Nigerian Journal of Paediatrics

Management of acute kidney injury with encephalopathy in A 5 year old male using improvised peritoneal dialysis in university of Uyo Teaching Hospital Uyo Nigeria A Case report

Niger J Paediatr 2019; 46 (2):68 - 72

CASE REPORT

Ikpeme E

CC – BY Management of acute kidney

injury with encephalopathy in a

5 -year old male using improvised

peritoneal dialysis in University of

Uyo Teaching Hospital, Uyo,

Nigeria: A Case report

DOI:http://dx.doi.org/10.4314/njp.v46i2.5

Accepted: 7th May 2019

Abstract: Acute kidney injury

cheaper and more widely available

(AKI) has become increasingly

alternatives like improvised cathe-

Ikpeme E

(

)

prevalent in both resource rich

ters e.g. nasogastric tube, rubber

Department of Paediatrics

and resource poor countries and is

catheter,

intercostal

drainage

University of Uyo Teaching

associated

with

significantly

catheter, haemodialysis catheters

Hospital Uyo Nigeria

higher morbidity and mortality in

and self-constituted fluid e.g. forti-

Email:

the later, where access to renal

fied ringers lactate, 0.9% sodium

enobong.ikpeme@gmail.com

replacement therapy (RRT) is

chloride with modified sodium

poor. Peritoneal Dialysis (PD) is a

lactate can been used with success.

well acknowledged and estab-

In this article, we share our experi-

lished form of RRT and it appears

ence on how acute PD was carried

to be the most practical modality

out successfully in a five-year old

in young children with AKI in

male with AKI complicated by

such countries. PD, though a

uraemic encephalopathy, using

cheaper alternative to haemodi-

improvised peritoneal dialysis and

alysis (HD), is still challenging

self-constituted PD solution in a

and unaffordable due to complex

place where standard renal re-

problems like lack of standard PD

placement therapy does not exist.

catheters and dialysate fluid, poor

access to health facilities for rural

Key words : AKI, improvised,

dwellers, late presentations to

peritoneal dialysis, uraemic-

health facilities and pervasive

encephalopathy

poverty. With some ingenuity,

Introduction

ing countries but declined in developed countries.⁹ The

use of PD has increased by 2.5 fold in developing coun-

tries especially with the increase in the number of peo-

Acute kidney injury (AKI) has become increasingly

prevalent in both developed and developing countries

ple living in poverty in poor resource countries. Of the

and is associated with poor outcomes.

1-4

AKI is associ-

total number of PD done in Africa, 85% of the patients

ated with significantly higher morbidity and mortality

reside in South Africa, contribution of north Africa to

PD is 0-3%. Recent reports from Nigeria, India and

especially in resource poor regions where access to

haemodialysis and other forms of renal replacement is

Brazil have demonstrated its continued efficacy in the

poor.

1-6

treatment of paediatricAKI.

5,7,12

Peritoneal Dialysis (PD) is a well acknowledged and

The choices of Renal replacement therapy in childhood

established form of renal replacement therapy(RRT).

7,8

AKI are limited in low resource settings.

Whilst

PD is comparable to other forms of dialysis in effective-

nephrologists in rich countries look for the choice of

ness in cases of AKI. Its use throughout the world is

modality of RRT to use in AKI, their counterparts in

increasing and has provided a means of managing some

resource poor countries are helpless due to lack of re-

patients who would otherwise have been denied treat-

sources for such interventions, leading to increased mor-

tality.

3,14,15,16

ment because haemodialysis was unavailable or contra-

However, PD appears to be the most practi-

indicated. Although there is a perception that the use of

cal modality for RRT in young children with AKI in

most resource poor countries. PD has served as the

PD is declining worldwide, over the last 12years the

number of PD patients increased in developing countries

primary means of dialysis in the management of AKI in

by 24.9 patients per million population and 21.8 patients

children to a large extent due to its advantages. These

per million population in developed countries. The pro-

include reduced cost when compared with haemodialy-

portion of PD patients remained unchanged in develop-

sis (HD), its ability to be carried out at home, less re-

quirement for highly trained personnel and major infra-

In this article, we share our experience on how acute PD

structure, requirement of a single access, improved qual-

was carried out successfully using improvised peritoneal

ity of life and freedom of activities, ease of implementa-

dialysis and self-constituted PD solution in a place

tion and lack of need for vascular access,

17,18

therefore, a

where standard renal replacement therapy does not exist.

therapeutic option for AKI in resource poor countries.

