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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 5  |  Issue : 1  |  Page : 49-51

Peritoneal dialysis via a central venous catheter in a Neonate with AKI


1 Department of Pediatrics, Eastern Regional Referral Hospital, Mongar, Bhutan
2 Department of Pediatrics, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
3 UNC Kidney Center, University of North Carolina at Chapel Hill, North Carolina, USA

Date of Submission22-Mar-2022
Date of Decision11-May-2022
Date of Acceptance06-Jun-2022
Date of Web Publication28-Jun-2022

Correspondence Address:
Tashi Tshering
Department of Pediatrics, Eastern Regional Referral Hospital, Mongar
Bhutan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajpn.ajpn_4_22

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  Abstract 


At most centers, peritoneal dialysis (PD) is regarded as the optimal dialysis modality for neonates with acute kidney injury (AKI) who require kidney replacement therapy. Appropriately sized peritoneal catheters are not universally available in all countries and regions and are not currently available in Bhutan. We describe the successful use of a triple-lumen central venous catheter in an 18-day-old term infant with sepsis-related AKI and uremic encephalopathy. Considering the infant's deteriorating neurologic status and kidney function, the baby's fluid, electrolyte, and metabolic derangements were successfully managed by PD using a central venous catheter to access the peritoneal cavity. In regions where appropriately sized neonatal PD catheters are not available, a central venous catheter may be a useful alternative for short-term PD access.

Keywords: Acute kidney injury, central venous catheter, kidney replacement therapy, newborn


How to cite this article:
Tshering T, Mynak ML, Glenn DA. Peritoneal dialysis via a central venous catheter in a Neonate with AKI. Asian J Pediatr Nephrol 2022;5:49-51

How to cite this URL:
Tshering T, Mynak ML, Glenn DA. Peritoneal dialysis via a central venous catheter in a Neonate with AKI. Asian J Pediatr Nephrol [serial online] 2022 [cited 2022 Aug 18];5:49-51. Available from: https://www.ajpn-online.org/text.asp?2022/5/1/49/348530




  Background Top


Acute kidney injury (AKI) is common in critically ill newborns, affecting 8%–24% of cases[1],[2],[3] and is associated with mortality in 10%–61% cases.[3] AKI is particularly frequent among infants with severe asphyxia and after cardiac surgery.[1],[4] In general, AKI may follow any medical condition whose pathophysiology includes hypovolemia, hypoxemia, or hypotension, with the most frequent causes being perinatal anoxia-ischemia (9%–61%)[3],[5] and sepsis (21%–36%).[3],[6] Rates of AKI may be as high as 68% in asphyxiated babies.[7]

Supporting kidney function in neonates is crucial during severe AKI, since this complication is often transient and reversible. Peritoneal dialysis (PD) is usually regarded as the preferred option for kidney replacement therapy (KRT) in neonates, given the general ease of catheter insertion, ability to source or mix dialysis fluid locally, and ability to more safely dialyze patients with hemodynamic instability. As such, PD remains the preferred procedure for renal replacement therapy in neonates in most settings around the world.[5]

While PD remains a recommended option for KRT treatment in neonates, the main challenge to introducing PD in newborn critical care units in Bhutan is obtaining appropriately sized catheters, as highlighted similarly in other resource-limited regions.[2],[8] In the present case of a neonate with sepsis-associated AKI, the neonate's critical condition compelled us to utilize an improvised femoral triple lumen vascular catheter as a PD catheter.


  Case Report Top


A 41+1-week-old male baby weighing 3400 g was delivered vaginally following an uneventful pregnancy to a 35-year-old third gravida second para (G3P2) mother in the Trashigang General Hospital, Bhutan. The Apgar scores were 8 and 9 at 1 and 5 min, respectively. The baby was discharged on the second day of life and was initially thriving at home. On day 18 of life, the neonate was admitted with refusal to feed and decreased responsiveness. He developed respiratory failure on day 1 of admission, requiring endotracheal intubation and mechanical ventilation, for which he was subsequently transferred to the Regional Referral Hospital in Monggar. Following physical and laboratory examination, the infant was diagnosed with septic shock and managed with fluid resuscitation totaling 60 ml/kg of normal saline, and intravenous (IV) antibiotics, namely ampicillin and gentamicin, for refractory shock, an infusion of dopamine was initiated. Although the baby had an adequate urine output of 1.3 ml/kg/hr, there was severe kidney impairment, with serum creatinine of 6.8 mg/dL and blood urea of 165 mg/dL. The infant developed repetitive movements of the upper and lower limbs within a few hours of admission, which were presumed to be seizures secondary to uremic encephalopathy. These seizures were refractory to midazolam, phenobarbitone, 10% calcium gluconate, and phenytoin. On day 2 of stay, renal function worsened further, with serum creatinine of 5.1 mg/dL and blood urea 170 mg/dL [Figure 1]. Clinically, the neonate remained listless with mild generalized edema. Due to the limitation of hospital resources, serum electrolytes and venous blood gas were not evaluated.
Figure 1: Changes in blood levels of urea and serum creatinine and key events and management during the early days of life. PD: Peritoneal dialysis

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Considering the infant's deteriorating neurologic status and kidney function, PD was initiated following parental consent. We used a triple lumen 7 French central venous catheter of 16 cm length (Cerato Trio®) [Figure 2]. An introducer needle was placed at the McBurney's point under ultrasound guidance to avoid injury to the viscera. After confirming entry into the peritoneal cavity, by clear fluid aspirate and by ultrasound, a guidewire was inserted through the needle. The insertion of the catheter was then followed along the guidewire. The guidewire was then removed and the tip of the catheter was directed into the pelvis. As the fluid flowed out into the catheter, an outer catheter tube was attached to a three-way connection to allow instilling dextrose 1.5% dialysate fluid and draining out into a drain bag using two ordinary IV infusion sets. Subcutaneous fat and skin were sutured, and the catheter was secured with a purse-string suture after confirming easy inflow and outflow.
Figure 2: Photograph of central venous catheter (a) being placed and (b) used for peritoneal dialysis

