Abstract
Importance of Identifying High Risk Pediatric Patients Who Require a Home Visit Prior to Initiating Peritoneal Dialysis
Background: Through standardized home visits, the dialysis team learned that not all home environments were suitable to start peritoneal dialysis (PD). Lack of suitable housing, limited resources, and environmental factors were identified as potential barriers to having an appropriate environment to start PD. These findings raise concerns to safely offer PD as a dialysis modality choice. Home visits prior to starting PD are not our program's standard practice, and the team recognized pre-visits would be useful to uncover barriers prior to placing a PD catheter.
Case Study: A patient managed on hemodialysis expressed interest in transferring dialysis modality to PD. Concerns arose due to patient's lack of resources, home environment, and limited understanding of medical regimen.
Intervention: To assess ability to safely transition to PD, health literacy was assessed using The Newest Vital Sign tool. A pre-dialysis home visit was completed by the dialysis social worker and PD nurse to assess if home environment was suitable.
Outcome: Patient and caregivers had limited health literacy. Assessment of learning style identified need for visual prompts and teach-back and repetition of material taught. The pre-dialysis home visit identified concerns with space, temperature to store supplies, shared home, electrical safety concerns, lack of ventilation with presence of mold, and no screens over windows. Prior to transitioning to PD, recommendations were made to correct issues found on home visit to enhance patient safety and to minimize harm. Dialysis social worker offered community resources to assist with recommended changes in the home environment.
Applicability to Practice: Inability to qualify for resources and low health literacy were risk factors to identify those who require a pre-home visit prior to initiating peritoneal dialysis.
Espiritu M.1, Vazquez E.1, Wong C.2, 1Lucile Packard Children's Hospital, Palo Alto, CA; 2Stanford University, Palo Alto, CA, U.S.A.
The Influence of 25-Hydroxyvitamin D on Growth in Infants and Toddlers on Dialysis
Background: There are many factors that contribute to the kidneys inability to keep Vitamin D stores within normal levels (WNL). Correcting this deficiency is vital in improving bone mineral disease in our pediatric population under going rapid growth. Our aim was to correct any 25-hydroxyvitamin D (Vit D) deficiency to reach optimal growth velocity.
Case Studies: The first patient was a 2-year-old male, ex 34-weeker with ESRD secondary to obstructive uropathy from posterior urethral valves. His history includes initiating peritoneal dialysis (PD) on Day 4 of life, anemia, bone mineral disorder, high-grade VUR with one incidence of peritonitis. The second patient was a 1-year-old male, ex 37-weeker with ESRD secondary to obstructive uropathy from posterior valves. His history includes initiating PD shortly after birth; however, initial catheter leaked and ultimately had to be removed and replaced after 1 month of age. He had a G-tube placement at 3 months of age and developed his peritonitis shortly after. He has mineral bone disorder, anemia, and short stature. The third patient was a 1-year-old male, ex 36-weeker with ESRD secondary to obstructive uropathy from posterior valves. At 6 months he had a PD catheter and G-tube placed with a LADDs procedure. The PD catheter was removed before ever used due to peritonitis. He started hemodialysis (HD) at 7 months of age. His history also includes mineral bone disorder, anemia, and short stature.
Approach: Vit D levels at or above 30 ng/mL are checked quarterly. If <30 ng/mL, patients started active Vit D supplementation following the NKF guidelines. Of our three dialysis toddlers, actual growth velocity was compared to average growth velocity by age group. This case study looks at the incidence of Vit D WNL with growth velocities being met or exceeded.
Results: A correlation existed when the growth velocity was met or exceeded and Vit D levels WNL. For Patient 1, 41% of the time growth velocity and Vit D levels were WNL. For Patient 2, 33% of the time growth velocity and Vit D levels were WNL. Finally, for Patient 3, 66% of the time growth velocity and Vit D levels were WNL.
Conclusion: Looking at our three youngest patients on dialysis, growth velocity and Vit D levels don't seem to have a strong influence on each other. More research is needed to assess the relationship between growth and Vitamin D.
Furey E., Arnold Palmer Hospital for Children, Orlando, FL, U.S.A.
Pediatric Peritoneal Dialysis Protocol Modification with Intra-abdominal Surgery—Quality Improvement Project
Introduction: Pediatric peritoneal dialysis (PD) patients are at increased risk of peritonitis following intra-abdominal surgeries such as insertion of gastrostomy tube. Following multiple perioperative peritonitis episodes, our institution implemented an ISPD guidelines based perioperative protocol in Sept 2016 for PD patients undergoing intra-abdominal surgeries. The protocol was distributed in writing for each patient to all nephrology, surgery, and resident team members. This quality improvement project aims to determine the impact of the protocol on peritonitis rates before and after implementation.
