the choice of modality of renal replacement treatment in children with renal failure is a challenge . although extracorporeal techniques such as continuous venovenous hemofiltration ( cvvh ) or continuous venovenous hemodiafiltration ( cvvhdf ) are used quite frequently in adult intensive care units ( icus ) , but it is not a common modality of renal replacement treatment in many pediatric icus . such techniques are very dependent on technology and are more costly than acute peritoneal dialysis ( pd ) . however , in developing countries , acute pd remains a viable option for the treatment of children with renal failure , particularly in patients with hemodynamical compromise , severe coagulation abnormalities and difficulty in obtaining vascular access . because of vascular access problem in children with acute renal failure ( arf ) and those with arf superimposed on chronic condition , especially when there is need for urgent dialysis which may last for more than a few days , it is important to start immediately and continue pd with a permanent peritoneal access . in most pediatric and adult pd centers because of catheter - related pd complications , dialysis begins after catheter has been implanted and sufficient time for healing has been allowed . however , catheter - related pd complications such as peritonitis , exit - site infection ( esi ) , tunnel infection , pericatheter leakage , and mechanical dysfunction are still major concerns . there is a paucity of published experience on children with immediate use of permanent tenckhoff catheter for pd from developing countries . in this article we report our experience on immediate use of permanent peritoneal access and continued pd for a prolonged time . data collection : fifty six children with end stage renal failure and acute renal failure from 2005 to 2011 which needed pd , immediately after catheter insertion was included . patients were included if there was a need for emergency dialysis ( which was expected that it lasts for days and weeks ) because of acute renal failure or acute condition on chronic renal failure . exclusion criteria were children less than 1 month and more than 14 years old , patients who did not have an emergent dialysis , patients who were under pd less than 3 weeks . the information on patients was obtained from the files of the hospital 's pediatrics ward  if they were hospitalized or in records available from follow up visits . after induction of general anesthesia and gastric decompression , the patient was placed in a supine position . a 10 mm incision was made left side 2 cm inferior to umbilicus , loop of the catheter was placed in the pelvic and after closing peritoneum and fascia a 10 cm subcutaneous tunnel was formed . the peritoneal cavity was flushed with 10 ml / kg of pd solution to check for gross bleeding or leakage . dialysis method : we used 10 cc / kg dialysis fluid with dwell time of 15 - 30 min for 3 days ; during next days volume of the fluid gradually increased up to 40cc / kg . after two weeks , dialysis was performed with 40cc / kg with dwel time of about 3 hours , 56 times a day . the regular use of mupirocin ointment at the exit site , intraperitoneal prophylactic antibiotics ( cephalexin 125mg / l of dialysis fluid ) and intraperitoneal heparin ( 500 iu / l of dialysis fluid ) was practiced in all patients . follow up : peritoneal fluid analyzes and microbial cultures were applied and patients were observed for complications during hospitalization . after discharge patients were visited every other week for 1 month and every month later on . all patients were operated by the same surgeon and the biochemical tests and analyses carried out in the same laboratory . data analysis : outcomes were analyzed in terms of peritonitis , esi , tunnel infection ( ti ) , pericatheter leakage , mechanical dysfunction , renal transplantation and mortality and changing to hemodialysis . esi , ti and peritonitis were defined according to the international society for pd guidelines / recommendations . peritonitis was defined as positive peritoneal fluid culture or if two of four of the following signs were present : abdominal pain , fever , cloudy peritoneal effluent , white blood cell count ( at least 50% polymorphonuclear leukocytes ) greater than 100/ml in dialysis fluid . esi was diagnosed in the presence of purulent discharge from the sinus tract , or marked pericatheter swelling , redness , and/or tenderness with or without a pathogenic organism cultured from the exit site ; ti was defined as presence of pain and signs of inflammation along the subcutaneous tunnel . fifty six patients were studied including 30 males ( 53.6% ) and 26 females ( 46.4% ) within the age range of 1 month to 14 years with mean age of 6.5 years . the body mass index ( bmi ) of patients were calculated with who bmi charts for pediatrics . bmi less than 3 percentile found in 30.2% patients , 53.2% had bmi between 3 and 9 percentile and 16.3% had bmi more than 97 percentile . no operative morbidity was seen . during a total of 499.5 continuous ambulatory pd ( capd ) months , 16 patients had 28 episodes of peritonitis ; which means one episode per 17.8 months . there were 3 ( 5.35% ) cases of catheter site leakage , 12 ( 21.4% ) catheter obstructions ( which led to omentectomy ) , 4 ( 7.2% ) esi ( 2 in the early postoperative period and 2 during follow up ( table 1 ) . leakage stopped in all of patients with decreasing the number and volume of dialysis fluid . the rate of early onset obstruction in patients without omentectomy at the time of insertion of catheter was high . none of the patients with omentectomy had at the time of insertion of catheter obstruction . incidence of early and late catheter related complications in patients on capd ( n = 56 ) the incidence of peritonitis is one episodes/17.8 months . capd : continuous ambulatory peritoneal dialysis the death due to catheter related complications were 1 per 56 patients and death due to non - catheter related causes was 10 per 56 patients ( table 2 ) . four deaths occurred among 21 children with acute