Abstract
Introduction
Urgent-start peritoneal dialysis (USPD) provides kidney replacement therapy (KRT) for children with acute kidney injury (AKI) or stage 5 chronic kidney disease (CKD) requiring dialysis. Pediatric data from resource-limited settings remain limited.
Methods
We retrospectively described 18 children who underwent USPD at a tertiary center in Jordan between January 2022 and December 2024. USPD was defined as initiation of peritoneal dialysis (PD) within 14 days of catheter insertion. Early complications occurred within 14 days of the first PD exchange, and late complications thereafter.
Results
Sixteen children had AKI, and two had stage 5 CKD. Etiologies were hemolytic uremic syndrome (6/18, 33.3%) and acute tubular necrosis (4/18, 22.2%). Thirteen (72.2%) initiated PD within 24 h: five at 4–12 h and eight at 24 h. Six developed early complications: a leak on 4/18 (22.2%) and an exit-site infection on 2/18 (11.1%), without overlap. Five developed late complications. Peritonitis affected 4/18 (22.2%) and accounted for five episodes; other late events included a leak in two children, an exit-site complication in one, and catheter obstruction in one, with overlapping categories. At one year, 9/16 children with AKI (56.3%) were no longer receiving dialysis, 3/16 (18.8%) remained on PD, and 4/16 (25.0%) had died. Of the two children with stage 5 CKD, one remained on hemodialysis, and one was dialysis-free after transplantation.
Conclusions
This descriptive, single-center experience on USPD delivery, complications, and one-year outcomes. The small sample, absence of a comparator group, and heterogeneity preclude conclusions about safety, timing effects, or predictors.
Keywords: Peritoneal dialysis, acute kidney injury, stage 5 chronic kidney disease, Peritonitis, kidney replacement therapy
LAY SUMMARY
We reviewed 18 children treated with urgent-start peritoneal dialysis at one hospital in Jordan. Sixteen had acute kidney injury, and two had stage 5 chronic kidney disease. Thirteen children began dialysis within 24 h. Six children developed an early complication: four had a fluid leak, and two had an exit-site infection. Five children developed later complications; four had peritonitis, and one of them had two episodes. At one year, nine of the 16 children with acute kidney injury no longer required dialysis, three remained on peritoneal dialysis, and four had died. Of the two children with stage 5 chronic kidney disease, one remained on hemodialysis and one no longer required dialysis after receiving a kidney transplant. Because this was a small study without a comparison group, it describes local experience but cannot determine whether one starting time is safer than another.
KEY MESSAGES
What is known: Urgent-start PD is used when children require kidney replacement therapy before completion of a conventional catheter break-in period, but pediatric outcome data are limited.
This study adds: Description of timing, procedures, complications, microbiology, and diagnosis-specific one-year outcomes in 18 children treated with USPD at a Jordanian tertiary center.
Potential impact: The findings provide practical descriptive information for centers developing pediatric USPD pathways while emphasizing the need for larger multicenter comparative studies.
Introduction
Acute kidney injury (AKI) is a major cause of morbidity and mortality in children worldwide, with the greatest burden in low- and middle-income countries. In these settings, timely access to kidney replacement therapy (KRT) may be limited by cost, infrastructure, and the technical demands of extracorporeal treatments such as hemodialysis and continuous KRT [1,2]. Peritoneal dialysis (PD) is therefore widely used as first-line KRT for pediatric AKI because it is technically simpler, requires less specialized infrastructure, and can be applied across a wide age range, including infancy [1,2].
In practice, however, the use of acute PD in children depends not only on clinical factors but also on the equipment available. Dedicated acute PD catheters are not consistently stocked in many pediatric centers, and clinicians sometimes rely on alternative or improvised devices to start dialysis without delay [3]. Such constraints highlight the need for standardized protocols that keep PD safe and consistent when it must be started urgently.
Real-world experience confirms that a PD-first approach is practical in resource-limited settings. In a large pediatric series from Cape Town spanning 22 years, PD was the initial dialysis modality in 78% of children treated for AKI. It was used successfully across all age groups, including infants [4].
