PART SEVEN
Pediatrics
Advances in Peritoneal Dialysis, Vol. 20, 2004
Kimberly K. Washburn,1 Helen Currier,2 Kristi J. Salter,1 Mary L. Brandt1,3
Surgical Technique for Peritoneal Dialysis Catheter Placement in the Pediatric Patient: A North American Survey
In the present study, we surveyed 425 members of the American Pediatric Surgical Association and the Canadian Association of Pediatric Surgeons to identify prevalent operative techniques used in the placement of peritoneal dialysis catheters by pediatric surgeons. Our survey assessed catheter type, skin and fascial incision orientations, deep-cuff positions, exit-site directions, and omentectomy. We received responses from 156 surgeons (36.7%) and excluded 18 of those responses. Among the assessed responses, 83 surgeons (60%) indicated that they had placed at least 1 catheter in the previous 12 months. Of the 83, 13% had placed 1 catheter, 52% had placed 2 – 5, 16% had placed 6 – 9, and 18% had placed 10+. We observed significant variability in all aspects of surgical technique. The most common catheter configuration was single-cuff (59%), curled end (60%), and non swan neck (72%). The most common surgical approach was a transverse skin incision (52%), a fascial incision through the rectus (68%), a deep cuff between the peritoneum and fascia (46%), a superiorpointing exit site (37%), and a superficial cuff distant to the exit site (53%). Routine omentectomy was reported by 59% of respondents. Only 15% reported using a laparoscopic approach on first attempt. Pediatric surgeons employ a variety of surgical techniques when placing peritoneal catheters. Some of the techniques used vary from the published recommendations. Quality can potentially be improved by wider dissemination of published surgical recommendations.
Key words Pediatrics, peritoneal dialysis catheter, surgical technique, catheter design, surgeon survey
From: 1Michael E. DeBakey Department of Surgery, Baylor College of Medicine; 2Texas Children’s Hospital; and 3Department of Pediatrics, Baylor College of Medicine, Houston, Texas, U.S.A.
Materials and methods After obtaining Institutional Review Board approval, we sent a self-report survey (n = 425) to the members of the American Pediatric Surgical Association
Introduction Peritoneal dialysis (PD) is the preferred method of dialysis for most children. Placing PD catheters in children poses unique challenges, which are reflected in the high complication rates for children—as high as 70% in some series (1). A logical, well-thoughtout surgical approach may reduce the risk of complications, because many complications can be traced to an error in surgical thinking or technique. The catheter type probably does not affect outcome, given that there are no good prospective studies to suggest that less occlusion occurs with a curled PD catheter as compared with a straight one. The data concerning infection rates with single-cuff catheters as compared with double-cuff catheters conflict (2–4). In small children, a single-cuff catheter may be preferable, because the distance between the two cuffs may make it difficult to achieve optimal subcutaneous cuff position without compromising the exit site (5). The literature suggests that optimal surgical placement of PD catheters in children includes placing the first (or only) cuff in an extra-peritoneal position, firmly anchored in fascia, and positioning a second cuff (if present) 1.5 – 2.0 cm from the exit site, with the exit site directed in a lateral or, preferably, downward direction (5). Although the data are inconclusive, most surgeons suggest that a partial omentectomy, when it can be accomplished easily, should be done (6,7).
