Introduction:
End-stage kidney disease (ESKD) in children is a death sentence in many parts of sub-Saharan Africa. Peritoneal dialysis (PD) in the management of children with end-ESKD is rare in most parts of sub-Saharan Africa. Whereas adaptations have been described for the use of PD in children with acute kidney injury, such has not been widely reported for ESKD. Challenges with the use of chronic PD in the management of ESKD in low resource settings include the cost of the PD catheter and the insertion kit. We present a case report of bedside surgical tunneled PD access with technique adaptations for a child in end-stage renal replacement as an initial step for the improvement of management of children with ESKD in low resource settings.
Methods:
Case report
Results:
A 13 year old boy who had been on follow up for background prematurity, bilateral renal hypoplasia, hypertension and CKD stage 4, presents to our hospital with a history of recurrent vomiting of 3 days duration. His urine output was reported as normal. He weighed 24kg, had no oedema, his height was 136 cm, his blood pressure was 110/70 mmHg, while his serum creatinine was 9.6mg/dl. Additionally, he had an episode of seizure while arrangement was being made for dialysis. Insertion of the Tenckoff catheter took place in the procedure room on the ward. Urethral catheter was passed to keep the bladder empty. Anesthesia was provided with with i.m pentazocine, i.v diazepam (titrated not to exceed a maximum dose of 0.3mg/kg) and local anaesthesia. The abdomen was pre-filled with normal saline. A mini incision in the abdominal wall in the midline half way between the umbilicus and the pubic symphysis and dilated. A sterile non-cuffed size 7.0 endotracheal tube was adapted as a make shift rigid peel over sheath for placement of the peritoneal end of the Tenchkoff catheter (Size 12Fr) and passed into the peritoneal cavity through the incision. The catheter was advanced through the endotracheal tube into the pelvic floor and endotracheal tube was thereafter removed. For the tunneling of the catheter, the proximal cuff was about 2 cm from the exit site while the distal cuff was buried in the rectus muscle. Intravenous ceftriaxone was given intra-procedure, and antibiotics continued thereafter. The patient was started on hourly circles of peritoneal dialysis the following day, as the patient required dialysis, but the consumables for paediatric haemodialysis were not available. We used locally manufactured PD fluid in 2L bags for the exchanges with a Y set configuration. He showed improvement as vomiting became less, and his serum creatinine dropped to 6.6mg/dl by the 10th day of peritoneal dialysis. He was being planned for CAPD and follow up at home. He however developed features of peritonitis on the 12th day of the peritoneal dialysis. Samples were sent for peritoneal dialysis mcs and he was started empirically on i.v piperacilin tazobactam, and i.p piperacilin tazobactam. He developed catheter outflow obstruction by the 13th day of peritoneal dialysis. He however remained stable, and his urine output was 1.4 mls/kg/day.
Conclusions:
PD was associated with preservation of residual kidney function in our patient. Long term chronic PD in low resource countries will require support especially with access to standard equipment and PD supporting staff.
I have no potential conflict of interest to disclose.
I did not use generative AI and AI-assisted technologies in the writing process.