The decision to start dialysis depends on a child’s overall clinical condition rather than on laboratory values alone. KDIGO guidelines recommend initiating KRT urgently when life-threatening disturbances of fluid balance, electrolytes, or acid–base status develop, and advise that this decision be guided by the broader clinical picture and trends in laboratory results rather than by any single urea or creatinine threshold [5].
This experience is mirrored in global practice. An international survey found wide regional variation in the availability and choice of pediatric dialysis modalities, with PD most commonly used in low-resource settings [6]. The International Society for Peritoneal Dialysis (ISPD) pediatric AKI guidelines likewise endorse PD as a suitable treatment for children with AKI and emphasize its particular value where extracorporeal therapies are costly or difficult to provide [1].
When PD is initiated soon after catheter insertion, before completion of the conventional break-in period, it is termed urgent-start PD (USPD) [7]. Definitions vary: a pragmatic definition specifies initiation within 14 days after catheter insertion, whereas stricter definitions require initiation within 72 h [7,8]. Pediatric evidence remains limited. A 15-year pediatric series described initiation within 24 h [9], while reports from resource-constrained settings have documented variable rates of dialysate leakage, catheter complications, and peritonitis, reflecting differences in case mix, protocols, staff training, and infection-prevention practices [10–14].
Existing pediatric cohorts are small and heterogeneous, and few studies report longer-term outcomes separately for AKI and stage 5 CKD. We therefore aimed to describe our single-center experience with pediatric USPD in Jordan between 2022 and 2024, including the clinical population, timing of initiation, PD procedures, early and late complications, microbiology, and diagnosis-specific one-year outcomes. All subgroup findings are presented for descriptive completeness rather than to infer comparative safety or cause-specific risk.
Materials and methods
Study design and participants
We retrospectively reviewed our single-center experience with pediatric USPD at a tertiary center in Jordan between January 2022 and December 2024. Children younger than 18 years were eligible if they required unplanned KRT for AKI or stage 5 CKD and initiated PD less than 14 days after catheter insertion (USPD). Of 26 children who underwent PD during this period, 18 met the USPD definition; 8 initiated PD ≥14 days after catheter placement (conventional-start PD) and were excluded (Figure 1). The conventional-start group was not analyzed comparatively because the study objective was to describe USPD, no comparative analysis had been prespecified, and the small heterogeneous groups would not support a meaningful comparison. No a priori sample-size calculation was performed; all eligible children treated during the study period were included, and none were excluded for missing timing or early-complication data.
Figure 1.
Patient flow diagram.
Definitions
USPD was defined as initiation of PD less than 14 days after catheter insertion, without a conventional break-in period [7,8]. AKI was classified using KDIGO diagnostic criteria [5] when serial serum creatinine and/or urine output data were available; retrospective staging was possible in all 16 children with AKI (15 stage 3, 1 stage 2). Stage 5 CKD was defined as established CKD with an estimated glomerular filtration rate <15 mL/min/1.73 m2 or kidney failure requiring maintenance KRT. Early complications were events occurring within 14 days of the first PD exchange; late complications occurred thereafter. Complications were classified as mechanical (dialysate leak, catheter obstruction/malfunction) or infectious (exit-site or catheter-wound infection, peritonitis). Peritonitis was diagnosed when at least two of the following were present: clinical features compatible with peritonitis; dialysate white blood cell count >100/µL after ≥2 h of dwell, with >50% polymorphonuclear leukocytes; and a positive dialysis-effluent culture [15]. Complication timing was indexed from the first PD exchange; affected-patient counts and event counts are distinguished throughout because one child could have more than one complication. Kidney-related terminology follows KDIGO consensus nomenclature [16].