Washburn et al. (APSA) and the Canadian Association of Pediatric Surgeons (CAPS). The survey included questions regarding surgeon demographics, degree of experience, and surgical technique. Demographic questions focused on the primary hospital of practice, university affiliation and teaching experience, number of surgical partners, and number of associated nephrologists at the relevant institution. Degree of experience was based on the number of catheters placed by the surgeon within the preceding 12 months. The surgeon’s preferred surgical technique was determined using questions concerning choice of catheter, placement of the cuff, and position of the exit site. Participants were given approximately 8 weeks to complete the survey by e-mail or postal mail. We excluded surveys that were incomplete and surveys returned by retired surgeons. Statistical analysis was performed using Microsoft Excel software. Results Of 425 surveys distributed, 156 were returned (36.7%). Among the 156 responses, 12 came from surgeons who were retired, and 6 were incomplete, leaving 138 valid surveys for analysis. Demographics Most surgeons practiced in an academic setting, with 108 pediatric surgeons (78.3%) being associated with a university-based hospital. On average, each surgical group consisted of 4 surgeons in addition to the respondent. Among the surgical partners, 88% had also placed catheters during the time period being reported. Among the responding surgeons, 81 stated that an average of 3 nephrologists practiced at the same facility. Experience with catheter placement The average number of catheters placed by all respondents in the preceding 12 months was 3. That number increased to 5 when surgeons who had placed no catheters were excluded (Figure 1). Of the 83 surgeons who had placed catheters, 11 (13.3%) had placed 1 catheter, 44 (53.0%) had placed 2 – 5 catheters, 13 (15.7%) had placed 6 – 9, and 15 (18.1%) had placed 10 or more (Figure 1). Surgical technique Single-cuff catheters were placed most frequently (59%). Curled-end catheters were also more frequently
219
1 Number of peritoneal dialysis catheters placed by individual surgeons. FIGURE
placed (60%). In addition, non swan neck catheters were more frequently placed (49%) than catheters with a swan-neck configuration (19%, Table I). Most surgeons favored a transverse incision (52%), a fascial incision through the rectus (68%), a deep-cuff position between the peritoneum and fascia (46%), a superior-pointing exit site (37%), and a superficial cuff position a convenient distance from the exit site (53%). Omentectomy was performed by 59% of surgeons. Only 14% of surgeons used laparoscopy; the other 86% preferred an open technique (Table II). Discussion Optimal surgical technique is critical to the success of a PD catheter, yet technique is not taken into account in many published reports of catheter survival. The survey sent to pediatric surgeons in the present study was preliminary and limited. Responses to the questions required retrospective recall, or an extensive review of records, or both. The overall response rate to the survey was relatively low, but adequate for evaluation. Despite those limitations, the resulting data suggest that most pediatric surgeons have limited experience in placing PD catheters. Moreover, wide variation exists in the surgical technique for placing PD catheters, and some of the techniques vary from published recommendations. Conclusions Quality can potentially be improved with wider acceptance of published surgical recommendations. Our data also reinforce the importance of surgical technique in evaluating catheter outcome and suggest that details concerning the placement of catheters should be included in any prospective study on improving catheter function and longevity.
220 TABLE I
Survey of Pediatric PD Catheter Placement Types of catheters placed
Type of cuff [n (%)] Single Double Not reported Type of end [n (%)] Straight Curled Not reported Type of neck [n (%)] Swan Non swan Not reported
TABLE II
1
2–5
Catheters placed 6–9
>10
Overall
4 (36) 7 (64) 0
27 (61) 11 (25) 6 (14)
8 (62) 5 (39) 0
10 (67) 5 (33) 0
49 (59) 28 (34) 6 (7)
4 (36) 7 (64) 0
9 (18) 27 (61) 8 (11)
7 (54) 5 (39) 1 (8)
3 (20) 11 (73) 1 (7)
23 (28) 50 (60) 10 (12)
2 (18) 5 (46) 4 (36)
9 (21) 20 (46) 15 (34)
1 (8) 8 (62) 4 (31)
4 (27) 8 (53) 1 (7)
16 (19) 41 (49) 26 (31)
1
2–5
Catheters placed 6–9
>10
Overall
13 (30) 6 (14) 22 (50) 3 (7)
1 (8) 2 (15) 10 (77) 0
3 (20) 3 (20) 8 (53) 1 (7)