Methods: Retrospective chart review was performed to identify all pediatric PD patients from 2010–2017 who also received intra-abdominal surgeries at our institution. Preprotocol is Jan. 2010 to Aug. 2016 and postprotocol is Sept. 2016 to Sept. 2017. Study variables include use of: cephalosporin, metronidazole, anti-fungal prophylaxis, and withholding of dialysis > 24 hrs. Primary outcome measure is peritonitis diagnosed within 7 days from surgery. Secondary outcome is adherence to protocol elements following implementation. Proportion and chi-square test were used for statistical analysis.
Results: There were N=14 unique patients. N=9 received 20 intra-abdominal procedures (pre) and N=6 received 16 intra-abdominal procedures (post). Median age at surgery was 9.2 mo (pre) vs. 21.2 mo (post). Full protocol compliance increased from 5% (1/20) to 50% (8/16). Metronidazole use increased from 20% (4/20) to 50% (8/16), p=0.06. Anti-fungal prophylaxis increased from 45% (9/20) to 81% (13/16), p=0.03. Patterns of withholding dialysis > 24 hr (80% vs. 87.5%) and use of cephalosporin (100% vs. 94%) were similar. Peritonitis incidence decreased from 36.4% (8/20) to 6.3% (1/16), p=0.03.
Discussion: Following protocol implementation, peritonitis incidence decreased significantly, with overall improvement in protocol adherence. Perioperative protocols involve multiple teams and direct communication improves adherence. Data analysis suggests that use of anti-fungal prophylaxis and metronidazole is still suboptimal. Limitation in the study is primarily due to small sample size, representing a single-center program.
Conclusions: Our ongoing PD program quality assessment indicates that sharing a clearly written perioperative protocol for intra-abdominal surgeries in PD patients improves the consistency of perioperative management and decreases the incidence of postoperative peritonitis.
Houston S., Ehrlich J., Jetton J., Lee-Son K., University of Iowa Stead Family Children's Hospital, Iowa City, IA, U.S.A.
Single Center Experience: a Case for Continuous Flow Peritoneal Dialysis in an Infant
Background: In neonates with AKI requiring renal replacement therapies, the most frequently used modality is peritoneal dialysis (PD). PD has often been criticized for having relatively poor clearance rates and ultrafiltration compared to other therapies. Prospective case studies have demonstrated increased clearance and UF in the use of continuous flow peritoneal dialysis (CFPD) compared to conventional PD. Few U.S. centers have reported their experiences of CFPD in the pediatric population reflecting its infrequent use as a renal replacement therapy in this region.
Methods: We report on our center's first experience with CFPD in the pediatric population.
Results: Our patient was a preterm infant with CKD secondary to renal hypodysplasia. AKI during the hospitalization prompted placing a double-cuffed Tenckhoff PD catheter for manual frequent low-volume PD. Development of a peritoneal leak prompted the placement of a second PD catheter (double-cuffed Tenckhoff). The patient was transitioned to intermittent HD for issues with clearance and UF on low volume passes. 2nd attempt at intermittent PD failed for the same reasons mentioned previously. CFPD was initiated using PD fluids transferred into IV bags, actively pumped through an Alaris Pump into the input PD catheter, and exiting passively through the output PD catheter attached to an external ventricular drainage system. Fluids output was assessed on an hourly basis and UF was measured accordingly. With this modality, we achieved significantly improved fluid removal and creatinine clearance with single-day PD KT/V of 2.7.
Discussion: Experience with CFPD is limited, with few centers having established protocols. We report on the safeness of the modality, but risks of procedures and infection must be considered before initiation. CFPD demonstrated more effective clearance of solute compared to conventional PD, and also greater fluid removal on similar concentrations of dialysate using CFPD.
Conclusion: Our experience demonstrates that CFPD is more efficient than manual low-flow PD in infants in terms of clearance and fluid removal. It should be considered when HD and intermittent PD are contraindicated in pediatric patient.
John J., Bunchman T., Xiao N., Virginia Commonwealth University Health Systems, Richmond, VA, U.S.A.
Training a Select Cohort of Pediatric Intensive Care Unit Nurses in Peritoneal Dialysis: a High-Risk, Low Volume Skill
Background: Peritoneal dialysis (PD) in the pediatric intensive care unit (ICU) is a specialized therapy which represents a low volume skill at our center. In 2016, our 24-bed pediatric ICU (PICU) had 146 PD treatment days from 11 patients; our 24-bed cardiovascular ICU (CVICU) had 94 PD treatment days from 2 patients. Historically, all ICU nurses (PICU: 110, CVICU: 103) are required to obtain and maintain PD competency; initial training is performed by the PD team and ongoing annual competency is managed by an ICU nurse educator. Data demonstrated that ICU nurses are least comfortable with PD cycler set up, trouble shooting, and PD sample collections. Despite the universal training requirement, both ICUs reported issues with maintaining competency and insufficient exposure to PD procedures.