Catheter placement and PD prescription
All children underwent open surgical placement of a double-cuff coiled Tenckhoff catheter under general anesthesia by a pediatric surgeon, with intravenous antibiotic prophylaxis before insertion. Through an infraumbilical midline incision, the peritoneum was opened, and any adhesions were released; in the Trendelenburg position, the catheter was advanced into the pelvis with the deep cuff placed preperitoneally, and a subcutaneous tunnel was fashioned to a lateral, caudal exit site with the superficial cuff approximately 2 cm from the exit. Catheter patency was confirmed intraoperatively by instilling and draining 100 mL of sterile saline. PD was initiated as manual continuous ambulatory PD using commercial glucose-based solutions (1.5% or 2.5% dextrose), selected based on ultrafiltration needs. The initial fill volume was 10 mL/kg with a 1-h dwell and hourly exchanges; subsequent fill volume and frequency were adjusted according to biochemical control, fluid balance, ultrafiltration, and clinical tolerance. Heparin (500 U/L) was added at the clinician’s discretion when fibrin or slow flow was observed.
Data collection and follow-up
Demographic, clinical, laboratory, treatment, and outcome data were extracted from medical records. Baseline variables included age, sex, weight, AKI or CKD classification, KDIGO stage, underlying diagnosis, comorbidities, intensive care unit admission, mechanical ventilation, inotrope use, fluid overload, indications for urgent KRT, and presenting serum urea, creatinine, electrolytes, hemoglobin, platelet count, and acid-base status. PD variables included time from catheter insertion to first exchange, initial fill volume, dwell time, exchange frequency, dialysis duration, complication type and timing, peritonitis episodes and cultures, antimicrobial treatment, catheter interventions, and one-year outcomes. Children were followed during admission and after discharge through nephrology clinic visits, electronic medical record review, and telephone contact when visits were missed. One-year status was classified separately for AKI (no dialysis, ongoing PD, ongoing hemodialysis, or death) and for stage 5 CKD (ongoing PD, ongoing hemodialysis, no dialysis after kidney transplantation, or death). One-year outcome data were available for all 18 children.
Statistical analysis
Descriptive calculations were performed using SPSS version 27. Age and continuous laboratory variables were summarized using the median and interquartile range; weight was summarized using the mean and standard deviation. Categorical variables were reported as counts and percentages, with numerators and denominators shown for each proportion. There were no missing data for the reported baseline values, KDIGO stage, timing, early-complication status, or one-year outcome. No formal hypothesis testing was performed given the small sample and the absence of a prespecified comparative hypothesis; percentages from very small diagnostic subgroups are presented for descriptive completeness only and should not be interpreted as precise risk estimates.
Ethics
The study was approved by the Institutional Review Board of The Hashemite University (Approval No. 2600044). As this was a retrospective review of routinely collected medical records with no direct patient contact and no disclosure of identifiable information, individual informed consent was waived.
Results
Patient characteristics and etiology
Eighteen children (11/18, 61.1% female) underwent USPD between January 2022 and December 2024 (Figure 1). Sixteen had AKI, and two had stage 5 CKD. Median age at PD initiation was 4.0 years (interquartile range, 2.3–8.5 years), and mean weight was 18.4 ± 11.4 kg. Fourteen children (14/18, 77.8%) required intensive care, seven (7/18, 38.9%) required mechanical ventilation, five (5/18, 27.8%) received inotropic support, seven (7/18, 38.9%) had fluid overload, and five (5/18, 27.8%) had documented comorbidities. Among the 16 children with AKI, 15/16 (93.8%) had KDIGO stage 3 AKI and 1/16 (6.3%) had stage 2 AKI. HUS was the most common etiology (6/18, 33.3%), followed by ATN (4/18, 22.2%). Stage 5 CKD, disseminated intravascular coagulation (DIC), and steroid-resistant nephrotic syndrome (SRNS) each accounted for 2/18 (11.1%); IgA nephropathy (IgAN) and rapidly progressive glomerulonephritis/IgA vasculitis (RPGN/IgAV) each accounted for 1/18 (5.6%) (Table 1).
Table 1.
