Background and Rationale Peritoneal dialysis (PD) is the primary kidney replacement
therapy (KRT) for children with end-stage kidney disease (ESKD), particularly in
low-resource settings. In these settings, continuous ambulatory peritoneal dialysis
(CAPD) is more accessible than automated PD (APD) or hemodialysis due to the lack of
power and expensive machinery.

However, standard CAPD regimens can lead to significant wastage of PD fluid. For example,
using standard 2-liter bags, children often use only a portion of each bag, discarding
the rest. Additionally, fixed-volume, fixed-dwell CAPD is often suboptimal for solute
clearance and ultrafiltration, particularly in patients with different peritoneal
membrane transport types.

Adapted APD (aAPD), pioneered by Fischbach et al., offers a better solution by combining
short, low-volume exchanges with longer, high-volume ones to improve ultrafiltration and
solute clearance. This study proposes a Modified CAPD (M-CAPD) that incorporates the
principles of aAPD but adapted for manual (non-automated) settings.

Rationale No existing studies have applied the aAPD approach to CAPD in children or
adults. This study addresses both clinical effectiveness and resource optimization in PD
for children in Southeast Asia.

General Objective

To compare Modified CAPD (M-CAPD) and Conventional CAPD (C-CAPD) in terms of:

- Clinical outcomes (ultrafiltration, solute clearance),

- Resource utilization (waste reduction),

- Caregiver burden. Specific Objectives

1. Ultrafiltration Efficiency i. Clinical parameters: BP, weight, edema, S3
gallop, lung crackles, tachycardia, tachypnea.

ii. Number of antihypertensive medications. iii. Bioimpedance analysis (BIA).
iv. Total 24-hour UF and residual urine output. v. Glucose exposure per day.

2. Solute Clearance Adequacy i. Serum electrolytes (Na, Cl, K, HCO₃-, Ca),
albumin, hemoglobin. ii. Phosphate clearance. iii. Renal and peritoneal Kt/V.
iv. Normalized protein catabolic rate (nPCR).

3. Caregiver Burden i. Measured using Pediatric Renal Caregiver Burden Scale
(PR-CBS). Study Design

- Design: Prospective, multicenter, randomized cross-over trial.

- Duration: 12 weeks of active intervention per participant.

- Setting: Pediatric dialysis centers in the Philippines, Malaysia, and Indonesia.

- Run-in Period: 2 weeks

- Intervention Phases: Each participant undergoes both C-CAPD and M-CAPD for 8 weeks
total (2 months per arm), with a 2-week washout in between.

- Randomization: Computer-generated random number assignment. Sample Size

- Assuming high correlation (r=0.95), 26 patients at PGH are sufficient (13 per arm).
Total across centers: 44 children aged 2 to ≤18 years.

Intervention Details Conventional CAPD (C-CAPD)

- PD solutions: 1.5%, 2.5%, 4.25% dextrose

- Fill volume: 1100-1400 mL/m²

- 3-4 exchanges per day

- Day and night dwell times: 3-6 hours (day), 8-10 hours (night) Modified CAPD
(M-CAPD)

- Follows C-CAPD with addition of 1-2 short, low-volume (15-30 min) exchanges before
full-volume dwell.

- Short dwell volume comes from remaining solution in the 2L bag. Monitoring and
Follow-Up

- Every 2 weeks (remote or in-person)

- Monitored parameters: BP, HR, weight, edema, UF, urine output

- Data collection notebook maintained by patient/caregiver Adverse Events Monitoring

Includes:

- Exit site infection

- Peritonitis

- Hypertension or fluid overload

- Dehydration (over-UF)

- Hyperglycemia

- Hospitalization

- Withdrawal criteria detailed Outcome Measures and Data Collection Timepoints:
Baseline, post-randomization (6 weeks), post-crossover (12 weeks)

Data Collected:

- Physical exam, vital signs, UF/urine output

- Lab values: electrolytes, albumin, hemoglobin, FBS

- Bioimpedance analysis

- Kt/V, nPCR

- PR-CBS for caregiver burden Data Analysis Plan

- Descriptive statistics: for demographics and baseline data

- Paired t-tests: for continuous outcomes

- McNemar's test: for categorical outcomes (e.g., edema)

- Outcomes compared within subjects (cross-over design) Ethical Considerations

- Guidelines followed: Declaration of Helsinki, ISO 14155:2011, Good Clinical
Practice, Philippine Data Privacy Act (2012)

- Ethics approval: To be obtained from institutional ethics boards

- Informed consent: Required from caregivers; assent from children ≥6 years Risks

- Minor discomfort from added blood draws

- No added infection risk from M-CAPD as procedure remains closed

- Risks managed with prompt clinical support and compensation Benefits

- Improved PD efficiency and fluid management

- Reduced glucose exposure and complications

- Less wastage of PD fluid

- Cost savings for families

- Enhanced caregiver education and burden reduction

- Potential improvement in health-related quality of life Compensation

- Covers: PD supplies, lab tests, transport, meals

- Provides treatment for study-related injuries

- Free antibiotics for PD-related infections Privacy and Confidentiality

- Strict adherence to data protection guidelines

- Anonymized data with unique identifiers

- Secure physical and digital storage

- Data access restricted to PI and trained assistant

- All data deleted within 2 years of study conclusion Dissemination Plan

- Results to be shared with physicians, caregivers, and published in peer-reviewed
journals

- All data anonymized in reports Intellectual Property and Legal Compliance

- Pre-existing IP remains with originator

- Jointly generated IP to be co-owned

- Philippine laws and UP policies govern research conduct Vulnerable Populations

- Pediatric patients with ESKD from lower socioeconomic backgrounds

- Extra care in informed consent and ethical oversight