25 11 43 4
(30) (13) (52) (5)
12 29 1 2
(27) (66) (2) (5)
1 (8) 12 (92) 0 0
5 (33) 9 (60) 1 (7) 0
23 56 2 2
(28) (68) (2) (2)
4 (9) 21 (48) 9 (21) 3 (7) 7 (16)
0 6 (46) 6 (46) 0 1 (8)
2 (13) 6 (40) 5 (33) 0 2 (13)
8 (10) 38 (46) 23 (28) 4 (5) 10 (12)
20 (46) 15 (34) 7 (16) 2 (5)
4 (31) 4 (31) 5 (39) 0
5 (33) 3 (20) 6 (40) 1 (7)
31 29 20 3
26 (59) 2 (5) 16 (36)
5 (39) 3 (23) 5 (39)
6 (40) 1 (7) 8 (53)
44 (53) 6 (7) 33 (40)
26 (59) 15 (34) 3 (7) 0
9 (69) 3 (23) 1 (8) 0
9 (60) 5 (33) 1 (7) 0
49 (59) 29 (35) 4 (6) 0
5 (11) 39 (89)
3 (23) 10 (77)
3 (20) 13 (80)
12 (15) 71 (86)
Specifics of surgical technique
Skin incision [n (%)] Midline 8 (72) Paramedian 0 Transverse 3 (27) Not reported 0 Fascial incision [n (%)] Midline 5 (46) Through rectus 6 (55) Lateral to rectus 0 Not reported 0 Deep cuff position [n (%)] Inside peritoneum 2 (18) Between peritoneum and fascia 5 (46) Superficial to posterior rectus 3 (27) Superficial to anterior rectus 1 (9) Not reported 0 Exit site [n (%)] Pointing superiorly 2 (18) Pointing laterally 7 (64) Pointing inferiorly 2 (18) Not reported 0 Superficial cuff position [n (%)] Convenient distance 7 (64) Specific distance from the exit site 0 Not reported 4 (36) Omentectomy performed [n (%)] Yes 5 (46) No 6 (55) Yes/no 0 Not reported 0 Laparoscopic placement for first attempts [n (%)] Yes 1 (9) No 10 (91)
(37) (35) (24) (4)
Washburn et al. Acknowledgment The authors thank Stuart L. Goldstein, MD, of the Department of Pediatrics, Baylor College of Medicine, Houston, Texas, for his assistance. References 1 Kimmelstiel FM, Miller RE, Molinelli BM, Lorch JA. Laparoscopic management of peritoneal dialysis catheters. Surg Gynecol Obstet 1993; 176:565–70. 2 Kim D, Burke D, Izatt S, et al. Single- or double-cuff peritoneal catheters? A prospective comparison. Trans Am Soc Artif Intern Organs 1984; 30:232–5. 3 Lewis MA, Smith T, Postlethwaite RJ, Webb NJ. A comparison of double-cuffed with single-cuffed Tenckhoff catheters in the prevention of infection in pediatric patients. Adv Perit Dial 1997; 13:274–6. 4 Furth SL, Donaldson LA, Sullivan EK, Watkins SL. Peritoneal dialysis catheter infections and peritonitis in children: a report of the North American Pediatric
221 Renal Transplant Cooperative Study. Pediatr Nephrol 2000; 15:179–82. 5 Brandt M, Brewer E. Placing peritoneal dialysis catheters in children. In: Nissenson AR, Fine RN, eds. Dialysis therapy. 3rd ed. Philadelphia: Hanley & Belfus; 2002: 468–70. 6 Nicholson ML, Burton PR, Donnelly PK, Veitch PS, Walls J. The role of omentectomy in continuous ambulatory peritoneal dialysis. Perit Dial Int 1991; 11: 330–2. 7 Pumford N, Cassey J, Uttley WS. Omentectomy with peritoneal catheter placement in acute renal failure. Nephron 1994; 68:327–8.
Corresponding author: Mary L. Brandt, MD , Texas Children’s Hospital, 6701 Fannin, CC 650.00, Houston, Texas 77030 U.S.A. E-mail:
[email protected]
Advances in Peritoneal Dialysis, Vol. 20, 2004
Johan G.J. Vande Walle, Ann M. Raes, Joke Dehoorne, Reiner Mauel
The aim of peritoneal dialysis (PD) remains to deliver “appropriate” renal replacement therapy, including sufficient ultrafiltration, correction of acid–base balance, and adequate dialysis dose. We switched our pediatric patients on automated PD from standard lactate-buffered glucose solution (Dianeal: Baxter Healthcare SA, Castlebar, Ireland) to bicarbonate/lactate–buffered solution (Physioneal: Baxter Healthcare SA) as soon as it became available in our country. We also decided to deliver “optimal” dialysis in children by prescribing a long daytime dwell with icodextrin solution (Extraneal: Baxter Healthcare SA). But, adding those three benefits together—APD, Physioneal, and a long dwell with icodextrin—the result, at least in children, was a possible overcorrection of acidosis and an evolution to alkalosis. Thought must be given to developing solutions with varying bicarbonate concentrations for various treatment modalities. Keywords Pediatrics, alkalosis, icodextrin, bicarbonate buffer Introduction The aim of peritoneal dialysis (PD) remains to deliver “appropriate” renal replacement therapy, which includes sufficient ultrafiltration, correction of acid– base balance, and adequate dialysis dose as defined by the Dialysis Outcomes Quality Initiative (DOQI) guidelines. Meeting that goal requires biocompatible peritoneal solutions, sufficient fill volumes to mobilize enough peritoneal surface, and sufficient contact From: Pediatric Nephrology, University Hospital, Gent, Belgium.