Baseline demographic, clinical, and laboratory characteristics at initial presentation (n = 18).
| Characteristic | Value |
|---|---|
| Age, median years (IQR) | 4.0 (2.3–8.5) |
| Age range, months (years) | 4–144 (0.3–12.0) |
| Age, mean years (SD) | 5.1 (3.9) |
| Sex, female/male, n (%) | 11 (61.1) / 7 (38.9) |
| Weight, mean kg (SD) | 18.4 (11.4) |
| Weight range, kg | 5.9–46.1 |
| Clinical population: AKI / stage 5 CKD, n (%) | 16 (88.9) / 2 (11.1) |
| Intensive care unit admission, n (%) | 14 (77.8) |
| Mechanical ventilation, n (%) | 7 (38.9) |
| Inotrope use, n (%) | 5 (27.8) |
| Fluid overload at presentation, n (%) | 7 (38.9) |
| Documented comorbidity, n (%) | 5 (27.8) |
| KDIGO AKI stage available, n/N (%) | 16/16 (100) |
| KDIGO stage 2 / stage 3 among staged AKI, n/N (%) | 1/16 (6.3) / 15/16 (93.8) |
| Metabolic acidosis, n (%) | 9 (50.0) |
| Serum urea, mmol/L, median (IQR) | 28.5 (18.3–45.5) |
| Serum creatinine, µmol/L, median (IQR) | 509 (184–742) |
| Serum potassium, mmol/L, median (IQR) | 4.7 (4.0–5.6) |
| Serum sodium, mmol/L, median (IQR) | 133 (129–136) |
| Hemoglobin, g/dL, median (IQR) | 8.0 (7.0–10.0) |
| Platelet count, ×10⁹/L, median (IQR) | 138 (76–249) |
| Blood pH among children with acidosis, median (IQR) | 7.24 (7.20–7.34) |
| Bicarbonate among children with acidosis, mmol/L, median (IQR) | 12.6 (11.2–15.7) |
| Urgent KRT indication: severe hypertension/hypertensive emergency, n (%) | 9 (50.0) |
| Urgent KRT indication: fluid overload/pulmonary edema/anuria, n (%) | 7 (38.9) |
| Urgent KRT indication: hyperkalemia, n (%) | 2 (11.1) |
| Urgent KRT indication: uremic symptoms/encephalopathy, n (%) | 2 (11.1) |
| Urgent KRT indication: persistent metabolic acidosis, n (%) | 1 (5.6) |
Abbreviations: AKI, acute kidney injury; CKD, chronic kidney disease; IQR, interquartile range; KDIGO, Kidney Disease Improving Global Outcomes; KRT, kidney replacement therapy; SD, standard deviation.
At initial presentation, median serum urea was 28.5 mmol/L (IQR, 18.3–45.5), creatinine 509 µmol/L (IQR, 184–742), potassium 4.7 mmol/L (IQR, 4.0–5.6), and sodium 133 mmol/L (IQR, 129–136). Median hemoglobin was 8.0 g/dL (IQR, 7.0–10.0), and median platelet count was 138 × 109/L (IQR, 76–249). Metabolic acidosis was documented in 9/18 children (50.0%); among these children, the median blood pH was 7.24 (IQR, 7.20–7.34), and the median bicarbonate was 12.6 mmol/L (IQR, 11.2–15.7). Documented indications for urgent KRT included severe hypertension or hypertensive emergency in 9/18 children (50.0%), fluid overload, pulmonary edema, or anuria in 7/18 (38.9%), hyperkalemia in 2/18 (11.1%), uremic symptoms or encephalopathy in 2/18 (11.1%), and persistent metabolic acidosis in 1/18 (5.6%); categories were not mutually exclusive (Table 1).
Timing of PD initiation
PD initiation occurred at varying intervals after catheter insertion. Thirteen of 18 children (72.2%) initiated PD within 24 h: 5/18 (27.8%) at 4–12 h and 8/18 (44.4%) at 24 h. The remaining 5/18 (27.8%) initiated PD after 24 h: 3/18 (16.7%) at 72 h and 2/18 (11.1%) at 6–7 days. The four timing groups therefore account for all 18 children (Figure 2).
Figure 2.
Distribution of the time from peritoneal dialysis catheter insertion to the first exchange.
