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Controversies in Nephrology Nursing

Peritoneal Dialysis as the Treatment of Choice for Pediatric Patients
Christy Price Rabetoy, Department Editor

CAPD Is the Best Modality for Children
Cyrena Gilman, MN, RN, CNN
Manager, Clinical Operations, Kidney/MSA Pediatric Dialysis
Indianapolis, IN
Chairperson, Pediatric SIG 1998-2000
Member, ANNA’s Hoosier Hills Chapter

Health care professionals agree that transplantation is the best renal replacement therapy for children. For those who cannot receive a transplant immediately, peritoneal dialysis (PD) offers the most normal, child-friendly, and family-friendly therapy. There are two ways to perform PD in children: Continuous cycling peritoneal dialysis (CCPD), also known as automated peritoneal dialysis (APD), and continuous ambulatory peritoneal dialysis (CAPD).

CAPD Is the Best Modality for Children

CAPD permits a very normal lifestyle. Three to four CAPD exchanges are done during normal waking hours. The relatively longer times between CAPD exchanges makes it the best modality for those who are low transporters on PET tests. High average to low average transporters can be treated successfully with CAPD as well (Harmon, Jabs & Alexander, 2000).

Although an exchange every 6 to 8 hours would be ideal (Warady, Schaefer, Alexander, Firanek, & Mujais, 2004), the timing of exchanges need not be rigid. CAPD generally can be adjusted as needed around school, sports, and family schedules. Our unit recommends exchanges before school, after school, mid-evening, and before bed during the week, and at breakfast, lunch, dinner, and bedtime on the weekends. Adolescents, particularly, enjoy being able to work exchanges around after-school or evening social activities. Most teens are not at all interested in going to bed between 6-8 p.m. With CAPD, there is no need for the young person to go to bed or be shut in their room early in the evening as may happen with CCPD in order to get enough time on the cycler. If all is going well, the child and family need to come to the dialysis facility only once a month for clinic. Thus, children on CAPD are free to attend school full time.

CAPD is low tech. There is no need for high-tech skills or even electricity, which is valuable for those families, such as the Amish, who do not have access to this amenity. There is no beeping, so there are not frequent interruptions of parents’ or the child’s sleep for dialysis issues. Some family members, especially older adults, may find it difficult to return to sleep if awakened in the middle of the night. CCPD becomes a prescription for sleep deprivation in that event. In our unit, even families who choose CCPD as their primary modality are required to learn CAPD. This provides them with a manual backup for times of machine breakage or of prolonged power failure due to bad weather.

Vacations and travel are part of a normal life. It is fairly easy to travel on CAPD; one just needs to take disposables. Most vendors will deliver supplies to vacation locations with just a couple of weeks’ notice. Furthermore, most pediatric facilities are easily able to provide backup support for a traveling patient on PD.

Because it is must be done 7 days a week, CAPD does create a high parental burden. However, families who view PD as just another body maintenance procedure are most successful. Those who perceive it as the mountain they must climb every day are less likely to thrive in the long term.

Peritonitis rates are generally higher in pediatric patients on PD than in adult patients on PD (Harmon et al., 2000). Although many have postulated that the eight connections/disconnections a day required for CAPD present an increased risk for infection, no studies have been published showing higher rates of peritonitis in patients on CAPD than in patients on CCPD.

Certainly cost is the least desirable reason for picking a dialysis modality. However, financial reality does need to factor in to some choices. The total volume of dialysate used per day for CAPD is smaller than that used for CCPD, which makes it more economical. Either Method I or Method II can be cost-effective for children using 2000 ml or larger CAPD exchanges. Small volume (< 1000 ml) PD solution bags have become less available over the past few years. This requires parents to measure smaller exchange volumes with a gram scale or an additional buretrol spiked into the PD system. The smaller dialysate bags that are available are significantly more expensive per ml of dialysis than “adult size” PD bags. However, Method II can help a dialysis facility deal with the high cost of small PD bags, if a child is eligible for Renal Medicare.

Summary

In our center, we believe that a PD modality should not be arbitrarily assigned by the dialysis facility. Rather, the choice of PD modality should be made based on the individual child’s treatment requirements and PET results as well as the family’s strengths, challenges, and desires (Harmon et al., 2000). The family has the choice whether to use CCPD or CAPD. Families and children who are able to switch back and forth between the two modalities as needed are the most flexible and most successful because they can build their therapy around their lifestyle and not the other way around (Hislop & Lansing, 1983).