Use of Bicarbonate/Lactate– Buffered Dialysate with a Nighttime Cycler, Associated with a Daytime Dwell with Icodextrin, May Result in Alkalosis in Children time. The original continuous ambulatory PD (CAPD) regime, with its 4 daily exchanges, was considered by many pediatricians to be a burden for the school-aged child. Many children were therefore placed on automated PD (APD) with a cycler, but without any change in the formula of the PD solution. Conventional PD solutions impair membrane characteristics and reduce the host defense mechanism, limiting the long-term survival of the dialysis technique. The toxicity to the peritoneal barrier is caused by any or all of the hyperosmolarity of the solution, its high concentrations of glucose and lactate, its acidic pH, and the glucose degradation products that are formed during manufacturing. New developments in solution technology (changes in buffer, sterilization technique, osmotic agent) and dialysis technique have tackled many of the aforementioned problems (1–3). Most reviews compare standard bioincompatible solutions in various PD techniques (CAPD, cycler, or cycler plus daytime high glucose), or they compare solutions with individual ameliorations against standard solutions. Almost no data are available to show the result of all possible ameliorations (osmotic agent, buffer, glucose degradation products, etc.) being made at the same time in a single study (4). In most studies, only one or two negative factors are changed, and the results are compared with conventional glucose-containing, lactate-buffered solutions. The number of studies of the new solutions in children is limited (5–8), but use of those solutions is already recommended for children (9,10). In our center, as in many others, overnight APD with a cycler is the treatment of choice to optimize social life, and especially schooling, for children. We
223
Vande Walle et al. switched our patients from standard lactate-buffered glucose solution (Dianeal: Baxter Healthcare SA, Castlebar, Ireland) to bicarbonate/lactate–buffered solution (Physioneal: Baxter Healthcare SA) as soon as it became available in our country. The experimental data and data in adult patients were so convincing that further use of a less physiologic solution seemed no longer defensible. Also, we decided to deliver “optimal” dialysis in children, by prescribing for all children a long daytime dwell with icodextrin solution (Extraneal: Baxter Healthcare SA). That decision was based on three considerations: •
• •
Without a daytime dwell, it is difficult to reach the DOQI dialysis dose guidelines in 40% of our pediatric patients. We wanted to increase the daytime ultrafiltration rate so as to reduce the glucose load overnight. We wanted to maximize dialysis efficiency for phosphate and middle molecules because of the alarming reports concerning cardiovascular calcifications in young adults.
Although icodextrin has not yet been extensively studied in pediatric patients, some short-term safety data are available (7,8), as is a great deal of adult experience (11,12). In children with inadequate ultrafiltration or dialysis dose on nightly intermittent PD with a cycler, adding a single daytime dwell of icodextrin is a tempting therapeutic option. It offers the abovementioned advantages over a daytime high glucose (3.86%) exposure; and, in children who do not need a daytime dwell for ultrafiltration, the overnight glucose concentration can be reduced and the PD contact time increased. When the present study was initiated, no data were available on the use of lactate/bicarbonate–buffered solutions in children as compared with pure bicarbonate-buffered solutions. We therefore retrospectively analyzed acid–base balance in 12 consecutive pediatric patients treated using overnight APD with Physioneal and a daytime dwell with Extraneal. Patients and methods Our retrospective analysis included 12 children (6 boys, 6 girls) aged 1.2 – 12 years who were treated with APD. Two patients were anuric (1 post transplantation); the others still had some residual renal function.
Results Automated PD Table I shows daytime and nighttime fill volumes. The nighttime volumes were not statistically different, because they were adjusted to a target fill volume of ±1200 mL/m 2 body surface area. A bicarbonate (25 mmol/L) / lactate (15 mmol/L)–buffered PD solution (Physioneal) was used. Daytime fill volumes with icodextrin (Extraneal) were ±10% – 20% lower than overnight volumes. Figure 1 shows serum HCO3– levels before and after introduction of a daytime dwell with icodextrin. Although the values overlap, the serum HCO3– levels increased significantly (p < 0.01). For patients 11 and 12, no pre-icodextrin data are recorded because icodextrin was introduced within 14 days after initiation of dialysis. Table II shows laboratory values for serum sodium, potassium, HCO3–, and chloride. As expected, chloride is significantly lower, compensating for the higher plasma bicarbonate. No significant differences were observed for potassium or sodium. Daytime and nighttime fill volumes and automated peritoneal dialysis exchanges in the study patients TABLE I
Fill volume (mL/m2 BSA) Nighttime Daytime Overnight exchanges (n)
1190±59 956±92 6.6±0.7
BSA = body surface area.