Early and late complications
Six children experienced six early complication events. Dialysate leak occurred in 4/18 children (22.2%), and exit-site infection occurred in 2/18 (11.1%); these events occurred in different children. Five children experienced late complications. Peritonitis affected 4/18 children (22.2%) and accounted for five episodes because one child experienced two relapsing episodes. Other late events included persistent or recurrent dialysate leak in 2/18 children (11.1%), a late exit-site complication documented as infection or allergic dermatitis in 1/18 (5.6%), and catheter obstruction in 1/18 (5.6%). Late complication categories overlapped. Available event-level details are summarized in Table 2.
Table 2.
PD-related complications and available event-level details (n = 18).
| Complication | Timing from first PD exchange | Affected children, n/N (%) | Overlap or microbiology | Recorded management/outcome |
|---|---|---|---|---|
| Dialysate leak | Early (≤14 d) | 4/18 (22.2) | Occurred in four different children; none had an early exit-site infection. | A conservative protocol was effective in controlling leaks in 2 cases; leaks persisted in another 2 cases |
| Exit-site infection | Early (≤14 d) | 2/18 (11.1) | Occurred in two different children and did not overlap with early leak. | Treatment was documented with topical and/ or systemic antibiotics. |
| Persistent/recurrent dialysate leak | Late (>14 d) | 2/18 (11.1) | Occurred in one child with DIC and one child with ATN; the ATN child also developed Candida peritonitis. | Catheter intervention was documented in both children. |
| Exit-site complication | Late (>14 d) | 1/18 (5.6) | Documented as recurrent exit-site infection/allergic dermatitis in a child with ATN who also developed Candida peritonitis. | Treatment and later catheter removal were documented. |
| Peritonitis | Late (>14 d) | 4/18 (22.2); 5 episodes | Two Candida episodes; one multidrug-resistant A. baumannii episode; two relapsing polymicrobial E. cloacae/M. morganii episodes in one child. | Antimicrobial treatment and/or catheter removal or reinsertion were documented in all four affected children. |
| Catheter obstruction | Late (>14 d) | 1/18 (5.6) | Occurred with relapsing polymicrobial peritonitis in the child with stage 5 CKD. | The child transitioned from PD to HD. |
Abbreviations: PD, peritoneal dialysis; HD, hemodialysis; CKD, chronic kidney disease.
Early complications affected 3/10 children younger than five years (30.0%) and 3/8 children aged five years or older (37.5%). They occurred in 4/13 children who initiated PD within 24 h (30.8%) and 2/5 who initiated after 24 h (40.0%) (Table 3). These figures are descriptive and were not compared inferentially.
Table 3.
Early PD-related complications by clinical and treatment characteristics (n = 18).
| Variable | Total (n = 18) | No early complication (n = 12) | Early complication (n = 6) |
|---|---|---|---|
| Age <5 years | 10 (55.6) | 7 (58.3) | 3 (50.0) |
| Age ≥5 years | 8 (44.4) | 5 (41.7) | 3 (50.0) |
| PD initiated ≤24 h | 13 (72.2) | 9 (75.0) | 4 (66.7) |
| PD initiated >24 h | 5 (27.8) | 3 (25.0) | 2 (33.3) |
| Fluid overload: yes | 7 (38.9) | 5 (41.7) | 2 (33.3) |
| Fluid overload: no | 11 (61.1) | 7 (58.3) | 4 (66.7) |
| ICU admission: yes | 14 (77.8) | 9 (75.0) | 5 (83.3) |
| ICU admission: no | 4 (22.2) | 3 (25.0) | 1 (16.7) |
| Mechanical ventilation: yes | 7 (38.9) | 3 (25.0) | 4 (66.7) |
| Mechanical ventilation: no | 11 (61.1) | 9 (75.0) | 2 (33.3) |
| Inotrope use: yes | 5 (27.8) | 2 (16.7) | 3 (50.0) |
| Inotrope use: no | 13 (72.2) | 10 (83.3) | 3 (50.0) |
Abbreviations: ICU, intensive care unit; PD, peritoneal dialysis.
