Niger J Paediatr 2019; 46 (2):68 - 72
injury with encephalopathy in a
5 -year old male using improvised
peritoneal dialysis in University of
Uyo Teaching Hospital, Uyo,
Nigeria: A Case report
Accepted: 7th May 2019
cheaper and more widely available
(AKI) has become increasingly
alternatives like improvised cathe-
prevalent in both resource rich
e.g. nasogastric tube, rubber
Department of Paediatrics
resource poor countries and is
University of Uyo Teaching
catheter, haemodialysis catheters
Hospital Uyo Nigeria
higher morbidity and mortality in
and self-constituted fluid e.g. forti-
the later, where access to renal
fied ringers lactate, 0.9% sodium
replacement therapy (RRT) is
chloride with modified sodium
poor. Peritoneal Dialysis (PD) is a
lactate can been used with success.
well acknowledged and estab-
this article, we share our experi-
lished form of RRT and it appears
ence on how acute PD was carried
be the most practical modality
out successfully in a five-year old
young children with AKI in
male with AKI complicated by
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
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 :
dwellers, late presentations to
peritoneal dialysis, uraemic-
health facilities and pervasive
poverty. With some ingenuity,
ing countries but declined in developed countries.
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.
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
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
treatment of paediatricAKI.
Peritoneal Dialysis (PD) is a well acknowledged and
The choices of Renal replacement therapy in childhood
established form of renal replacement therapy(RRT).
AKI are limited in low resource settings.
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-
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
resource poor countries. PD has served as the
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
24.9 patients per million population and 21.8 patients
children to a large extent due to its advantages. These
million population in developed countries. The pro-
include reduced cost when compared with haemodialy-
portion of PD patients remained unchanged in develop-
(HD), its ability to be carried out at home, less re-
quirement for highly trained personnel and major infra-
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,
where standard renal replacement therapy does not exist.
therapeutic option for AKI in resource poor countries.
also helps in better preservation of haemodynamics
and maybe more physiologic and less inflammatory than
haemodialysis due to the absence of contact between
blood and synthetic membrane, with a reduced risk of
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-
(UUTH), Uyo, on account of oliguria, presented with
in the treatment of AKI, the most important being
complaints of fever of 10 days, cough of 8 days and
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
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
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.
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
therefore transferred to a secondary health facility where
received intravenous artesunate and metronidazole.
Availability of standard PD catheters and dialysate fluid
While in the facility, he was noticed not have made
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-
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
Improvised catheters e.g. nasogastric tube,
referred to UUTH for expert management.
rubber catheter, intercostal drainage catheter, haemodi-
had no history of urinary symptoms prior to onset of
have been used for PD in resource
illness, although he routinelyhad water-based herbal
poor settings. This improvised catheters have a higher
risk for dialysate leakage, infection and blockage.
Also, where standard PD fluid is not available, self-
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
0.9% sodium chloride with modified sodium
34cpm, percussion notes resonant with only vesicular
lactate has been used with success.
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.
pertension). Digestive system revealed normal buccal
mucosa, abdomen full, tenderness in the epigastric re-
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
Acute kidney injury secondary to Severe Malaria was
should be promoted. Some countries have adopted the
first policy in their centres primarily to reduce the
cost of dialysis and more centres can adopt this policy.
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
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
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
dialysate fluid used was constituted due to unavailability
Repeat E/U/Cr done showed Creatinine 982umol/l, urea
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
of normal saline
corrected with 54mEq of 8.4% sodium bicarbonate, re-
of 10% dextrose
ceived enalapril 5 mg daily. Fluid was restricted to pre-
of 8.4% sodium bicarbonate
vious day output plus insensible loss.
was immediately scheduled to commence peritoneal
dialysis, which was delayed because of mother’s refusal
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
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
dialysis prescription was ordered.
were normal. BP=150/100mmHg.
Dwell time: 1 hour-2 hours
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
There were no complications of dialysis.
was discharged home and has been seen in the ne-
phrology clinic at several follow up visits with normal
renal function results.
There was no catheter leakage in this patient and this is
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
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-
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
parenteral antibiotics. Pre-procedural prophylactic use
report the successful management of a five year old
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.
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.
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.
dialysate for emergent peritoneal dialysis has also been
reported in other tertiary hospitals in Nigeria.
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.
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-
in resource limited settings and its careful utilisation
ment for dedicated PD catheters include: nasogastric
may reduce the high morbidity and mortality of paediat-
modified suprapubic aspiration catheter,
ble lumen haemodialysis catheter, among others.
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