1 Serum HCO3– levels in the study patients before (closed diamonds) and after (open diamonds) introduction of a daytime dwell with icodextrin [Extraneal (Baxter Healthcare SA, Castlebar, Ireland)]. FIGURE
224
Alkalosis in Children
Blood chemistries before and during icodextrin administration TABLE II
Sodium (mmol/L) Potassium (mmol/L) Chloride (mmol/L) HCO 3– (mmol/L) Duration of observation (months) a
Before
During
133±2 4.3±0.4 92±3 23±2 3 (0.2–8)
134±2 4.1±0.5 89±5 a 27±2 a 3 (1.2–9)
Significant difference.
Discussion The introduction both of bicarbonate-buffered solution and of glucose polymer–based solution may offer major advantages in the treatment of children with chronic renal failure. But although bicarbonate-based or bicarbonate (25 mmol/L) / lactate (15 mmol/L)–based solution (Physioneal) is definitely the choice for the future, frequent overnight cycles with a high HCO3– concentration, when combined with a daytime dwell of Extraneal, may result in alkalosis. Of course, the icodextrin solution itself is not what creates the problem, because filling the abdomen with a daytime Physioneal dwell would in theory aggravate the situation further. But the introduction of icodextrin solution, which lacks the long- and short-term negative effects of the high glucose concentrations needed to prevent backfiltration, makes a daytime dwell so feasible that such dwells are likely to be used on a much larger scale to optimize dialysis adequacy. Our observation suggests that the concentration of base in the solution has to be adapted and tailored to the prescribed dialysis modality. To better understand this idea, it is good to look back on the purpose of the buffer concentration. The level of buffer in standard PD solutions was calculated for the use of 4 daily 2-L exchanges in adults. It balances the almost full resorption of lactate, acid production by the body, and HCO3– losses into the dialysate. Why did the buffer concentration have to be ±40 mmol/L lactate? Daily acid production can be estimated to be ±1.5 – 2 mmol/kg body weight, data that are well known from correction of distal tubular acidosis. If a patient has a body weight of about 60 kg, then daily acid production is 90 – 120 mmol, which normally would be compensated by the kidney, and must now be compensated by dialysis with 4 daily
2-L exchanges containing lactate. At 80% lactate resorption, the result is a net positive balance of 256 mmol/L (32 mmol/L × 8 L = 256 mmol daily resorption). But that calculation does not take into account the negative balance from losses of plasma HCO3– into the dialysate (15 – 20 mmol/L HCO3, or 120 – 180 mmol total loss). Polymer-based peritoneal dialysate (icodextrin solution) was initially designed to treat ultrafiltration failure in patients, especially when that ultrafiltration failure was caused by high glucose absorption attributable to a high-transport peritoneal membrane during long dwell periods (7,8). In adult patients, a single nighttime dwell with icodextrin solution offered ultrafiltration equal to that achieved with 3.86% glucose (7,8). Because icodextrin solution was developed when the buffer of choice was still lactate, icodextrin was produced with a lactate concentration of 40 mmol/L as buffer, resulting in almost full resorption during the long dwell, and a loss of 24 ± 3 mmol/L HCO3– from plasma into the solution. The result is a daily positive balance of about 16 mmol/L per dialysate dwell. But compared with classical Dianeal solution, no adjustment for the difference in buffer equilibrium was made. The introduction of the cycler in the pediatric PD population was mainly a success, because in the initial years practitioners believe that the same dialysis adequacy and ultrafiltration dose could be maintained, but with more freedom for the child during the day. Most children receive 6 – 8 nighttime dwells with conventional lactate solutions, without a daytime dwell. During the shorter dwells, lactate reabsorption from the peritoneal solution is only partial; but, because of the higher D/P gradient, total overnight lactate reabsorption is probably higher than during 4 dwells over 24 hours. But because that phenomenon is mainly offset by HCO3– losses into the dialysate, introduction of APD—with its higher frequency of exchanges, but shorter overall dwell times—did not disturb the balance. The introduction of bicarbonate solutions during APD in children resulted in a significant increase in serum bicarbonate (to 24 ± 2.7 mmol/L from 23.2 ± 2.7 mmol/L) and an increase in base excess [to 1.2 ± 3.0 mmol/L from –1.4 ± 2.5 mmol/L (6)]. That result was to be expected, because the calculated dose of buffer in the solutions underestimated the HCO3– losses with conventional lactate solutions.
