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Journal of Pediatric Urology (2014) xx, 1e2

Editorial comment on “A novel alternativefor renal replacement therapy fordeveloping countries: Two-year successfulcolonic dialysis via malone antegradecontinent enema stoma”

A.J. Lorenzo

Hospital for Sick Children, University of Toronto, Toronto, ON, Canada

Received 2 December 2013; accepted 2 December 2013

“Dans les champs de l’observation le hasard ne favoriseque les esprits prepares”

[In the field of observation, chance favors the preparedmind]

Louis Pasteur

Lecture, University of Lille, December 1854

Innovations are often the product of pressure to “thinkoutside the box” in order to address a difficult clinicalproblem. Although case reports are considered a low formof evidence, the present one [1] stands out and sparks cu-riosity, generating admiration for astute clinicians thatlooked at things from a completely different perspectiveanddtaking advantage of their particular circum-stancesdcame up with an astute solution. By doing so, aworld of new options opens in front of us, particularlyconsidering the increasing level of comfort with creatingMACE-type channels to address bowel problems.

As written in the Old testament, there is nothing newunder the sun. If one looks hard enough many things havebeen previously explored, including the idea of “intestinaldialysis” [2]. However, after a brief flurry of publications

E-mail addresses: armando.lorenzo@sickkids.ca, AJLMD@aol.com.

Please cite this article in press as: Lorenzo AJ, Editorial comment on “countries: Two-year successful colonic dialysis via malone antegradehttp://dx.doi.org/10.1016/j.jpurol.2013.12.008

1477-5131/$36 ª 2013 Published by Elsevier Ltd on behalf of Journal ohttp://dx.doi.org/10.1016/j.jpurol.2013.12.008

many years ago, it faded against other options for renalreplacement. This makes one pause and wonder if thephenomenon was driven by availability of more attractivealternatives or by failure to achieve satisfactory andreliable clearance of waste products by using thegastrointestinal mucosa as a dialysis membrane. Perhapsprevious attempts employed the wrong bowel segment,failed to select an optimal dialysis solution, or wronglypersisted at trying to de-functionalize the selectedsegment from the rest of the digestive system. Irre-spective of the reason, if the reintroduced concept provesto be equivalent (or not dramatically inferior) to otherstrategies, it could be of value for patients with recurrentperitonitis and/or line sepsis awaiting transplantation, inlow-income settings with limited access or expertise withsterile techniques for dialysis, or as an alternative forpatients who otherwise would have required hemodialysisearly on in life. For example, since first reviewing thisreport for the journal I encountered a small neonate inrenal failure who was not a candidate for peritonealdialysis owing to the pressing need to create a colostomyto address a high ano-rectal malformation. It would betempting to simultaneously bring the appendix to the skinand try to mirror the favorable experience hereinreported.

Customary to most Editorial Comments, healthy skepti-cism and a call for more data are in order. In particular, Iam somewhat concerned about the impact of contempo-raneous co-interventions on initiation of colonic dialysis,

A novel alternative for renal replacement therapy for developingcontinent enema stoma”, Journal of Pediatric Urology (2014),

f Pediatric Urology Company.

2 A.J. Lorenzo

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which may have been critical contributors to the describedimprovement. Hypertension and volume overload appear tobe the main reasons driving the recommendation for dial-ysis, both of which are clearly amenable to medical therapy(two diuretics and three antihypertensive drugs; all pro-vided at respectable doses!). It is also crucial to rememberthat this patient produces large amounts of urine, whichmakes fluid balance easier to manage as long as intake anddaily weights are carefully monitored and regulated.Although I can’t argue with favorable changes in blood ureanitrogen and creatinine, the reported modest impact mayhave little to do with the patient’s clinical progress, moreso if lack of compliance with dialysis was associated withnot taking her medications (situations that can easily gohand-in-hand).

Please cite this article in press as: Lorenzo AJ, Editorial comment on “countries: Two-year successful colonic dialysis via malone antegradehttp://dx.doi.org/10.1016/j.jpurol.2013.12.008

It would be foolish not to explore the presented conceptfurther. I am delighted to see that an animal study seems tobe in progress and, hopefully, many others will follow. Ifthese data are as promising as expected, this could herald arenaissance for intestinal dialysis and an admirable stepforward based on innovative thinking.

References

[1] XXX. A novel alternative for renal replacement therapy fordeveloping countries: two-year successful colonic dialysis viamalone antegrade continent enema stoma. J Pediatr UrolXXXX;XX: XeX.

[2] Schloerb PR. Intestinal dialysis for kidney failure. Personalexperience. ASAIO Trans 1990;36:4e7.

A novel alternative for renal replacement therapy for developingcontinent enema stoma”, Journal of Pediatric Urology (2014),