By: Abdulla Ehlayel, MD, FAAP & Sai Sudha Mannemuddhu, MD, FAAP
If your child has certain types of kidney disease or injury, their kidneys may not be able to remove waste and extra fluid from the body the way they should. When this happens, dialysis can do some of the work that healthy kidneys normally do.
Peritoneal dialysis (PD) is a type of dialysis that is typically done at home for patients with end-stage kidney disease (such as kidney failure). It can also be used in the hospital for patients with acute kidney injury. It can help children stay healthy while waiting for a kidney transplant or, in some cases, while their kidneys recover.
Here's how PD works, how to prepare for treatment, what daily life with PD may look like and how to help keep your child safe and healthy during dialysis.
How does peritoneal dialysis work?
A soft tube known as the PD catheter, is placed in the abdomen (belly), usually near the belly button. This allows fluid to move from bags of special dialysis solution (such as dialysate) into the abdomen and then back out through a long tube.
In most cases, a dialysis machine or cycler is used to infuse the dialysate and then drain the PD fluid. This process helps the body get rid of waste products and excess body fluid.
What preparations are needed before starting PD?
Catheter placement
The PD catheter is inserted by the surgical team and is usually allowed to heal in place for about 2 weeks before being used. It can be used sooner if deemed necessary by the medical team.
To help the catheter heal properly, the area where the catheter exits the skin over the belly (the exit site) should be kept dry and clean and the child should temporarily avoid playing sports or engaging in other rigorous activities.
Training for family members and caregivers
Before your child starts PD at home, a dialysis nurse will provide training for parents, caregivers and, in some cases, the older child themselves. The training usually takes 1 to 2 weeks to complete.
During this training, you'll learn how to:
- Care for the catheter exit site
- Perform PD treatments safely
- Recognize and help prevent infections
- Handle common questions or problems that may come up at home
The dialysis team will make sure you feel comfortable with each step before your child begins PD at home.
Home visit by the dialysis team
A home visit by members of the dialysis team usually takes place as well, either before the child goes home on dialysis or soon after.
The team will help identify a suitable location for the dialysis machine near an electrical outlet, an appropriate place for fluid to drain, and storage space required for the many PD supplies that are needed.
The home visit will also address other important issues (such as pets in the home) and will help to make home dialysis as safe and effective as possible.
Where is PD done? How often does my child need PD?
PD is usually conducted at home in the child’s bedroom. PD treatments that use a dialysis machine (cycler) occur every night while the child is sleeping and typically last 8-12 hours.
Parents and caregivers are taught how to connect and disconnect the child from the cycler and how to monitor the machine while the child is connected to it. PD is most successful when it starts and ends at the same times each day, so it is best to establish a nighttime routine.
Can PD be done during travel?
Patients on PD can travel, but it takes extra preparation and planning to be able to conduct PD while outside the home.
PD can also be performed without a cycler. In this case, caregivers or older patients are taught how to fill the abdomen with dialysate, allow it to remain in the abdomen (dwell) for a predetermined period of time, and then empty it. This process usually occurs 4 times every 24 hours.
What are the advantages of PD?
Since PD is conducted at home, there is less need to travel to a dialysis unit or hospital to receive dialysis, as is the case with hemodialysis.
PD is generally very well tolerated by children, even when it is done while they sleep. Since it happens each night, it mimics healthy kidneys by allowing waste products to be eliminated from the body each day instead of being retained by the body.
In contrast, hemodialysis at the hospital is usually conducted only a few times each week, which can lead to increased fluid retention and other side effects of kidney failure.
How do I take care of the PD catheter?
The PD catheter requires special care to avoid getting infected. Care consists of cleaning the skin around the exit site and placing a topical antibiotic at the exit site to help prevent infection.
The dialysis team may also recommend that gauze (such as dressing) be placed over the exit site, and that the dressing be changed often. It is also important to avoid situations that may result in the PD catheter being tugged on or accidentally pulled out. The catheter can be effectively secured under clothing so that it is not visible.
How does PD affect a child’s activities?
Children can go to daycare or school, as suitable for their age group. The child will need to follow up with the dialysis team (physician, nurse, dietitian, social worker and others) in the clinic at least once a month. They can participate in sports that do not involve the risk of injury to the PD catheter. There may be other limitations due to other medical problems.
Can a child on PD participate in sports?
It is a good idea to have the child on PD and their caregivers talk with the dialysis team about any sports in which the child wishes to participate. Most dialysis teams will recommend that the child not swim or sit in a bathtub while the PD catheter is in place to avoid infection.
Showering may be allowed, provided the dressing is changed afterwards. Patients should check with their dialysis team to receive their specific care instructions.
What are the possible complications of PD?
Complications that can occur with PD include the following:
Infection can occur at the site where the catheter exits from the skin (exit site infection), underneath the skin along the path of the PD catheter ("tunnel" infection), or inside the belly (peritonitis). Symptoms of peritonitis include fever, abdominal pain and cloudiness of the drained PD fluid. Infections with PD require prompt attention, which typically includes antibiotics as recommended by the dialysis team.
Inguinal hernia and hydrocele (fluid collection in the scrotum of boys) can occur when filling the abdomen with dialysate. Consultation with the surgeon may be needed to treat this.
Female adolescents may notice blood-tinged drained PD fluid at the time of their menstrual cycle. This may be considered normal and should be discussed with the dialysis team.
Inadequate removal of waste products or excess retained body fluid can occur and may require a change in the number of hours dialysis is performed, a change in the contents of the dialysate or other modifications of the dialysis procedure as recommended by the dialysis team.
About Dr. Ehlayel
Abdulla Ehlayel, MD, FAAP, is a pediatric nephrologist at King Faisal Specialty Hospital in Riyadh. He received his medical degree from the University of Jordan and completed his residency training at Children’s Hospital of Michigan in Detroit. He then completed fellowship training at the Children's Hospital of Philadelphia. Within the American Academy of Pediatrics, he is a member of the Section on Nephrology.
About Dr. Mannemuddhu
(Sai) Sudha Mannemuddhu, MD, FAAP is a pediatric nephrologist at East Tennessee Children's Hospital, Knoxville, TN. She is a clinical assistant professor and Assistant Pediatrics Clerkship director at the University of Tennessee and Clinical adjunct faculty at Lincoln Memorial University in Knoxville, TN. Dr Mannemuddhu completed her pediatrics residency training at the Andhra Medical College, King George Hospital, India, and at Miami Children's Hospital, Miami, FL. She then completed her pediatric nephrology fellowship training at the University of Florida, Gainesville. Within the American Academy of Pediatrics, she is a member of the Section on Nephrology (SONp) Executive Committee and a writing panel member for the SONp/NKF/ASPN Patient Education Collaborative.