Vande Walle et al. Our data clearly demonstrate that care must be taken in the attempt to put the benefits from different solutions together. Conclusions In children, APD is still a good option that minimizes the burden of PD during the daytime and provides an optimal social and school life. However, in many children—and definitely when residual renal function is absent—APD provides insufficient Kt/V. So, given today’s knowledge, the question is not finding a reason to introduce a long daytime dwell, but finding a reason not to introduce it if the goal is to obtain sufficient dialysis efficiency for phosphate and the middle molecules. The choice of icodextrin is rational, because it avoids high glucose solutions with their toxicity from pH, high osmolality, and glucose degradation products, and their high glucose resorption and associated metabolic disturbances. Moreover, icodextrin is now available in Europe. The choice of multi-chambered, bicarbonate/lactate–buffered solutions is also logical, not only because of the physiologic pH and HCO3– as buffer, but also because of the absence of glucose degradation products. But, adding the three benefits together—APD, Physioneal, and a long dwell with Extraneal—the result, at least in children, is a possible overcorrection of acidosis and an evolution to alkalosis. That tendency might be interpreted as more corrective of metabolic acidosis (6), but practitioners should be reluctant to make that interpretation, considering the potential effects on Ca–P equilibrium. Thought must therefore be given to developing solutions with varying bicarbonate concentrations for various treatment modalities: namely, patients on APD or CAPD, or patients on APD with a daytime dwell. References 1 Topley N. Membrane longevity in peritoneal dialysis: impact of infection and bio-incompatible solutions. Adv Ren Replace Ther 1998; 5:179–84. 2 Jörres A, Bender TO, Witowski J. Glucose degradation products and the peritoneal mesothelium. Perit
225 Dial Int 2000; 20(Suppl 5):S19–22. 3 Mactier RA, Sprosen TS, Gokal R, et al. Bicarbonate and bicarbonate/lactate peritoneal dialysis solutions for the treatment of infusion pain. Kidney Int 1998; 53:1061–7. 4 Garcia–Lopez E, Lindholm B, Tranæus A. Biocompatibility of new peritoneal dialysis solutions: clinical experience. Perit Dial Int 2000; 20(Suppl 5):S48–56. 5 Schmitt CP, Haraldsson B, Doetschmann R, et al. Effects of pH-neutral, bicarbonate-buffered dialysis fluid on peritoneal transport kinetics in children. Kidney Int 2002; 61:1527–36. 6 Haas S, Schmitt CP, Arbeiter K, et al. Improved acidosis correction and recovery of mesothelial cell mass with neutral-pH bicarbonate dialysis solution among children undergoing automated peritoneal dialysis. J Am Soc Nephrol 2003; 14:2632–8. 7 de Boer AW, Schroder CH, van Vliet R, Willems JL, Monnens LA. Clinical experience with icodextrin in children: ultrafiltration profiles and metabolism. Pediatr Nephrol 2000; 15:21–4. 8 Van Hoeck K, Rusthoven E, Vermeylen L, et al. Nutritional effects of increasing dialysis dose by adding an icodextrin daytime dwell to nocturnal intermittent peritoneal dialysis (NIPD) in children. Nephrol Dial Transplant 2003; 18:1383–7. 9 Shockley TR, Martis L, Tranæus AP. New solutions for peritoneal dialysis in adult and pediatric patients. Perit Dial Int 1999; 19(Suppl 2):S429–34. 10 Schroder CH and the European Paediatric Peritoneal Dialysis Working Group. The choice of dialysis solutions in pediatric chronic peritoneal dialysis: guidelines by an ad hoc European committee. Perit Dial Int 2001; 21:568–74. 11 Peers E, Gokal R. Icodextrin: overview of clinical experience. Perit Dial Int 1997; 17:22–6. 12 Posthuma N, ter Wee P, Donker AJ, Dekker HA, Oe PL, Verbrugh HA. Peritoneal defense using icodextrin or glucose for daytime dwell in CCPD patients. Perit Dial Int 1999; 19:334–42.
Corresponding author: Johan Vande Walle, MD, Renal Unit, University Hospital, 185 De Pintelaan, B-9000 Gent, Belgium. E-mail:
[email protected]
