|Year : 2012 | Volume
| Issue : 2 | Page : 84-86
Managing acute kidney injury in a child with improvised peritoneal dialysis in Kano, Nigeria
Patience N Obiagwu, Garba D Gwarzo, Helen Akhiwu, Aminu Wada
Department of Paediatrics, Aminu Kano Teaching Hospital, Kano, Nigeria
|Date of Web Publication||12-Mar-2013|
Patience N Obiagwu
Department of Paediatrics, Aminu Kano Teaching Hospital, Kano
Source of Support: None, Conflict of Interest: None
Acute kidney injury (AKI) is a relatively common condition in children. Management is daunting in resource-limited settings. This is a case report of a 5½-year-old girl who developed AKI secondary to hemolytic-uremic syndrome and managed with improvised peritoneal dialysis. A 5½-year-old girl presented to the emergency unit with features of acute renal failure following a febrile illness. A diagnosis of hemolytic-uremic syndrome was made. Peritoneal dialysis was commenced using improvised dialysis fluid, peritoneal catheter and drain set. She had an average of five cycles daily for 16 days with significant improvement in her clinical and laboratory parameters. After 4 weeks on admission, she was discharged home in a clinically stable state. The management of AKI, though challenging, can be achieved with improvised peritoneal dialysis in resource-limited settings.
Keywords: Acute kidney injury, improvised peritoneal dialysis, paediatrics
|How to cite this article:|
Obiagwu PN, Gwarzo GD, Akhiwu H, Wada A. Managing acute kidney injury in a child with improvised peritoneal dialysis in Kano, Nigeria. Niger J Basic Clin Sci 2012;9:84-6
|How to cite this URL:|
Obiagwu PN, Gwarzo GD, Akhiwu H, Wada A. Managing acute kidney injury in a child with improvised peritoneal dialysis in Kano, Nigeria. Niger J Basic Clin Sci [serial online] 2012 [cited 2021 Apr 22];9:84-6. Available from: https://www.njbcs.net/text.asp?2012/9/2/84/108472
| Introduction|| |
Acute kidney injury (AKI) is a serious disorder of kidney function that may follow a number of disease conditions in children.  These conditions include septicemia, severe malaria, acute diarrheal disease with severe dehydration, and hemolytic-uremic syndrome.  AKI remains a significant contributor to childhood morbidity and mortality worldwide.  The management of AKI includes life-saving interventions such as renal replacement therapy (RRT) of which dialysis is one modality. In advanced countries, many modes of dialysis are available to the nephrologists to choose from, , whereas in resource-limited settings, the unavailability of such interventions is a major constraint with consequent high mortality in children with AKI requiring dialysis. ,,
Peritoneal dialysis (PD) is a simple, safe and efficient renal replacement therapy method.  It is able to correct AKI-induced metabolic, electrolytic and acid-base disorders and volume overload both in and out of the intensive care unit setting.  It can be performed in areas where the standard PD catheters and solutions are not readily available.  It involves the instillation of solutions of appropriate constituents and osmotic concentrations into the peritoneal cavity for solute and water removal by diffusion, osmosis and convection.  Despite the availability of newer modalities in the developed world, PD continues to be used extensively in many resource-limited countries. , This article shows how improvised acute PD was carried out successfully on a child, in a place where there were limited facilities for the standard procedure.
| Case Report|| |
A 5½-year-old girl was referred to our hospital from a secondary care facility on account of generalized body swelling and inability to pass urine for 8 days. These followed a history of profuse diarrhea and continuous fever for 2 days. She had received intravenous fluids and medications from the referring center.
Important physical findings on examination were fever, pallor and generalized oedema. She was lethargic, and had a pulse rate of 120 beats per minute and a blood pressure of 130/100 mmHg (stage 2 hypertension). She had a distended, nontender abdomen with a soft, enlarged liver and demonstrable ascites. There were normal findings on respiratory system examination.
Her laboratory investigations on admission showed severe anemia (hemoglobin of 5 g/dL), leucocytosis (white blood cell count of 14.3 × 10 9 /L) and thrombocytopenia (platelet count of 68 × 10 9 /L). There were features of hemolysis, toxic granulations of neutrophils and reduced platelets on blood film. Serum chemistry revealed findings in keeping with acute renal failure: urea of 49.3 mmol/L, creatinine of 535 μmol/L, potassium of 5.2 mmol/L, sodium of 130 mmol/L, chloride of 98 mmol/L, bicarbonate of 10 mmol/L. Abdominal ultrasound scan revealed normal sized kidneys with a slightly enlarged liver and moderate ascites.
A diagnosis of anuric AKI secondary to hemolytic-uremic syndrome was made. On account of a rapid deterioration in clinical status within 24 hours of admission in spite of initial conservative management, a decision to commence improvised PD was made. We used a size 14 nasogastric tube to improvise for the peritoneal catheter, a three-way tap and urine bag to improvise for the drain set, and constituted PD fluid of different strengths −2.5% and 1.25% using intravenous Lactated Ringer's solution. The improvised 2.5% PD fluid was used initially as she was volume-overloaded. It was constituted by removing 30 ml of fluid from a 500 ml bag of Lactated Ringer's solution, adding 25 ml of 50% dextrose water and 5 ml of 8.4% sodium bicarbonate, giving a calculated osmolarity of 403 mOsm/L. The 1.25% fluid was used when she was euvolaemic. For a 1.25% PD fluid, 17.5 ml of fluid was removed from the Lactated Ringer's solution, and 12.5 ml of 50% dextrose water and 5 ml of 8.4% sodium bicarbonate were added to the remaining fluid, giving a calculated osmolarity of 346 mOsm/L.
| Results|| |
[Table 1] shows the concentrations of the constituents of the improvised PD fluids.