Goal: Improve ICU nurses’ competency and comfort with PD by developing a training module targeting a smaller cohort of nurses.
Approach: Critical care nursing teams identified a subcohort of nurses to train (110 ICU nurses across both ICUs). PD Coordinators held 10 high-intensity classes over 5 mo. Training focused on areas of deficit identified by ICU nurses. To address the low volume, 6-mo check-ins and annual PD competency reviews were developed to support and maintain practice.
Outcomes: After the initial training, nurses self-reported improved comfort levels in target categories including manual PD, cycler PD, trouble shooting, MD notification guidelines, and order review. Prior to initiating this process improvement project, nurses self-reported comfort averaged 3.42±0.52 (out of 5). Following the intervention, ICU nurses self-reported comfort level increased to 4.55±0.24 (p<0.001) across the same assessment areas.
Application in Clinical Practice: Developing a specialized ICU PD RN team responsible for PD-dependent patients will increase frequency of skill utilization, ultimately increasing expertise and improving the quality of PD care within the ICU setting.
Lee J.1, McCabe L.1, Espiritu M.1, Wong C.2, Sutherland S.2, 1Division of Nephrology, Lucile Packard Children's Hospital, Palo Alto, CA; 2Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, U.S.A.
Reinforcing Home Adherence to Aseptic Technique in Peritoneal Dialysis Using Visual Tools
Background: Peritoneal dialysis (PD) patients and their families who demonstrate ongoing technical proficiency have decreased rates of hospitalization and infection, with increased rates of treatment adherence and satisfaction. Compared to written instructions, visual imagery enhances learning and adherence and avoids health literacy discrepancies. We developed a multilingual learning tool combining pictures and text as cues to reinforce proper aseptic technique for children on PD.
Methods: We surveyed PD patients, families, and staff to identify potential areas for breaks in aseptic technique. We grouped identified areas to correspond sequentially with steps in PD initiation and termination. A place mat was created combining pictures and brief instructions, with one side for initiation and the other for termination. Versions in English, Spanish, and Arabic were developed with certified medical interpreters.
Results: Place mats were distributed to families of PD patients for home use in the language of their choice. After one month, we surveyed families during clinic visits as to the utility and clarity of the placemats in highlighting aseptic technique. All surveyed families and patients were enthusiastic about the use of this visual tool, citing its value in clearly reinforcing the sequence and steps of PD. The graphics were also considered effective and simple prompts, replacing reliance on text alone. Other language options were appreciated by non-English speakers. Based on survey responses, the place mat content was revised to add further emphasis on initial preparatory steps and proximity of emergency supplies. Laminated place mats are now used as part of initial PD education and have been distributed to all prevalent PD patients.
Discussion: This quality improvement initiative underscores the importance of family engagement and concrete messaging in developing aids to reinforce adherence to best practices in delivering home peritoneal dialysis. The use of graphics minimizes dependence on language fluency and literacy. Availability of the place mat at home promotes retention of recommended practices, while also actively involving the family and patient in infection prevention.
Conclusions: Quality improvement initiatives in home dialysis benefit from family and patient involvement. Use of visual aids and graphics augments adherence to prescribed technique. The availability of varied language options recognizes the importance of cultural sensitivity in health literacy.
MacDonald J.1, Pengeroth L.1, Pak T.1, Traum A.1,2, Somers M.1,2, 1Boston Children's Hospital, Boston, MA; 2Harvard Medical School, Boston, MA, U.S.A.
Standardizing Approach to Developing Formula Compositions for Dialysis-Dependent Infants and Young Children to Improve Monitoring of Nutritional Intake
Background: Dialysis-dependent infants and young children pose unique challenges in many regards; meeting nutritional requirements in particular can be difficult. Good nutrition is essential for proper growth, development, and wound healing. Special considerations are required to develop complex, custom formula to meet caloric, protein, and micro- and macro- nutrient requirements while balancing fluid and electrolyte restrictions. Multiple formulas and modulars are often used, and calculations of nutrients are time-consuming and may vary depending on provider.
Aim: The purpose of this study was to improve accuracy of calculations, identify patients not receiving recommended nutritional goals, and standardize reporting of the nutritional content of the formula mixture.