Because the diagnostic subgroups contained only 1 to 6 children, the following percentages are presented for descriptive completeness only and do not provide stable estimates of etiology-specific risk. Early complications occurred in 1/6 children with HUS, 2/4 with ATN, 2/2 with DIC, and 1/2 with stage 5 CKD; no early complication was recorded in the SRNS, IgAN, or RPGN/IgAV groups. Late complications occurred in 2/4 children with ATN, 2/2 with DIC, and 1/2 with stage 5 CKD; no late complication was recorded in the HUS, SRNS, IgAN, or RPGN/IgAV groups.
Illness severity and complications
Most children were critically ill at PD initiation. Early complications were recorded in 4/7 mechanically ventilated children and 2/11 children who were not ventilated; in 3/5 children receiving inotropes and 3/13 not receiving inotropes; and in 2/7 children with fluid overload and 4/11 without fluid overload (Table 3). These distributions were not tested and should not be interpreted as associations.
Peritonitis: incidence and microbiology
Peritonitis affected 4/18 children (22.2%) and accounted for five late episodes. Candida species were isolated from two children with ATN, multidrug-resistant Acinetobacter baumannii from one child with DIC, and Enterobacter cloacae and Morganella morganii from a child with stage 5 CKD who experienced two relapsing episodes. The latter child also developed catheter obstruction and transitioned to hemodialysis. Antimicrobial treatment and catheter removal or reinsertion were documented in all four affected children (Table 2).
One-year outcomes
One-year outcomes were interpreted separately by clinical population. Among 16 children with AKI, 9/16 (56.3%) were no longer receiving dialysis, 3/16 (18.8%) remained on PD, and 4/16 (25.0%) had died. Among the two children with stage 5 CKD, one remained on hemodialysis, and one was no longer receiving dialysis after kidney transplantation. Across the full cohort, the one-year status was no dialysis in 10/18 (55.6%), ongoing PD in 3/18 (16.7%), hemodialysis in 1/18 (5.6%), and death in 4/18 (22.2%). The four deaths within one year occurred in children with DIC (2/2), ATN (1/4), and SRNS (1/2). Available records indicated that both DIC deaths occurred in the setting of DIC and multiorgan failure. In contrast, the ATN death occurred in a child with Wolcott-Rallison syndrome, diabetic ketoacidosis, and liver failure. The immediate cause of death in the SRNS child was not fully documented. The retrospective records did not permit formal adjudication of whether PD-related complications contributed to death.
Patient-level complications, treatments, and one-year outcomes among the six children who experienced early complications are summarized in the supplementary table (Table S1).
Discussion
In this descriptive single-center experience, 16 children had AKI and two had stage 5 CKD requiring unplanned KRT. Thirteen of 18 initiated PD within 24 h of catheter insertion. Six children experienced an early complication, while five experienced late complications. Peritonitis affected four children and accounted for five episodes. These observations describe local practice and outcomes; they do not establish comparative safety, effectiveness, or timing-related risk.
Timing and early mechanical complications
Most children were acutely and often critically ill, so the timing of dialysis was determined by clinical necessity rather than elective allocation. In this setting, delaying KRT solely to complete a catheter break-in period would often have been inappropriate unless another KRT modality was immediately available. The observed early-complication frequencies in children starting within 24 h (4/13) and after 24 h (2/5) must therefore not be interpreted as a comparative test of timing. Prior pediatric reports similarly describe urgent initiation with dialysate leak as the main early mechanical event and emphasize that age, body size, catheter characteristics, fill volume, and surgical factors may be as important as timing [9,17–19].
Our protocol used surgically placed double-cuff Tenckhoff catheters, low initial fill volumes, gradual volume escalation, and trained nursing staff. These measures are consistent with ISPD guidance aimed at reducing intra-abdominal pressure, leakage, and infection during acute pediatric PD [1]. The present sample is too small to determine which components of the protocol were associated with individual outcomes.
Peritonitis and infectious profile
Late peritonitis affected four children and accounted for five episodes: two Candida episodes, one multidrug-resistant A. baumannii episode, and two relapsing polymicrobial Enterobacter cloacae/Morganella morganii episodes in one child with stage 5 CKD. The latter child also developed catheter obstruction and transitioned to HD. This organism profile is clinically relevant in critically ill hospitalized children exposed to broad-spectrum antimicrobials and invasive devices. Prevention depends on aseptic insertion and exchange technique, structured staff training, and standardized exit-site care [1,15,20]. Because exposure duration varied and the cohort was small, we did not calculate a patient-time incidence rate or directly compare our percentage with those from chronic-PD or larger acute-PD cohorts [21].