She had an average of five PD cycles daily over 16 days, using the different strengths of PD fluids depending on her volume status. Her urine output gradually increased from 0 to 1.1 ml/kg/hr. Dialysis was discontinued on the 16 th day and she was monitored for 4 days before discharge. The results of her serum chemistries while on admission are as outlined in [Table 2].
| Discussion|| |
The use of the peritoneum as a dialyzing membrane was reported by Putnam in 1923, initially in dogs and subsequently in humans.  Over the decades, sophisticated equipment were developed including peritoneal catheters, automated machines, and standardized PD solutions. In many resource-limited settings like ours, many of these innovative technologies are not readily available for patient care. Experience of the procedure is also limited. Such were the challenges in this case leading to the use of improvised equipment in the management of an acutely ill child. PD cycles were not regular because there were only very few doctors and nurses available to perform the cycles. There was also lack of expertise in the dialysis procedure. There were also occasional leaks from the improvised catheter insertion site requiring surgical reviews. However, the setup worked very well in this case in spite of the numerous challenges. Peritonitis, which is a major challenge in PD, did not arise in this case, probably because the patient was on parenteral antibiotics and attempts at asepsis were made within the limits of available resources.
Antwi in Ghana made use of improvised PD in successfully managing a child with AKI in an intensive care unit setting, adding prophylactic antibiotics to the PD fluids.  Prior to this, in the same center, there had been a very high case-fatality rate of acute renal failure,  similar to reports from a tertiary institution in southwestern Nigeria.  It could be argued that this may not have been the case if the children had received improvised PD. Similar life-saving measures using improvised PD have also been carried out in a teaching hospital in southeastern Nigeria  as well as by the forward surgical units in the combat zones of Afghanistan and Iraq in persons with combat-related acute renal failure  with favorable outcomes.
| Conclusions|| |
We have reported the case of a 5½-year-old girl with AKI requiring dialysis, managed with improvised PD. The management of AKI in a resource-limited setting can be challenging. In spite of this, attempts at saving the lives of children with AKI can still be done using improvised methods within limits of safety. In light of this, we recommend that improvised peritoneal dialysis be strongly considered in situations where facilities are limited, where there is no immediate access to a better equipped facility and where the procedure can be carried out safely with the aim of saving the lives of children with AKI.
| Acknowledgment|| |
We wish to acknowlegde the contributions of all members of the Department of Paediatrics for their individual and collective support in the management of this patient.
| References|| |
|1.||Olowu WA, Adelusola KA. Pediatric acute renal failure in southwestern Nigeria. Kidney Int 2004;66:1541-8. |
|2.||Goldstein SL. Paediatric acute kidney injury: It's time for real progress. Pediatr Nephrol 2006;21:891-5. |
|3.||Belsha CW, Kohaut EC, Warady BA. Dialytic management of childhood acute renal failure: A survey of North American pediatric nephrologists. Pediatr Nephrol 1995;9:361-3. |
|4.||Walters S, Porter C, Brophy PD. Dialysis and paediatric acute kidney injury: Choice of renal support modality. Pediatr Nephrol 2009;24:37-48. |
|5.||Anochie IC, Eke FU. Paediatric acute peritoneal dialysis in southern Nigeria. Postgrad Med J 2006;82:228-30. |
|6.||Antwi S. Aetiology and mortality outcomes of children with acute renal failure at KATH. A presentation at the College of health sciences, Kwame Nkrumah University of Science and Technology 25 th July 2011. Available from: http://www.hdl.handle.net/123456789/544. [Last assessed on 2012 Feb 10]. |
|7.||Burdmann EA, Chakravarthi R. Peritoneal dialysis in acute kidney injury: Lessons learned and applied. Semin Dial 2011;24:149-56. |
|8.||Antwi S. Peritoneal dialysis using improvised PD catheter and self-constituted dialysis solution. Proceedings at the fifteenth congress of the International Pediatric Nephrology Association New York, 2010. Available from: http://www.hdl.handle.net/123456789/569. [Last assessed on 2012 Feb 10]. |
|9.||Phadke KD, Dinakar C. The challenges of treating children with renal failure in a developing country. Perit Dial Int 2001;21:s326-9. |
|10.||Putnam TJ. The living peritoneum as a dialyzing membrane. Am J Physiol 1923;63:548-65. |
|11.||Onwubalili JK. Successful peritoneal dialysis using 0.9% sodium chloride with modified M/6 sodium lactate solution and recycled catheters. Nephron 1989;53:24-6. |
|12.||Pina JS, Moghadam S, Cushner HM, Beilman GJ, McAlister VC. In-theater peritoneal dialysis for combat-related renal failure. J Trauma 2010;68:1253-6 |
[Table 1], [Table 2]