is lower than that in
adults (per unit weight)
b) To perform PD, an BICU environment^ is not always
necessary
c) PD is not safe in patients with bleeding diathesis
d) Controlled and precise fluid balance can be obtained
with acute intermittent PD
2. The maximum dwell volume in PD is:
a) 800 ml/m2
b) 1000 ml/m2
c) 1200 ml/m2
d) 1400 ml/m2
3. All of the following are true with reference to composition
of standard 1.7 % peritoneal dialysis fluid with the excep-
tion of:
a) Osmolarity of 355 mOsm/l
b) Sodium of 130 mmol/l
c) Potassium of 2 mmol/l
d) Dextrose of 1.7 g/dl
4. Which of the following regimens of PD has highest small
solute clearance as compared to standard PD:
a) Tidal PD
b) Continuous flow PD
c) High-volume PD
d) All have similar solute clearances
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
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