renal failure and 7 among 35 children with chronic renal failure ( tables 3 , 4 ) . outcome of the immediate use of the permanent peritoneal dialysis catheter in children with end stage renal disease dialysis duration ( month ) and causes of acute renal failure rpgn : rapid progressive glomerulonephritis / hus : hemolytic uremic syndrome dialysis duration ( month ) and causes of chronic renal failure capd : continuous ambulatory peritoneal dialysis / hd : hemodialysis capd is a viable option for esrd in children in developing countries and can be used as a bridge between esrd and renal transplantation . it is particularly very useful where there are no pediatric hemodialysis facilities within easy reach . current recommendation in this regard is a waiting period of 1421 days between catheter insertion and pd initiation . this period of delay in starting pd results in the need for bridging hemodialysis in patients who require immediate dailysis . bridging hemodialysis usually requires temporary hemodialysis catheters with vascular access problems and risk of hemodialysis catheter complications . it has been shown that hemodialysis catheters are associated with high rates of infection , thrombosis , central venous stenosis , inflammatory stress and lead to increased morbidity . in some developing countries , pediatric haemodialysis facilities are unavailable , and there is no maintenance hemodialysis program in most of the nephrology centers . thus , pd remains the only available option for patients who need immediate dialysis and it could be a bridge between end - stage renal failure and transplantation . so in acute situations , when the need for dialysis lasts for more than a few days , and with acute on chronic condition in end - stage renal failure , it is important that a permanent peritoneal access is implanted and pd begins immediately . concern for early use of catheters derives mainly from the perceived risk of both dialysate leaks and the subsequent risk of peritonitis and poor survival rate of peritoneal access . it has been reported that the risk of leakage is increased in patients with little or no break - in period and may increase the risk of other catheter - related complications like infection and catheter malfunction . however , there are only a few reports about risks and benefits of immediate use of pd for prolonged time and there is no clear consensus about the starting time of pd after catheter insertion . in a recent report by ghaffari , 18 patients who presented urgently with chronic kidney disease stage 5 were offered pd as the initial and urgent modality of dialysis . concurrently , 9 patients with delaying use of pd catheters were included as the comparative group . in this study peritonitis , esi , catheter - related complications , and other complications were similar between the two groups , although the number of minor leaks was higher in the urgent - start group . in other study by jo et al the rate of pericatheter leakage and other catheter - related complications were relatively low in capd patients with using urgently pd catheters . pericatheter leakage , catheter tip migration , esi , and peritonitis developed in only 1.9% , 1.9% , 3.9% , and 3.9% of patients , respectively . some reports indicate that the standard survival of patients on pd has been improved to 90% at first year in developed societies . reviewing the reports of patients on capd from developing countries indicate that the mortality is still high and varying between 50% in iran , 26.6% in india and 33% in saudi arabia . in our study the overall mortality rate was 19.6% and the most of them coexisted with multiorgan involvement ( tables 3 and 4 ) . in this study , total follow up duration was 499.5 months and 16 patients had 28 episodes of peritonitis ( 5% were early onset and 23% late onset ) , which is one episode per 17.8 months . the reported peritonitis rate by other studies vary from one episode per 19.9 patient - months to one episode per 13.2 patient - months . over the past several decades , there has been a steady decline in the rate of peritonitis in both children and adults that is largely due to improvements in connection technology and a decreased incidence of touch contamination . present study indicated that catheter- related complications were not higher than those previously reported using urgently pd catheters when pd could be initiated immediately after catheter implantation . in addition , it could be a safe bridge between end - stage renal failure and transplantation
objectiveperitoneal dialysis remains the only available option for patients which need immediate dialysis and it could be a bridge between end - stage renal failure ( esrd ) and transplantation . there is a paucity of published experience of children with immediate use of permanent tenckhoff catheter for peritoneal dialysis from developing countries . in this study 
 we report our experience on immediate use of permanent peritoneal access and continued peritoneal dialysis for a prolonged time.methodsfifty six patients were studied including 30 males and 26 females within the age range of 1 month to 14 years with mean age of 6.5 years in urmia , northwest iran.findingsno operative morbidity was seen . during a total of 499.5 continuous ambulatory peritoneal dialysis months , 16 patients had 28 episodes of peritonitis , which means a overall result of one episode per 17.8 months . 
 there were 3 patients ( 5.35% ) with catheter site leakage , 12 ( 21.4% ) catheter obstructions ( which led to omentectomy ) , 4 ( 7.2% ) exit site infections ( 2 patients in the early postoperative period and 2 patients in during follow up ) . 
 death due to catheter related complications occurred in 1 per 56 patients and due to non - catheter related causes in 10 per 56 patients.conclusionpresent results indicate that catheter - related complications were not higher than those previously reported and peritoneal dialysis could be initiated immediately after catheter implantation and could be a safe bridge between end - stage renal failure ( esrd ) and transplantation .