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The PD fluid was customized to be bicarbonate based and of 1.5% dextrose strength [Table 1]. The initial fill volume was limited to 10 ml/kg to minimize the risk of dialysate leakage. Later, each dwell had a volume was 60 ml. Volumes were then progressively raised as tolerated by the patient to approximately 17 ml/kg. The in time, dwell time, and drain time were kept at 10 min, 40 min, and 10 min, respectively. PD was continued for 2.5 days with hour cycles. There was no catheter-related complication except for minor peritoneal fluid leakage from the exit site. Ultimately, kidney function recovered, and the catheter was withdrawn 4 days later. On 31 days of life, the infant was discharged from the hospital. At one week follow-up, the child's blood urea and creatinine were 21 mg/dL and 0.4 mg/dL, respectively, and that at 9 weeks, were 12 mg/dL and 0.4 mg/dL, respectively.
Table 1: Improvised, bicarbonate-based, peritoneal dialysis fluid

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  Discussion Top


Despite significant advances in the pathophysiology of AKI, newborn mortality associated with AKI remains high at 10%–60% in a variety of clinical settings.[2],[9] The early identification and management of AKI play a crucial role in mitigating AKI-associated morbidity and mortality. When conservative management fails, KRT in the form of PD or continuous KRT should be employed to complement kidney function and allow for recovery from AKI. It has been reported that the early use of KRT decreases morbidity and mortality related to AKI.[10] In most settings, PD is the modality of choice to control uremia in neonates with severe AKI as continuous KRT in neonates is technically challenging.[2],[10]

Access for PD in neonates also has its challenges. It is not always simple to place an appropriately sized peritoneal catheter in neonates, chiefly due to space limitations in the peritoneal cavity. Rigid catheter insertion can cause intrabdominal injury, including intraperitoneal hemorrhage and perforation of intestines or other viscera by the sharp stylet or trocar. Other considerations include the limited availability of neonatal-sized acute PD catheter and Y-connection sets and cost constraints in low-resource settings.[8] Hospitals in Bhutan too face similar challenges with limited access to neonatal size catheters and dialysate.

The literature reports other approaches to secure peritoneal access, including the use of IV cannulas, suction catheter tips, plastic catheters, angiocaths, and neonatal chest drains.[2],[8],[10] Rath et al. report using a 16G IV cannula in term neonates and young infants with low rates of visceral injury and low cost.[8] Guidewire-based insertion of femoral vein catheters has also been reported to have few complications such as catheter blockage, dialysate leak, premature closure, and peritonitis.[10]

To conclude, we describe that how PD can be implemented using a central vascular catheter to access the peritoneal cavity in patients with AKI who do not respond to conservative care in settings where the appropriately sized PD catheters are not available. Our experience supports the short-term safety and effectiveness of central venous catheters in sick neonates with AKI when alternatives are not available. The case report also highlights regional challenges and emphasizes the need for collective action to provide adequate disposables in Asia's resource-limited regions.

Acknowledgment

We praise the NICU nurses and the pediatric ward who helped this infant tremendously and for helping to compile the report.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Andreoli SP. Acute renal failure in the newborn. Semin Perinatol 2004;28:112-23.  Back to cited text no. 1
    
2.
Ao X, Zhong Y, Yu XH, Marshall MR, Feng T, Ning JP, et al. Acute peritoneal dialysis system for neonates with acute kidney injury requiring renal replacement therapy: A case series. Perit Dial Int 2018;38:S45-52.  Back to cited text no. 2
    
3.
Durga D, Rudrappa S. Clinical profile and outcome of acute kidney injury in neonatal sepsis in a tertiary care centre. Int J Contemp Pediatr 2017;4:635.  Back to cited text no. 3
    
4.
Coe K, Lail C. Peritoneal dialysis in the neonatal intensive care unit. Management of acute renal failure after a severe subgaleal hemorrhage. Adv Neonatal Care 2007;7:179-86.  Back to cited text no. 4
    
5.
Gouyon JB, Guignard JP. Management of acute renal failure in newborns. Pediatr Nephrol 2000;14:1037-44.  Back to cited text no. 5
    
6.
Vachvanichsanong P, Dissaneewate P, Lim A, McNeil E. Childhood acute renal failure: 22-year experience in a university hospital in southern Thailand. Pediatrics 2006;118:e786-91.  Back to cited text no. 6
    
7.
Aggarwal A, Kumar P, Chowdhary G, Majumdar S, Narang A. Evaluation of renal functions in asphyxiated newborns. J Trop Pediatr 2005;51:295-9.  Back to cited text no. 7
    
8.
Rath B, Gopalan S, Gupta S, Puri RK, Talukdar B. Simpler tools for peritoneal dialysis of term newborns and young infants. Indian Pediatr 1994;31:1131-2.  Back to cited text no. 8
    
9.
Drukker A, Guignard JP. Renal aspects of the term and preterm infant: A selective update. Curr Opin Pediatr 2002;14:175-82.  Back to cited text no. 9
    
10.
Kohli HS, Bhalla D, Sud K, Jha V, Gupta KL, Sakhuja V. Acute peritoneal dialysis in neonates: Comparison of two types of peritoneal access. Pediatr Nephrol 1999;13:241-4.  Back to cited text no. 10
    


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