PD also helps in better preservation of haemodynamics

and maybe more physiologic and less inflammatory than

Case Report

haemodialysis due to the absence of contact between

blood and synthetic membrane, with a reduced risk of

A five-year old male who was referred from a secondary

blood borne infection posed by hemodialysis.

health facility to the University of Uyo Teaching Hospi-

Though PD is cheap, easy and reliable, it has its limita-

tal (UUTH), Uyo, on account of oliguria, presented with

tion in the treatment of AKI, the most important being

complaints of fever of 10 days, cough of 8 days and

an intact peritoneal cavity with adequate peritoneal

vomiting of 7 days duration. He did not pass urine for 4

clearance capacity. It is less efficacious for severe acute

days with associated abdominal pain, but no change in

pulmonary oedema and in life threatening hyperkalae-

colour of urine, no haematuriaordiarrhoea.

mia. It uses high fluid volume and may impair diaphrag-

matic movement in very ill patients on ventilators in the

There was an initial presentation at a maternal and child

ICU. In resource poor countries, though PD is a

health facility where he had some investigations done

cheaper alternative to HD, it is still challenging and un-

(Malaria Parasite test was positive ++, Widal test titres

affordable due to complex problems. Lack of standard

were significant). The patient was admitted there and

PD catheters, poor access to health facilities for rural

treated with unidentified intramuscular injections for 5

dwellers, late presentations to health facilities and perva-

days, intravenous ciprofloxacin and amoxicillin cap-

sive poverty all constitute significant issues in the man-

sules. Oral antimalarial medications probably the arte-

agement of AKI in children.

3,7,13,15

Despite newer mo-

mether based combination therapy (ACTs) was also

dalities in management of AKI, PD is still used exten-

given for 3 days but symptoms did not improve. He was

sively in resource poor settings

5,21

therefore transferred to a secondary health facility where

he received intravenous artesunate and metronidazole.

Availability of standard PD catheters and dialysate fluid

While in the facility, he was noticed not have made

is still a big challenge in resource poor countries. De-

urine for a 24-hour period. Serum Electrolyte/Urea/

spite the above challenges, with some ingenuity, cheaper

Creatinine (sE/U/Cr) estimation revealed a deranged

and more widely available alternatives maybe employed

panel: Creatinine = 780µmol/l, Urea = 17.1mmol/l, So-

as materials in PD and used to save children in resource

dium = 149mmol/l, Chloride = 120mmol/l, Potassium =

poor settings from morbidity and mortality from

2.8 mmol/l, and Bicarbonate = 19mmol/l. He was then

AKI.

3,13,22,23

Improvised catheters e.g. nasogastric tube,

referred to UUTH for expert management.

rubber catheter, intercostal drainage catheter, haemodi-

He had no history of urinary symptoms prior to onset of

alysis catheter

3,13,22,23

have been used for PD in resource

illness, although he routinelyhad water-based herbal

poor settings. This improvised catheters have a higher

enemas fortnightly.

risk for dialysate leakage, infection and blockage.

[7]

Also, where standard PD fluid is not available, self-

At presentation he was conscious, not pale, anicteric,

constituted fluid can be used e.g. fortified ringers lactate

acyanosed, afebrile, with no signs of dehydration, no

recommended by the international society for peritoneal

facial swelling and no pedal oedema. His weight was

23kg, height 120cm BSA= 0.876m Respiratory rate was

dialysis guidelines has been lifesaving in children with

AKI,

3,22

0.9% sodium chloride with modified sodium

34cpm, percussion notes resonant with only vesicular

lactate has been used with success.

