Acute dialysis-associated peritonitis in children with D+ hemolytic uremic syndrome

Abstract

Acute peritoneal dialysis (PD) is the preferred therapy for renal replacement in children with post-diarrheal hemolytic uremic syndrome (D+ HUS), but peritonitis remains a frequent complication of this procedure. We reviewed data from 149 patients with D+ HUS who had undergone acute PD with the aim of determining the prevalence and risk factors for the development of peritonitis. A total of 36 patients (24.2%) presented peritonitis. The median onset of peritonitis manifestations was 6 (range 2-18) days after the initiation of dialysis treatment, and Gram-positive microorganisms were the predominant bacterial type isolated (15/36 patients). The patients were divided into two groups: with or without peritonitis, respectively. Univariate analysis revealed that a longer duration of the oligoanuric period, more days of dialysis, catheter replacement, stay in the intensive care unit, and hypoalbuminemia were significantly associated to the development of peritonitis. The multivariate analysis, controlled by duration of PD, identified the following independent risk factors for peritonitis: catheter replacement [p = 0.037, odds ratio (OR) 1.33, 95% confidence interval (CI) 1.02-1.73], stay in intensive care unit (p = 0.0001, OR 2.62, 95% CI 1.65-4.19), and hypoalbuminemia (p = 0.0076, OR 1.45, 95% CI 1.10-1.91). Based on these findings, we conclude that the optimization of the aseptic technique during catheter manipulation and early nutritional support are targets for the prevention of peritonitis, especially in critically ill patients.

Laboratory predictors of acute dialysis in hemolytic uremic syndrome

“…Various clinical and laboratory parameters are used to guide decision making in the initiation of renal replacement therapy in D + HUS patients, but there are currently no strict guidelines . Subsequently, criteria for initiation of dialysis in these patients are extremely variable; whereas some nephrologists successfully treated non‐anuric D + HUS children without dialysis despite marked azotemia, others proposed dialysis for all patients regardless of the presence of any apparent indications other than azotemia .…”

“…The indications for dialysis were anuria lasting >24 h, electrolyte abnormalities refractory to supportive measures, hypervolemia, and major neurologic manifestations (seizures, stroke, coma) …”

“…Management of AKI in D + HUS patients is supportive and includes appropriate fluid and electrolyte management, anti‐hypertensive therapy if necessary, and initiation of renal replacement therapy when appropriate . One‐half to two‐thirds of children with D + HUS need dialysis during the acute stage, while the rest have milder renal involvement without the need for dialysis . The indications for dialysis in D + HUS are similar to those in other forms of AKI, but there is no evidence for the optimum level of renal function for starting renal replacement therapy nor for the optimum dialysis modality .…”

“…[1][2][3] Onehalf to two-thirds of children with D + HUS need dialysis during the acute stage, while the rest have milder renal involvement without the need for dialysis. [2][3][4][5][6] The indications for dialysis in D + HUS are similar to those in other forms of AKI, but there is no evidence for the optimum level of renal function for starting renal replacement therapy nor for the optimum dialysis modality. 2,3,6 Consequently, the disparity in dialysis rates between different health centers may be partly explained by the varying guidelines for its initiation.…”

“…As a general consensus the indications for dialysis in D + HUS patients are hypervolemia manifested as pulmonary edema, congestive cardiac failure or refractory hypertension, anuria lasting >24 h preventing adequate nutritional support, major neurologic manifestations (seizures, stroke, coma), electrolyte/acid-base imbalances (hyperkalemia, symptomatic hypo or hypernatremia, or refractory metabolic acidosis), and an increase in urea >200 mg/L or symptomatic uremia. [2][3][4][5][6] Nevertheless, the final decision to initiate renal replacement therapy is not strict and may be affected strongly by physicians' beliefs, patient characteristics (including age and extrarenal involvement such as severe neurologic or bowel compromise), experience with the modality and organizational structure (including resource availability, institution complexity and cost of therapy). 7,8 Consequently, the initiation of renal replacement therapy is defined by the attending physicians in a case-bycase manner.…”