Methods: A nutrition calculator tool was developed to standardize approach and reduce variability in calculating and reporting the nutritional composition of a formula. The calculator reports the nutrients for a custom formula mixture to include calories/kg, protein/kg, potassium mEq, phosphorus mg, calcium mg, and vitamin D IU, as these were the outputs most often reported in nutrition notes. Chart review was conducted to include patients on dialysis who were less than 5 years of age who received more than 90% of their total intake from tube feeds.
Results: Ten children included in study had a median age 2.1 years (range 0.5–4 years old). Seventy percent (n=7) of these patients were on 3 or more nutritional products in their formula mixture. Eighty percent (n=8) of patients had a 5% or more difference in a nutritional component by dietitian's calculation compared to the calculator tool's output.
Discussion: Utilizing a nutrition calculator to evaluate the nutrients in complex feeds allows for an efficient method to decrease variability and improve accuracy and quality of nutritional practices for children on dialysis.
Future Directions: Incorporate tool into electronic medical record to automatically alert providers if nutritional components from ordered formula with modulars do not meet patients’ needs.
Sheldon C., Voorheis G., Chau S., Wong C., Lucile Packard Children's Hospital at Stanford, Palo Alto, CA, U.S.A.
Parental Education for Peritoneal Dialysis in Republic Of Macedonia
Background: Peritoneal dialysis is the primary dialysis technique for children with end-stage renal disease in Republic of Macedonia. Macedonia is a multiethnic country with population of 2 million inhabitants (about 400,000 children). In this work we evaluated the factors which influence the education of the parents to perform the automated peritoneal dialysis at home.
Methods: Parental education was performed at the Dept. of Nephrology, University Children's Hospital. All nephrology nurses participated in the education process. The dialysis was performed on the Serena Device according to the manufacturer's instruction. In 2014, all patients were switched from Gambro to Fresenius devices (Sleep-safe). The following parameters were recorded: age of the parents, ethnicity, education, employment, learning time of the technique (days).
Results: There were 30 children who underwent APD treatment, 36 parents underwent training at the hospital. The ethnicity was Macedonia (50%), Albanian (36.6%), Turkish (6.7%), Roma (6.7%). Both parents were educated in 16.7%, one parent in 83.4% (all mothers). The mean education time was 3.5 days (range 2–9). There was no difference according to the above-mentioned parameters, except for education (low educated 4.7 days, educated 2.9 days, p<0.05).
Conclusion: Although our cohort of APD patients is small, analysis showed that majority of fathers are not involved in the education. The only parameter which influenced the length of the education is education. Thus, peritoneal dialysis staff should pay more attention to parents with low education status.
Srojanovska S., Dimovska L., University Pediatric Clinic, Skopje, Gjorce, Macedonia.
Single-Center Experience and Outcomes for Neonates less than 3 kg Initiating Peritoneal Dialysis
Background: Though recent literature reports favorable outcomes in growth, development, and renal transplantation in infants on dialysis, the decision to initiate peritoneal dialysis (PD) in neonates varies by center. There are no guidelines on what gestational age and size would be appropriate to offer PD in a neonate. Pediatric dialysis centers may not consider PD in neonates less than 3 kg and may initiate hemodialysis as bridge until infant is large enough to accommodate infant PD catheters.
Goal: To review outcomes for neonates less than 3 kg with end-stage renal disease (ESRD) initiated on chronic PD.
Methods: Retrospective chart review to identify infants with ESRD, whose birth weight was less than 3 kg, and who initiated PD before 28 days of age. Outcomes reviewed included transplant and death.
Results: In review of our center's data from 2009 to 2017 year-to-date, 16 patients had birth weight less than 3 kg and were less than 28 days old when PD was initiated for ESRD. Mean gestational age was 34 1/7±3 3/7 weeks with 68% (n = 11) patients were premature (range 27 4/7 to 35 4/7 weeks for premature group). The mean birth weight was 2.23±0.52 kg for neonates who initiated PD, with the lowest birth weight being 1.23 kg. Median time to start PD was 6 days after birth (range 0 to 23 days). One-year patient survival was 75% (n=14). Fifty percent (n=8) of patients received a renal transplant with 100% patient and graft survival to date. Of the 5 patients who passed away, mean birth weight was 2.07±0.57 kg. Three families chose to withdraw care due to comorbidities.
Discussion: Neonates with ESRD have unique challenges and may require early and aggressive treatment, including prompt initiation of PD with optimal nutrition and management of comorbidities to successfully bridge patient to transplant.
Conclusion: Dialysis in infants is demanding and requires working closely with specialized neonatology, surgical, and nephrology/dialysis teams to optimize outcomes for neonates less than 3 kg.
Wong C.1, McCabe L.2, Gallo A.1, Concepcion W.1, 1Stanford University, Stanford, CA; 2Stanford Children's Health, Palo Alto, CA, U.S.A.