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Adequacy of peritoneal dialysis in children: consider the membrane for optimal prescription
Michel Fischbach1, Celine Dheu, Laure Seugé-Dargnies
1Nephrology Dialysis and Transplantation Children's Unit, University Hospital, University Louis Pasteur, Strasbourg, France. Michel.Fischbach@chru-strasbourg.fr
Insights
Optimizing peritoneal dialysis (PD) involves tailoring fill volume and dwell times. Adequate fill volume, scaled by body surface area, and appropriate dwell times are crucial for effective dialysis and patient outcomes.
Area of Science:
- Nephrology
- Renal Replacement Therapy
Background:
- Peritoneal dialysis (PD) prescription adequacy is key before optimization.
- The peritoneal membrane acts as a dynamic dialyzer with recruitable surface and vascular areas.
- Current PD prescriptions often use insufficient fill volumes due to tolerance concerns, potentially increasing risks.
Purpose of the Study:
- To highlight the importance of an adequate peritoneal dialysis prescription, focusing on fill volume and dwell times.
- To emphasize understanding the peritoneal membrane as a dynamic surface for tailored PD prescriptions, especially in pediatric patients.
- To guide optimal PD prescription strategies for improved patient outcomes and membrane health.
Main Methods:
- Scaling fill volume by body surface area (mL/m2).
- Utilizing intraperitoneal pressure measurement (cm H2O) for controlled fill volume enhancement.
- Individualizing dwell times based on solute clearance, ultrafiltration, and dialysate reabsorption.
Main Results:
- A peak fill volume of 1400-1500 mL/m2 is achievable in children aged 2+ years.
- Short dwell times optimize small-solute clearance and ultrafiltration; long dwell times improve phosphate clearance but risk reabsorption.
- Newer PD fluids (glucose degradation product-free, neutral pH, non-exclusively lactate-buffered) benefit membrane recruitment and vascular function.
Conclusions:
- An individually adapted PD prescription, considering fill volume and dwell times, is essential for effective dialysis.
- Fill volume should be scaled by body surface area and increased under clinical guidance using intraperitoneal pressure monitoring.
- Optimized PD prescriptions using modern fluids can enhance membrane function and patient outcomes.
Abstract:
The peritoneal dialysis (PD) prescription should be adequate before being optimal. The peritoneal membrane is a dynamic dialyzer: the surface area and the vascular area both have recruitment capacity. At bedside, prescription is based mainly on tolerance of the prescribed fill volume, and therefore a too-small fill volume is often prescribed. A too-small fill volume may lead to a hyperpermeable exchange, with potentially enhanced morbidity-or even mortality-risks. Better understanding of the peritoneal membrane as a dynamic dialysis surface area allows for an individually adapted prescription, which is especially suitable for children on automated PD. Fill volume should be scaled for body surface area (mL/m2) and, to avoid a hyperpermeable exchange, for a not-too-small amount. Fill volume enhancement should be conducted under clinical control and is best determined by intraperitoneal pressure measurement in centimeters of H2O. In children 2 years of age and older, a peak fill volume of 1400-1500 mL/m2 can be prescribed in terms of tolerance, efficiency, and peritoneal membrane recruitment. Dwell times should be determined individually with respect to two opposing parameters: Short dwell times provide adequate small-solute clearance and maintain the crystalloid osmotic gradient (and, thereby, the ultrafiltration capacity). Long dwell times enhance phosphate clearance, but can lead to dialysate reabsorption. The new PD fluids (that is, those free of glucose degradation products, with a neutral pH, and not exclusively lactate-buffered) appear to be the best choice both in terms of membrane recruitment and of preservation of peritoneal vascular hyperperfusion.
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