Comparison of chronic peritoneal dialysis outcomes in children with and without spina bifida.

This study was designed to compare chronic peritoneal dialysis (CPD) long-term outcomes (patient and technique survival, incidence of peritonitis, and overall average death outcomes) between seven patients with lumbar spina bifida (SB) and 20 controls without SB. Both groups were matched for potentially outcome-confounding factors: gender, and socioeconomic status (SES). SES was established using modified Graffar's method. No significant differences were found in CPD outcomes. The incidence of peritonitis was one episode per 17.6 and 10.3 months in SB patients and controls, respectively (p = 0.5). Overall patient survival at 5 years was 86% and 73% in SB patients and controls, respectively (p = 0.55). Overall average death rate between SB and control patients was 47.6/1,000 and 79.4/1,000 patient years, respectively (p = 0.63). Overall technique survival at 5 years was 83% and 73% in SB patients and controls, respectively (p = 0.84). There were no cases of retrograde brain ventricular infection secondary to PD-related peritonitis. We conclude that SB is not a risk factor for CPD, and therefore, it is an effective renal replacement alternative in children with SB.

Hydrothorax due to ventriculopleural shunting in a child with spina bifida on chronic dialysis: third ventriculostomy as an alternative of cerebrospinal diversion.

The purpose of this paper is to describe the risks of ventriculopleural shunt in patients with spina bifida and end-stage-renal-diseases (ESRD), and to describe endoscopic third ventriculostomy as an alternative for the combination of cerebrospinal shunt and dialysis modality. We report a 16-year-old boy with spina bifida on chronic dialysis with a massive unilateral hydrothorax and respiratory distress complicating a ventriculopleural (VPL) shunt. Two thoracocenteses were performed, draining 3200 ml of a clear fluid. The VPL shunt was removed and revised successfully to a third ventriculostomy (TVE). Peritoneal dialysis (PD) was the initial dialysis modality. After 12 months on PD, the patient was transferred to hemodialysis (HD) because of refractory peritonitis. Hydrothorax developed while the patient was on PD, reaching its maximum 2 months after the transference to HD. To our knowledge there has been no other report of ventriculopleural (VPL) shunt failure, and endoscopic TVE, as a cerebrospinal fluid (CSF) diversion alternative in patients on chronic dialysis.

Twenty years' pediatric chronic peritoneal dialysis in Uruguay: patient and technique survival.

In this study we analyze the impact of the patient's socioeconomic status (SES) and the distance from the patient's home to the dialysis center (DPH-DC), classified as < or =300 km or >300 km, on the patient and technique survival of 59 patients starting chronic peritoneal dialysis (CPD) between May 1983 and January 2004 at a single center in Uruguay. SES was established using Graffar's method. Mean duration of CPD was 38.1+/-26.0 months. Mean age at the start of CPD was 8.4+/-5.2 years. Overall patient and technique survival at 5 years were 86.4% and 77.9%, respectively. Twenty (33.8%) patients were transferred to hemodialysis. Eight (13.5%) patients died. The incidence of peritonitis was one episode every 9.1 months. There was no statistically significant difference in patient and technique survival between the patients in the low and high SES groups (p=0.72 and 0.99, respectively), and between those in the two DPH-DC groups, (p=0.22 and p=0.99, respectively). Logistic regression analysis confirmed low SES and DPH-DC >300 km are not predictors of patient death (p=0.79 and p=0.09, respectively) or technical failure (p=0.35 and p=0.15, respectively). No SES- and DPH-DC-related statistically significant differences were found in patient and technique survival.

Peritoneal dialysis in children with spina bifida and ventriculoperitoneal shunt: one center's experience and review of the literature.

OBJECTIVE: The goal of this paper was to review the viability of peritoneal dialysis (PD) in patients with spina bifida and/or ventriculoperitoneal shunt (VPS). SETTING: Pediatric dialysis unit in a tertiary-care hospital. DATA SOURCE: The course and outcome in 9 children, 5 from the authors' experience and 4 from reported experience, are analyzed. RESULTS: One patient died of a cause unrelated to PD or VPS, 2 were transferred to hemodialysis because of recurrent peritonitis, 1 discontinued PD transiently, 2 were transplanted, and 3 continue on PD. Six of these 9 children had a functioning VPS, and none presented evidence of ventriculitis or VPS dysfunction, even though 4 had PD-related peritonitis. One child presented with a massive PD-related hydrothorax. CONCLUSIONS: (1) Having a VPS is not an absolute contraindication to PD; the available data support the viability of PD in patients with spina bifida and/or a VPS. (2) If cerebrospinal fluid diversion is needed simultaneously or after starting PD, an extraperitoneal site should be a better choice than VPS. This should avoid the risk of intra- and postoperative infection in the PD catheter secondary to surgical intervention for VPS insertion. (3) Loss of peritoneal function is a potential late risk related to cerebrospinal fluid and PD. (4) Spina bifida patients on PD present specific diagnostic challenges due to overlapping symptoms (e.g., vomiting, abdominal tenderness, fever) secondary to PD- or VPS-related complications (e.g., peritonitis, visceral injury by devices) or primary disease (e.g., neurogenic bladder, pyelonephritis), with inherent risks of delaying adequate treatment. Cloudy peritoneal effluent is an early indication of peritonitis, although it is not specific. (5) Early evaluation by a pediatric surgeon and a neurosurgeon is required for effective management of complications and selection of more efficient individualized therapeutic alternatives. Prompt treatment of complications is crucial. A registry of children with spina bifida on PD and the accumulation of a large population followed up for longer periods will provide an objective assessment of their problems and management.