Adequacy of Peritoneal Dialysis/Assessing Peritoneal Function in Pediatric Patients

Historically, peritoneal dialysis (PD) adequacy has been characterized by specific quantitative targets of creatinine or urea removal (e.g., creatinine clearance or Kt/Vurea). While in adults, Kt/Vurea targets have been based on limited evidence of an association between solute clearance and patient morbidity/mortality, similar associations do not apply to children and adolescents because of the low mortality rate experienced by patients in these age groups and the absence of any well-substantiated correlations between their clinical status and the small solute clearance achieved by dialysis. In turn, the most recent International Society for Peritoneal Dialysis (ISPD) practice recommendations pertaining to the provision of PD to adults and children emphasize the importance of the well-being of the person receiving dialysis in contrast to an emphasis on the removal of specific toxins. Accordingly, the focus of the dialysis prescription has shifted from simply achieving “an adequate Kt/Vurea” to delivering “high-quality, goal-directed” dialysis care with realistic treatment goals that are established through shared decision making between the care team and the patient/family. Dialysis adequacy in pediatrics, therefore, should encompass a more comprehensive assessment of patient well-being, including quality of life and patient-specified goals, growth and nutritional management, bone-mineral and cardiovascular health, and psychomotor development, in addition to sufficient small solute and middle molecule clearance. Nonetheless, Kt/Vurea provides a (relatively) reproducible measure that can help clinicians avoid grossly inadequate dialysis and will likely remain important for regulatory and quality assurance purposes for the foreseeable future.