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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 17  |  Issue : 2  |  Page : 70-72

Concomitant insertion of peritoneal dialysis catheter and ventriculoperitoneal shunt in children: a report of two cases


1 Department of Pediatrics, Abha Maternity and Children’s Hospital, King Khalid University, Abha, Kingdom of Saudi Arabia
2 Department of Pediatric Nephrology, Abha Maternity and Children Hospital and Head of Dialysis Centers, King Khalid University, Abha, Kingdom of Saudi Arabia
3 Department of Child Health, College of Medicine, King Khalid University, Abha, Kingdom of Saudi Arabia

Date of Submission01-Jul-2017
Date of Acceptance21-Aug-2017
Date of Web Publication21-Sep-2017

Correspondence Address:
Ruba Abo Essa
Department of Pediatrics, Abha Maternity and Children’s Hospital, Abha, Kingdom of Saudi Arabia Zip code: 61321
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jesnt.jesnt_5_17

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  Abstract 

The aim of this study was to know and validate whether the use of ventriculoperitoneal shunt (VPS) and peritoneal dialysis catheter (PDC) is a safe and acceptable option in children requiring PD and VPS. A case of myelomeningocele with accompanied paraplegia and hydrocephalus was treated surgically in the neonatal period with placement of VPS. Later the child developed a neurogenic bladder with recurrent cystitis, which culminated into severe bilateral ureterohydronephrosis and progressive chronic renal disease. In a second case, a boy with an immaculate past history, admitted in a local hospital for meningitis complicated by hydrocephalus, necessitating the insertion of VPS, was treated. During the course of his illness, the child developed acute renal failure, volume overload, and severe hypertension and ended up in our pediatric ICU. We experienced two cases in our artificial kidney unit with concomitant insertion of VPS and PDC with an excellent outcome. On the basis of the outcomes of our patients as well as results from other centers, we conclude that the concurrent use of a VPS and PDC is a safe and acceptable option in child requiring PD and VPS.

Keywords: hydrocephalus, peritoneal dialysis, ventriculoperitoneal shunt


How to cite this article:
Essa RA, Muzalef A, Al-Qahtani S. Concomitant insertion of peritoneal dialysis catheter and ventriculoperitoneal shunt in children: a report of two cases. J Egypt Soc Nephrol Transplant 2017;17:70-2

How to cite this URL:
Essa RA, Muzalef A, Al-Qahtani S. Concomitant insertion of peritoneal dialysis catheter and ventriculoperitoneal shunt in children: a report of two cases. J Egypt Soc Nephrol Transplant [serial online] 2017 [cited 2017 Dec 17];17:70-2. Available from: http://www.jesnt.eg.net/text.asp?2017/17/2/70/215229


  Introduction Top


End-stage renal disease (ESRD) is a rare but significant health problem in children, with a reported incidence of 5–10 children per million each year [1]. Being the most severe form of chronic kidney disease, it is associated with various social, medical, and financial problems. Children with ESRD have a 10-year survival rate of about 80% with an age-specific mortality rate of 30 times compared with children without ESRD. Most of these children succumb to cardiovascular complications and infections [2]. Because of its universal applicability and superior compatibility, peritoneal dialysis (PD) remains the most preferred treatment modality for ESRD [3].

Hydrocephalus is an abnormal accumulation of cerebrospinal fluid in the brain impairing vision, hearing, cognitive, and cranial nerve function, and, if untreated, can lead to death. It can either be congenital with an incidence of between 0.5 and four per 1000 children [4] or secondary to infections, bleedings, head trauma, and central nervous system tumors.

Currently, hydrocephalus is treated effectively with the insertion of ventriculoperitoneal shunt (VPS) and a PD; it is considered to be a successful bridge to renal transplantation [5].

The synergistic use of peritoneal dialysis catheter (PDC) and VPS in a child is very rare and there is a paucity of data with no large case series found in the literature. Here, we report two cases in which patients underwent both dialysis and cerebrospinal fluid shunting.


  Case report 1 Top


An 11-year-old girl, a case of myelomeningocele with accompanied paraplegia and hydrocephalus, was treated surgically in the neonatal period with placement of VPS. Later the child developed a neurogenic bladder with recurrent cystitis, which culminated into severe bilateral ureterohydronephrosis and progressive chronic renal disease. Subsequently, she also suffered from severe hypertension, cerebrovascular accident, and right-sided hemiparesis. Because of various socioeconomic reasons, the family did not go for PD and the follow-up was poor.

