Successful peritoneal dialysis using a percutaneous tube for peritoneal drainage in an extremely low birth weight infant: a case report
© The Author(s). 2017
Received: 13 September 2017
Accepted: 2 November 2017
Published: 9 November 2017
Peritoneal dialysis (PD) for acute kidney injury (AKI) of newborns has been performed safely. AKI occurs in 8 to 24% of extremely low birth weight (ELBW) infants. Although PD has only been used occasionally in ELBW infants, prognosis is poor for ELBW infants with AKI. Several reports have described successful PD in these infants, but no guideline-based evidence concerning indications for renal replacement therapy in ELBW infants are currently available. Here, we report on our experience with PD in an ELBW infant with AKI resulting from septic shock.
A male was born at 24 weeks and 3 days gestation weighing 264 g by emergency cesarean section due to complications of pregnancy in a patient with hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome. On day of life (DOL) 15, the inability to ventilate, along with cardiovascular dysfunction, acute kidney injury, and ascites under tension led to the tentative diagnosis of abdominal compartment syndrome (ACS). On DOL 17, placement of a percutaneous drainage tube immediately released compression of the tense abdomen. Although intra-abdominal pressure reduction with percutaneous drainage temporarily improved respiratory status, circulatory impairment persisted and infections were not well controlled. Finally, the patient developed anuria. On DOL 21, peritoneal dialysis (PD) was started by initially inserting a drainage tube. Although the patient had catheter-associated peritonitis, urine output improved by DOL 44 and PD was discontinued on DOL 53. On DOL 75, extubation was conducted without circulatory dysfunction. The patient was discharged on DOL 224.
We emphasize that starting PD treatment before the onset of anuria is important in ELBW infants with AKI. Although the catheter used in our case was initially inserted for drainage of ascites, this type of catheter is sufficiently useful for PD in ELBW infants, and PD using a drainage tube may represent a safe, effective, and minimally invasive treatment for ELBW infants. To our knowledge, this is the first report to describe the use of a percutaneous tube to conduct successful PD for peritoneal drainage in an ELBW infant. This is the lowest-weight ELBW infant with successful PD reported to date.
Peritoneal dialysis (PD) for acute kidney injury (AKI) of newborns has been performed safely. AKI occurs in 8 to 24% of extremely low birth weight (ELBW) infants, and although PD has only occasionally been conducted in ELBW infants, prognosis is poor for ELBW infants with AKI. Moreover, dialysis catheters suitable for ELBW infants are difficult to find due to their small body size and inelastic abdominal wall. Although several reports have described successful PD, no guideline-based evidence concerning indications for renal replacement therapy in ELBW infants has appeared. We report here on our experience with PD in an ELBW infant with AKI resulting from septic shock.
This case has two clinical implications. The first is that starting PD treatment before the onset of anuria is important in ELBW infants with AKI. The second is that although the catheter used in our case was initially inserted for drainage of ascites, this type of catheter is sufficiently useful for PD in ELBW infants, and PD using a drainage tube may represent a safe, effective, and minimally invasive treatment for ELBW infants.
ACS is underreported in children, and the actual incidence in critically ill patients may be much higher than the reported incidence of 0.9 to 12%. In patients with established ACS, the reported mortality rate is between 50 and 80% . ACS is categorized as “primary” if it is related to injury or disease of the abdominopelvic region (trauma, aneurysm rupture, hemoperitoneum, acute pancreatitis, retroperitoneal bleeding) and “secondary” if it is related to systemic conditions (sepsis, major burns, capillary leak, massive fluid resuscitation). ACS in ELBW infants is demonstrated clinically by worsening respiratory ventilation, increased abdominal circumference, and oliguria. However, currently accepted monitoring techniques cannot be used in ELBW infants. The earliest sign of ACS in ELBW infants is the inability to ventilate accompanied by increased abdominal girth, occurring well before anuria. However, the three signs of ACS are almost uniformly present, albeit to varying degrees, in all septic ELBW infants. Therefore, a possible diagnosis of ACS should be considered much more frequently than it generally is.
Timely placement of a percutaneous drainage tube in the abdominal cavity is effective and less invasive and can be deployed successfully for ELBW infants with ACS . In our case, we observed a temporary improvement in respiratory status and circulatory impairment after decompression by ascetic fluid drainage using a percutaneous drainage tube. However, the patient developed anuria. We hypothesize that AKI may have been associated with the onset of neonatal sepsis, the immaturity of organs associated with ELBW, a severe form respiratory distress syndrome that requires high parameters of mechanical ventilation, or hypotension. We further emphasize that starting PD treatment before the onset of anuria is important in ELBW infants with AKI.
To our knowledge, this is the first report to describe the use of a percutaneous tube to successfully conduct PD for peritoneal drainage in an ELBW infant. This is the lowest-weight ELBW infant with successful PD reported to date.
SY made the conception and design of this case report. Authors other than SY contributed to the collection, analysis, and interpretation of the data. SY wrote the draft manuscript, and other authors performed the critical revision of the manuscript. All authors gave final approval of the version to be published. SY has overall responsibility and guarantees the scientific integrity.
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