ESPN 51th Annual Meeting

ESPN 2018


 
INTRATHORACIC DIALYSATE LEAK IN A CHILD ON PERITONEAL DIALYSIS
JASNA SLAVICEK 1 PETRA DZEPINA 1 MAJA BAN 1 DANKO MILOšEVIć 1 KRISTINA VRLJICAK 1

1- CHC ZAGREB
 
Introduction:

 Peritoneal dialysis( PD) is one of most common methods of replacing kidney function in pediatric patients with end stage chronic kidney disease. Dialysate leak in other spaces is one of the most frequent non-infectious complication of PD. Intrathoracic dialysate leak is very rare in children. The goal of this study was to show diagnostic approach and clinical course of a child on PD, who had intrathoracic dialysate leak.

Material and methods:

 A seven-year-old boy,  with  Sy Joubert, on PD, since he was 3 years old, presented with subfebrile state ( temperature 37.5°C), productive cough, slightly elevated sistolic blood pressures (140 mmHg) and vomiting once a day during the last few days. Parents stated he had a slight protrusion of the left hemiabdomen during evening exchanges. On examination, he had mild pharyngeal erythema  edematous face and trunk, without any edema of extremities. Laboratory results  showing mild anemia (Hb 97 g/L) and alkalosis (pH 7.55, pCO2 5.7 kPa, HCO3 37.6 mmol/L, BE 15.2). There were no signs of peritonitis (leukocytes in dialysate 0.01). Abdominal ultrasound revealed no signs of dialysate leak in abdominal wall. A diagnosis of respiratory tract infection was established and the treatment with ceftriaxone was started which was maintaned through the next 4 days. During the follow up,  the productive cough, vomiting and higher sistolic blood pressure (160 mmHg) were still present. He was then hospitalized.

Results:

 On the first in-hospital day, the chest X-ray revealed left pleural effusion therefore left thoracic drainage was performed. About 700 ml of fluid was obtained. Fluid analysis was inconclusive of dialysate leak (glucose level 7.8 mmol/L, LDH 390 U/L, protein 12 g/L), therefore peritoneal dialysis was continued. Drain was removed on the third in-hospital day. Another treatment with ceftriaxone was started and continued through 10 days. On the sixth in-hospital day, scintigraphy with Tc-99m marked albumins of thorax, abdomen and pelvis was performed. Unfortunately, the scintigraphy result arrived subsequently. In the mean time, on the 11th in-hospital day, patient developed dispnoea with lower saturations (SaO2 88%) and the control chest X-ray showed new left pleural effusion, which was confirmed with chest CT. A new left thoracic drainage was performed. Based on subsequently arrived result of scintigraphy, the diagnosis of  intrathoracic dialysate leak was established followed by discontinuation of APD and start of CVVHD on previously inserted central venous line. The CVVHD was continued through one month up until no signs of  dialysate leak were found on chest and abdomen CT. We started a new APD protocol with smaller fillings.

Conclusions:

 Dialysate leak in extraperitoneal spaces is one of the most common non-infectious complications of PD in children.The intrathoracic dialysate leak phenomenon in pediatric population is very rare. In the event of unilateral pleural effusion in a child on PD it is important to include intrathoracic dialysate leak in differential diagnosis. Suspension of PD and temporary HD may be helpful.