Combined amino acid and glucose dialysate in children on automated peritoneal dialysis.
C renal failure (CRF) presenting in childhood may have a long-standing adverse effect in nutrition and growth. This is because growth in childhood is predominantly dependent on nutrition, and decreased spontaneous oral intake was demonstrated in several studies in children with CRF.1 Energy intake correlates negatively with glomerular filtration rate (GFR), and the intake deteriorates with the severity of CRF. Children undergoing peritoneal dialysis (PD) were observed to suffer from wasting, and/or protein energy malnutrition. Early introduction of enteral feeding may result in normal growth, if it maintains an adequate energy intake.2 Recently, the use of amino acid (AA) containing dialysis fluids was considered for its nutritional benefits in malnourished dialyzed children.3 Some studies have reported a significant improvement in some nutritional parameters, while others have shown no significant improvement in the same parameters.3 It was demonstrated that AA dialysis is an efficient form of peritoneal dialysis in patients on automated peritoneal dialysis (APD), and should be considered for children with poor nutritional status for whom enteral nutrition supplementation has been unsuccessful.4 Peritoneal dialysis solutions containing a mixture of AA and glucose in a proper ratio can serve as a source of protein and calories.4 The objective of this prospective study was to find out if the use of AA dialysate will improve nutritional markers and growth in children receiving APD. We also investigated whether AA dialysate had any adverse side effects. All children on APD who are followed-up at the King Abdul-Aziz University Hospital (KAUH) between September 2008 and September 2009 were recruited for the study. Syndromatic and children on growth hormone were excluded from the study. Seven children (5 girls and 2 boys) fulfilled the criteria, and their parents gave their consent for their inclusion in the study. Their mean age was 11.33 ± 3.7, and the mean duration on PD before the study was 15 ± 0.8 months. None of the children had secondary pubertal signs. During the study period, children received hourly APD cycles of 1100-1400 ml/M2 for 10 hours, utilizing a mixture of manufactured AA dialysate (1.1%), and dextrose solution (1.5 or 2.5%) with a 1:1 ratio. Children were studied for a 12-month duration. The following were monitored at a 3-month interval: height standard deviation score (HtSDS); body mass index (BMI); serum albumin; pre-albumin; renal function tests; bone profile; acid-base disturbances; and serum AA levels (alanine, arginine, asparagine, aspartic acid, citrulline, glutamic acid, glutamine, glycine, histidine, isoleucine, leucine, lysine, methionine, ornithine, phenylalanine, serine, tryptophan, taurine, threonine, and tyrosine). The measurement of AA in the serum was carried out during the day when the children were not receiving APD. Dialysis efficiency was measured by the clearance of urea nitrogen (Kt) divided by urea distribution volume (v). The Kt/V was measured before and at the end of the study. All studied children were prescribed high calorie diet (70-100 kcal/kg/day), which was given orally as they refused enteral feeding (nasogastric or gastrostomy). Their adherence to high calorie diet was doubtful. The peritoneal WBC was checked monthly as part of the study protocol. This study was approved by the research ethical committee at KAUH, and it was conducted according to the principles of Helsinki Declaration. The analysis of variance (ANOVA) test was used for statistical analysis. A p < 0.05 was considered significant. The KIGS software (Pfizer International Growth database) was used to calculate HtSDS and BMI. The results were expressed as mean + standard deviation. There was no difference in the peritoneal equilibration test (PET) before, and after finishing the study. Similarly the ultra-filtrate (UF) did not change before, during, or after the study. The mean Kt/V before the study was 2.04 ± 0.33, and it was 1.7 ± 0.78 (p=0.32) after the study. There was no improvement in HtSDS, and there was no significant difference between the start and follow-up visits (p=0.996) (Figure 1). Most of the children were malnourished at the start of the study, as their BMI was less than 20, except for one child with a BMI of 25.5. The median BMI at the start was 15 (range: 13.6-25.5). There was no improvement in the BMI (p=0.996), and there was no significant difference between the start and follow-up visits (p=0.95). There was no improvement in the serum albumin (normal range; 33-48 g/L), that is: mean at the start was 31.9 ± 3.6; at 3 months was 28.3 ± 5.9; at 6 months was 27.4 + 7.6; at 9 months was 29.9 Brief Communication