Registration Form

Center Identification

Center name

Head of unit

Address

Country

Phone

Fax

E-mail

Unit/Hospital Homepage

LOCAL IPPN INVESTIGATORS (up to 3 persons)

Lead investigator Name:

Lead investigator Title:

Lead investigator Position:

Lead investigator E-mail:

2. Name:

2. Title:

2. Position:

2. E-mail:

3. Name:

3. Title:

3. Position:

3. E-mail:

Center Information

Number of fully trained pediatric nephrologists:

Number of pediatric dialysis nurses:

Psychologist available

Social worker available

Dietician available

Estimated encatchment in millions general population:

Number of stage III CKD patients:

Number of stage IV CKD patients:

Number of stage V CKD patients in predialysis care:

Number of ESRD patients currently on chronic PD:

Number of ESRD patients currently on chronic hemodialysis:

Number of ESRD patients currently in post-transplant care:

Renal Replacement Services Offered by Center:

CAPD (Continuous Ambulatory Peritoneal Dialysis):

APD (Automated Peritoneal Dialysis):

if yes: Type(s) of cycler devices used

Homechoice (Baxter):

Pax X-tra (Baxter):

Sleep Safe (Fresenius Medical Care):

PD night (Fresenius Medical Care):

APD 06:

Other (specify):

Hemodialysis:

Hemofiltration/Hemodiafiltration:

Continuous Extracorporeal Techniques:

Plasmapheresis/Immunoadsorption:

PD Procedures

Duration of PD training:(days)

Numbers of caregivers trained:

Frequency of exit-site care:

Agent used for exit site cleaning

water/soap

polyvidone iodine

betadine

octenidine

alcohol solutions

amuchina

other (please specify)