Improvised PD

breath sounds. Pulse rate was 68bpm, normal volume

fluid if not prepared under strict asepsis increases the

and rhythm, Blood pressure=120/80mmHg (stage I hy-

risk of peritonitis.

24,25

pertension). Digestive system revealed normal buccal

mucosa, abdomen full, tenderness in the epigastric re-

In low resource settings, PD can be successfully per-

gion with no organomegaly and no ascites. A diagnosis

formed for the management of childhood AKI and

of Acute kidney injury secondary to Severe Malaria was

should be promoted. Some countries have adopted the

made.

PD first policy in their centres primarily to reduce the

cost of dialysis and more centres can adopt this policy.

Fig 1

There should be ease of access to standard and afford-

able PD catheters and fluids and automated peritoneal

dialysis should be increased. Establishment of regular

PD programs in most tropical countries has been estab-

lished though more education and training of health

workers are still needed.

Establishing PD centres in

developing countries would increase the use of PD and

identifying the strengths, special circumstances, defi-

ciencies peculiar to developing countries and strategize

accordingly.

He was admitted and a urinary catheter was inserted for

Mother eventually consented to peritoneal dialysis 7

urine collection and monitoring urine output, which

days into admission following seizures from uraemic

drained 5 ml of urine from the bladder. Urinalysis done

and hypertensive encephalopathy. Treatment instituted

was essentially normal. HIV serology was non- reactive,

included furosemide, IV labetolol, oral aldomet 250mg

HbsAg-negative, anti hepatitis C- negative, genotype

bd. Consequent to the absence of Tenckhoff catheter, a

AA, FBC-essentially normal, abdominal ultrasound scan

size 16 silicon catheter was improvised and was success-

revealed increased echogenicity of the kidneys with

fully inserted in the theatre through a subumbilical inci-

some preservation of corticomedullary differentiation;

sion into the pelvic peritoneal cavity via the seldinger

findings in keeping with grade 3 bilateral renal paren-

technique with functioning of the catheter. Also, the

chymal disease.

dialysate fluid used was constituted due to unavailability

Repeat E/U/Cr done showed Creatinine 982umol/l, urea

of standard fluids. This was done by mixing the follow-

16mmol/l, bicarbonate of 10mmol/l. Estimated GFR by

ing into a urine bag under sterile conditions:

Swartz equation was 7.57ml/min/1.73m He had acidosis



1000mls of normal saline

corrected with 54mEq of 8.4% sodium bicarbonate, re-



440mls of 10% dextrose

ceived enalapril 5 mg daily. Fluid was restricted to pre-



60mls of 8.4% sodium bicarbonate

vious day output plus insensible loss.



10mg/L of ceftazidime

He was immediately scheduled to commence peritoneal



30mg/L of vancomycin

dialysis, which was delayed because of mother’s refusal



500iu of heparin

to consent to procedure and procure necessary items for



+/- 4 mmol/L of potassium chloride

procedure on account of financial constraint. Urine flow

rate ranged from 0.3- 0.7ml/kg/ hour. Patient developed

This was connected to the silicon catheter through a drip

generalized oedema, blood pressure increased to

giving set for administration of fluid into the abdominal

130/100mmHg (stage 2 hypertension). He also devel-

cavity. The same end of the silicon catheter used for

oped 2 episodes of convulsion, generalized tonic clonic

fluid administration was used for draining peritoneal

which lasted less than 5 minutes and aborted with diaze-

fluid into another urine bag and the volume was re-

pam. Repeat E/U/Cr: Creatinine 1118umol/l, urea 32.5

corded to balance the fluid.

mmol/l, bicarbonate 10mmol/l and other electrolytes

A dialysis prescription was ordered.

were normal. BP=150/100mmHg.