Eventually, she was admitted in our hospital as an acute renal failure superimposed on a chronic renal failure. She showed signs of hypertensive encephalopathy and seizures before the scheduled insertion of the PDC and was admitted in the pediatric ICU. The patient underwent a computed tomography scan, which ruled out the obstructed VPS, and was started on urgent hemodialysis. Later the child underwent peritoneal catheter insertion and was started on automated PD program ([Figure 1]). Because of her seizures, the patient was started on antiepileptic drugs and antihypertensive medications.
Figure 1 Both ventriculoperitoneal shunt tube and peritoneal dialysis tube are in place.

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Her laboratory investigations revealed the baseline blood urea nitrogen of 68 mg/dl and creatinine of 2.4 mg/dl. There was marked increment before dialysis, which showed urea of 187 mg/dl and creatinine of 7.1 mg/dl. She had normocytic normochromic anemia with hemoglobin of 9.5 g/dl, secondary hyperparathyroidism, calcium of 8.7 mg/dl, phosphorus of 7.6 mg/dl, parathyroid hormone of 1252 ng/l, and alkaline phosphatase of 581 IU/l. Echocardiogram showed significant left ventricular and septal hypertrophy.

After placing on the PD and VPS, the clinical course had been significant with an episode of PD-related peritonitis. PD fluid showed a white blood cell count of 1400 cells/ml, of which lymphocytes constitutes 98%, red blood cell of 0–1/high power field, and no growth on culture. She was treated with intraperitoneal antibiotics for 10 days and improved without any complications of VPS or any manifestations of central nervous system infection. After 1 year of follow-up the patient is maintained on automated PD program waiting for renal transplant.


  Case report 2 Top


The second case is that of a 4-year-old boy, with an immaculate past history, admitted in a local hospital for meningitis complicated by hydrocephalus, necessitating the insertion of VPS. During the course of his illness, the child developed acute renal failure, volume overload, and severe hypertension and ended up in our pediatric ICU. A PDC was inserted and he was started on Automated Peritoneal Dialysis (APD) program as a live-saving measure. Unfortunately, his condition progressed to ESRD. The patient had to be on both VPS and PD for almost a couple of years, both remain completely functional during the entire course of treatment and did not result in any significant complication. Eventually, the patient was transplanted successfully.


  Discussion Top


The primary objective of our case studies was to identify the various complications that may have influenced the outcome in patients with a concomitant use of a VPS and a PDC, as there is a scarcity of data resulting in a lack of evidence-based practice recommendations [6].

It is not uncommon for patients with VPS to end up with ESRD because of different reasons. The safety and viability of PD in patients with a VPS have been a matter of great concern and have derived a mixed response from different quarters [7].

Although results from Warady et al. [8] in early 90s were encouraging, many still are reluctant to adopt this practice. Common reasons cited for this avoidance are infections and nonfunctioning of the shunt. VPS and PD can lead to a damaged peritoneum [9]. Similarly, ascites and sclerosing encapsulating peritonitis secondary to a VPS are also reported [10],[11]. Hydrothorax can occur in patients with a VPS [12] and on PD [13].

Despite few reports of peritonitis, there has been no episode of meningitis reported in patients with concurrent insertion of a VPS and PDC, which shows that the risk for an ascending ventriculitis or meningitis is very slim [14].

One study in Poland reveals that patients with myelomeningocele on VPS and PD have a greater risk for complications [15]. Similarly, VPS dysfunction is another caveat in such patients [16] and needs close monitoring.However, it has been endorsed by various studies in which it was found that the concurrent use of both VPS and PDC in a patient is not a contraindication and can be used successfully with the help of a professional team [5],[14],[17].

In our patients, VPS was placed initially and subsequent ESRD prompted the insertion of PDC. Except for an episode of peritonitis in the first patient, no other complications were noted, which could be attributed to a good nursing care, appropriate family support, and an experienced multidisciplinary team.

We also suggest that a registry of patients with myelomeningocele and spina bifida on PD should be established, where they are followed up for longer periods, which will provide an objective assessment of their problems and management.