CCPD Is the Therapy of Choice for Pediatric Patients with ESRD
Deborah Miller, MSN, RN, CNN
Clinical Nurse Specialist
Pediatric Kidney Center
Inova Fairfax Hospital for Children
Falls Church, VA
Chairperson, Pediatric SIG 1996-1998
Member, ANNA’s Capitol Chapter

As nephrology professionals, we share a common goal: to provide the best possible treatment for our patients with an eye towards long-range success. How we define success may vary, but, as a clinical nurse specialist in pediatric nephrology, I have to consider normal growth and development as one of the most important goals of any therapy. I believe continuous cycling peritoneal dialysis (CCPD) offers the best peritoneal dialysis situation for children.

CCPD has been available for over 20 years, and it is the most prevalent modality for dialysis on children. This therapy provides the opportunity for daily dialysis in a home setting as the child sleeps. As technology has advanced and cyclers have become smaller and more portable, it has become a more flexible form of treatment, allowing families to travel easily. Unlike in earlier years, my patients rarely tell me when they are going out of town for short trips, as there is no pretravel coordination necessary.

The cycler is designed to be used at night and allows for days free from intrusive treatments. Although the child must adhere to a careful diet and take medications during the course of the day, these actions are easily incorporated into the day’s events. With nightly dialysis, the child can go to school, participate in after school activities such as sports and clubs or bicycling with his/her friends. His/her lifestyle remains nearly as normal as a child who does not have ESRD. Learning to interact socially, and participating with peers in school, play, or sports events are important for normal social development. For the families, this is paramount to approximating a normal life for their child.

For the last 12 years, our practice has used CCPD exclusively. We have used it successfully with small babies, toddlers, young school-aged children, and adolescents. Our bias towards this therapy has everything to do with lifestyle. There have been numerous research studies that investigated the incidences of infections with CAPD vs. CCPD. Originally CCPD had an edge; however, with newer CAPD techniques such as twin bags and flush before fill, the infection rates remain comparable (Oo, Roberts, & Collins, 2005). Although cost is not the major consideration, the CAPD smaller solution bags most be ordered at considerable cost, and they are not available as twin bags. Alternatively, parents can measure with a fish scale, but this is often inaccurate. Using the conventional Y-set with the smaller bags negates the infection prevention advantages of the twin bag system.

With regards to treatment adequacy, if the patient has some residual renal function the differences between CAPD and CCPD are minimal (Gao. Lew, & Bosch, 1999). Intuitively, we know that CAPD is a more steady state because of its schedule of 4 divided cycles. However, in those high peritoneal transporters (which children tend to be), CCPD, with its capacity for rapid cycles, can give better clearance. All of the babies we have had on CCPD have run for 12 hours, taking advantage of their longer sleeping hours to maximize clearance. The younger children also generally sleep longer so they can run 10 hours easily. As the children get older, go to bed later, and leave only 10 minutes to reach the bus, a quick disconnect from CCPD gets them off to a running start. Since these same teenagers sleep until noon on weekends, we extend their time on weekends to 10 or 12 hours to get in some extra clearance time. While not exactly a steady state, it works and this gives older children more control over their schedule. I firmly believe that yielding some control helps with adherence.

With CCPD, the day dwell is usually less than the evening fill volume, allowing the child to participate in physical education and other physical activity without “that sloshing sensation.” There is less appetite suppression as well since the child is less “full.” When the child is prone as in sleep, we can increase the amount of the dwell beyond what is tolerated in an upright position. Being able to adjust the therapy by increasing the fill volume or by extending time on days off from school provide simple ways to increase clearance without interfering extensively in the child’s life. With school nurses and nurse’s offices becoming increasingly rare, doing an exchange during the school day is difficult or impossible. CCPD avoids that problem.

End stage renal disease in a child is a difficult lifestyle transition regardless of the chronic modality chosen. In pediatrics, we take seriously our charge to tailor the therapy within the child’s lifestyle. CCPD offers great advantages to this end; however, ultimately, the choice whether to use CCPD or CAPD remains with the family.

References
Gao, H., Lew, S.Q., & Bosch, J.P. (1999). Biochemical parameters, nutritional status and efficiency of dialysis in CAPD and CCPD patients. American Journal of Nephrology, 19(1), 7-12.

Oo, T.N., Roberts, T.L., & Collins, A.J. (2005). A comparison of peritonitis rates for the USRDS. Database: CAPD versus continuous cycling peritoneal patients. American Journal of Kidney Diseases, 45(2), 372-380.

The Controversies in Nephrology Nursing department focuses on exploring ethical and clinical issues within the nephrology clinic practice in a point/counterpoint format. Address correspondence to: Christy Price Rabetoy, Department Editor, through the ANNA National Office; East Holly Avenue/Box 56; Pitman, NJ 08071-0056; (856) 256-2320; or by emailing her at christycpr@comcast.net. You may also log onto this column at www.nephrologynursingjournal.net (clink on Department link) and email your comments to the Editor (see Discussion Area). The opinions and assertions contained herein are the private views of the contributors and do not necessarily reflect the views of the American Nephrology Nurses' Association.