One-year outcomes
Separating outcomes by the underlying clinical population materially changes their interpretation. Among children with AKI, nine were no longer receiving dialysis at one year, three remained on PD, and four had died. Among the two children with stage 5 CKD, one remained on hemodialysis, and one was no longer receiving dialysis after kidney transplantation. Reporting the transplant recipient separately prevents absence of dialysis from being misinterpreted as recovery of native kidney function.
Clinical context and interpretation
The high frequencies of intensive care admission, ventilation, inotrope use, and fluid overload show that this was a severely ill population. Pediatric AKI studies consistently associate fluid overload and multi-organ dysfunction with adverse outcomes [22–24], and larger prediction studies emphasize overall illness severity rather than any single kidney measure [25]. In our small sample, these variables are only contextual descriptors; no association with PD complications or mortality can be inferred.
Relevance to practice
The contribution of this study is its detailed description of a pediatric USPD pathway in an underreported setting. PD remains an important KRT option where access to extracorporeal therapies, pediatric equipment, or trained personnel is limited [2,3,6,10–14]. The findings support the value of reliable catheter access, written protocols, nursing training, and infection-prevention processes. Still, they should not be interpreted as evidence that USPD is safer or more effective than conventional-start PD or another KRT modality.
Limitations
This study has several important limitations. It represents a small, retrospective, single-center experience without a prespecified comparator group, so the estimates are imprecise and not generalizable. The cohort included both AKI and stage 5 CKD, with several diagnostic subgroups comprising only one or two children. Although KDIGO stage, free-text KRT indications, initial PD prescription, complication timing, microbiology, and available catheter-management details were abstracted, the records did not consistently provide age-adjusted anthropometry, complete antimicrobial regimens, standardized documentation distinguishing infection from allergic exit-site inflammation, patient-time peritonitis rates, or formal cause-of-death adjudication. Clinical practice and documentation may also have changed during the three-year study period. Accordingly, all findings are descriptive and hypothesis-generating.
Conclusion
This descriptive single-center experience reports how USPD was delivered to 18 children with AKI or stage 5 CKD in Jordan. Most initiated PD within 24 h because of urgent clinical need. Early complications comprised dialysate leak and exit-site infection; late complications included peritonitis, persistent or recurrent leak, an exit-site complication, and catheter obstruction. Diagnosis-specific one-year reporting distinguished AKI dialysis-free recovery, ongoing PD, death, and stage 5 CKD outcomes of hemodialysis or no dialysis after transplantation.
The study provides practical guidance for centers establishing pediatric USPD pathways, particularly in settings where extracorporeal KRT is difficult to deliver. However, the sample size, retrospective design, clinical heterogeneity, and absence of a comparator group preclude conclusions about safety, optimal timing, comparative effectiveness, or predictors of complications and survival. Larger prospective multicenter studies with standardized event reporting and patient-time denominators are needed.
Supplementary Material
Acknowledgements
The authors thank the nursing and technical staff of the Pediatric Nephrology and Pediatric Surgery services at Prince Hamzah Hospital, Amman, for their dedicated care of the children in this cohort. We are also grateful to the medical records team for facilitating access to the patient files. Finally, we thank the families of the children included in this study, whose cooperation and trust made this work possible.
Funding Statement
The author(s) reported there is no funding associated with the work featured in this article.
Declaration of Helsinki
This study was conducted in accordance with the principles of the Declaration of Helsinki.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Institutional review board statement
The Institutional Review Board of the Hashemite University provided approval for this study (IRB No. 2600044).
Informed consent statement
Written informed consent was waived by our institutional IRB due to the retrospective nature of the study.
Data availability statement
The anonymized datasets used and analyzed in the current study are available from the corresponding author upon request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The anonymized datasets used and analyzed in the current study are available from the corresponding author upon request.