neonates , especially very low - birth - weight infants , are at high risk for acute kidney injury ( aki ) , and aki is an independent predictor of morbidity and mortality in this patient population [ 15 ] . when used in neonates , renal supportive therapy ( rst )
the decision to offer rst to the smallest of patients is complicated by a number of challenges including limited availability of appropriately sized dialysis catheters , lack of machines designed for neonates , technical difficulties associated with access placement in small infants , as well as individual physician practices , biases and beliefs .
limited available literature documenting the use of peritoneal dialysis ( pd ) in extremely low - birth - weight ( elbw ) infants describes uniformly high rates of technical complications ( 2560% ) and mortality ( > 50% ) [ 68 ] . for these reasons
, practitioners may defer rst in favor of diuretic therapy and nutritional restriction in elbw neonates or offer no dialytic support at all .
we report the successful provision of pd to an 830-g premature infant with oligo - anuric aki and deteriorating respiratory status using a commercially available temporary pd catheter .
the patient was a male infant born at 28 and 3/7 weeks gestation weighing 830 g. he was twin b of a monochorionic twin gestation , and the donor in a twin  twin transfusion syndrome .
the pregnancy was complicated by oligohydramnios , worsening cardiac function and hydrops in twin a necessitating preterm delivery via cesarean section .
twin b 's apgar scores were 8 and 8 , at 1 and 5 min , respectively ; however , he developed respiratory distress and required intubation .
metolazone was added , but he remained anuric . a renal ultrasound demonstrated echogenic kidneys with normal doppler flow and an empty bladder . by dol 3
, the infant 's weight had risen to 1050 g , a 27% increase from birth weight .
laboratory studies were significant for serum sodium 128 meq / l ( reference range , 135145 meq / l ) , serum creatinine 2.3 mg / dl ( reference range , 0.20.9 mg / dl ) and blood urea nitrogen ( bun ) 69 mg / dl ( reference range , 1020 mg / dl ) .
the infant was transferred to the university of iowa children 's hospital neonatal intensive care unit for respiratory and renal management .
total fluids were restricted to a volume of 75 ml / kg / day for the first 24 h post - transfer with further restriction to 60 ml / kg / day and 1 g / kg / day of protein on dol 45 due to worsening fluid overload and significant decline in respiratory status .
the infant 's renal parameters indicated severe anuric renal failure , with a bun and creatinine of 87 and 2.7 mg / dl , respectively .
on dol 5 , the infant 's weight was 1096 g , indicating a 32% fluid weight gain from birth . given the dire clinical picture and the likelihood of death without intervention , the neonatology , pediatric surgery and pediatric nephrology teams reviewed the risks and benefits of rst with the patient 's family and devised a pd plan for the infant .
the primary technical challenge for initiating pd in this elbw infant was that standard cuffed pd catheters , with lengths from 31 to 39 cm , are too large for an elbw infant 's small abdominal domain .
acute pd catheters with 8 cm catheter lengths represent the smallest commercially available pd catheter .
however , these are likely still too large for an 800-g infant when placed in the standard fashion via an infra - umbilical stab incision with the catheter directed into the pelvis . to use a true pd catheter rather than improvised equipment ( e.g. large - bore intravenous cannula )   that would be prone to complications
, we thus considered a novel placement approach using an acute pd catheter inserted into the left upper quadrant .
an 8.5-french , 8-cm commercial temporary pd catheter ( pediatric peritoneal dialysis set  cook medical ) was placed at the bedside by a pediatric surgeon .
using the seldinger technique , the pd catheter was exchanged for the dilator and directed into the pelvis such that the catheter remained straight .
a purse - string suture was used to secure a watertight closure of the posterior rectus sheath .
the subcutaneous tissues and skin were closed with running suture to prevent leakage of peritoneal fluid and permit initiation of pd immediately . the exit site was closed around the catheter and dressed .
catheter placement was confirmed radiographically ( see figure 1a and b ) and with successful instillation and aspiration of saline from the catheter . see figure 2 for photograph of catheter location . 

1.(a ) ap x - ray demonstrating pd catheter placement coursing from the left upper quadrant into the left paracolic gutter .
( b ) lateral x - ray demonstrating pd catheter placement coursing from the left upper quadrant into the left paracolic gutter . 

( a ) ap x - ray demonstrating pd catheter placement coursing from the left upper quadrant into the left paracolic gutter .
