Use of new peritoneal dialysis solutions in children

Abstract

Standard peritoneal dialysis (PD) solutions with low pH and containing high concentrations of lactate and glucose have been demonstrated to negatively affect the peritoneal membrane, mesothelial cell viability, residential peritoneal cells, and also to inhibit phagocytic functions. An increasing body of experimental evidence supports the idea that the peritoneal hypervascularization and fibrosis observed in long-term PD are causally related to the acute and chronic toxicity of conventional PD solutions. A Physioneal (lactate/bicarbonate mixed buffer pH 7-7.4), Physioneal, Extraneal (7.5% icodextrin), Nutrineal (1.1% amino-acid-containing solution) regimen, for example, offers a significant reduction in carbohydrate load (approximately 40-50%), lower exposure to and absorption of glucose degradation products, reduced oxidative stress, and improved volume control when compared with a first-generation DDDD (4 x Dianeal) regimen. The positive aspects of each solution that we have observed in our patients allow a recommendation on the potential benefit of using these solutions in children treated with PD. In fact, data from the literature as well as the results of the studies reported in this paper show that in children the application of neutral pH bicarbonate/lactate-buffered solution for the standard nighttime APD prescription, icodextrin solution for a long daytime dwell, and AA-based solution in malnourished patients is safe and effective. Extended clinical trials should be encouraged to better define the PD schedules for the combined use of these solutions that may be associated with the best clinical efficacy and the highest level of biocompatibility.

Solutions for peritoneal dialysis in children: recommendations by the European Pediatric Dialysis Working Group

“…A clinical impact of chronic icodextrin metabolite accumulation has not yet been discerned. The caloric load associated with a single daytime dwell of 600 ml/m 2 of icodextrin is below 5% of the daily allowance of energy in children [70]. There are no data available on the potential long-term metabolic effects in a growing and developing child.…”

“…The GDP content of the icodextrin solution is low, lactate concentration is high, and the pH is low ( Table 2). Although the transperitoneal absorption rate is much lower than that of glucose, 40-45% of the icodextrin molecules are absorbed in adults and in children within 12-14 h [69][70][71]. Icodextrin is metabolized to maltose and its derivatives, which accumulate in the human body and increase serum osmolality by 5 mosmol/ l [72].…”

Peritoneal Dialysis in Children

“…Transient outbreaks of sterile peritonitis due to contamination of dialysate with peptidoglycan, a bacterial membrane compound, repeatedly occurred in the past [175,1]. In pediatric patients icodextrin absorption, which occurs via convective pathways such as peritoneal lymphatics, is about 45 % after 14 h [43]. Icodextrin is metabolized by amylase to maltose and a number of oligosaccharides.…”

“…Daytime solute clearance is also influenced by convective transport associated with net UF that in turn depends on the type and concentration of the osmotic agent, the fill volume-related IPP, and the membrane transport status. Increased UF and convective clearance can be achieved during the daytime using high glucose concentrations and in particular using icodextrin solution [43,248].…”

“…Side effects are mild and rare and mainly consist of skin rash, which usually resolves without any sequelae after icodextrin discontinuation [43]. Transient outbreaks of sterile peritonitis due to contamination of dialysate with peptidoglycan, a bacterial membrane compound, repeatedly occurred in the past [175,1].…”