Acute Peritoneal Dialysis Adequacy among Children at a National Referral Hospital in Kenya: A Cross-Sectional Study in a Resource-Limited Setting

Technical Summary: Acute Peritoneal Dialysis Adequacy Among Children in Kenya

Problem Statement
Acute peritoneal dialysis (PD) serves as a critical renal replacement therapy for children with acute kidney injury (AKI), particularly in resource-limited settings where hemodialysis is less accessible. However, the adequacy of PD in pediatric populations remains a concern, as inadequate clearance can lead to persistent uremia, prolonged hospitalization, increased mortality, and the need to transition to hemodialysis. While adult guidelines (K/DOQI) suggest specific targets for urea clearance (Kt/V > 0.3) and creatinine clearance (> 9 L/day/1.73m²), these thresholds may not be directly applicable to children with AKI due to altered urea distribution volumes and protein catabolism. Furthermore, there is a scarcity of data regarding target clearance values for children undergoing acute PD, particularly within African populations. This study addresses the gap in knowledge by assessing PD adequacy and describing urea and creatinine clearance among children receiving acute PD at a national referral hospital in Kenya.

Methodology
The researchers conducted a cross-sectional study at Kenyatta National Hospital (KNH), a teaching and referral hospital in Nairobi, between September 2024 and January 2025.

• Participants: The study enrolled 64 children (median age 18 days; 43% female) admitted to the pediatric renal unit with a documented diagnosis of AKI (defined by KDIGO guidelines) who were managed with PD.
• Exclusion: Three children were excluded due to significant catheter leakage or bleeding.
• Intervention: PD was performed using surgically placed Tenckhoff catheters with improvised dialysate and manual exchanges. The study focused on the first 24 hours of dialysis.
• Data Collection: Researchers extracted data on total drain volumes, serum and effluent concentrations of electrolytes, urea, and creatinine.
• Calculations: Daily urea and creatinine clearances were calculated using the formula: Clearance = Effluent volume × (Effluent solute concentration / Serum solute concentration). Urea clearance was normalized to total body water (Kt/V), and creatinine clearance was normalized to body surface area (1.73m²).
• Statistical Analysis: A paired t-test was used to compare mean serum urea and creatinine concentrations before and after 24 hours of dialysis. Descriptive analysis was employed to compare solute clearance between groups receiving different dialysate dextrose concentrations (1.5% vs. 2.5%).

Key Results

• Demographics and Presentation: The majority of participants (68.8%) were neonates (≤ 28 days). All children presented with azotemia, and 62.5% had oliguria (< 0.3 ml/kg/hour). Hypernatremia and hyperkalemia were present in 50% and 35.9% of patients, respectively.
• Prescription Parameters: The mean fill volume was 9.3 ± 1.4 ml/kg. The vast majority (92.2%) received 1.5% dextrose dialysate, while 7.8% received 2.5%. A dwell time of 1 hour was used in 98.4% of cases.
• Clearance Outcomes:
  • Serum Reduction: There was a statistically significant reduction in mean serum urea (from 53.06 to 32.28 mmol/L) and creatinine (from 602.2 to 289.4 µmol/L) after the first 24 hours of dialysis (p < 0.001).
  • Median Clearances: The median daily creatinine clearance was 5.13 L/day/1.73m² (IQR 2.34–7.38), and the median daily urea clearance (Kt/V) was 1.03 (IQR 0.76–3.31).
• Prescription Correlations:
  • Fill volume showed weak, non-significant positive correlations with both urea (r = 0.037) and creatinine (r = 0.14) clearance.
  • Participants receiving 2.5% dextrose dialysate demonstrated higher median urea and creatinine clearance compared to those receiving 1.5%, though the small sample size in the 2.5% group limits definitive statistical comparison.

Significance and Claims
The study concludes that peritoneal dialysis achieves measurable and clinically meaningful clearance of urea and creatinine among children with AKI at Kenyatta National Hospital. The observed median daily creatinine clearance (5.13 L/day/1.73m²) and Kt/V (1.03) are comparable to findings in other pediatric acute PD studies, particularly those involving post-cardiac surgery patients.

The authors highlight that neonates constitute the majority of dialysis recipients in this setting, reflecting a high burden of neonatal AKI driven by sepsis, birth asphyxia, and hemodynamic instability. The study asserts that locally delivered PD can achieve substantial solute clearance within the first 24 hours, evidenced by the significant reduction in serum solutes. However, the authors remain modest regarding broader generalizations, noting limitations such as the single-center design, small sample size, short duration, and the use of retrospective data. They emphasize the need for larger, multicenter studies to further validate these findings and evaluate the safety and efficacy of hypertonic dialysate solutions in this population.