( b ) lateral x - ray demonstrating pd catheter placement coursing from the left upper quadrant into the left paracolic gutter .
following catheter placement , manual pd using the dialy - nate system was initiated with 16 ml volume dwells ( 20 ml / kg based on birth weight ) of 45 min using 1.5% dianeal for 24 cycles per day .
the infant developed hypotension , so dwell times were decreased to 30 min followed by 25-min drain periods , resulting in better blood pressures while maintaining adequate ultrafiltration and clearance . within 72 h of initiating pd ,
the infant achieved a net ultrafiltration of 46 ml / pass . with successful dialysis ,
after 3 days , total fluid intake was liberalized to 120 ml / kg / day for venous nutrition .
weight decreased to 1024 g from a peak of 1092 g over the course of 10 days .
the infant was transitioned from high frequency to conventional ventilation on dol 13 . by dol 15 , urine output
ml / kg / hr , and the infant maintained appropriate fluid balance during trials off pd .
renal labs improved prior to discharge to a bun of 28 mg / dl and a serum creatinine of 0.9 mg / dl .
he is being followed by pediatric nephrology for the monitoring of his chronic kidney disease .
current laboratory studies demonstrate a serum creatinine of 0.5 mg / dl at age 16 months , suggesting an estimated glomerular filtration rate of 61 ml / min/1.73 m by the modified schwartz equation .
the primary technical challenge for initiating pd in this elbw infant was that standard cuffed pd catheters , with lengths from 31 to 39 cm , are too large for an elbw infant 's small abdominal domain .
acute pd catheters with 8 cm catheter lengths represent the smallest commercially available pd catheter . however , these are likely still too large for an 800-g infant when placed in the standard fashion via an infra - umbilical stab incision with the catheter directed into the pelvis . to use a true pd catheter rather than improvised equipment ( e.g. large - bore intravenous cannula )   that would be prone to complications
, we thus considered a novel placement approach using an acute pd catheter inserted into the left upper quadrant .
an 8.5-french , 8-cm commercial temporary pd catheter ( pediatric peritoneal dialysis set  cook medical ) was placed at the bedside by a pediatric surgeon . a small stab incision was made in the left upper quadrant .
a dilator was then placed through the stab incision into the abdomen . using the seldinger technique ,
the pd catheter was exchanged for the dilator and directed into the pelvis such that the catheter remained straight .
a purse - string suture was used to secure a watertight closure of the posterior rectus sheath .
the subcutaneous tissues and skin were closed with running suture to prevent leakage of peritoneal fluid and permit initiation of pd immediately .
catheter placement was confirmed radiographically ( see figure 1a and b ) and with successful instillation and aspiration of saline from the catheter . see figure 2 for photograph of catheter location . 

1.(a ) ap x - ray demonstrating pd catheter placement coursing from the left upper quadrant into the left paracolic gutter .
( b ) lateral x - ray demonstrating pd catheter placement coursing from the left upper quadrant into the left paracolic gutter . 

( a ) ap x - ray demonstrating pd catheter placement coursing from the left upper quadrant into the left paracolic gutter .
( b ) lateral x - ray demonstrating pd catheter placement coursing from the left upper quadrant into the left paracolic gutter .
photograph of pd catheter placement . following catheter placement , manual pd using the dialy - nate system was initiated with 16 ml volume dwells ( 20 ml / kg based on birth weight ) of 45 min using 1.5% dianeal for 24 cycles per day .
the infant developed hypotension , so dwell times were decreased to 30 min followed by 25-min drain periods , resulting in better blood pressures while maintaining adequate ultrafiltration and clearance . within 72 h of initiating pd ,
the infant achieved a net ultrafiltration of 46 ml / pass . with successful dialysis ,
after 3 days , total fluid intake was liberalized to 120 ml / kg / day for venous nutrition .
weight decreased to 1024 g from a peak of 1092 g over the course of 10 days .
the infant was transitioned from high frequency to conventional ventilation on dol 13 . by dol 15 , urine output
had improved to 34 ml / kg / hr , and the infant maintained appropriate fluid balance during trials off pd .
renal labs improved prior to discharge to a bun of 28 mg / dl and a serum creatinine of 0.9 mg / dl .
he is being followed by pediatric nephrology for the monitoring of his chronic kidney disease .
current laboratory studies demonstrate a serum creatinine of 0.5 mg / dl at age 16 months , suggesting an estimated glomerular filtration rate of 61 ml / min/1.73 m by the modified schwartz equation .
to our knowledge , our case report includes the smallest infant with whom pd was successful using a standard , commercially available pd catheter .
