Peritoneal dialysis (PD), hemodialysis, continuous hemodialysis, hemofiltration-hemodiafiltration or slow continuous ultrafiltration are therapeautic options for renal replacement therapy (RRT) for acute kidney injury (AKI) [1]. PD is the preferred modality than hemodialysis because it is more physiological, results in less pro-inflammatory effects than hemodialysis, simplicity of the method, minimal requirement of equipment and avoidance of the morbidity of vascular access [2-4]. However, the morbidity and mortality rates of PD in premature infants may be high because of concomitant systemic problems that contribute to the development of AKI. There are limited studies demonstrating the experience of PD in very low birthweight (VLBW) and extremely low birthweight (ELBW)  neonates. We report experience of PD in preterm neonates with AKI and risk factors of AKI, complications of PD and causes of deaths.

Methods

This retrospective study was conducted in the Department of Neonatology, Zeynep Kamil Maternity and Children’s Training and Research Hospital, University of Health Sciences, Istanbul. Data on VLBW and ELBW premature neonates who underwent PD for AKI between January 2015 and June 2018 were collected. Medical information for demographic data, laboratory parameters, post-treatment recovery and mortality rates were extracted.

PD was indicated for AKI (urine output of <0.7 mL/kg/h for 24 h or anuric for 12 h) [5] and failure of conservative treatment (furosemide or water restriction in cases without hypovolemia) or signs of uremia (impaired cardiac and respiratory function or seizures), refractory hyperkalemia, and metabolic acidosis or fluid overload. PD catheters were inserted by a pediatric surgeon under sterile conditions with local anesthesia at the bedside. The multifunctional catheter is polyethylene, disposable, non-traumatic, rounded with distal two-hole, and can also be used for aspiration or discharging (10 F, Bicakcilar, Turkey).  A single-headed multifunctional flexible catheter was placed percutaneously in the left lower quadrant following a 0.5-1 cm horizontal incision below the umbilicus in the supine position. Approximately 4 h after the catheter placement, manual PD administration was started at 10 mL/kg/h and gradually increased up to 20-30 mL/kg/h with the standard dialysate solutions with glucose concentrations of 1.36%, 2.27%, or 3.86% (Dianeal, Baxter Healthcare, Deerfield, USA). The catheter was connected to the peritoneal dialysate fluid and drain bags. The one hour-PD cycle comprised of three periods: filling (10 minutes), dwelling (30 minutes), and draining (20 minutes). Heparin and antibiotics were added to dialysis fluid at a dose of 40 U/L with 125 mg  ampicillin and 125 mg cefazoline per liter.

Statistical analysis was performed using SPSS 16 for Windows. Continuous data was expressed as median and interquartile range (IQR). Categorical data was expressed as proportions and compared using Chi-square test. Nonnormally distributed numerical and ordinal variables were compared with the Mann Whitney U test. Student t-test was performed to compare parametric variables. Paired t-test was used to compare paired samples. A P value of less than 0.05 was considered statistically significant.

Results

Twenty one (2.8%) (11 males) out of 714 neonates (birth weight <1500 g) required PD during the study period. The median (IQR) birth weight and gestational age of the neonates were 720  g (555,1055)  and 26 weeks (23, 27.5), respectively. Fifteen (71.4%) neonates were ELBW and 12 (57%) were delivered by cesarean section. Underlying factors for the development of AKI were patent ductus arteriosus (PDA) (n=15), necrotizing enterocolitis (NEC) (n=10), sepsis (n=7), asphyxia (n=2) and hydrops fetalis (n=2).  Median (IQR) PD onset time was 7 days, (4.5,13.5)  and median (IQR) PD duration was 3 days (1.5, 3.5). Demographical data and biochemical parameters before and after PD are depicted in Web Table I. Significant difference was observed in pH levels (P=0.007), unlike other parameters. There was no improvement with PD for oliguria and hyperkalemia in ten neonates, serum urea levels in 15 neonates and acidosis in eight neonates.

Dialysis related complications were observed in nine patients (42.8%) neonates. Leakage developed in 6 (28.5%) neonates, but did not hamper working and catheter revision was performed in  3 (14.2%) neonates with catheter obstruction. Intestinal perforation or bladder injury was not observed. Color change was observed in the peritoneal fluid in 5 (23.8%) neonates with a history of perforated NEC but cultures were sterile.  The mortality rate was 81% (n=17).  

DISCUSSION

The present study reports etiology of AKI and experience with PD in ELBW and VLBW neonates. The retrospective nature and the small number of cases are the main limitations of this study. The main causes of AKI in VLBW and ELBW infants are sepsis, asphyxia, respiratory distress syndrome (RDS), PDA and NEC [6-9]. PD is the most preferred RRT strategy for AKI treatment in preterm infants in our clinic. Slow and controlled fluid removal provided by PD makes fluid elimination safer without hemodynamic instability [10]. However, inappropriate placement, occlusion or leakage of the catheter, peritonitis, and  perforation are frequent factors that restrict its use [11]. Mortality with catheter related complications significantly decreased with the use of Tenckhoff catheters [12]. However, the limited availability of appropriately sized PD catheters for VLBW and ELBW infants is a common challenge. Yu, et al. [6] performed PD using vascular catheter  in babies with birth weight <1000 g. Bed-side catheter insertion and ease of use of a multifunctional flexible 10F catheter makes it an accessible and inexpensive choice. Problems such as insufficient flow and high risk of leakage around the catheter may be seen. Leakage rates may vary from 5.8 – 29% [7,8,13], similar to our results.

The morbidity and mortality rates with PD are higher in neonates with multisystem problems [14], reported earlier 59.3-81.3% [7,8,15,16]. Mortality rate in the present study was higher, probably as the median gestational age and  birth weight of were lower. Tetta, et al. [17] reported high (95%) mortality rate in premature babies with multiorgan failure and sepsis, which could be related to the underlying causes, rather than complications of PD.

To conclude, PD is technically feasible in VLBW and ELBW neonates using a flexible 10F catheter.  Clinical and biochemical improvement in AKI is governed by uderlying cause of AKI.

Contributors: MAO, ST, NNK, EO, HOK, GV, AC, GK: conception and design of the work, acquisition, analysis, and interpretation of data for the work;  drafting the work or revising it critically for important intellectual content; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. 

Funding: None; Competing interest: None stated.

What This Study Adds?

• Peritoneal dialysis is technically feasible in premature neonates weighing below 1500g using a multifunctional catheter.

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