Peritoneal Dialysis in the Pediatric Intensive Care Unit Setting

Acute kidney injury (AKI) is a common complication in pediatric and neonatal intensive care units (ICUs). Renal replacement therapy (RRT) is frequently needed in children in whom supportive therapy is not enough to satisfy metabolic demands or to provide adequate nutrition in cases of oliguric kidney failure. The decision to begin dialysis should not be delayed, because experience in infants shows that the shorter the time from the ischemic insult to the beginning of dialysis, the higher the survival rate. The use of continuous RRT (CRRT) in pediatric patients in the ICU has almost tripled; at the same time, the use of peritoneal dialysis (PD) and intermittent hemodialysis has markedly declined. Patient age seems to be the most important factor influencing the decision on the choice of dialysis modality. Although CRRT is reported as the preferred dialysis modality for acutely ill children, PD is still the most common modality used in patients under 6 years of age. Among the several advantages that PD offers, relatively low cost is probably the most significant. Other advantages include technical simplicity, lack of a need for anticoagulation or placement of a central venous catheter, and excellent tolerance in hemodynamically unstable patients. Much controversy exists regarding the adequacy of PD in hypercatabolic patients in the ICU. Nonetheless, when Kt/V has been applied to acutely ill children, it has been shown that PD can provide adequate clearances for most infants. No prospective studies have evaluated the effect of dialysis modality on the outcomes of children with AKI in the ICU setting. The decision about dialysis modality should therefore be based on local expertise, resources available, and the patient's clinical status.