  Conclusion Top


On the basis of the outcomes of our patients as well as results from other centers, we conclude that concurrent use of a VPS and PDC is a safe and acceptable option in children requiring PD and VPS.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
McDonald SP, Craig JC. Long-term survival of children with end-stage renal disease. N E J Med 2004; 350:2654–2662.  Back to cited text no. 1
    
2.
Mortazavi F, Maleki M. Management and outcome of children with end-stage renal disease in northwest Iran. Indian J Nephrol 2012; 22:94–97.  Back to cited text no. 2
  [Full text]  
3.
Schaefer F, Warady BA. Peritoneal dialysis in children with end-stage renal disease. Nat Rev Nephrol 2011; 7:659–668.  Back to cited text no. 3
    
4.
Jorgensen J, Williams C, Sarang-Sieminski A. Hydrocephalus and ventriculoperitoneal shunts: modes of failure and opportunities for improvement. Crit Rev Biomed Eng 2016; 44:91–97.  Back to cited text no. 4
    
5.
Chan YH, Ma AL, Tong PC, Lai WM, Tse NK. Chronic peritoneal dialysis in Chinese infants and children younger than two years. Hong Kong Med J 2016; 22:365–371.  Back to cited text no. 5
    
6.
Manning TC, Avellino AM, Symons J, Ojemann J, Ellenbogen RG. Cerebrospinal fluid shunting in children on renal dialysis. Report of two cases. Pediatr Neurosurg 2008; 44:65–67.  Back to cited text no. 6
    
7.
Ram Prabahar M, Sivakumar M, Chandrasekaran V, Indhumathi E, Soundararajan P. Peritoneal dialysis in a patient with neurogenic bladder and chronic kidney disease with ventriculoperitoneal shunt. Blood Purif 2008; 26:274–278.  Back to cited text no. 7
    
8.
Warady BA, Hellerstein S, Alon U. Advisability of initiating chronic peritoneal dialysis in the presence of a ventriculoperitoneal shunt. Pediatr Nephrol 1990; 4:96.  Back to cited text no. 8
    
9.
Grunberg J, Rebori A, Verocay MC. Peritoneal dialysis in children with spina bifida and ventriculoperitoneal shunt: one center’s experience and review of the literature. Perit Dial Int 2003; 23:481–486.  Back to cited text no. 9
    
10.
Chidambaram B, Balasubramaniam V. CSF ascites: a rare complication of ventriculoperitoneal shunt surgery. Neurol India 2000; 48:378–380.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Yukinaka M, Nomura M, Mitani T, Kondo Y, Tabata T, Nakaya Y et al. Cerebrospinal ascites developed 3 years after ventriculoperitoneal shunting in a hydrocephalic patient. Int Med 1998; 37:638–641.  Back to cited text no. 11
    
12.
Hadzikaric N, Nasser M, Mashani A, Ammar A. CSF hydrothorax-VP shunt complication without displacement of a peritoneal catheter. Childs Nerv Syst 2002; 18:179–182.  Back to cited text no. 12
    
13.
Rose GM, Conley SB. Unilateral hydrothorax in small children on chronic continuous peritoneal dialysis. Pediatr Nephrol 1989; 3:89–91.  Back to cited text no. 13
    
14.
Dolan NM, Borzych-Duzalka D, Suarez A, Principi I, Hernandez O, Al-Akash S et al. Ventriculoperitoneal shunts in children on peritoneal dialysis: a survey of the International Pediatric Peritoneal Dialysis Network. Pediatr Nephrol 2013; 28:315–319.  Back to cited text no. 14
    
15.
Jachimiak B, Jarmolinski T. A child with myelomeningocele as a dialytic patient. Przegl Lek 2006; 63(Suppl 3):176–179.  Back to cited text no. 15
    
16.
Kazee MR, Jackson EC, Jenkins RD. Management of a child on CAPD with a ventriculoperitoneal shunt. Adv Perit Dial 1990; 6:281–282.  Back to cited text no. 16
    
17.
Aksu N, Yavascan O, Anil M, Kara OD, Bal A, Anil AB. Chronic peritoneal dialysis in children with special needs or social disadvantage or both: contraindications are not always contraindications. Perit Dial Int 2012; 32:424–430.  Back to cited text no. 17
    


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  Introduction
  Case report 1
  Case report 2
  Discussion
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