Chronic Kidney Failure

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CRF chronic renal failure

Text of Chronic Kidney Failure

  • Care of the Pediatric Patienton Peritoneal Dialysis

    Clinical Process for Optimal Outcomes

    PediatricCovers.QX 2/17/04 1:55 PM Page 1

  • Cover art by Morgan Ghosey, age 16

    C O N T R I B U T I N G A U T H O R S

    Bradley A. Warady, M.D.

    Franz Schaefer, M.D.

    Steven R. Alexander, M.D.

    Catherine Firanek, B.S.N.

    Salim Mujais, M.D.

    PediatricCovers.QX 2/17/04 1:55 PM Page 2

  • Ensuring adequate dialysis and optimal patient care is a multifaceted process in children

    with end stage renal disease who receive peritoneal dialysis. Whereas clinicians typically

    utilize clinical and laboratory indices when attempting to define and achieve adequate

    dialysis, optimal care cannot be achieved by focusing on solute clearances alone. Attention

    to nutrition therapy, correction of anemia and growth retardation, control of osteodys-

    trophy, prevention/treatment of peritonitis and preparation for transplantation are also

    mandatory, and excellence in each aspect of management is necessary if an optimal

    patient outcome is to be achieved.

    Care of the Pediatric Patient on Peritoneal Dialysis was developed based on a review

    of the current medical literature and the authors clinical experience. It has been designed

    to serve as a resource that can be easily integrated into clinical programs caring for

    children, with the discussion of each major topic consisting of a treatment algorithm

    and a brief but pertinent review of associated background material. An appendix with a

    variety of clinical tools and list of references is also included. By its nature, this guide

    cannot be considered to be exhaustive, and users are encouraged to pursue specific issues

    that may not be covered herein. This guide is also not intended to be the practice of

    medicine, nor does it replace sound medical clinical judgment.

    Children who receive peritoneal dialysis and their families are deserving of the best care

    we can possibly provide, in order to give them every opportunity to achieve their desired

    goals. The authors hope that the information contained within this guide assists you to

    that end.

    Care of the Pediatric Patienton Peritoneal Dialysis

    Clinical Process for Optimal Outcomes

    Introduction

    Pediatric Guide-SC3.qxd 2/17/04 1:30 PM Page 3

  • Care of the Pediatric Patienton Peritoneal Dialysis

    Clinical Process for Optimal Outcomes

    Predialytic Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

    Modality Selection and Preparation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

    PD Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

    Automated Peritoneal Dialysis (APD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

    Continuous Ambulatory Peritoneal Dialysis (CAPD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

    Ultrafiltration Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

    Peritonitis Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

    Management of Growth Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

    Recombinant Growth Hormone Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

    Management of Malnutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

    Mineral Metabolism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

    Management of Anemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

    Preparation for Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

    Appendix:

    Guidelines for 24-Hr Dialysate Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

    Guidelines for 24-Hr Urine Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

    Clearance Calculations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

    Residual Renal Clearance Calculations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

    PET in Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

    Measurement of Intraperitoneal Pressure (IPP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

    References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

    Table of Contents

    Pediatric Guide-SC3.qxd 2/17/04 1:30 PM Page 5

  • Predialytic Monitoring

    Copyright 2004, Baxter Healthcare Corporation. All rights reserved.

    Pred

    ialy

    tic M

    onito

    ring

    Pediatric Guide-SC3.qxd 2/17/04 1:30 PM Page 7

  • TREATMENT GOAL

    Full compensation for the complications of chronic kidney disease Timely preparation for transplantation Seamless transition to dialysis

    DIALYSIS INITIATION: ABSOLUTE INDICATIONS

    GFR

  • 9 Copyright 2004, Baxter Healthcare Corporation. All rights reserved.

    oodmatocrit,ur urine

    every

    choice

    g

    CLINICAL PROCESS FOR OPTIMAL OUTCOMES

    PREDIALYTIC MONITORING

    Select dialysis modality.Initiate dialysis

    Child with advanced chronic renal failure (calculated GFR

  • Copyright 2004, Baxter Healthcare Corporation. All rights reserved.

    Pediatric Guide-SC3.qxd 2/17/04 1:30 PM Page 10

  • Modality Selectionand Preparation

    Copyright 2004, Baxter Healthcare Corporation. All rights reserved.

    Mod

    ality

    Sel

    ectio

    n an

    dPr

    epar

    atio

    n

    Pediatric Guide-SC3.qxd 2/17/04 1:30 PM Page 11

  • PD TRAIN

    Theory (>15 Functions

    Practical/Tech Aseptic te

    exchangesfeeding (in

    Peritonitis an Recognitio

    treatment

    Noninfectiou Hypotensi

    HOME V

    Psychosocial Family stru

    Environment Presence o

    formula pfor treatm

    Safety Asses Locked me

    Equipment A Blood pres

    Treatment As Dressing c

    blood pres

    Cycler Manag Average st

    plan for an

    TREATMENT GOAL

    Improvement of patients physical and mental well-being Adequate performance of home dialysis by caregivers Minimal interference with family/school/social life

    INDICATIONS FOR PD IN PREFERENCE TO HD

    Patient/caregiver choice if the modality is medically suitable Very small/very young patients Lack of vascular access Contraindications to anticoagulation Cardiovascular instability Poorly controlled hypertension/hypertensive cardiomyopathy (relative) Lack of proximity to a pediatric HD center (relative) Desire for normal school attendance More liberal fluid intake

    ABSOLUTE CONTRAINDICATIONS TO PD

    Omphalocoele Gastroschisis Bladder extrophy Diaphragmatic hernia Obliterated peritoneal cavity and peritoneal membrane failure

    RELATIVE CONTRAINDICATIONS TO PD

    Imminent living-related transplantation Impending/recent major abdominal surgery Lack of an appropriate caregiver Patient/caregiver choice if an alternate modality is available and medically suitable

    Copyright 2004, Baxter Healthcare Corporation. All rights reserved.12

    Modality Selection MCLINICAL PROCESS FOR OPTIMAL OUTCOMES

    Mod

    ality

    Sel

    ectio

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    nPediatric Guide-SC3.qxd 2/17/04 1:30 PM Page 12

  • PD TRAINING CONTENT

    Theory (>15 hours) Functions of the kidney, pathophysiology of renal failure, osmosis, diffusion, fluid balance

    Practical/Technical (>15 hours) Aseptic technique, blood pressure monitoring, exit site care, performance of PD

    exchanges, setup and function of cycler, problem-solving alarms, NG/gastrostomy tubefeeding (infants/small children)

    Peritonitis and Exit site/Tunnel Infection Recognition of signs and symptoms, initiating treatment, medicating bags for ongoing

    treatment

    Noninfectious Complications Hypotension/hypertension, catheter flow problems, hernias

    HOME VISIT CONTENT

    Psychosocial Assessment Family structure, financial status, school schedule

    Environmental Assessment Presence of heat, running water and electricity, function of smoke detector and telephone,

    formula preparation facilities (infants/small children), purity of water supply, isolated areafor treatment

    Safety Assessment Locked medicine cabinet, storage of needles, location of local hospital

    Equipment Assessment Blood press

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