Peritoneal Dialysis in the First 60 Days of Life By David E. Matthews, Karen W. West, Frederick J. Rescorla, Dennis W. Vane, Jay L. Grosfeld, Rebecca S. Wappner, Jerry Bergstein, and Sharon Andreoli Indianapolis, Indiana 9 This report describes a 7-year experience with acute peritoneal dialysis in 31 neonates and infants less than 60 days of age, There were 20 boys and 11 girls, ages 3 to 60 days. Tenckhoff catheters of modified length were placed in the newborn intensive care unit (ICU), pediatric ICU, or surgery suites, and hourly exchanges (20 cc/kg) were started immediately postoperatively, Diagnoses included congenital metabolic disorders (11 ), acute tubular necrosis (6), postcardiopulmonary bypass with renal failure (5), renal cortical necrosis (5}, obstructive uropathy (2), renal agenesis (1), and bilateral renal dysplasia (1). Complica- tions included: peritonitis (4), bowel perforation (1), exit site infection (3), leaking dialysate (4), catheter obstruction (2), inguinal hernias (3), umbilical hernia (1), and retroperi- toneal hemorrhage (1). There were 19 deaths (61.3%) from 1 to 90 days postinsertion in this high risk group. The (1), and post liver transplant (1). Effective dialysis (lower- ing of blood urea nitrogen (BUN) or ammonia, correction of acidosis, decrease in fluid overload) was possible in all cases. Five of the 12 survivors remain on chronic dialysis awaiting renal transplantation. Peritoneal dialysis is effec- tive in the newborn period in the management of metabolic disturbances as well as renal failure. Morbidity and mortal- ity (61.3%) is related to the near-morbid condition of the baby at the time of insertion and the severity of the complex underlying diagnosis often associated with mul- tiorgan failure. 9 1990 by W.B. Saunders Company. INDEX WORDS: Renal failure; peritoneal dialysis. T HE ABILITY of the peritoneum to act as a dialyzing membrane was established by Putnam in 1922, and further developed by Ganter later that decade. 1 Due to the high incidence of complications (mainly infectious), clinical applicability of peritoneal dialysis was limited until resurgence in the use of this technique following the innovations described by Popo- vich, Tenckhoff, and others in the 1960s and 1970s.2'3 Since that time, peritoneal dialysis has become an effective and increasingly popular alternative to hemo- dialysis in the management of patients with end-stage renal disease. Although the greatest benefit of this From the Sections of Pediatric Surgery and Nephrology, Depart- ment of Surgery, Indiana University Medical Center, and the James Whitcomb Riley Hospital for Children, Indianapolis, IN. Presented at the 20th Annual Meeting of the American Pediatric Surgical Association, Baltimore, Maryland, May 28-31, 1989. Address reprint requests to Jay L. Grosfeld, MD, Surgeon- in-Chief, J.W. Riley Hospital for Children, 702 Barnhill Dr, Indianapolis, IN 46223. 9 1990 by W.B. Saunders Company. 0022-3468/90/2501-0020503.00/0 modality of treatment was initially observed in adult patients, peritoneal dialysis gradually became more practical for use in the pediatric setting as equipment and techniques were adapted for smaller patients. These refinements in peritoneal dialysis have resulted in a more effective treatment of renal failure and certain metabolic conditions for neonates and young infants--a group in whom the technical difficulties related to hemodialysis had greatly limited previous therapy. The incidence of acute renal failure in patients admitted to newborn intensive care units (ICU) is approximately 6% to 8%. The mortality rate in this population may approach 45%. 4,5 Recent reports indi- cate that peritoneal dialysis is technically possible in very small infants, and may decrease the morbidity and mortality associated with renal failure in the newborn period. 4'6s These reports, however, mainly concern isolated cases or small series of patients. A large series detailing the experience with peritoneal dialysis in neonates is lacking. The purpose of this report is to describe a 7-year experience with acute peritoneal dialysis in 31 critically ill infants less than 60 days of age at a single, high-risk tertiary pediatric facility. MATERIALS AND METHODS From March 1982 to March 1989, 31 infants less than 60 days of age were managed with peritoneal dialysis at the James Whitcomb Riley Hospital for Children, Indiana University Medical Center. Twenty patients were boys and 11 were girls. Eight of 31 infants were premature (<38 weeks gestation). The average weight of the infants at the time of catheter insertion was 3.67 kg (range, 1.90 to 6.24 kg). The average age at catheter insertion was 23 days (range, 3 to 60 days). Indications for dialysis included congenital metabolic disorders (urea cycle defects with hyperammonemia or lactic acidosis) in 1t babies, acute tubular necrosis in 6, postcardiopulmonary bypass with renal failure in 5, renal cortical necrosis in 5, obstructive uropathy in 2, renal agenesis in 1, and renal dysplasia in 1 (Fig 1). Patients were evaluated for comprehensive history, age, sex, weight, technique of catheter placement, technique of dialysis, duration of dialysis, clinical course, complications, pertinent laboratory data, mortality, and autopsy findings. An estimate of the overall severity of illness was obtained by calculating the physiological stability index (PSI) score (modified by Georgieff et al) for each infant at the time of catheter placement. 9 This scoring system modified specifically for newborn infants takes into account 23 laboratory and vital sign variables in seven categories (cardiovascular, respiratory, neurologi- cal, hematologic, renal, gastroenterology, and metabolic). The PSI has a potential scoring range between zero (a physiologically stable child) and 84 (significant severe physiological instability associated with multiple organ failure and sepsis). 110 Journal of Pediatric Surgery, Vo125,No 1 (January),1990:pp 110-116