rst was indicated given severe oligo - anuric aki resistant to medical management , fluid overload resulting in respiratory and hemodynamic compromise and inability to provide adequate nutrition secondary to fluid restriction .
use of rst in neonates is often limited by lack of size - specific equipment .
pd was chosen for rst due to the lack of appropriately sized vascular catheters for a patient of such small size . due to our infant 's extremely small size and severe fluid overload ,
his initial dialysis prescription also required adaptation with increased initial fill volumes of 20 ml / kg to overcome the comparatively large amount of dead space within dialysis tubing ( a catheter volume of 0.4 ml and a connecting tube volume of 3.0 ml ) .
limited existing literature documents high mortality rates in elbw infants treated with pd , though the high rates in some reports are likely related to the underlying medical conditions .
for example , two case series using pd in neonates each reported > 50% mortality but included many infants with inborn errors of metabolism [ 6 , 7 ] .
continuous veno - venous hemodialysis is the preferred therapy for patients with this condition because of its superior efficacy ; inefficient clearance with pd is not adequate for rapid removal of ammonia in these cases .
similarly , one group reported a 75% mortality rate in the use of pd for infants with necrotizing enterocolitis , a condition associated with high mortality rates as well as one which would be considered a relative contraindication to the use of pd   because of the inflammation in the abdomen and high risk for infection .
in addition to high mortality rates , the available literature describes high rates of complications such as catheter leak and peritonitis during the use of pd in small infants , likely related to the lack of size - specific equipment for these patients .
use of varying catheter types , both commercial and improvised , for pd in elbw neonates has been described .
two larger case series of pd in neonates ( bw range , 14 kg ) report technical success using rigid catheters in the infra - umbilical position [ 6 , 7 ] . the patients in these series
describe successful use of a flexible 10-french blake silicone drain in a 40-week term infant requiring pd .
detail novel use of a vascular catheter placed in the right upper quadrant ; however , high rates of catheter leak , poor drainage , and kinking were noted .
similarly , use of a large - bore intravenous cannula has been described ; however , again this improvised device was prone to malfunction with leak and kinking .
to our knowledge , this case illustrates the first time a standard , temporary pd catheter has been placed successfully via a left upper abdominal quadrant insertion site facilitating uncoiled extension into the left paracolic gutter in an elbw infant
. early initiation of rst for aki and fluid overload in neonates may have important short- and long - term systemic effects .
adult and experimental data suggest that mortality due to aki may be related to multi - organ functional and transcriptional changes , especially in the lungs [ 1619 ] .
aki is implicated in the development of bronchopulmonary dysplasia due to pulmonary edema from volume overload and the associated elevation in pro - inflammatory cytokines .
the adult critical care literature demonstrates that critically ill patients with aki are more difficult to wean from mechanical ventilation .
these findings bolster the need for early fluid removal and treatment of aki in neonates given the implications for sequelae of chronic lung disease in this vulnerable population .
herein , the neonatology team was able to transition our infant from high frequency to conventional ventilation within 1 week of dialysis initiation .
our infant 's severely fluid restricted state prior to rst initiation eliminated any opportunity to provide nutrition without further fluid accumulation .
adequate nutritional support may be unintentionally deferred in critically ill patients due to fluid restriction , preparation for surgical / procedural interventions and/or concern for feeding intolerance .
the resultant malnutrition in the setting of aki is associated with increased morbidity and mortality [ 23 , 24 ] .
nutritional deficit , specifically protein debt , is linked to higher risk for infection , reduced wound healing and increased need for mechanical ventilation .
provision of adequate nutritional support to critically ill patients is a major benefit of rst .
the smallest of patients are at high risk for morbidity and mortality secondary to aki , yet there remains a dearth of clinical equipment and expertise available to provide adequate rst for these patients .
technical adaptation is required for placement of pd catheters in elbw infants ; however , renal recovery following severe oligo - anuric aki is possible and can be followed by excellent growth , development and improvement in lung function .
these infants should not be excluded from consideration for initiation of rst because of their small size .
 critically ill neonates are at high risk for acute kidney injury ( aki ) . 
 renal supportive therapy ( rst ) can be an important tool for supporting critically ill neonates with aki , particularly in cases of oliguria and fluid overload . 
 there are few reports of rst for management of oligo - anuric aki in the extremely low - birth - weight infant weighing < 1000 g. we report successful provision of peritoneal dialysis ( pd ) to an 830-g neonate with oligo - anuric aki through adaptation of a standard pediatric acute pd catheter . 
Background
Case report
Procedure
Discussion
Conclusion