Dwell volume=30ml/kg=750ml

Dwell time: 1 hour-2 hours

Fig 2

The patient had on average 12 cycles of dialysis in the

first 48 hours of the procedure then 8 cycles for the re-

maining 5 days.He improved as generalized oedema

regressed, urinary output increased, blood pressure nor-

malized and the concentration of deranged electrolytes

gradually decreased to normal. Urine output increased

from normal to polyuria up to 7ml/kg/hour. Dialysis was

eventually discontinued and urine output returned to

normal and child was observed and peritoneal catheter

removed.

There were no complications of dialysis.

He was discharged home and has been seen in the ne-

phrology clinic at several follow up visits with normal

renal function results.

Days

Creatin

Urea

So-

Chlo-

Potas-

Bicar-

ine

dium

ride

sium

bonate

Before

1118

32.5

137

101

4.8

Fig 3

Day 2

771.75

33.41

144.9

114.9

3.27

18.6

Day 3

623.81

30.39

143.6

114.7

3.47

22.6

Day 5

466.71

22.33

145.7

110.6

2.99

21.3

Day 7

324.87

12.98

145.8

106.0

2.52

22.5

Day 9

250.10

10.95

148.7

108.3

2.88

22.0

Day 10

208.62

13.60

149.1

109.5

4.07

22.1

Day 14

115.80

12.30

149.5

110.7

4.87

22.3

1week

89.28

4.94

147.3

107.2

4.37

22.1

post

discharge

2 weeks

87.52

4.53

141.0

101.3

4.61

22.0

Discussion

There was no catheter leakage in this patient and this is

in contrast to the report from Kano

where this was

Peritoneal dialysis forms the mainstay of therapy for

observed necessitating surgical reviews. There was no

AKI due to the relative ease of administration, none re-

catheter blockage likely due to the use of heparin in the

quirement for electricity or specialised machines which

self-constituted dialysate.

are grossly inadequate in resource-limited countries.

Also PD is preferred for renal replacement therapy in

Other catheter related problems such as intraperitoneal

children less than 5 years of age.

The ability to per-

or exit site infection was not also observed in the index

form peritoneal dialysis is essential to prevent increasing

patient. This could be because of strict asepsis combined

kidney failure related mortality especially in children

with prophylactic inclusion of vancomycin and cef-

living in poverty.

tazidime in the self-constituted dialysate, as well as use

of parenteral antibiotics. Pre-procedural prophylactic use

We report the successful management of a five year old

of vancomycin and cephalosporin in self-constituted

Nigerian boy with AKI most probably due to severe

dialysate was also recommendation of the guidelines for

prevention for peritoneal dialysis-related infections.

[29,30]

malaria using improvised peritoneal dialysis. The patient

recovered renal function despite the challenge of non-

Peritonitis, which is a major contributor of PD failure

availability of dialysate and standard PD catheter with-

did not also occur. This could be due to the short dura-

out any procedure-related complications.

The self-

tion of the procedure as the patient had clinical and labo-

constituted dialysate was adapted from University

ratory improvement within two weeks coupled with ade-

Teaching Hospital, Enugu. The use of self-constituted

quate pre-procedural preventive measures. Full recovery

was also noted in previous case reports.

23, 27,28

dialysate for emergent peritoneal dialysis has also been

The pa-

reported in other tertiary hospitals in Nigeria.

19,27

tient is still on follow-up with evidences of normal clini-

Ghana, Antwi successfully carried out the life-saving

cal and laboratory kidney function.

procedure of improvised PD using self-constituted

dialysate in the paediatric intensive unit. Other resource

limited countries have also used self-constituted dialys-

ate with success.

18,28

Conclusion

Catheter placement was done by the paediatric surgeon

using size 16 silicone catheter which was our closest

Improvised peritoneal dialysis is a life-saving procedure

substitute for the standard flexible Tenckoff catheter.

for children with AKI requiring renal replacement ther-

Previous reports’ alternative materials used as replace-

apy in resource limited settings and its careful utilisation

ment for dedicated PD catheters include: nasogastric

may reduce the high morbidity and mortality of paediat-

tube,

[27]

modified suprapubic aspiration catheter,

dou-

ric AKI.

ble lumen haemodialysis catheter, among others.

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